Medicare Post-Acute Care: Quality Measurement Final Report. REPORT 1: Selecting and Evaluting Eight Targeted Conditions

03/29/2001

Korbin Liu and Barbara Gage, The Urban Institute

Andrew Kramer, University of Colorado Health Sciences Center

June 1998

This report was prepared under contract #HHS-100-97-0010 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and The Urban Institute. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the ASPE Project Officer, Jennie Harvell, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: Jennie.Harvell@hhs.gov.

Conclusions and opinions in this paper are solely those of the authors and do not necessarily reflect the views of the Urban Institute, University of Colorado or ASPE.


I. INTRODUCTION

The Administration has signaled its intent to move towards an integrated Medicare post-acute care financing and service delivery system. In order to integrate post-acute care services, information is needed on the cost-effectiveness of different post-acute care providers for different conditions. This project will design a set of quality of care measures for Medicare post-acute care services provided by SNFs, HHAs, rehabilitation hospitals and long-term care hospitals. The project will focus on four clinical conditions that are found in the post-acute care population. As a preliminary step to selecting the four conditions, the range of possibilities will first be narrowed to eight conditions. This report describes our analysis leading to the selection of the eight conditions.

We think that, as a general rule, the criteria used to identify the eight conditions at this stage should have policy-related implications. This orientation helps to make the findings from the eventual study more valuable to BBA prescribed and other reform initiatives directed at Medicare post-acute care services and the growth of the Medicare risk HMO program. This orientation also complements, rather than duplicates, our current plans to employ clinically-related criteria to narrow the eight conditions to the four conditions that will be the focus of the eventual outcomes study.

In light of the goal of this project to examine the relative quality outcomes of treating specific conditions across post-acute care providers, a necessary criterion for the selection of the conditions is that they are being treated in more than one post-acute care provider modality. For this study, we are examining the types of post-acute care cases that receive services from skilled nursing facilities (SNFs), home health agencies (HHAs) and rehabilitation facilities (RFs), and to a lesser extent long-term care hospitals. Although it would be particularly desirable to select conditions that are found in the caseload of all three provider types, the nature of RFs implies that only the subset of post-acute care patients that require intensive, inpatient rehabilitation will be found in this setting. A substantial proportion of post-acute care patients do not need this level of therapy services, but do need skilled nursing, medical social work and aide assistance. These services can be provided either in SNFs or by HHAs. Hence, we will not restrict the selection to only conditions that can be observed in all three settings. Rather, we will include some conditions that are treated largely in RFs or SNFs and others that are treated primarily in SNFs or by HHAs (or in some cases long-term care hospitals).

As has been noted in prior reserch (Steiner and Neu, 1993; ProPAC, 1996), post-acute care use of SNFs, HHAs and RFs is concentrated in relatively few types of cases (at least in terms of broad categorizations of patients, such as by DRGs). This situation persisted in 1995. We examined the 39 most prevalent DRGs among post-acute care users of SNFs, HHAs, and RFs, and found that those selected DRGs accounted for 53% of all SNF episodes, 36% of all HHA episodes and 68% of all RF episodes. Hence, we anticipate that selection of conditions based on some variant of those DRG categories will provide information on a sizeable proportion of Medicare’s post-acute care population.

We envisioned three steps in the process to arrive at the eight conditions that will be proposed for further analysis. The first step is to conceptualize methods for defining post-acute care conditions and identify selected conditions using this framework. The second is to establish criteria for choosing eight conditions among the unlimited number of possible conditions. The final step is to apply the criteria to narrow down the range of possibilities. The following sections address the three steps.


II. APPROACHES FOR DEFINING CONDITIONS

Various approaches are possible to define conditions for studying outcomes of post-acute care services. The commonly used approach in past studies is the selection of conditions on the basis of hospital DRGs or diagnosis (e.g. hip fracture, stroke, congestive heart failure). Two major studies of outcomes of post-acute care services across different modalities were conducted by Kramer and colleagues (1997) and Kane and colleagues (1997a, 1997b). Kramer examined the outcomes of hip fracture and stroke patients, selected on the basis of hospital diagnoses representing the two conditions. Kane selected cases based on the hospital DRGs. Along with hip fracture (DRG 210) and stroke (DRG 14) cases, Kane examined outcomes of people discharged from hospitals with congestive heart failure (DRG 127), chronic obstructive pulmonary disease (DRG 88) and hip replacement procedures (DRG 209). The selection of those hospital diagnoses or DRGs was not surprising because hip fractures and strokes are two of the most prevalent conditions treated by Medicare post-acute care providers. Moreover, the five DRGs selected by Kane accounted for almost 30 percent of Medicare-sponsored post-acute services (ProPAC, 1996).

