Potentially Preventable Readmissions

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Potentially Preventable Readmissions

Clinical Review
Dr. Norbert Goldfield 3 May 2010
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What is a Potentially Preventable Readmission
(PPR)?

• 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.

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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).

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Why Develop a Method to Identify Potentially
Preventable Readmissions?

• Compare performance to enhance quality of care
• Costs associated with readmissions are
  substantial
• Possible measure for pay for performance systems
• Readmission rates will provide additional
  information on quality of care and the need for
  better coordination of services
• Length of stay, cost and mortality address only
  limited aspects of quality of care
• Death in hospital is a relatively rare event

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General Guidelines for PPRs
Readmission Readmission
Initial Admission Medical Surgical
Medical PPR except if clearly unrelated acute events Not PPR unless initial medical diagnosis clearly should have resulted in surgery
Surgical PPR except conditions clearly unrelated PPR if related to prior surgery
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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

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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 (gt30 days) reduce confidence
  that readmission is causally linked to the prior
  discharge

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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

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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

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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.

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Potentially Preventable Readmissions within 30
Days
All admissions 1,537,267
Readmissions within 30 days 186,605
Global Exclusions 24,164
Not Potentially Preventable 44,202

Total Exclusions 68,366
Potentially Preventable Readmissions 118,239
Percent of readmissions potentially preventable
118,239/186,605 63.4 Source MD HSCRC 2008-2009
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