Understanding and Interpreting Adverse Drug Event (ADE) Readmission Reports Lindsay Holland Director, Care Transitions Health Services Advisory Group (HSAG) October 24, 2017
Today s Webinar Objectives Review the Medicare Fee-for-Service (FFS) ADE data report. Discover how to use the report to identify patients on high-risk medications who are at higher risk for readmission. Describe and demonstrate how to use the ADE report in your facility. 2
HSAG: Your Partner in Healthcare Quality HSAG is California s Medicare Quality Innovation Network-Quality Improvement Organization (QIN-QIO). QIN-QIOs in every state and territory are united in a network administered by the Centers for Medicare & Medicaid Services (CMS). The QIN-QIO program is the largest federal program dedicated to improving health quality at the community level. 3
Overview HSAG is contracted by CMS to work with healthcare providers to: Improve coordination of care Reduce hospital readmissions Improve medication safety for ADEs for patients in the community 4
Readmissions and Medication Safety HSAG works with hospitals to reduce ADEs ADEs contribute to readmissions and are the leading cause of preventable patient harm. 1 High-priority medication targets for the National Action Plan for Adverse Drug Event Prevention 2 (common, preventable, and measurable ADEs): Anticoagulants Diabetic agents Opioids 5 1. Gurwitz JH, Field TS, Harrold LR, et al. Incidence and preventability of adverse drug events among older persons in the ambulatory setting. JAMA. 2003;289(9):1107 16. 2. U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). National Action Plan for Adverse Drug Event Prevention. Washington, DC: Author.
Emergency Department (ED) Visits for ADEs Associated with anticoagulants 17.6% of the visits, with 48.8% of cases resulting in hospitalization. Associated with diabetic agents 13.3% of the visits, with 38.5% resulting in hospitalization. Associated with opioids 6.8% of the visits, with 24.6% resulting in hospitalization. 6 Shehab N, Lovegrove MC, Geller AI, Rose KO, Weidle NJ, Budnitz DS. US Emergency Department Visits for Outpatient Adverse Drug Events, 2013-2014. JAMA. 2016;316(20):2115-2125. doi: 10.1001/jama.2016.16201.
30-Day Readmissions Among Medicare FFS Beneficiaries on HRMs in California Q2 2016 Q1 2017 30-Day All-Cause Readmission Rate 18.4% 30-Day HRM Readmission Rate 21.6% Readmissions among beneficiaries on HRMs are much more frequent than the general population, suggesting ample opportunity for improvement. Percent of 30-day readmissions with an anticoagulant or diabetes agent ADE are much higher than the percent of readmits with an opioid ADE. 7 Data files provided to Health Services Advisory Group (HSAG) by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A and Par-D claims for Medicare Fee-for-Service beneficiaries.
Adverse Drug Event Facility Report For Your Community Hospital Q3 2014 Q1 2017
High-Risk Medication (HRM) Categories Data sources are Medicare Fee for Service (FFS) Part-A and Part-D claims. Beneficiaries are considered on a HRM if they have more than 30 days of HRM coverage (opioids, anticoagulants, or diabetic agents) during the time period of interest. Beneficiaries may qualify as being on a HRM for more than one drug class. Adverse Drug Events (ADEs) are evaluated in both the inpatient (IP) and emergency department (ED) setting based on the beneficiary s HRM drug classification. If a beneficiary is on an opioid, and has a claim identified as an ADE related to opioids, this is counted in the numerator. If a beneficiary is on an opioid, and has a claim identified as an ADE related to anticoagulants, this is not counted in the numerator. Missing data points or figures indicate there were no applicable data for your hospital during the specified time period. 9
ADE Rates Q2 2016 Q1 2017 Note: Overall will not be equal to the total of the individual drug categories as some beneficiaries are considered high risk for more than one sub population. 10
Anticoagulant ADEs by Diagnosis Code 1 Q3 2014 Q1 2017 ICD-9 Description Count ICD-10 Description Count Diagnosis Diagnosis Code Code 79092 Abnormal coagulation profile 25 E9342 Anticoagulants causing adverse effect in therapeutic use 20 7847 Epistaxis 9 59970 Hematuria, unspecified 9 5789 Hemorrhage of gastrointestinal tract, unspecified 7 5781 Blood in stool 6 5693 Hemorrhage of rectum and anus 4 78630 Hemoptysis, unspecified 4 R791 Abnormal coagulation profile 36 T45515A Adverse effect of anticoagulants, initial encounter 16 K922 Gastrointestinal hemorrhage, unspecified 16 R319 Hematuria, unspecified 13 R040 Epistaxis 10 K625 Hemorrhage of anus and rectum 9 K2971 Gastritis, unspecified, with bleeding 4 R042 Hemoptysis 4 53783 Angiodysplasia of stomach and duodenum with hemorrhage 3 T45511A Poisoning by anticoagulants, accidental (unintentional), initial encounter 4 53551 Unspecified gastritis and gastroduodenitis with hemorrhage 2 R310 Gross hematuria 3 1 Only the top 10 diagnosis codes are shown. 11