Another approach for selecting conditions is to define them by functional measures (e.g., disability prior to the acute event, ADL disability after the acute event, changes in ADL disabilities before and after the acute event). This approach reflects the need for rehabilitation services, which is one of the major causes for people to receive post-acute care. Because many post-acute care patients require more skilled nursing care than rehabilitation services, they may be underrepresented if this approach is used. On the other hand, medical post-acute care patients may also be functionally dependent at various times during the episode of acute and post-acute care. Another potential drawback of this approach for selecting conditions is the variation in medical conditions that is associated with functional disability. Because disabled populations have such varied medical problems, it may be difficult to predict outcomes on the basis of functional status. Moreover, outcomes based on disabilities may be influenced by the accessibility and use of informal care; comparisons between post-acute care providers may be confounded if such factors are not controlled for in analyses.

A third option is to define conditions by care requirements (e.g., ventilator dependent, wound care, rehabilitation). As with the preceding approach, this strategy for selecting groups of post-acute care patients may be constrained by the diversity of underlying conditions of people requiring particular types of care. For quality measurement purposes, it is is important that study groups are relatively homogeneous so that differences in outcomes are related to site of care and not underlying medical needs. Thus, if similar quality measures can be used for all patients that are ventilator-dependent or that require wound care, it would not be critical to distinguish the exact diagnosis underlying the need for a ventilator or for wound care. On the other hand, we might have to select, for the study, subgroups of ventilator-dependent people by underlying medical conditions and levels of comorbidity (See Kramer, et al. 1990 for a further discussion of patient classification and quality measure development).


III. SELECTION CRITERIA

We reflected on various criteria that could be used to aid in the selection process and have arrived at four categories: (1) Overlap across providers of potential users of post-acute care; (2) High volume cases, either as a proportion of hospital discharges or as a high post-acute care admission group, (3) Medicare service use patterns; (4) Analytical practicality.

Overlap across post-acute care providers. This criterion, as noted above, is a requirement of the study. The aim is to develop quality measures to determine if treatment modality is responsible for differences in outcomes, all other things being equal. As a first step, it is important to be able to make comparisons between the different Medicare post-acute care providers. According to this criterion we will identify conditions that are found in substantial numbers across the different providers. Because rehabilitation facilities can only admit patients who require and can tolerate three hours of therapy per day, some conditions will be those that are treated largely in either RFs or SNFs. Conditions will also be chosen that may be treated either in SNFs or HHAs (and if possible long-term care hospitals).

High volume. Because of the policy-orientation of condition selection at this stage, we include the criterion of high Medicare volume of post-acute care services. For the eventual demonstration project to have program impact, the conditions selected will have to occur in relatively high proportions among Medicare’s post-acute care users or be a relatively high proportion of Medicare’s costs for post-acute care services. This approach is consistent with most of the prior research on post-acute care services, starting with the Rand studies in the 1980's (Neu and Harrison, 1989, Steiner and Neu, 1993).

In addition, the BBA mandated that, for selected hospital DRG’s, cases involving transfers from PPS hospitals to post-acute care providers would result in adjustments in the payment amount of those DRGs. The DRGs were chosen because they represent the highest volume of discharges to post-acute care or a disproportionate use of post-acute care services. The 10 specific DRG’s that have been selected by the Health Care Financing Administration are: strokes (DRG 14), amputations for circulatory system disorders (DRG 113), hip and limb procedures (DRGs 209-211), hip fractures (DRG 236), skin graft/debridement for skin ulcers (DRGs 263-264), organic disturbances and mental retardation (DRG 429), and tracheostomies (DRG 483). The adjustment in DRG payments could have an effect on the pattern of care for patients with those DRGs. Because of the potential change in practice patterns, it would be useful to select conditions in this group so more information will be available to determine if quality is negatively affected by the change in payment method.

Utilization patterns. This criterion covers a range of Medicare service use issues that may be important to consider in the selection of specific conditions to track across post-acute care episodes. Four issues illustrate this criterion.

First, a substantial proportion of post-acute care episodes ends with a hospital readmission. It can be shown, for example, that the rate of hospital readmission varies by DRG. Hospital readmission could reflect severity of patients’ condition and/or quality of care. Regardless, hospital readmission probably reflects higher patient costs. While hospital readmission can be used as an outcome measure, it might also be useful in selecting types of conditions to review because it provides an indication of relatively higher (lower) Medicare episode costs.

Second, some post-acute care patients receive care, in sequence, from more than one type of post-acute care provider. Selecting conditions for which patients frequently use more than one type of post-acute care provider can be useful in not only targeting relatively high cost cases, but also ones in which quality of care may be more questionable.

