APR DRG Data Discovery
Vanessa Dorr RN MSN Midas+ DataVision Clinical Consultant
Henry Johnson MD, MPH Midas+ Vice President and Medical Director
Agenda
• Review:
– 3M APR DRG Methodology
– DataVision: Web and Server Applications
• Data Discovery:
– Resource use and Length of Stay:
• Wren Memorial, Cardiac Services
• Michael Memorial Orthopedic Services
– Mortality
• Vitale Memorial Hospital, Percutaneous Coronary Intervention (PCI)
• Summary and Questions
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Severity Adjustment Systems
• All Patient Diagnostic Related Group (AP DRG) – 1987: New York passed prospective payment for all
non-Medicare patients
• All-Payer Severity-adjusted DRG (APS DRG) – Different methodology, also developed from the DRG
model
• All Patient Refined DRG (APR DRG) – Researched and developed by New York Department
of Health (NYDH) in partnership with 3M™ Health Information Systems (HIS)
• Others: – STS, APACHE, Disease Staging, MedisGroups
21st Annual Midas+ User Symposium • May 20–23, 2012 • Tucson, Arizona
3M™ APR DRG
• Expanded the scope of DRGs to add:
– Severity of Illness (SOI)
• The extent of physiologic decompensation or organ system loss of function
– Risk of Mortality (ROM)
• The likelihood of dying
21st Annual Midas+ User Symposium • May 20–23, 2012 • Tucson, Arizona
Development Process: Clinically Coherent with Sufficient Case Volume
• Start with All Patient DRGs (AP DRGs)
• Consolidate – Combine the “with CC” and “without CC” DRGs
– Each APR DRG has a four-point “CC” scale built in
• Pediatric additions
• Add APR DRGs for mortality – Eliminate any unique DRGs for deaths only
21st Annual Midas+ User Symposium • May 20–23, 2012 • Tucson, Arizona
Subclass Assignment
• Assign each secondary diagnosis a SOI and ROM level (subclass) from 1 to 4
• In an iterative fashion, assign a subclass number based on dominant secondary diagnoses
• Some modifications for age
– Hypertension in children is considered major as a secondary
• Some modifications for specific APR DRGs
– Chronic Renal Failure as a secondary is Moderate, except if the APR DRG is diabetes, in which case it is Major
21st Annual Midas+ User Symposium • May 20–23, 2012 • Tucson, Arizona
Testing
• After the clinical model for SOI and ROM is developed for each base APR DRG, it is evaluated with historical data to be sure the subclasses predict resource use (SOI) and mortality rate (ROM).
• Version 20.0 was evaluated with a national database of 8.5 million discharges, all payers, from 1,000 hospitals from 10 states, and 47 children’s hospitals in the U.S.
21st Annual Midas+ User Symposium • May 20–23, 2012 • Tucson, Arizona
Beginning with APR DRG v.20
• For each APR DRG subclass, a Relative Weight (RW) was calculated to reflect the resources required for a patient in that APR DRG subclass.
• The subclass RW allows calculation of an overall Case Mix Index (CMI) for the hospital or by physician or physician group, which is severity-adjusted.
• Allows for more refined reimbursement
21st Annual Midas+ User Symposium • May 20–23, 2012 • Tucson, Arizona
APR DRG v20: Relative Weights
Base Rate RW Payment
4,113.00$ 0.5804 2,387.19$
4,113.00$ 0.793 3,261.61$
4,113.00$ 1.2736 5,238.32$
4,113.00$ 3.0052 12,360.39$
21st Annual Midas+ User Symposium • May 20–23, 2012 • Tucson, Arizona
Cautions
• APR DRG SOI and ROM subclasses are ranked categories unique to each APR DRG and cannot be averaged across APR DRGs (they are not really numbers).
– For example, congestive heart failure patients in severity subclass 4 are not comparable to patients with a fractured leg in severity subclass 4.
• In version 20.0 or later, you can average the RW.
