23 september 2010

Dr. H. Pincé – UZ Leuven

Validity of PPR grouper for a university hospital

Objectives

• Exploration and validation of the software: does PPR classification system correctly identify PPR’s ?

• Utility of PPR CS based on MHD in Belgium ?

Methodology• Input MHD 2008 UZL• Output PPR CS: 2 datasets

– For readmission interval 15 and 30 days– APR-DRG 27.0– Each admission gets a record type– Identification of “chains” of clinically

related admissions of the same patient– Validation of these chains by record

review

Methodology

Results• Software does not take into account whether a

readmission is planned or unplanned• Top PPR adjusted APR chain level = APR-DRG

480: Major Male Pelvic Procedures – Radical prostatectomy where patient leaves

hospital with transurethral catheter in situ – and gets systematically a planned readmission

within a week for • cystography, • removal of the transurethral catheter, • and education pelvic muscles

Top PPR adjusted APR chain level = APR-DRG 480: Major Male Pelvic Procedures• Malignancies excluded ?

Procedures for malignancies are NOT excluded as IA

• Hospitalisation necessary ?Operational items, lack of capacity in

ambulatory care settingAcademic research : prospective study

physiotherapistsDecreasing numbers: more conservative

attitude

Results

• =>Selection of only these chains with at least one unplanned readmission

• => decrease PPR rate with 1.45%

Results• 15 days interval

• Top 5 PPR adjusted APR chain level– Also in top 10 Florida study– No Pareto principle :

•200 different DRG’s•Top 20 DRG’s -> 35% of chains•80% of chains -> 90 different DRG’s

Results

• Number of chains per DRG in top 5: 25-28

• Of each top 5 DRG record review of 10 chains– Clinically related ? Yes– Potentially preventable ???– Often rather complex cases

Example• APR-DRG 139 other pneumonia

– Boy 10 years– Development disorder– With severe psychomotoric retardation– Intractable epilepsy– Frequent aspiration pneumonia– And problems with nutrition (PEG-sonde)– Chain of 4 admissions, all DRG 139

severity 4

Example

• APR-DRG 140 Chronic Obstructive Pulmonary Disease

– Often COPD GOLD III or IV– Often geriatric patients with multipathology– % with DNR code, or deceased in the

meanwhile

Results

• 30 days interval: 2 top 5 DRG’s

– ‘Clinically related’ ? Yes

– 30 days: clinical relationship reason: more “Ambulatory care sensitive conditions”

Remarks 1) oncology

Exclusion of oncology only for medical admissions

PPR rate ↑ when a lot of surgery for malignancies

APR-DRG 221 PPR chains: 60% malignancies

Remark 2) psychiatry

• Top 10 Florida : 3 psychiatric DRG’s

• More readmissions when psychiatric sdx

• In Belgium in MHD: AAAAAA code• 7 à 8 % of IA with major mental

health issue

Remark 3) difference IA <-> OA• Differences between

– IA with PPR chain – and OA without PPR chain

• LOS• Severity distribution

Remark 3) different LOS

• Mean LOS of IA with PPR chain > mean LOS of OA without PPR chain

• Standardized for DRG/severityhypothesis of ‘premature

discharge’ ???

Remark 3): different severity distribution

Limitations

• No exhaustive validation of 1) planned readmissions identified by PPR2)unplanned readmissions identified by

PPR3) planned readmissions not identified by

PPR4) unplanned readmissions not identified by

PPR

Conclusion• no feedback available about clinically

related readmissions• FB Flemish Community

– 7 days interval– unplanned readmissions– basis: stayhosp: “code readmission” –

“number of days since former discharge”; filled in by hospital; “scope” = MCD, day care and ambulatory emergencies included

– few exclusions– no notion of ‘clinically related’

Conclusion PPR software

• Computes number of days between discharge and subsequent admission– Dates are needed: available in MHD

(not in MCD)

• Focus on clinical relationship– Clinically related : validity OK– Potentially preventable ???

Conclusion PPR software

• => Selection unplanned readmissions

• => Risk adjustment is needed:SRR: Standardised Readmission Ratio

oBelgian benchmark is neededoFeedback, risk adjusted, interesting

Conclusion PPR software

• Indicator !– Interpretation together with other

indicators like SMR, clinical indicators

• CAVE financial implications– Severity 4 for UZ’s always negative

financial results (BFM, drug forfait)– Risk adjustment based on

administrative data is difficult !