Steven J. Korzeniewski, PhD-Candidate, MSc, MA, Director, Statistical Analysis Resource Group (SARG) & Chief Scientific Officer, Haggerty Rd Ste. 100, Farmington Hills, MI Telephone: (248) ,

Most US hospitals are unable to identify their patients that readmit to other hospitals. [Jencks SF, Williams MV, Coleman EA. Rehospitalizations Among Patients in the Medicare Fee-for-service Program. N Engl J Med. 2009;360: ] Hospitals lacking access to data on their patients that readmit elsewhere are unable to: Calculate their total readmission rates Investigate trends Evaluate performance National interest in reporting is mounting, particularly following the recent and historic passage of healthcare reform legislation. CMS now reports risk standardized rates for selected conditions, but these represent a minority of overall readmissions An infrastructure capable of such reporting did not exist in Michigan, Until NOW….

Coordinate multi-payer data sharing to construct readmission profiles for Michigan hospitals and assist them in evaluating intervention effectiveness. Structure: Led by MPRO’s Statistical Analysis Resource Group Director, includes: -analysts from many of Michigan’s health plans -representatives from hospitals, universities and the Michigan Health & Hospital Association. -Dr. Stephen Jencks, IHI Consultant, participates at times as well.

During bi-weekly meetings, the data workgroup has devised both a data extract procedure and readmissions reporting template. Data extract procedure Standardized program for pulling member-level data that defines and categorizes readmissions. Readmissions Reporting Template Presents a wealth of readmissions information within a single page layout.

Health plans extract member-level data for all acute care admissions from their respective systems. Admissions are sorted sequentially and categorized as ‘at risk’ or ‘not at risk’ of readmission. Admissions not at risk of rehospitalization include: Transfers to another inpatient facility (i.e., rehabilitation, skilled nursing or hospice), those ending in a patient’s death or in the patient leaving the hospital against medical advice, and admissions occurring within 30 days of the end of the data period. Remaining admissions are considered at risk of readmission.

Data Elements of Interest Unique Identification Number per Patient DRG (and contributing elements)Patient Zip Code Unique Identification Number per Admission Name of HospitalPrincipal ICD-9 Diagnosis Code Type of BillHospital NPI numberPrincipal ICD-9 Procedure Code Admission DateType of Admission Product Group (commercial or Medicaid/Medicare) Discharge DatePatient Gender Follow-up Care (inpatient/outpatient) Discharge Status NumberPatient Age in YearsEnrollment Date MSDRG (and contributing elements) Patient Date of BirthDisenrollment Date

Data are currently transmitted in summary form to MPRO whom aggregates the information to populate the final readmissions report template.  The next slide depicts the 2008 calendar year data.  Disseminated reports include technical specifications and a detailed narrative describing data accompanied in the report.

Reporting Template: 8 Time Period: CY2008 Payers: HAP, Health Plus, Medicaid, Priority Health, Medicare, BCN, BCBSM PRODUCT Line See Data Definitions for Column Descriptions abcdefghI AGE GROUP Type of Index Admission Discharges at Risk RA to the Same HospitalRA to a Different HospitalRA to Any Hospital NN%N%N% Commercial Adult M81,7358, %2,8443.5%11, % S84,8784,4805.3%1,1231.3%5,6036.6% O41, %1740.4%1,1712.8% Pediatric M11, %1941.7%9688.6% S3, %320.9%2136.0% O %61.1%264.8% Post-neonatal M3, %581.8%2548.0% S %242.7%768.7% Neonatal M24, %1490.6%4351.7% S %102.6%369.3% Total 252,99615,6716.2%4,6141.8%20,2878.0% Medicaid FFS (managed care data not shown for presentation purposes) Adult M64,0175,2348.2%2,1343.3%7, % S18,5131,0135.5%3171.7%1,3307.2% O31, %2030.7%1,1433.7% Pediatric M7,0391, %1041.5%1, % S1, %131.0% % O1, %131.1%484.2% Post-neonatal M2, %863.5% % S %113.1%6217.5% Neonatal M31, %4031.3%7502.4% S7356.9% % Total 157,6149,3956.0%3,2892.1%12,6848.1% Medicare (FFS) Adult M280,01245, %11,6574.2%56, % S117,3119,7978.4%2,7122.3%12, % Total 398,83655, %14,5733.7%69, % Total by Age Group Adult737,54478, %21,8843.0%100, % Pediatric26,3782,5919.8%3691.4%2, % Post-neonatal7, %1832.5% % Neonatal58, %5811.0%1,2832.2% Grand Total829,76882,5429.9%23,0172.8%105, % Information Otherwise Unavailable