• Beware choosing a population by MS-DRG or ICD-9 diagnosis and running reports or doing analysis for the whole population by APR DRG SOI or ROM.
21st Annual Midas+ User Symposium • May 20–23, 2012 • Tucson, Arizona
DataVision Architecture
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Midas+ Care Management
Midas+ Solutions: Tucson AZ
Standardized Measures:
DataVision
Navigator
National Comparisons:
DataVision
Web Application
Hospital Server
APR DRG Reports
• APR-DRG Lives/Days Saved Report
– Compares the facility's mortality and average length of stay (ALOS) data observed/expected (O/E) ratio statistics with the Midas+ comparative database (CDB) mean
– Provides site percentile rank in comparison with the CDB
– Predicts the number of lives and days that might be saved if outcomes improved to a different percentile
• Hospital APR-DRG Service Line Profile
– Lists all 3M™ APR DRG–defined service lines for the facility
– Provides mortality, ALOS, and Potentially Preventable Readmission (PPR) O/E ratio or delta statistics based on the CDB mean
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APR DRG Reports
• Hospital APR-DRG Ranking Profile
– Lists all APR DRGs and provides mortality, ALOS, and Potentially Preventable Readmission (PPR) O/E ratio or delta statistics based on the CDB mean
• APR-DRG Comparative Trend Analysis
– A two-part report that displays the length of stay O/E ratio and the mortality O/E ratio for the selected APR DRG, comparing the facility’s performance with percentiles from the CDB
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APR DRG Reports
• APR-DRG Subclass Detail
– A three-part report that examines facility
• LOS for the APR DRG, stratified by four severity-of-illness (SOI) levels
• Mortality rates for the APR DRG, stratified by four ROM levels
• Potentially Preventable Readmissions, stratified by four SOI levels
– This report includes percentile comparisons with the comparative database
• Single APR-DRG Comparison Profile
– Lists all providers for a specific APR DRG and provides mortality and ALOS statistics for each provider
– Can be viewed by provider name or code
– Parameter allows report to be viewed by attending or principal procedure provider
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APR DRG Reports
• APR-DRG Specialty Comparison Report – Compares a single provider to her peers for LOS and mortality, within
the hospital and with the comparative database
– Based on mapping of specialty groups specialties with admitting or attending activity
• Provider APR-DRG Detail Report – Lists all APR DRGs for a selected provider and provides mortality and
LOS statistics for each APR DRG as well as a specialty comparison
• All APR-DRG Provider Summary – Observed and expected mortality and LOS data for each of the facility’s
providers
– This report is useful for identifying high-volume providers
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• What is in the ToolPack?
– 256 fields . . .
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What Is New on Your Server?
Description # fields
Patient Demographics 14
Encounter description, including LOS 15
Admitting/Attending Physician 8
Discharging Physician 3
Payer, charge, and cost data 6
DRG (CMS) related 10
Principal Diagnosis 3
Principal Procedure 5
Count of Diagnoses, Count of Not Present on Admission 2
Secondary Diagnoses (total 25 possible, including principal) 72
Secondary Procedures (total 20 possible, including principal) 95
Consultants (total 5) 10
Primary Care physician 2
APR DRG-related 10
Birthdate 1
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New fields in Excel Toolpack Export
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APR DRG 174
APR DRG DESC Percutaneous cardiovascular
procedures w AMI
APR DRG Severity 2
APR DRG Mortality Risk 2
APR DRG MDC 5
CDB APR DRG All Inpatient Expected 2.9
CDB APR DRG All Inpatient Expected
Mortality
0.41%
CDB APR DRG Acute Care Expected 2.9
CDB APR DRG Acute Care Expected
Mortality
0.41%
Resource Use and Length of Stay:
Wren Memorial, Cardiac Services
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Question: What determines LOS?
• Discharge planning
• Events that prolong stay
Why is looking at long LOS important?
