APRDRGs : Readmission Module

1
APR-DRGs Readmission Module

• 3M HIS
• Clinical Research Department

2
This Session Will Provide

• A Brief Description of the Clinical Research
  Group at 3M HIS
• Summary of the APR-DRG Readmission Module

3
3M HIS Clinical Research Experience

• 3M HIS Experience in developing classification
  and payment/quality systems
• Development of the first DRG Prospective Payment
  System (PPS) in NJ in 1980
• Under contract with CMS, maintenance of the CMS
  DRGs since the inception of Medicare PPS in 1983
  including recently released MS-DRGs
• Design and development of the first outpatient
  PPS for Iowa Medicaid
• Under contract with CMS, maintenance of the APCs
  since the inception of the Medicare outpatient
  PPS in 2000
• Under contract with CMS, design, development and
  maintenance of acute long term care hospital PPS
• Extensive experience in implementing PPS systems
  internationally including a prospective budgeting
  system based on APR-DRGs for Belgium
• Design and development of ICD-10 PCS
• Design and development of Potentially Preventable
  Readmission (PPRs) and Potentially Preventable
  Complication (PPCs) using APR-DRGs
• Mapping of ICD-9-CM Diagnoses to ICD-10-CM
  Diagnoses
• Under contract to the Federal Government,
  development of Clinical Risk Groups (CRGs) and
  CRxGs (privately funded - using pharmaceutical
  data) for population profiling/ risk adjustment/
  physician profiling
• Under contract with NIMH, working together with
  Johns Hopkins/ U of Maryland to develop new
  payment system for inpatient mental health
  services.

4
In Every Country There Are Four Sources for
Variation in Health Services

• Patient/family variation
• Caregiver/clinician variation
• Hospital/system variation
• Community variation
• Payers rarely tie financial or quality
  incentives to any of these sources of variation.
  Today we have the tools such as readmissions to
  measure each of these sources of variation for
  each type of health care encounter. Payers need
  to offer quality and financial incentives to
  aggressively control the costs and improve the
  quality of this variation. Medpac states that we
  should start with readmissions (June 2008 report)

5
Value can be measured for each of the 4 kinds of
health care encounters

• Ambulatory Patient Groups (APGs) Visits
• All-Patient Refined DRGs (APR-DRGs) Hospital
  Stays
• Clinical Risk Groups (CRGs) EpisodesAPR-DRGs/C
  RGs plus Health Status-Long Term Care

Value Max Outcomes Quality / Payment
Quality
Payment
6
Reasons for Success of Medicare Inpatient PPS

• The success of any payment system that is
  predicated on providing incentives for cost
  control is almost totally dependent on the
  effectiveness with which the incentives were
  communicated. .. Because the DRGs were developed
  to group clinically similar patients, an
  extremely important means of communication
  between the clinical and financial aspects of
  care was created.
• Federal Register, May 4, 2001

7
Assumptions Underlying the Development of PPRs

• Not all readmissions are preventable
• Patients who have had a problem with the quality
  of inpatient care or outpatient care following
  discharge will be more likely to be readmitted
• Discharged too sick, too quick
• Poor discharge planning
• Poor follow-up care
• A hospital with a higher than expected rate for
  these types of quality problems will be more
  likely to have higher rates of readmissions
• For certain types of patients
• Across the board

8
Research Approach for Development of PPRs

• Define exclusion criteria for identifying initial
  discharges for which a subsequent readmission is
  excluded from consideration as a PPR (e.g.
  discharged against medical advice)
• Develop criteria for determining if a readmission
  is potentially preventable (i.e. a PPR)
• Develop a method of determining the risk of a PPR
  occurring and develop a method for computing
  actual and expected hospital PPR rates
• Test methodology in large databases

9
PPR Initial Discharge Exclusions

• If any of the following conditions apply to the
  initial discharge, a subsequent readmission is
  excluded from consideration as a PPR
• Major or metastatic malignancies
• Neonates
• Multiple trauma, burns
• Left against medical advice
• Transferred to another acute care hospital
• Obstetrical
• Other exclusions
• Specific eye procedures and infections
• Cystic fibrosis-pulm dx
• Died

10
Research Approach for Development of PPRs

• Define exclusion criteria for identifying initial
  discharges for which a subsequent readmission is
  excluded from consideration as a PPR (e.g.
  discharged against medical advice)
• Develop criteria for determining if a readmission
  is potentially preventable (i.e. a PPR)
• Identify chains of related readmissions
• Develop a method of determining the risk of a PPR
  occurring and develop a method for computing
  actual and expected hospital PPR rates
• Test methodology in large databases

11
Clinical Criteria for Determining Potentially
Preventable Readmissions

• The reason for the readmission can be a
  consequence of the prior discharge.
• Poor quality during the prior hospitalization
• Poor coordination between the inpatient and
  outpatient health care team
• The reason for readmission can be a consequence
  of inadequate outpatient follow-up
• If the reason for readmission is unrelated to the
  prior hospitalization, it is not considered a
  potentially preventable readmission (e.g.,
  admission for trauma) and is not designated as a
  PPR

