1. PPR Clinical Vetting Session:
November 1st 2010

2. Identification of clinically unrelated readmissions designated as preventable
It will always be possible to identify individual cases for which the readmission was a) probably planned or b) probably not preventable
Identifying exceptions to the PPR logic misses the point of a system that is based on rates, and seeks to identify deviation from expected performance based on peer-hospital rates
It is precisely because of the impossibility of specifying all possible rules, exceptions, and details for what constitutes a preventable readmission that the PPR system is built upon the comparison of rates.

3. Identification of clinically unrelated readmissions designated as preventable - 2
The guiding principle in identifying combinations of initial admissions and readmissions that might be potentially preventable was the following:
If a hospital has a rate of a particular kind of readmission that is substantially higher than its peer hospitals, then reasonable clinicians would be concerned that a problem with the quality of patient care existed.
Unless the APR DRG pair that constitutes a potentially preventable readmission can be demonstrated to be typically planned or unpreventable, then the existing logic, which was the product of an intensive iterative process of clinical hypothesis generation and testing, should stand.

4. How responsible is the discharging hospital for readmissions for the deterioration of a chronic condition?

5. Time Interval for Preventable Readmissions

6. Risk Adjustment – APR DRG Severity of Illness Levels

7. Top 10 Medical APR DRGs for Frequency of PPRs, by SOI (Florida 2005-2006)
All Pts
SOI 1
SOI 2
SOI 3
SOI 4
194
Heart Failure
Chains
15,053
1,304
8,151
4,675
923
Rate
12.5
8.9
11.7
15.0
19.4
140
Chronic Obstructive Lung Disease
8,271
1,737
3,745
2,416
373
9.7
7.3
9.3
12.7
17.3
750
Schizophrenia
7,592
3,382
3,931
251 28
17.7
17.1
18.1
20.8
16.8
139
Other Pneumonia
7,579
393
3,295
3,394
497
7.7
2.7
6.5
11.4
16.4
751
Major Depressive Disorder
5,608
1,814
3,391
339 64
10.9
8.3
12.6
16.5
10.8
198
Angina Pectoris & Coronary Atherosclerosis
5,151
1,414
2,685
982 70
5.6
3.7
6.2
9.9
753
Bipolar Disorders
4,830
2,366
2,260
179 25
14.0
15.3
18.8
11.6
720
Septicemia & Disseminated Infection
4,370 46
881
1,808
1,635
3.6
19.3
460
Renal Failure
4,288 92
471
3,250
475
12.8
11.0
10.6
21.1
201
Card Arrhythmia & Conduction Disturbance
4,066
898
1,950
1,070
148
6.3
4.0
6.4
10.2
16.0
All Other Medical APR DRGs
41,412
8,036
15,942
13,011
4,423
2.9
1.7
2.5
5.0
9.4
Total Medical APR-DRG
108,220
21,482
46,702
31,375
8,661
3.2
4.7
7.4
These numbers are 1) the total number of PPR chains (Number of initial admissions with at least 1 PPR) and 2) the rate – no. of PPR chains/ no. of candidate admissions

8. Top 10 Surgical APR DRGs for Frequency of PPRs, by SOI (Florida 2005-2006)
Surgical APR DRG
All Pts
SOI 1
SOI 2
SOI 3
SOI 4
175
Percutaneous Cardiovascular Procs w/o AMI
Chains
7,260
3,222
2,850
1,043
145
Rate
7.9
6.4
9.0
12.7
14.8
221
Major Small & Large Bowel Procedures
3,426
606
1,201
913
706
9.4
6.0
8.3
11.1
19.5
173
Other Vascular Procedures
3,186
627
1,140
1,075
344
11.3
6.9
10.2
16.9
23.7
174
Percutaneous Cardiovascular Procedures with AMI
3,115
791
1,288
648
388
9.8
10.0
14.4
18.5
165
Coronary Bypass with Cath or PCI
2,638
101
909
1,073
555
12.3
7.2
9.3
13.9
21.5
301
Hip Joint Replacement
2,870
1,123
1,106
445
196
6.2
5.1
8.9
21.4
308
Hip/femur Procedure x Joint Replacement d/t Trauma
2,395
234
1,115
835
211
8.0
4.9
10.6
302
Knee Joint Replacement
2,373
780
1,323
233 37
4.0
2.9
4.5
7.4
13.1
161
Cardiac Defibrillator & Heart Assist Implant
2,048
113
614
1,132
189
171
Perm Card Pacemaker w/o AMI, CHF, or Shock
2,044
523
1,068
382 71
8.1
5.5
8.7
19.6
All Other Surgical
36,608
8,940
13,142
10,196
4,330
6.1
3.2
12.4
18.6
Total Surgical APR-DRG
67,963
17,060
25,756
17,975
7,172
6.8
19.0