Basic Steps:
• Start with DataVision web application:
– SmartReport
– APR-DRG Reports
• Next, move to server for patient data
– Report Toolpack
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Total of 1,214.3 days, or 3.3 beds/day if we can go to the mean.
Can we do better?
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Wren March 2011 to February 2012
APR DRG
CodeDescription
#
Cases
Obs
ALOS
Expec
ted
LOS
Ratio
Perce
ntile
Rank
20th Percentile
Pred ALOSDays saved # hospitals
194 Heart failure 1313 5 4.69 1.07 78th 3.81 1553.51 676
201Cardiac arrhythmia & conduction
disorders615 3.62 3.24 1.12 82nd 2.67 580.16 671
175Percutaneous cardiovascular
procedures w/o AMI384 3.53 2.91 1.21 82nd 2.47 407.00 457
190 Acute myocardial infarction 186 5.23 4.19 1.25 93rd 3.15 386.92 653
174Percutaneous cardiovascular
procedures w AMI312 4.34 3.87 1.12 79th 3.37 303.54 434
If we can perform better than 80% of the hospitals in the comparative database, for these five APR-DRGs in the cardiac service line, we will save 3,231 bed days, or almost 9 extra beds/day – more room for transferring ICU patients and decreasing waits in the Emergency Department.
To the Server:
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Midas+ Care Management
Midas+ Solutions: Tucson AZ
Standardized Measures:
DataVision
Navigator
National Comparisons:
DataVision
Web Application
Hospital Server
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Wren
APR DRG 194
Heart Failure
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Wren
APR DRG 174
PCI w AMI
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Wren
APR DRG 175
PCI w/o AMI
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Wren
APR DRG 190
AMI
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Wren
APR DRG 201
Card Arrhy
Condn Disords
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Steps to Data Discovery
• Web application: reviewed
SmartReport
• Hospital APR-DRG Ranking Profile
• Set parameters to Days Delta
• Take contents to Excel to view and
rank
• Hospital APR-DRG Service Line
Profile
• Drill down to a service line
• Days Saved Report – bring out to
Excel
• Estimate total Days Saved at 20th
percentile
• Check by Attending and Principal
Procedure Provider
• To server: build APR Indicators
• Run Toolpacks
Resource Use and Length of Stay:
Michael Memorial,
Orthopedics
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To the Server:
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Midas+ Care Management
Midas+ Solutions: Tucson AZ
Standardized Measures:
DataVision
Navigator
National Comparisons:
DataVision
Web Application
Hospital Server
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Michael Mem
APR DRG 301
Total Hip Repl
Christopher
APR DRG 301
Total Hip Repl
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Steps to Data Discovery
• Web application: review
SmartReport
• APR-DRG Service Line Profile
• Set parameters to Days Delta
• Review APR-DRG 313 . . . .
• Choose APR-DRG that is easily
“actionable”
• Look at AP-DRG 301, Total Hips
• To server: build APR Indicators
• Run Toolpack
Mortality: Vitale Memorial Percutaneous Coronary Intervention
• Consider:
– Does the hospital have a hospice unit?
• Recall that on the DataVision web application
– Acute Care is All Patients, excluding
» Obstetrics
» Rehabilitation
» Behavioral Health
» Hospice
– Does the hospital use code V66.7 Palliative Care?
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To the Server:
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Midas+ Care Management
Midas+ Solutions: Tucson AZ
Standardized Measures:
DataVision
Navigator
National Comparisons:
DataVision
Web Application
Hospital Server
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Vitale
APR DRG 174
PCI w AMI
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Steps to Data Discovery
• Review SmartReport, find high
mortality rate
• Run Comparative Trend Analysis
• APR-DRG Ranking Profile
• Facility/Mortality Data
• Hospice present
• Review SmartReport
• Facility/Mortality Data: No hospice
• Lives/Days Saved Report: APR 174
• Remove V66.7 coded patients
• View CTA and subclass detail
• Profile by Doctor
• To server: build Indicator, run
ToolPack