Third, because of the emergence of “subacute” care, which refers to treatment for patients with more complex needs, it may be important to select conditions that are characteristically viewed as requiring this level of care. Lewin-VHI (Manard, Bieg, Cameron, et al., 1995) concluded that the term subacute care tends to refer to a level of care that some nursing facilities, home care providers and others have been providing for years under a variety of different names (e.g., high end skilled care). Ventilator-dependent patients, for example, are often cited as illustrative of subacute care patients. Other “types of illnesses” treated by subacute care providers include stroke, hip fracture, spinal cord injury, pulmonary disease, and cardiovascular disease. Learning about the quality of subacute care is also motivated by the growing use of this level of care in the managed care environment, and particularly in situations where subacute care replaces inpatient hospital care.

Fourth, when the casemix-adjusted prospective payment systems for SNFs, HHAs and RFs are implemented, there may be some mismatches between payments and costs of specfic casemix categories. Conditions that are potentially subject to such mismatches would be important to consider in light of possible changes in utilization that reflect access and quality problems.

Analytical practicality. The final criterion refers to the practical aspects of selecting particular conditions for analysis. Assuming that a subset of the conditions that we select at this stage will eventually be the ones that are analyzed for the design of the demonstration, it is important to consider ways to minimize subsequent problems even at this stage of selecting the initial eight conditions. We identified two issues that fall under the criterion of analytical practicality.

First, a condition that is selected should include cases that are relatively homogeneous, thereby enhancing our ability to compare outcomes across provider modalities. Although risk adjustment strategies will be used in the eventual study, that process cannot fully compensate for potential variability of a given condition.

Second, the conditions that are chosen should be ones that are relatively recognizeable and understandable to a policy audience as well as to clinical ones. Applying this selection criterion will help to enhance the dissemination of study findings and the likelihood that results may be incorporated into future policy analyses or policies governing post-acute care services.


IV. APPLICATION OF CRITERIA IN THE SELECTION OF EIGHT CONDITIONS

We examined different approaches for defining conditions and employed the criteria discussed in the previous section to identify likely candidates for the eight conditions. This section discusses the rationale behind our selection.

A. Approach for Defining Conditions

As noted above, few studies have addressed patient outcomes when making comparisons across provider types. The conditions selected in those studies were either hospital DRGs or hospital diagnoses. We started with this strategy, partly because of the literature and partly because such DRG and diagnosis information is available from Medicare claims data. In current research using 1995 Medicare claims data, we have already constructed episodes of hospital and post-acute care use. Hence, it is posssible for us to examine expeditiously conditions based on this information source. Moreover, the claims data also allow us to examine conditions based on use of particular Medicare services (e.g., ventilators).

A major shortcoming of the Medicare claims data, for this project, is that it provides no information on functional status (e.g., ADLs, IADLs). Hence, using this data source precludes the possibility of establishing conditions based on disability. Although we considered examing other sources of information, such as the Medicare Current Beneficiary Survey, which collect information on functional status of Medicare enrollees, we focused our efforts on the claims data because of limitations in those sources. Notably, the number of cases of post-acute care use of survey samples is very small compared to the number of cases when using Medicare claims. The sample size problem of surveys means that relatively few post-acute care events can be measured. Sample size limitations are exacerbated when we focus on subgroups of beneficiaries (e.g., persons with more than 3 ADL dependencies) or when we focus on patients using particular types of post-acute care providers (e.g., rehabilitation facilities).

Episodes of post-acute care use. We employed data from the 5-percent sample of 1995 Medicare claims data to examine episodes of post-acute care use. By creating episodes, in which SNF, HHA, and RF use was linked to hospital stays and to each other, it was possible to identify nationally representative patterns of post-acute care when a single or multiple providers were involved. We could also relate the post-acute use to the DRGs or diagnoses of the qualifying hospital stay, and any other information on the hospital claims, including services used (e.g., ventilator). We could also measure the duration of the total episode of post-acute care use.

Initial selection of DRGs. Because of the importance to this study of identifying conditions that are found in multiple post-acute care settings and occur in substantial numbers, we used an initial screening process to select cases that met the two criteria. We sorted post-acute care use of SNFs, HHAs, and RFs, respectively, by the DRG of the preceding hospital stay. We selected the 20 most prevalent DRGs for each of the three provider types. Because certain DRGs (e.g., hip fracture, stroke) were found in the top 20 lists of more than one provider type, we ended up with 32 unique DRGs from the original list of 60. Finally, we created a file containing all hospital stays with those 32 DRGs, regardless of whether it was followed by use of any of the post-acute care providers. These DRGs accounted for two-thirds of all Medicare post-acute care episodes. The distribution by discharge destination (including no post-acute care use) of these high volume DRGs is presented in Table 1.

