Potentially Preventable Readmissions

1. Potentially Preventable Readmissions Clinical Logic and Review July 2010

2. A return hospitalization within a specified time interval that reasonable clinicians would agree was likely related to the initial hospital stay, and was potentially preventable by means of: Excellent care during the first hospitalization; and Best possible coordination with the outpatient setting – including: outpatient health professional team and the patient/family/caregiver. What is a Potentially Preventable Readmission (PPR)?

3. What is Not a Potentially Preventable Readmission? A return hospitalization that is: Due to an unrelated event that occurred after discharge (broken leg due to trauma), or Due to a related but unpreventable event that occurred after discharge (alteration in consciousness after admission for a brain tumor) Planned at the time of the discharge from the initial admission (angioplasty after an admission for angina).

4. General Guidelines for PPRs

5. PPR Global Exclusions • If any of the following conditions apply to the initial admission, a subsequent readmission is globally excluded from consideration as a PPR • Admissions for which follow-up care is intrinsically extensive and complex • Major or metastatic malignancies treated medically • Multiple trauma, burns • Discharge status indicates limited hospital & provider control • Left against medical advice • Transferred to another acute care hospital • Neonates • Other exclusions • Specific eye procedures and infections • Cystic fibrosis with pulmonary diagnoses • Died – not included as candidate initial admissions (denominator) • PPR Definition Manual Appendix E for List of Globally Excluded APR DRGs • PPR Definition Manual Appendix G for List of Major and Metastatic Malignant Diagnoses

6. Clinical Factors make a readmission not potentially preventable • No clinical relationship to prior discharge • Cholecystectomy two weeks after hip replacement • Discharge status of prior discharge • AMA and transferred to another acute care hospital • Type of prior discharge • Follow-up care is intrinsically complex and extensive • Metatastic malignancies, Multiple trauma, Burns • Longer interval between discharge and readmission • Long time intervals (>30 days) reduce confidence that readmission is causally linked to the prior discharge

7. Clinical Relation Reasons 1 and 2 1 Medical readmission for a continuation or recurrence of the reason for the initial admission, or for a closely related condition. • The most common example of this type of readmission is a patient discharged from and admission for Congestive Heart Failure who is then readmitted for the same reason 2 Medical readmission for an acute decompensation of a chronic problem that was not the principal reason for the initial admission, but may be related to care either during or after the initial admission. • Such readmissions could be triggered by failure to renew lapsed prescriptions or incomplete instruction about returning to a previous medical regimen at the time of discharge, miscommunication about changes in a regimen that could affect an underlying chronic condition, lack of prompt follow-up by a primary care team, or failure to communicate in-hospital events, changes in the medical regimen, and issues that require ongoing monitoring to the primary care provider. 2a Ambulatory care sensitive conditions as designated by ARHQ • Examples would be patients who, regardless of the reason for their initial admission, are readmitted for uncontrolled diabetes, asthma or COPD exacerbation, uncontrolled hypertension, or urinary tract infection 2b All other readmissions for a chronic problem that may be related to care either during or after the initial admission • Examples would be readmissions for diabetic neuropathy, interstitial lung disease, cardiomyopathy, or Alzheimer dementia

8. Clinical Relation Reasons 3, 4, and 5 3 Medical readmission for an acute medical condition or complication that may be related to or may have resulted from care during the initial admission or in the post-discharge period after the initial admission. • Examples: Patients discharged after elective surgery readmitted with a urinary tract infection likely related to an indwelling foley catheter during the initial admission; or readmitted with a post-operative wound infection 4 Readmission for a surgical procedure to address a continuation or a recurrence of the problem causing the initial admission. • Examples: Patients discharged after coronary angioplasty then readmitted for coronary bypass grafts (CABG); patients discharged after an admission for unexplained abdominal pain readmitted to undergo an appendectomy 5 Readmission for surgical procedure to address a complication that may be related to or may have resulted from care during the initial admission. • Example: Patients readmitted for extensive surgical debridement for a post-operative wound infection

9. Clinical Relation Reasons 6a, b and c 6 Readmissions for substance abuse and mental health reasons. These readmissions are tallied separately because of the uncertainty regarding the hospital and outpatient teams’ ability to prevent readmission. 6a. Readmission for mental health reasons following an initial admission for a non-mental health, non-substance abuse reason • Example: Initial admission for acute MI, readmission for schizophrenia 6b. Readmission for a substance abuse diagnosis reason following an initial admission for a non-mental health, non-substance abuse reason • Example: Initial admission for pneumonia, readmission for acute alcohol intoxication 6c. Mental health or substance abuse readmission following an initial admission for a substance abuse or mental health diagnosis • Example: A patient hospitalized for Bipolar disorder, discharged than readmitted for cocaine intoxication; a patient discharged after a hospitalization for acute alcohol toxicity, readmitted for an exacerbation of schizophrenia. The most common example in this category is a patient admitted for schizophrenia and readmitted for the same reason.

10. Potentially Preventable Readmissions within 30 Days Percent of readmissions potentially preventable: 118,239/186,605 = 63.4% Source: MD HSCRC 2008-2009