Tag Archives: avoidable events

International best practice benchmarks identify potential avoidable inpatient admissions

Milliman’s International Best Practice Benchmarks help quantify potentially avoidable admissions and bed-days within a healthcare system to identify potential value opportunities. The benchmarks can be applied to any healthcare system (public or private) where stakeholders are seeking opportunities to reduce waste and improve efficiencies. Milliman’s Joanne Buckle and Tanya Hayward provide more perspective in this presentation.

Recent analyses of interventions for avoidable emergency department visits

Over the past several years there has been substantial interest in reducing avoidable emergency department (ED) visits. A wide variety of strategies have been employed to achieve these reductions, including:

  • Benefit design changes such as increasing visit copays or putting limits on the reimbursement of number of unnecessary ED visits by a single patient
  • Provider incentives through programs such as patient-centered medical homes (PCMHs) to reduce the avoidable ED rate
  • Structural delivery system changes to emphasize urgent care facilities and after-hours primary care

Many of these interventions rely on analytics based on the avoidable ED algorithm from New York University (NYU), which uses a probabilistic algorithm based on primary diagnosis code to identify the likelihood of avoidable ED visits within populations. Several analyses have now been done that analyze the effectiveness and/or the safety of these interventions.

The first analysis was done by the Washington state Health Care Authority (HCA). It cites an over 10% decrease in ED utilization and ED per member per month (PMPM) costs in the first six months of a program instituting seven best practices for Medicaid enrollees in the state. The best practices included the electronic exchange of information between emergency departments, patient education of ED utilizers, sharing of lists of frequent ED utilizers, development of ED care plans, guidelines and monitoring of narcotic prescribing, and the periodic review of feedback reports. For more information on this program, read HCA’s report, Emergency Department Utilization: Assumed Savings from Best Practices Implementation.

The second is a peer-reviewed study by ED physicians, whose conclusion is that the NYU ED algorithm does a relatively poor job in identifying an individual patient’s need for an ED visit. In this study they compared presenting complaint data with ED discharge diagnosis run through the NYU ED algorithm. They found that the presenting complaint predicted poorly whether the visit should have been avoided and that doing so could have safety consequences. While arguably the NYU ED algorithm wasn’t designed to guide individual patient decisions, the article is thought-provoking and undoubtedly can be cited as an argument against ED visit interventions. Read this recent article in the Journal of the American Medical Association (JAMA), “Comparison of Presenting Compaint vs. Discharge Diagnosis for Identifying ‘Nonemergency’ Emergency Department Visits,” for more information.

I’d expect many more articles to be published about these interventions in the coming months and years. It will be important for informatics to be aware of these evaluations.

This article first appeared at Milliman MedInsight.

Potentially avoidable events: The link to care coordination

Care coordination is a critical success factor in the broader spectrum of improved outcomes and effective cost management. There are many considerations when evaluating care coordination successes and opportunities.

Potentially avoidable events have been identified as a means of opportunity savings and improved access to care, including, but not limited to:

• Preventable hospitalizations
• Avoidable emergency department (ED) visits

These are critical components to analyze because:

• They may be an indication of access difficulties to the appropriate primary care
• When evaluating these events, it is also important to understand the geographic and socioeconomic factors to help identify opportunities for improved care coordination within a given population
• From a financial perspective, these events can also contribute to higher costs, presenting an opportunity for savings if better care coordination is in place
• The ability to identify and monitor occurrences of these types of events depends on the ability to identify events that are potentially preventable and events that are not preventable

Preventable hospitalization: Prevention quality indicators (PQI) of the Agency for Healthcare Research and Quality (AHRQ) provide a consistent and industry-accepted basis for objective measurement and analysis. Based on the AHRQ literature, hospitalization for an ambulatory care sensitive condition (ACSC) is considered to be a measure of access to appropriate primary healthcare. As a reminder, ACSCs are medical problems that are potentially preventable. While not all admissions for ACSCs are avoidable, it is assumed that appropriate ambulatory care could prevent the onset of this type of illness or condition, control an acute episodic illness or condition, or manage a chronic disease or condition. For example, hypertension (high blood pressure) is a condition that can be treated outside of a hospital. With proper medication and management of care, most people should not need to be hospitalized for hypertension. When interpreting the data, a disproportionately high rate is presumed to reflect problems in obtaining access to appropriate primary care.

The identified conditions include angina, asthma, chronic obstructive pulmonary disease (COPD), diabetes, grand mal status and other epileptic convulsions, heart failure and pulmonary edema, and hypertension.

Avoidable ED visits: The use of algorithms that provide bucketing of ED visits based on diagnosis codes supports the analysis of preventable ED visits. Some examples include the New York University algorithm and the Medi-Cal algorithm. Below is a sample from a large data set for a one-year period showing the percent of visits identified as preventable/avoidable and primary care treatable at a high-level rollup by line of business. Further analysis would include population-specific information to identify factors contributing to these types of visits. Risk adjusting these populations and evaluating by more specific demographics such as age and gender will provide further detail to drive an action plan to reduce these types of visits.

In closing, a better understanding of costs and benefits—how and to whom to target incentives, at which levels of risk—is essential for care coordination and other improvement initiatives to be economically viable and sustainable.

An interesting strategy to address readmissions: Nurse Led Clinics Battle Readmissions.

This article first appeared at Milliman MedInsight.