Based on the 5-percent file, we identified a total of 157,280 episodes involving the 32 DRGs. For the 32 DRGs as a whole, only 51.6 percent of the episodes did not have post-acute care. The most common type of post-acute care service was home health care (24.4 percent), followed by SNF care (12.6 percent). Rehabilitation facilities accounted for almost 2 percent of the episodes involving the DRGs, and 9.2 percent of those episodes involved the use of more than one of the three post-acute care providers.

The numbers of post-acute care episodes by DRG show that many of the DRGs from previous studies continued to be important in 1995. These include stroke (DRG 14 with 12,002 cases), chronic obstructive pulmonary disease (DRG 88 with 7,569 cases), heart failure (DRG 127 with 14,165 cases), major joint replacement procedures (DRG 209 with 12,969 cases), and hip and femur procedures (DRGs 210 and 211, with a combined 5,926 cases).

B. Application of Criteria

High volume and multiple providers. With the data from Table 1, we derived the DRG distributions of discharge locations only for cases that did use post-acute care; effectively, we excluded the cases that did not use any of the three post-acute care modalities. These distributions are presented in Table 2. From this table, we can identify specific DRGs that meet the high volume and/or multiple providers criteria.

The number of post-acute care episodes by DRG in Table 2 ranged from 10,950 for major joint procedure (DRG 209) to 337 for back and neck procedures without complications (DRG 215). As an initial step toward identifying 8 conditions for further consideration, we made a decision rule to focus on DRGs with at least 1,500 episodes in Table 2.1 Given that we were using the 5 percent claims file, this minimum number is equivalent to 20,000 episodes in 1995. This decision rule defines 17 DRGs in Table 2 as high volume conditions: DRG 14, DRG 15, DRG 79, DRG 88, DRG 89, DRG 106, DRG 121, DRG 127, DRG 138, DRG 148, DRG 174, DRG 182, DRG 209, DRG 210, DRG 296, DRG 320, and DRG 416.

Looking at the distributions of the DRGs by provider type, it is apparent that rehabilitation facilities are not frequent providers for many of them. Some of the DRGs with the highest percentages using RFs are stroke (DRG 14; 10.6 percent), major joint procedure (DRG 209, 9.8 percent), hip procedure (DRG 210, 4.9 percent), and tracheostomy (DRG 483; 10.3 percent). It is interesting to note that, although back and neck procedures (DRGs 214 and 215) did not make the high volume cut-off, a very high proportion (11.1 percent, 10.1 percent) of their episodes involved using rehabilitation facilities The DRGs with high proportions of patients using rehabilitation facilities also tended to have lower than average proportions using HHAs. HHA use was the lowest for DRG 210, but the total number of episodes for DRG 210 is very large.

Given the decision rules that we employed, there are 17 DRGs that are high volume conditions and 3 DRGs (i.e., DRG 214, DRG 215, DRG 483) that are exceptionally interesting for this study. Of those 20 conditions, 5 are relatively well distributed across SNFs, HHAs, and RFs. Because those 5 DRGs also use RFs in relatively high proportions, the remaining 15 high volume DRGs are best suited for paired comparisons between SNFs and HHAs.

Variations in utilization patterns. For the 20 DRGs, we derived summary statistics to examine variations in the patterns of Medicare service utilization, such as hospital readmissions and lengths of stay. These statistics are presented in Table 3.

Hospital readmissions are high for most of the DRGs, ranging from 19.0 percent for back and neck procedures without complications (DRG 215) to 51.7 percent for chronic obstructive pulmonary disease (DRG 88). Most of the DRGs have approximately one-third of cases being readmitted to hospitals within the year. Other DRGs with relatively low proportions of cases readmitted to hospitals are major joint replacement (DRG 209), hip procedure (DRG 210), and back and neck procedure with complications (DRG 214). Other DRGs with relatively high hospital readmission rates include congestive heart failure (DRG 127), acute myocardial infarction (DRG 121), and heart arrythmia (DRG 138).

For all episodes, the median length of stay (LOS) was 33 days. Hip procedures (DRG 210) had a relatively long LOS of 44 days. In contrast, back and neck procedures without complications (DRG 215) had a relatively short median LOS of 23 days. It is important to note that one cause of episodes to end is a hospital readmission. Hence, for DRG 215, when a readmission occurred, it occurred relatively quickly.

Stroke (DRG 14), major joint procedure (DRG 209), hip fracture without major procedure (DRG 210), and back and neck procedure with complications (DRG 214) had among the highest post-acute care episode costs, with stroke, for example, having a median cost of $5,399. This finding is consistent with these cases being rehab DRGs which require considerable amounts of therapy services. Tracheostomy (DRG 483) also had very high costs, with a median of $5,303. In contrast, DRGs with relatively low costs included congestive heart failure (DRG 127), pneumonia (DRG 89), and chronic obstructive pulmonary disease (DRG 88).