9. Percutaneous cardiovascular procedures w/o AMI
Predicted v. Actual Number of PPRs for Reporting Year 2007 Florida, Selected APR DRGs (Based on Calendar Year 2005 Rate)
Admission Volume
APR
Description
SOI
CY 05
PPR Rate
RY07
Volume
Predicted
Actual
540
Cesarean delivery 1
0.03%
56,689 15 16 2
0.06%
17,269 11 9 3
0.09%
4,820 4
0.98%
295
Sub Total
0.04%
79,073 33 28
139
Other pneumonia
3.14%
6,828
215
246
7.38%
21,987
1,622
1,677
12.71%
12,314
1,565
1,654
17.77%
1,387
222
8.58%
42,516
3,648
3,799
175
Percutaneous cardiovascular procedures w/o AMI
7.90%
20,312
1,604
1,474
11.15%
14,902
1,662
1,596
15.84%
4,906
777
761
18.04%
639
115
164
10.20%
40,759
4,158
3,995

10. Predicted v. Actual Number of PPRs for Reporting Year 2007 Florida, Selected APR DRGs (Based on Calendar Year 2005 Rate)
APR
Description
SOI
PPR Rate
2007
Volume
Predicted
Actual
194
Heart failure 1
11.04%
4,852
535
591 2
14.61%
24,769
3,618
3,767 3
18.53%
14,833
2,748
2,820 4
18.38%
1,870
344
373
Sub Total
15.64%
46,324
7,245
7,551
750
Schizophrenia
21.26%
4,610
980
941
22.42%
10,138
2,273
2,407
25.44%
791
201
191
20.51% 45 9 12
22.23%
15,584
3,464
3,551
460
Renal failure
13.76%
387 53 47
13.29%
2,283
303
286
14.21%
16,040
2,279
2,258
18.17%
1,331
242
295
14.36%
20,041
2,878
2,886

11. PPR Performance Florida data, FY 2005 vs RY 2006
Pearson Correlation Coefficient =
(Calendar year ’05, Reporting year ’07)
Hospital level R-square = 0.45

12. “Elective” Admissions as a proxy for planned readmissions

13. Readmissions with one of these procedures following an Initial Admission for DRG 301 (Total Hip Replacement) WILL be considered preventable:
0070
Revision of hip replacement, both acetabular and femoral components
0071
Revision of hip replacement, acetabular component
0072
Revision of hip replacement, femoral component
0073
Revision of hip replacement, acetabular liner and/or femoral head only
8153
Revision of hip replacement, not otherwise specified

14. Readmissions with one of these procedures following an Initial Admission for DRG 301 (Total Hip Replacement) will be considered PLANNED, and not preventable:
0085
Resurfacing hip, total, acetabulum and femoral head
0086
Resurfacing hip, partial, femoral head
0087
Resurfacing hip, partial, acetabulum
8151
Total Hip Replacement
8152
Partial Hip Replacement

15. Re DRG 173 (Other Vascular Procedures)
Readmissions for endovascular grafts following peripheral vascular procedures (procedure 3971) will be classified as planned.
Re the suggestion that “Some patients cannot physiologically tolerate enough contrast and require 2 different vascular bypass procedures in order to perform multiple grafting.”
This is not only an unusually rare group of patients but should be randomly distributed between hospitals.
Thus this consideration does not merit excluding the entire group of readmissions, many of which are potentially preventable and should be adequately addressed in a rate-based system.

16. Re APR DRG 304 (Dorsal and Lumbar Fusion)
Regarding the suggestion that “These fusion procedures may be done in a staged process requiring 2 separate planned admissions”:
Based on consultation with orthopedists about this situation, staging is rarely done for dorsal and/or lumbar fusions.