Diabetic Agent ADEs by Diagnosis Code 2 Q3 2014 Q1 2017 ICD-9 Diagnosis Code Description 25080 Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled 25082 Diabetes with other specified manifestations, type II or unspecified type, uncontrolled E9323 Insulins and antidiabetic agents causing adverse effect in therapeutic use Count 2512 Hypoglycemia, unspecified 8 9623 Poisoning by insulins and antidiabetic agents 4 79029 Other abnormal glucose 2 25081 Diabetes with other specified manifestations, type I [juvenile type], not stated as uncontrolled 63 24 10 1 ICD-10 Diagnosis Code Description Count E11649 Type 2 diabetes mellitus with hypoglycemia without coma 51 E1169 Type 2 diabetes mellitus with other specified complication 17 E162 Hypoglycemia, unspecified 8 E10649 Type 1 diabetes mellitus with hypoglycemia without coma 6 T383X5A E1369 T383X1A Adverse effect of insulin and oral hypoglycemic [antidiabetic] drugs, initial encounter Other specified diabetes mellitus with other specified complication Poisoning by insulin and oral hypoglycemic [antidiabetic] drugs, accidental (unintentional), initial encounter E1069 Type 1 diabetes mellitus with other specified complication 1 2 1 1 2 Only the top 10 diagnosis codes are shown. 12
Opioid ADEs by Diagnosis Code 3,4 Q3 2014 Q1 2017 ICD-9 Description Count ICD-10 Description Count Diagnosis Diagnosis Code Code E9352 Other opiates and related narcotics causing adverse effect in therapeutic use 6 T40601A Poisoning by unspecified narcotics, accidental (unintentional), initial encounter 10 E8502 Accidental poisoning by other opiates and related narcotics 96509 Poisoning by opiates and related narcotics, other 5 96500 Poisoning by opium (alkaloids), unspecified 4 78097 Altered mental status 1 29281 Drug-induced delirium 1 78009 Other alteration of consciousness 1 78609 Other dyspnea and respiratory abnormalities 1 E9500 Suicide and self-inflicted poisoning by analgesics, antipyretics, and antirheumatics 486 Pneumonia, organism unspecified 1 5 1 F1123 Opioid dependence with withdrawal 4 R4182 Altered mental status, unspecified 4 T402X1A Poisoning by other opioids, accidental (unintentional), initial encounter T40605A Adverse effect of unspecified narcotics, initial encounter 3 T403X1A Poisoning by methadone, accidental (unintentional), initial encounter T402X5A Adverse effect of other opioids, initial encounter 2 F11921 Opioid use, unspecified with intoxication delirium 1 T402X2A T404X1A Poisoning by other opioids, intentional self-harm, initial encounter Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter 3 2 1 1 3 Only the top 10 diagnosis codes are shown. 4 Some opioid ADEs require two diagnosis codes used in combination. 13
Readmission Rates for HRM Beneficiaries 14
Readmissions for HRM Beneficiaries on an Anticoagulant 15
Readmissions for HRM Beneficiaries on a Diabetic Agent 16
Readmissions for HRM Beneficiaries on an Opioid 17
Readmissions by Drug Category 18
Overall ED Utilization Within 30 Days of Discharge from an IP Visit 19
Overall ED Utilization Within 30 Days of Discharge from an IP Visit for HRM Beneficiaries on an Anticoagulant 20
Overall ED Utilization Within 30 Days of Discharge from an IP Visit for HRM Beneficiaries on a Diabetic Agent 21
Overall ED Utilization within 30 Days of Discharge from an IP Visit for HRM Beneficiaries on an Opioid 22
General Utilization by HRM Beneficiaries 23
General Utilization by HRM Beneficiaries on an Anticoagulant 24
General Utilization by HRM Beneficiaries on a Diabetic Agent 25
General Utilization by HRM Beneficiaries on an Opioid 26
Anticoagulant ADEs by Prescription Q3 2014 Q1 2017 Drug Class Number of ADEs Warfarin 120 Direct Factor Xa Inhibitors (New Oral Anticoagulants) 56 Direct Thrombin Inhibitors 7 Heparins and Heparinoid-Like Agents 3 27
Diabetic Agent ADEs by Prescription Q3 2014 Q1 2017 Drug Class Number of ADEs Insulin 106 Sulfonylureas 47 Dipeptidyl Peptidase-4 (DPP-4) Inhibitors 12 Thiazolidinediones 8 Antidiabetic Combination Agents 3 Meglitinides 3 Glucagon-Like Polypeptide-1 (GLP-1) Receptor Agonists Sodium-Glucose Co-Transporter (SGLT) Inhibitors 2 1 Alpha-Glucosidase Inhibitors 1 28
Opioid ADEs by Prescription Q3 2014 Q1 2017 Drug Class Number of ADEs Hydrocodone Combinations 18 Morphine 7 Codeine and Codeine Combinations 5 Oxycodone 5 Methadone 3 Fentanyl 3 Hydromorphone 2 Buprenorphine 1 Oxymorphone 1 29
Thank you! Lindsay Holland Director, Care Transitions HSAG lholland@hsag.com
CMS Disclaimer This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for California, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. CA-11SOW-C.3.6-10232017-01