The use of different types of post-acute care providers during an episode was highest among patients with stroke (DRG 214), hip fracture procedures (DRG 209, DRG 210), or back and neck procedures (DRG 214, DRG 215). About one-third of the episodes for those DRGs involved use of some combination of SNF, HHA and RF care. In contrast, the DRGs with the lowest proportions using multiple providers of care were arrythmia (DRG 138), esophagitis (DRG 182), and congestive heart failure (DRG 127). These DRGs also had relatively low costs.


V. RECOMMENDATIONS

A summary of characteristics of the 20 high volume or exceptional DRGs is presented in Table 4. The rehabilitation DRGs and the medical DRGs are separated and each group is ranked according to the number of episodes of post-acute care.

The two hip procedure DRGs (DRGs 209 and 210), along with stroke (DRG 14), are very high volume post-acute care cases and are among the 10 “transfer” DRGs. They are also served in relatively high proportions by all three provider types (SNFs, HHAs, and RFs). Moreover, many stroke and hip fracture episodes involve relatively high use of multiple post-acute care providers. Because many hip fractures are treated with a joint replacement (or arthroplasty), we will not define the hip fracture group exclusively by DRG assignment. Rather, we will define one group as hip fracture reflecting the emergent nature of the procedure and include patients from DRG 209, DRG 210, and DRG 211 who meet this criterion. A subgroup of the patients will have had arthroplasty. We do not plan to include elective hip replacements in the eight conditions. Thus, we will include hip fracture from DRG 209, DRG 210, DRG 211 and stroke from DRG 14 for further review. Other strokes coded under DRGs 1 and 5 (craniotomy and extravascular procedures) will also be included with those coded under DRG 14.

Back and neck procedures (DRGs 214 and 215) are interesting conditions that have not been widely studied. Our analysis indicated that people with those DRGs make substantial use of rehabilitation facilities, as well as SNFs and HHAs, so that three site comparisons are possible. In addition, utilization characteristics of back and neck procedure DRGs are somewhat similar to those of hip fracture cases (e.g., low hospital readmissions, high costs). Hence, back and neck procedures present an interesting alternative to such cases as we attempt to study “new” conditions. We recommend including back and neck procedures for further consideration.

Congestive heart failure (DRG 127) and pneumonia (DRG 89) are the highest volume conditions among the medical DRGs. CHF has a relatively high hospital readmission rate and a relatively low likelihood of being treated by multiple providers. Pneumonia is a condition that is easily recognizeable by policy makers and lay people, and while it is a relatively low cost DRG, it is treated in large numbers both in SNFs and by HHAs. More pneumonia cases are likely to be identified in other DRGs such as respiratory infections (DRG 79) and pleural effusions (DRGs 85 and 86). We recommend including these two conditions for further study.

Two other medical conditions that are treated in high volume by post-acute care providers are chronic obstructive pulmonary disease (DRG 88) and circulatory disorders with acute myocardial infarction (DRG 121). Both DRGs have very high use rates in HHAs, but are also treated in SNFs. Both are also relatively low cost and have high hospital readmission rates. Thus, we are also recommending these for further study. For both of these conditions, we anticipate that other cases can be identified by ICD9 codes included under different DRGs. For example, COPD cases may be identified under lung diseases (DRGs 92 and 93) or acute bronchitis (DRGs 96 and 97).

The tracheostomy DRG (DRG 483) appears in all three of the post-acute care settings and is relatively high cost. Moreover, it is a DRG that involves ventilator care, and ventilator care is often noted as a characteristic of “subacute care.” The increasing importance of subacute care in managed care is a significant policy-oriented criterion for supporting the study of ventilator-related conditions. We recommend including tracheostomy (and other ventilator-related conditions) for further study.

In sum, our review resulted in the recommendation of three rehab DRGs, four medical DRGs, and ventilator-related conditions for further study. Several of the recommended conditions are “transfer” DRGs and many of them can be examined in comparisons involving SNFs, HHAs, and RFs.


VI. CONCLUSION

The analysis to recommend 8 conditions for further study focused on DRGs. Although DRGs have been used to select conditions for post-acute care outcome studies, they were examined here principally to identify broad areas for more detailed consideration. In particular, we think that some of the DRGs might be heterogeneous in terms of diagnoses that are included. More precise specification of conditions for further study may involve subsetting of diagnoses in any given DRG or combining diagnoses from multiple DRGs. On the other hand, this initial screen of potential conditions for further study, based on DRG-related conditions, provides a policy-oriented group of conditions that policy and clinical experts can recognize and understand.