12
General Guidelines for PPRs
13
PPRs Must Be Clinically Related To Prior
Discharge either the pdx and/or sdx

• Case 1 PPR
• Initial discharge Asthma
• Readmission 8 days post discharge Asthma
• Case 2 PPR
• Initial discharge Acute MI
• Readmission 6 days post discharge with Diabetes
  Mellitus
• Case 3 Not a PPR
• Initial discharge Pneumonia
• Readmission 4 days post discharge Fractured
  femur skull
• sustained in motor vehicle accident
• Case 4 Not a PPR Initial discharge CHF
  Readmission 6 days post discharge Appendectomy
• Case 5 PPR Initial discharge Abdominal Pain
  Readmission 2 days post discharge Appendectomy

14
Research Approach for Development of PPRs

• Define exclusion criteria for identifying initial
  discharges for which a subsequent readmission is
  excluded from consideration as a PPR (e.g.
  discharged against medical advice)
• Develop criteria for determining if a readmission
  is potentially preventable (i.e. a PPR)
• Identify chains of related readmissions
• Develop a method of determining the risk of a PPR
  occurring and develop a method for computing
  actual and expected hospital PPR rates
• Test methodology in large databases

15
Chain Rules

• Chain Rules were defined for creating a
  readmission chain (that is an initial index
  admission followed by a number of related
  readmissions)
• For example Any elective surgical admission that
  occurs after a medical admission is not
  considered to be related and thus terminates a
  chain.

16
Example of a Readmission Chain
Initial Admission CABG surgery Readmission Post
op wound infection Readmission PTCA

• Both readmissions are related to the CABG surgery
• Without readmission chains the readmission
  sequence is a CABG discharge with one readmission
  followed by an unrelated PTCA admission
• With readmission chains the readmission sequence
  is a CABG discharge with two related readmissions.

17
Example of PPR Chains
18
Research Approach for Development of PPRs

• Define exclusion criteria for identifying initial
  discharges for which a subsequent readmission is
  excluded from consideration as a PPR (e.g.
  discharged against medical advice)
• Develop criteria for determining if a readmission
  is potentially preventable (i.e. a PPR)
• Identify chains of related readmissions
• Develop a method of determining the risk of a PPR
  occurring and develop a method for computing
  actual and expected hospital PPR rates
• Test methodology in large databases

19
Issues in developing a method for computing
actual to expected readmission rates

• Readmission window of time 15 days Readmission
  to same hospital or any hospital public reports
  must be across payment incentives start with
  same. Internal CQI can start with same
• Computation of expected value for beneficiaries
  with mental illness see below
• Age groups age adjustment for elderly

20
Outliers Chains

• Some patients can have long chains of PPRs in one
  initial discharge
• Some patients can have many initial discharges
  with one or more PPRs
• E.g. sickle cell.
• Only 1 chain counts as a PPR (i.e. 1 readmission
  or 10 readmissions in a chain they all count
  the same)

21
Beneficiaries with Mental Health Illness

• These patients with other co-existing mental
  health illnesses (e.g. patient with diabetes and
  psychosis who is admitted for complications of
  diabetes) will be readmitted at a higher rate
  than patients without a mental health issue.
• Any initial discharge with mental health
  diagnosis could be excluded
• However, this would represent a disservice to
  these patients and not encourage hospitals to
  implement effective coordinated care programs
• Adjust expected PPR rate calculation for patients
  with and without significant chronic mental
  illness. Thus the expected PPR rate takes into
  account those initial admissions which have a
  significant mental health dx recorded on the
  initial admission.

22
Readmission Frequency and Rate for the Top 10
Medical Initial Admissions Florida 2004-2005
23
Readmission Frequency and Rate for the Top 10
Surgical Initial Admissions Florida 2004-2005
24
Top 5 Reasons for Readmission for Two Initial
Admission APR-DRGs

• ACUTE MYOCARDIAL INFARCT 2,358
• 194 HEART FAILURE 459
• 198 ANGINA PECT CORONARY ATH 354
• 190 ACUTE MYOCARDIAL INFARCT 347
• 166 COR BYPASS W/O CARD CATH 205
• 175 PERCUT CARDIOVASC W/O AMI 185
• CORONARY BYPASS W/CARD CATH 1,386
• 194 HEART FAILURE 165
• 721 POST-OP/POST-TRAUM INFEC 134
• 143 OTHER RESPIRATORY DIAGNOSES 118
• 198 ANGINA PECT CORONARY ATH 90
• 201 CARD ARRHYTHMIA 90

25
Final Thoughts

• The APR DRG Readmission Module is a clinically
  meaningful classification system which provides
  useful information to consumers and hospitals on
  readmission rates.
• PPRs are the first step and the first step only
  in the CQI process to decrease readmissions. We
  all need to work collaboratively to improve care.
  

26
ANY Questions about clinical aspects of this
methodology/ other tools weve developed after
this Presentation?

• Norbert Goldfield, M.D. nigoldfield_at_mmm.com