Solventum™ Potentially Preventable Readmissions (PPRs) Classification System

A potentially preventable readmission (PPR) is a readmission within a specified time interval that is determined to be clinically related to a previous admission and potentially preventable. Similarly, a potentially preventable revisit to the emergency department (PPR ED) is an emergency department visit within a specified time window that is determined to be clinically related to an initial hospital admission and potentially preventable.

Solventum PPRs are most commonly utilised by payers, government agencies, hospitals, hospital systems, and researchers. Users generally perform analyses on multi-hospital data sets to compare performance on a risk-adjusted basis and to identify opportunities for improvement. The same is anticipated for the recently released PPR ED methodology.

Here are a few examples of the value the PPR and PPR ED methodologies can bring to customers.

• Improving quality. Through concerted effort, Minnesota hospitals prevented more than 7,000 readmissions over a two-year period. Over 80 hospitals participated in a learning collaborative, using Solventum PPRs to track progress and provide detailed quarterly reports to each hospital.
  
  
• Public reporting. The New York Department of Health reports risk-adjusted PPR rates for each hospital on its website.
  
  
• Enabling insight. In an all-payer analysis in Rhode Island, 6.3 percent of inpatients experienced at least one potentially preventable readmission. PPR rates varied by category, from 1.1 percent for obstetrics to 12.6 percent for adult mental health and/or substance abuse conditions. Two-thirds of readmissions were to the same hospital, but that percentage also varied by category. 
  
  
• Paying for outcomes. Texas Medicaid is one of several payers that measures PPRs and incentivises reductions.
  
  
• Monitoring hospital and managed care performance. The Ohio Medicaid programme uses Solventum PPRs to monitor hospital and managed care plan performance by comparing the actual number of PPRs with the number that would be expected for a hospital or plan of the same case mix.

Solventum PPR and PPR ED grouping logic is consistent for all users, although different organisations may utilise various versions. (It is advised to use the latest version.) Each user independently determines the appropriate applications. Currently, Solventum does not provide software that mimics the PPR and PPR ED reimbursement analysis employed by particular payers.

Solventum PPRs and PPR EDs are integrated with other Solventum patient classification methodologies: Solventum PPRs and PPR EDs are identified from claims grouped using the Solventum™ All Patient Refined Diagnosis Related Groups (APR DRG) methodology. Solventum APR DRGs are also used to risk-adjust PPR and PPR ED rates across hospitals or other inpatient populations.

Solventum PPRs, including PPR EDs, are one of the five Solventum™ Potentially Preventable Event methodologies. The others are:

• Solventum™ Potentially Preventable Complications (PPCs)
• Solventum™ Potentially Preventable Admissions (PPAs)
• Solventum™ Potentially Preventable Emergency Department Visits (PPVs)
• Solventum™ Potentially Preventable Services (PPS)

Solventum PPVs are a population-based outcome measure that identifies emergency department visits that could potentially have been prevented with better care in the community. Unlike PPR EDs, Solventum PPVs are not tied to a previous inpatient stay.

Solventum PPRs and PPR EDs are available in the following Solventum products:

• Solventum™ 360 Encompass™ System
• Solventum™ Coding and Reimbursement System
• Solventum™ Advanced CDI Transformation Services
• Solventum™ Clinical Documentation Improvement Solution
• Solventum™ Reimbursement Calculation Software
• Solventum™ Core Grouping Software (CGS)
• Solventum™ Grouper Plus Content Services (GPCS)
• Solventum™ Data to Action Solution

Available to licensees on the Solventum customer support website (covering both PPRs and PPR EDs):

• PPR Methodology Overview
• PPR Definitions Manual
• PPR Norms File (Excel)
• PPR Setup Guide

Solventum experts are available to advise hospitals, health plans, government agencies, and other interested parties on how to obtain maximum value from the use of Solventum PPRs and PPR EDs. For example, Solventum consultants can help hospitals measure the incidence of potentially preventable readmissions and ED revisits, compare against benchmarks and help design programmes for improvement. Solventum consultants can also help payers and other organisations measure Solventum PPRs and PPR EDs across hospitals, design pay-for-outcomes incentive programmes and facilitate learning collaboratives to improve care.

Data requirements depend on whether the analysis is limited to inpatient readmissions or also includes revisits to the emergency department where the patient is treated and released. A Solventum PPR analysis can be conducted without ED data, but a PPR ED analysis requires both inpatient and ED data. In either case, all necessary data can be obtained from standard hospital claims, such as the UB-04 form or the X12N 837I electronic transaction. (The methodology is not designed to accept data from professional claims, such as those submitted by urgent care clinics.) Individual records must be linked using consistent identifiers for both the patient and the hospital.