REFERENCES

Kane, R.L., Q. Chen, M. Finch, et al., 1997. “Functional Outcomes of Post-Hospital Care for Stroke and Hip Fracture Patients Under Medicare.” Manuscript, University of Minnesota School of Public Health.

Kane, R.L., Q. Chen, M. Finch, et al., 1997a. “The Optimal Outcomes and Costs of Post-Hospital Care Under Medicare.” Manuscript, University of Minnesota School of Public Health.

Kramer, A.M., J.F. Steiner, R.E. Schlenker, et al., 1997b. “Outcomes and Costs After Hip Fracture and Stroke.” Journal of the American Medical Association 277 (5): 396-404.

Kramer, A.M., P. W. Shaughnessy, M. K. Bauman, and K. S. Crisler, 1990. “Assessing and Assuring the Quality of Home Care: A Conceptual Framework.” The Milbank Quarterly 68 (3): 413-442.

Lewin-VHI (Manard, B., K. Bieg, R. Cameron, et al.), 1995. Subacute Care: Policy Synthesis and Market Area Analysis. Submitted to Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. [Full Report]

Neu, C.R. and S. C. Harrison, 1989. “Medicare Patients and Postacute Care.” RAND Report R-3780-MN. Santa Monica, California: The RAND Corporation.

Steiner, A. And C.R. Neu, 1993. “Monitoring the Changes in Use of Medicare Posthospital Services.” RAND Report MR-153-HCFA. Santa Monica, California: The RAND Corporation.

Prospective Payment Assessment Commission (ProPAC), 1996. Medicare and the American Health Care System: Report to the Congress. Washington, D.C.


NOTES

  1. Exeptions to this general rule were DRG 15 (n = 1,477) for which almost 1,500 episodes were recorded, DRG 214 (n = 883) and DRG 215 (n=337) because they are an alternative to widely studied hip procedures, and DRG 483 (n=386) because it is likely to involve ventilator care and is a “transfer” DRG.


TABLE 1: Distributions of Hospital Discharge Destinations, by Selected DRG
DRG # DRG Name All
Locations
(Number)
Discharge Destinations (Percentage)
No Post-
Acute
Care
Rehab
Only
SNF
Only
HHA
Only
More
than one
PAC
Total Number/Average Percentage 157,280 51.63 1.97 12.66 24.49 9.25
001 Craniotomy age >17 except for trauma 961 46.20 8.53 12.70 16.44 16.13
005 Extracranial vascular procedures 3,132 84.29 1.15 1.56 10.89 2.11
014 Specific cerebrovascular disorders except TIA 12,002 33.82 7.05 21.08 18.68 19.37
015 Transient ischemic attack and precerebral occlusion 4,124 64.19 0.99 7.52 22.70 4.61
079 Respiratory infections and inflammations age >1 5,231 52.76 0.19 22.14 20.59 4.32
088 Chronic obstructive pulmonary disease (COPD) 7,569 57.68 0.30 6.72 32.05 3.24
089 Simple pneumonia and pleurisy age >17 with cc 11,445 57.52 0.12 14.40 24.50 3.46
104 Cardiac valve procedures w/ cardiac cath 759 44.14 3.16 5.01 39.53 8.17
106 Coronary bypass with cardiac cath 3,410 45.54 1.52 3.99 42.17 6.77
107 Coronary bypass w/o cardiac cath 2,018 47.87 1.49 3.07 42.96 4.61
112 Percutaneous cardiovascular procedures 5,130 85.32 0.19 0.82 12.83 0.84
113 Amputation for circulatory system disorders except UP 798 24.44 5.14 33.33 17.04 20.05
121 Circulatory disorders w AMI 3,476 46.63 0.29 12.43 35.39 5.26
124 Circulatory disorders except AMI 2,822 81.11 0.32 0.67 17.04 0.85
127 Heart failure and shock (CHF) 14,165 51.82 0.17 8.96 35.69 3.36
132 Atherosclerosis with cc 2,698 75.02 0.15 2.63 20.87 1.33
138 Cardiac arrhythmia and conduction disorders with 5,214 71.12 0.15 4.83 22.06 1.84
140 Angina pectoris 3,116 76.89 0.00 2.18 20.12 0.80
143 Chest pain 3,389 88.05 0.09 1.56 9.94 0.35
148 Major small and large bowel procedures with cc 4,766 48.41 0.46 10.41 33.17 7.55
174 G.I. hemorrhage with cc 5,966 69.29 0.12 8.28 19.78 2.53
182 Esophagitis gastroent and miscellaneous digestive disorders 5,537 71.90 0.09 5.20 20.90 1.91
209 Major joint and limb reattachment procedures 12,969 15.57 8.31 16.39 26.42 33.30
210 Hip and femur procedures except major joint age 5,031 12.70 4.33 39.30 11.65 32.02
211 Hip and femur procedures except major joint age 895 12.85 6.93 33.30 13.97 32.96
214 Back and neck procedures with cc 1,740 49.25 5.63 5.63 22.07 17.41
215 Back and neck procedures without cc 1,293 73.94 2.63 3.17 13.92 6.34
236 Fractures of hip and pelvis 1,283 22.14 3.66 31.57 17.61 25.02
239 Pathological fractures and musculoskeletal and con 1,769 31.83 1.47 20.69 28.15 17.86
243 Medical back problems 2,168 42.90 1.94 16.10 25.78 13.28
294 Diabetes age > 35 2,022 46.04 0.20 9.59 40.36 3.81
296 Nutritional and miscellaneous metabolic disorders >1 5,353 48.70 0.32 17.65 28.08 5.25
320 Kidney and urinary tract infections age >17 wit 4,124 50.87 0.12 20.59 24.30 4.12
416 Septicemia age > 17 4,694 57.56 0.23 18.60 19.26 4.35
429 Organic disturbances and mental retardation 1,207 38.19 0.17 35.13 21.29 5.22
468 Extensive o.r. procedure unrelated to principa 1,447 45.06 1.87 16.45 25.36 11.26
471 Bilateral or multiple major joint procs of low 397 13.60 16.62 10.58 16.62 42.57
478 Other vascular procedures with cc 2,188 47.35 1.23 9.00 35.47 6.95
483 Tracheostomy except for mouth larynx or pharyn 972 60.29 4.12 17.59 9.77 8.23


