Selected Readmission Data from FL AHCA Data and Possible Payment Application May 1, 2007
Development of Potentially Preventable Readmissions (PPRs)
Hannan et al : Predictors of Readmission for Complications for Coronary Artery Bypass Graft Surgery (JAMA August 13,2003) ...
Readmissions can be prevented by: <ul><li>Providing excellent care during the first hospitalization; and   </li></ul><ul><...
Determining  the Potentially Preventability of a Readmission  – a General Rule <ul><li>If for a specific type of discharge...
Clinical Criteria for Determining Potentially Preventable Readmissions <ul><li>The reason for the readmission can be a con...
General Guidelines for PPRs Default:  Potentially Preventable Example:  Admission for diabetes  following discharge for AM...
Three other factors make a readmission not potentially preventable <ul><li>Discharge status of prior discharge </li></ul><...
Readmission Chains <ul><li>A sequence of readmissions that are all related to a single initial discharge </li></ul><ul><ul...
Example of a Readmission Chain <ul><li>Both the post op wound infection and PTCA readmissions are related to the CABG surg...
Source of Data: Florida AHCA
Source of Data: Florida AHCA
Readmission Issues <ul><li>Readmission window of time </li></ul><ul><li>Readmission to same hospital or any hospital </li>...
Deficit Reduction Act of 2005  <ul><li>“For discharges occurring on or after October 1, 2008, the diagnosis-related group ...
PPR Payment Adjustment would have the Following Benefits <ul><li>Provides a payment increase to hospitals that have low PP...
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3M - Development of Potentially Preventable Readmissions

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3M - Development of Potentially Preventable Readmissions

  1. 1. Selected Readmission Data from FL AHCA Data and Possible Payment Application May 1, 2007
  2. 2. Development of Potentially Preventable Readmissions (PPRs)
  3. 3. Hannan et al : Predictors of Readmission for Complications for Coronary Artery Bypass Graft Surgery (JAMA August 13,2003) <ul><li>Of approximately 16,000 patients who underwent CABG surgery: </li></ul><ul><li>15.3% were readmitted within 30 days after discharge </li></ul><ul><li>Of these readmissions, 85% were readmitted for purposes that were identified as complications directly related to the CABG. </li></ul><ul><li>Approximately 60 of the 2,111 readmitted patients died during their readmission </li></ul>
  4. 4. Readmissions can be prevented by: <ul><li>Providing excellent care during the first hospitalization; and   </li></ul><ul><li>Putting into place the best possible coordination plans with the outpatient setting – including both the outpatient health professional team and the patient/family/caregiver. </li></ul>
  5. 5. Determining the Potentially Preventability of a Readmission – a General Rule <ul><li>If for a specific type of discharge (e.g., coronary bypass surgery) a hospital that has a statistically significant higher rate of specific types of readmissions than comparable hospitals, the health care team will believe that opportunities to improve exist for either quality of care during the initial discharge and/or the coordination process and discharge planning in the outpatient sector. </li></ul>
  6. 6. Clinical Criteria for Determining Potentially Preventable Readmissions <ul><li>The reason for the readmission can be a consequence of the prior discharge. </li></ul><ul><ul><li>Poor quality during the prior hospitalization </li></ul></ul><ul><ul><li>Poor coordination between the inpatient and outpatient health care team </li></ul></ul><ul><li>The reason for readmission can be a consequence of inadequate post discharge outpatient follow-up </li></ul><ul><li>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 </li></ul>
  7. 7. General Guidelines for PPRs Default: Potentially Preventable Example: Admission for diabetes following discharge for AMI Exception: Unrelated acute events Example: Admission for trauma following discharge for AMI Default: Potentially Preventable Example: Admission for angina following discharge for PTCA Exception: Unrelated acute events Example: Admission for eye infections following discharge for PTCA Default: Not Potentially Preventable Example: Admission for appendectomy following discharge for pneumonia Exception: Prior discharge diagnosis was reason for surgery Example: Admission for appendectomy following discharge for abdominal pain Default: Not Potentially Preventable Example: Admission for cholecystectomy following discharge for CABG Example: Admission for PTCA following discharge for CABG Surgical Medical Surgical Medical Initial Discharge Readmission
  8. 8. Three other factors make a readmission not potentially preventable <ul><li>Discharge status of prior discharge </li></ul><ul><ul><li>AMA and transferred to another acute care hospital </li></ul></ul><ul><li>Type of prior discharge </li></ul><ul><ul><li>Follow-up care is intrinsically complex and extensive </li></ul></ul><ul><ul><ul><li>Metatastic malignancies </li></ul></ul></ul><ul><ul><ul><li>Multiple trauma </li></ul></ul></ul><ul><ul><ul><li>Burns </li></ul></ul></ul><ul><li>Length of time interval between discharge and readmission </li></ul><ul><ul><li>Long time intervals (>30 days) reduce confidence that readmission is causally linked to the prior discharge </li></ul></ul>
  9. 9. Readmission Chains <ul><li>A sequence of readmissions that are all related to a single initial discharge </li></ul><ul><ul><li>Essentially an episode of related hospitalizations </li></ul></ul><ul><ul><li>Provides a more precise description of the readmission pattern associated with the care rendered during and following specific types of initial discharges </li></ul></ul>
  10. 10. Example of a Readmission Chain <ul><li>Both the post op wound infection and PTCA readmissions are related to the CABG surgery </li></ul><ul><li>Without readmission chains the readmission sequence is a CABG discharge with one readmission followed by an unrelated PTCA admission </li></ul><ul><li>With readmission chains the readmission sequence is a CABG discharge with two related readmissions. </li></ul>Initial Admission: CABG surgery Readmission: Post op wound infection Readmission: PTCA
  11. 11. Source of Data: Florida AHCA
  12. 12. Source of Data: Florida AHCA
  13. 13. Readmission Issues <ul><li>Readmission window of time </li></ul><ul><li>Readmission to same hospital or any hospital </li></ul><ul><li>Computation of expected value for beneficiaries with mental illness </li></ul><ul><li>Excluded sites of service </li></ul>
  14. 14. Deficit Reduction Act of 2005 <ul><li>“For discharges occurring on or after October 1, 2008, the diagnosis-related group to be assigned under this paragraph for a discharge described in clause (ii) shall be a diagnosis-related group that does not result in higher payment based on the presence of a secondary diagnosis code described in clause (iv).” </li></ul><ul><li>Clause (iv) specifies high cost on high volume infections that were not present at the time of admission and would “reasonably have been prevented through the applications of evidence based guidelines” </li></ul>
  15. 15. PPR Payment Adjustment would have the Following Benefits <ul><li>Provides a payment increase to hospitals that have low PPR rates </li></ul><ul><li>Provides a payment decrease to hospitals that have high PPR rates </li></ul><ul><li>Introduces an explicit pay for performance component in the IPPS </li></ul><ul><li>By altering payment on case by case basis the incentive to reduce the occurrence PPRs is reinforced for each patient, thereby, strengthening the effectiveness of the incentive to improve quality as it relates to PPCs and PPRs. </li></ul>
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