Do pneumonia readmissions flagged as potentially preventable by the 3M PPR software have more process of care problems? A cross-sectional observational study.
BACKGROUND
In the USA, administrative data-based readmission rates such as the Centers for Medicare and Medicaid Services' all-cause readmission measures are used for public reporting and hospital payment penalties. To improve this measure and identify better quality improvement targets, 3M developed the Potentially Preventable Readmissions (PPRs) measure. It matches clinically related index admission and readmission diagnoses that may indicate readmissions resulting from admission- or post-discharge-related quality problems.


OBJECTIVE
To examine whether PPR software-flagged pneumonia readmissions are associated with poorer quality of care.


METHODS
Using a retrospective observational study design and Veterans Health Administration (VA) data, we identified pneumonia discharges associated with 30-day readmissions, and then flagged cases as PPR-yes or PPR-no using the PPR software. To assess quality of care, we abstracted electronic medical records of 100 random readmissions using a tool containing explicit care processes organised into admission work-up, in-hospital evaluation/treatment, discharge readiness and post-discharge period. We derived quality scores, scaled to a maximum of 25 per section (maximum total score=100) and compared cases by total and section-specific mean scores using t tests and effect size (ES) to characterise the clinical significance of findings.


RESULTS
Our abstraction sample was selected from 11,278 pneumonia readmissions (readmission rate=16.5%) during 1 October 2005-30 September 2010; 77% were flagged as PPR-yes. Contrary to expectations, total and section mean quality scores were slightly higher, although non-significantly, among PPR-yes (N=77) versus PPR-no (N=23) cases (respective total scores, 71.2±8.7 vs 65.8±11.5, p=0.14); differences demonstrated ES >0.30 overall and for admission work-up and post-discharge period sections.


CONCLUSIONS
Among VA pneumonia readmissions, PPR categorisation did not produce the expected quality of care findings. Either PPR-yes cases are not more preventable, or preventability assessment requires other data collection methods to capture poorly documented processes (eg, direct observation).
Center for Healthcare Organization and Implementation Research, Bedford VAMC Campus, Bedford, Massachusetts, USA Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA.
Ann M
AM
Borzecki
Center for Healthcare Organization and Implementation Research, Boston VA Campus, Boston, Massachusetts, USA.
Qi
Q
Chen
Center for Healthcare Organization and Implementation Research, Boston VA Campus, Boston, Massachusetts, USA School of Management, Boston University, Boston, Massachusetts, USA.
Joseph
J
Restuccia
Center for Healthcare Organization and Implementation Research, Boston VA Campus, Boston, Massachusetts, USA Department of Surgery, Boston University School of Medicine, Boston, Massachusetts, USA.
Hillary J
HJ
Mull
Center for Healthcare Organization and Implementation Research, Boston VA Campus, Boston, Massachusetts, USA School of Management, Boston University, Boston, Massachusetts, USA.
Michael
M
Shwartz
Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA Department of Infectious Disease, VA Boston Healthcare System, Boston, Massachusetts, USA.
Kalpana
K
Gupta
Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA Center for Healthcare Organization and Implementation Research, Boston VA Campus, Boston, Massachusetts, USA.
Amresh
A
Hanchate
Department of Infectious Disease, VA Boston Healthcare System, Boston, Massachusetts, USA Department of Medicine, Harvard University School of Medicine, Boston, Massachusetts, USA.
Judith
J
Strymish
Center for Healthcare Organization and Implementation Research, Boston VA Campus, Boston, Massachusetts, USA Department of Surgery, Boston University School of Medicine, Boston, Massachusetts, USA.
Amy
A
Rosen
D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D003430:Cross-Sectional Studies; D057286:Electronic Health Records / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000379:methods*; D010351:Patient Discharge / Q000706:statistics & numerical data*; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011014:Pneumonia / Q000453:epidemiology*; D058996:Quality Improvement / Q000706:statistics & numerical data; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012720:Severity of Illness Index; D012985:Software Design; D014481:United States; D014493:United States Department of Veterans Affairs
Health services research; Performance measures; Quality measurement