TABLE 2: Discharge Destinations of Post-Acute Care Users, by Selected DRG
DRG # DRG Name All
Locations
(Number)
Discharge Destinations (Percentage)
Rehab
Only
SNF
Only
HHA
Only
More
than one
PAC
Total Number/Average Percentage 76,081 4.08 26.16 50.62 19.13
001 Craniotomy age >17 except for trauma 517 15.86 23.60 30.56 29.98
005 Extracranial vascular procedures 492 7.32 9.96 69.31 13.41
014 Specific cerebrovascular disorders except TIA 7,943 10.65 31.85 28.23 29.27
015 Transient ischemic attack and precerebral occlusion 1,477 2.78 20.99 63.37 12.86
079 Respiratory infections and inflammations age >1 2,471 0.40 46.86 43.59 9.15
088 Chronic obstructive pulmonary disease (COPD) 3,203 0.72 15.89 75.74 7.65
089 Simple pneumonia and pleurisy age >17 with cc 4,862 0.29 33.90 57.67 8.14
104 Cardiac valve procedures w/ cardiac cath 424 5.66 8.96 70.75 14.62
106 Coronary bypass with cardiac cath 1,857 2.80 7.32 77.44 12.44
107 Coronary bypass w/o cardiac cath 1,052 2.85 5.89 82.41 8.84
112 Percutaneous cardiovascular procedures 753 1.33 5.58 87.38 5.71
113 Amputation for circulatory system disorders except UP 603 6.80 44.11 22.55 26.53
121 Circulatory disorders w AMI 1,855 0.54 23.29 66.31 9.87
124 Circulatory disorders except AMI 533 1.69 3.56 90.24 4.50
127 Heart failure and shock (CHF) 6,825 0.35 18.59 74.08 6.97
132 Atherosclerosis with cc 674 0.59 10.53 83.53 5.34
138 Cardiac arrhythmia and conduction disorders with 1,506 0.53 16.73 76.36 6.37
140 Angina pectoris 720 0.00 9.44 87.08 3.47
143 Chest pain 405 0.74 13.09 83.21 2.96
148 Major small and large bowel procedures with cc 2,459 0.89 20.17 64.29 14.64
174 G.I. hemorrhage with cc 1,832 0.38 26.97 64.41 8.24
182 Esophagitis gastroent and miscellaneous digestive disorders 1,556 0.32 18.51 74.36 6.81
209 Major joint and limb reattachment procedures 10,950 9.84 19.42 31.30 39.44
210 Hip and femur procedures except major joint age 4,392 4.96 45.01 13.34 36.68
211 Hip and femur procedures except major joint age 780 7.95 38.21 16.03 37.82
214 Back and neck procedures with cc 883 11.10 11.10 43.49 34.31
215 Back and neck procedures without cc 337 10.09 12.17 53.41 24.33
236 Fractures of hip and pelvis 999 4.70 40.54 22.62 32.13
239 Pathological fractures and musculoskeletal and con 1,206 2.16 30.35 41.29 26.20
243 Medical back problems 1,238 3.39 28.19 45.15 23.26
294 Diabetes age > 35 1,091 0.37 17.78 74.79 7.06
296 Nutritional and miscellaneous metabolic disorders >1 2,746 0.62 34.41 54.73 10.23
320 Kidney and urinary tract infections age >17 wit 2,026 0.25 41.91 49.46 8.39
416 Septicemia age > 17 1,992 0.55 43.83 45.38 10.24
429 Organic disturbances and mental retardation 746 0.27 56.84 34.45 8.45
468 Extensive o.r. procedure unrelated to principa 795 3.40 29.94 46.16 20.50
471 Bilateral or multiple major joint procs of low 343 19.24 12.24 19.24 49.27
478 Other vascular procedures with cc 1,152 2.34 17.10 67.36 13.19
483 Tracheostomy except for mouth larynx or pharyn 386 10.36 44.30 24.61 20.73