Reporting Template: 9 Data Description These data are 30-day all-cause acute care readmissions by age and type of initial discharge. These rates are not adjusted or standardized in any way; accordingly, rates are not intended for comparison of different facilities. Calculated rates include both scheduled and unscheduled readmissions due to difficulties in defining and removing ‘scheduled’ readmissions. Discharges that did not result in transfer to another acute care facility are counted in column ‘c’ and constitute the denominator of the readmission rates listed in columns ‘e’, ‘g’ and ‘I’. Patients having left against medical advice are not excluded from these data because they are potential targets of quality improvement interventions; this is expected to have minimal impact, if any, on the reported rates. Same-day readmissions are counted as 30-day all-cause readmissions to ensure a broad view of potential qualitiy improvement opportunities is provided. Medicaid & Medicare eligible beneficiaries are reported by Medicaid. Above average numbers of patients having scheduled admissions within 30-days of discharge (i.e., certain types of cancer patients, patients with gastrointestinal disorders scheduled for surgery later, etc. ) will increase the readmission rates reported here. We are working towards refining our efforts to remove scheduled readmissions from future reports. Brief Data Definitions (coloumn descriptions) - Expanded Definitions Available in 'Definitions Tab' a Age at time of discharge: Neonatal: birth <= Age <1 month; Post-neonatal: 1 month <= Age < 1 year; Pediatric:1 year <= Age < 18 years; Adult: 18 years <= Age. b Categorization of initial discharge following acute care admission; M=Medical, S=Surgical, O=Obstetric c Number of acute care discharges that were not transferred to other acute care centers & were not the result of the patient leaving against medical advice. d Number of acute care readmissions within 30-days of discharge where the patient was admitted to the hospital of discharge e Percent of acute care readmissions within 30-days of discharge where the patient was admitted to the hospital of discharge f Number of acute care readmissions within 30-days of discharge where the patient was admitted at a hospital other than the discharge hospital. g Percent of acute care readmissions within 30-days of discharge where the patient was admitted to a hospital other than the discharge hospital h Total number of acute care readmissions within 30-days of discharge.

22670 Haggerty Road, Suite 100, Farmington Hills, MI ~ Pilot reports have been disseminated. Plans are reporting aggregate data by calendar year quarter from  Initial reports due to be disseminated shortly will include a facility level crude trend analysis  Statewide profiles will also be disseminated for comparative purposes We are drafting data use agreements to facilitate claim-level data sharing  Most plans have verbally agreed to share these data, although full approval has yet to be received.  Some have already processed letters of commitment to do so We are seeking external funding to engage the ReWaRD towards evaluation of existing and newly implemented MI STA*AR interventions given that no other data source in Michigan can support such analyses.

22670 Haggerty Road, Suite 100, Farmington Hills, MI ~ ■ Allows for development of a comprehensive analytic file of virtually all readmissions in Michigan. ► Facilitates exploration of ♦Risk standardization methods ♦Methods of defining ‘preventable’ readmissions ♦Evaluation of interventions (Provider and Payer level)

22670 Haggerty Road, Suite 100, Farmington Hills, MI ~ The Rehospitalization Workgroup for Reporting Data is a subcommittee tasked with facilitating multi-payer data sharing ■ While the original mission was to provide readmission reports to all Michigan hospitals, it is now expanding to include evaluation of readmission reduction initiatives through application of epidemiologic methods. Barriers and other considerations include funding, HIPPA concerns, and data access issues. QUESTIONS?