Each inpatient stay is first assigned to a Solventum™ All Patient Refined Diagnosis Related Group (APR DRG). Data fields that are particularly important include admission and discharge dates, discharge status, birth date, gender, diagnosis codes with present on admission (POA) indicators, and ICD-10-PCS procedure codes. Because there are several reasons why a patient may have more than one inpatient claim within a short timeframe, we recommend that the user evaluates the reliability of the discharge status data provided by hospitals (e.g., transfers, left against medical advice, still a patient).

When the analysis also includes revisits to the emergency department, ED claims are also required. For PPR ED development, emergency department claims were defined by the combination of bill type 13X and revenue code 45X or 981. Users are responsible for selecting criteria appropriate to their own analysis. PPR ED analysis also requires the diagnosis codes that are routinely reported on outpatient hospital claims but does not require line-level detail such as procedure or revenue codes.

The challenge in readmission policy has always been to differentiate readmissions that were potentially avoidable from those that were not. In the early 2000s, Solventum developed the Solventum™ Potentially Preventable Readmissions (PPR) methodology. In 2007, the Medicare Payment Advisory Commission used the Solventum methodology to report that 13.3 percent of Medicare inpatients had a PPR within 30 days, costing the Medicare programme $12 billion in 2005. In 2008, Solventum researchers published the PPR methodology in the Health Care Financing Review. This article has been cited 250 times as the Solventum PPR methodology has spread across the U.S.

As with the other Solventum™ Potentially Preventable Event methodologies, three core concepts are essential:

1. We recognise that not all readmissions are potentially preventable.
2. What matters is not the individual readmission but rather the overall rate of potentially preventable readmissions. Instead of an approach to quality of “this should never happen,” Solventum uses a more realistic and meaningful approach of “this has happened too often.”
3. Any comparisons across hospitals, health plans, attending physicians or any other patient populations must be risk-adjusted.

The Solventum PPR methodology starts by assigning every inpatient stay to a Solventum™ All Patient Refined Diagnosis Related Group (APR DRG). The basic Solventum PPR approach is to decide whether each combination of the initial admission Solventum APR DRG and the readmission Solventum APR DRG has a plausible clinical connection that indicates a potentially preventable readmission. That approach was supplemented by extensive clinical logic to add precision in identifying Solventum PPRs.
 

The Solventum PPR methodology may be most easily understood by looking at the table above. For example, readmissions are not considered potentially preventable:

• If they are unrelated to the initial admission (Patient 1)
• If the patient has certain conditions like metastatic cancer (Patient 2)
• If the initial discharge was against medical advice (Patient 3) or was a transfer to another acute care hospital (Patient 4)

Patient 5 does have a potentially preventable readmission, because heart failure is a chronic condition that would have been present and managed in the initial admission. Results from the Solventum PPR software can then be used to draw comparisons, taking into account differences in case mix across different populations. Case mix adjustment reflects not only the reason for the admission but also the severity of illness.

In 2019, Solventum enhanced the PPR method by adding PPR ED logic to identify returns to the emergency department that did not result in an inpatient readmission. Previously, there was no widely available methodology to track this useful quality measure of inpatient care and follow-up care in the community. In parallel with the Solventum PPR approach, the PPR ED logic distinguishes ED visits that were and were not clinically related to an initial inpatient stay within a specified window, such as 15 or 30 days. The PPR ED logic uses diagnosis information from the ED claim to assign the visit to a Solventum APR DRG, which is compared with the Solventum APR DRG for the initial admission. As with Solventum PPRs, supplemental logic adds precision in identifying potentially preventable revisits to the ED.

The PPR and PPR ED software shows which specific inpatient stays and ED visits were considered potentially preventable, in each case with a defined reason for the assignment. These detailed data have proven very useful to clinicians and healthcare managers in taking action to improve outcomes. For example, a common finding is that the risk of a PPR peaks at two or three days after discharge.

Further information on the Solventum PPR and PPR ED logic is shown in an online definition manual available to all licensed clients.

The Solventum PPR and PPR ED clinical logic is maintained by a team of Solventum clinicians, data analysts, nosologists, programmers and economists. The methodology is updated annually to reflect changes in the standard diagnosis and procedure code sets as well as Solventum enhancements to the clinical logic.