TABLE 3: Utilization and Cost Statistics on High Post-Acute Care (PAC) Use, by Selected DRG
DRG # DRG Name Readmission
Rate
(%)
Median
LOS
(days)
Median
PAC Costs
($)
Multiple
PAC Users
(%)
All Episodes 36.3 33 $2,327 19.1
014 Specific cerebrovascular disorders except TIA 32.6 40 5,399 29.3
015 Transient ischemic attack and precerebral occlusion 36.8 39 2,420 12.9
079 Respiratory infections and inflammations age >1 41.5 30 2,607 9.2
088 Chronic obstructive pulmonary disease (COPD) 51.7 36 1,507 7.7
089 Simple pneumonia and pleurisy age >17 with cc 40.4 30 1,830 8.1
106 Coronary bypass with cardiac cath 33.0 27 1,099 12.4
121 Circulatory disorders w AMI 45.4 31 1,539 9.9
127 Heart failure and shock (CHF) 49.4 36 1,600 7.0
138 Cardiac arrhythmia and conduction disorders with 43.7 36 1,573 6.4
148 Major small and large bowel procedures with cc 37.7 31 1,846 14.6
174 G.I. hemorrhage with cc 38.7 32 1,793 8.2
182 Esophagitis gastroent and miscellaneous digestive disorders 47.0 38 1,689 6.8
209 Major joint and limb reattachment procedures 19.7 32 3,621 39.4
210 Hip and femur procedures except major joint age 26.8 44 6,146 36.7
214 Back and neck procedures with cc 24.1 28 3,226 34.3
215 Back and neck procedures without cc 19.0 23 2,070 24.3
296 Nutritional and miscellaneous metabolic disorders >1 39.8 35 2,488 10.2
320 Kidney and urinary tract infections age >17 wit 39.3 37 2,669 8.4
416 Septicemia age > 17 39.1 30 2,745 10.2
483 Tracheostomy except for mouth larynx or pharyn 45.9 33 5,303 20.7


TABLE 4: Distributions of Hospital Discharge Destinations, by Selected DRG
DRG # DRG Name Volume All
Sites
Hospital
Readmit
LOS Cost More
than one
PAC
Practical
Issues
Rehabilitation
014 Specific cerebrovascular disorders except TIA 7,943 X   Hi Hi Hi Res
015 Transient ischemic attack and precerebral occlusion 1,477     Hi      
209 Major joint and limb reattachment procedures 10,950 X Lo   Hi Hi Res
210 Hip and femur procedures except major joint age 4,392 X Lo Hi Hi Hi Res
214
215
Back and neck procedures 1,220 X Lo Lo   Hi  
Medical
079 Respiratory infections and inflammations age >1 2,471         Lo  
088 Chronic obstructive pulmonary disease (COPD) 3,203   Hi   Lo Lo Res
089 Simple pneumonia and pleurisy age >17 with cc 4,862         Lo  
106 Coronary bypass with cardiac cath 1,857       Lo    
127 Heart failure and shock (CHF) 6,825   Hi   Lo Lo Res
148 Major small and large bowel procedures with cc 2,459            
121 Circulatory disorders w AMI 1,855   Hi   Lo Lo  
138 Cardiac arrhythmia and conduction disorders with 1,506       Lo Lo  
174 G.I. hemorrhage with cc 1,832       Lo Lo  
182 Esophagitis gastroent and miscellaneous digestive disorders 1,556   Hi Hi Lo Lo  
296 Nutritional and miscellaneous metabolic disorders >1 2,746            
320 Kidney and urinary tract infections age >17 wit 2,026         Lo  
416 Septicemia age > 17 1,992            
Procedure
483 Tracheostomy except for mouth larynx or pharyn 386 X Hi   Hi    


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