Statistical Brief #6

Potentially Avoidable Hospitalizations: New York State Medicaid Program, 2009

  • Brief is also available in Portable Document Format (PDF)

New York State Department of Health
Division of Quality and Evaluation
Office of Health Insurance Programs

Wendy Patterson, Michael Lindsey


    Two types of potentially avoidable hospitalizations were identified: potentially preventable readmissions (readmissions that could potentially have been prevented with the appropriate inpatient or post- discharge care) and hospital admissions for ambulatory care sensitive conditions.

    In 2009, there were 62,043 potentially preventable readmissions occurring within 30 days of an initial admission costing a total of $589 million.

    There were an additional 90,546 potentially avoidable ambulatory car sensitive admissions, costing $824 million.

    Together, there were a total of 152,589 potentially avoidable hospitalizations costing $1.4 billion, $1.1 billion for fee for service inpatient admissions and $335 millio for managed care inpatient admissions.

    13% of hospitalizations for managed care recipients and 20% of hospitalizations for fee for service recipients were potentially avoidable

    New York City recipients accounted for 67% of all the potentially avoidable hospitalizations and 72% of the total dollars spent on these hospitalizations.

Hospital admissions for ambulatory care sensitive conditions are increasingly viewed as a way to improve the coordination of services between the inpatient and outpatient settings and to promote higher quality of care of outpatient care. Potentially preventable readmissions (PPR) are hospital admissions that could potentially have been prevented with the appropriate care during the initial admission, or adequate discharge planning and follow-up and coordination of care between the inpatient and outpatient settings. Prevention quality indicators (PQI) identify ambulatory care sensitive conditions for which hospital admissions might have been avoided if the patient had received timely and adequate care in the community. Previous statistical briefs have analyzed 2007 New York State Medicaid inpatient data to identify potentially preventable readmissions using the 3M PPR Software, version 26.1. Avoidable admissions, as indicated by the AHRQ prevention quality indicators, were also analyzed using 2007 Medicaid inpatient data (Statistical Brief #5). Together, potentially preventable readmissions and avoidable admissions are used in this report to identify potentially avoidable hospitalizations for the Medicaid population in New York State in 2009.

This report analyzes Medicaid inpatient hospital discharges for 2009 from all Article 28 (acute inpatient) hospitals. The PPR software, version 28.0, was used to identify readmissions that were potentially preventable within 30 days of the initial admission. The AHRQ logic, version 4.2, was used to identify avoidable admissions based on all the adult PQIs and a subset of 4 pediatric quality indicators. The potentially preventable readmissions were identified first and then set aside. The remaining admissions were analyzed to determine if any could have been avoided, as indicated by the prevention quality indicators. By using this approach, if the admission was already identified as a PPR, it could not be counted again as a PQI and therefore the double counting of an admission as both a potentially preventable readmission and avoidable admission was circumvented. If the hospitalization was identified as either a PPR or PQI, it was considered a potentially avoidable hospitalization. Results are presented for both fee for service (FFS) and managed care (MC) admissions, as well as by the recipient´s region of residence, New York City (NYC) and the rest of the state (ROS).

The number and cost of potentially preventable readmissions within 30 days of the initial admission by recipient status and region are reported in Table 1. In 2009, 62,043 potentially preventable readmissions occurred after an initial admission. These readmissions cost a total of $589 million. Patients living in NYC accounted for 69% of these readmissions and 74% of the total cost. Nearly three-fourths of the PPRs (72%) and approximately 80% of the total cost for PPRs were associated with FFS admissions. In NYC, 73% of all PPRs were FFS admissions, compared to 70% in the rest of the state. FFS admissions in NYC represented the highest number of PPRs and also the highest cost.

An avoidable admission was defined as an admission that was for an ambulatory care sensitive condition, as defined by the PQI logic. An admission could be identified by more than one PQI, but in this analysis if the admission flagged on multiple PQIs it was counted only once as an avoidable admission. In 2009, there were a total of 90,546 avoidable admissions, not already identified as a potentially preventable readmission, costing $824 million. Table 2 illustrates that 58,868 avoidable admissions (65%) were for NYC recipients. These NYC admissions were 70% of the total cost for all avoidable admissions. Slightly over two-thirds of all avoidable admissions (68%) were FFS, accounting for 74% of the overall cost of avoidable admissions. As was the case for PPRs, the majority of avoidable admissions and associated costs were FFS admissions in the NYC region.

Table 5 contains the number of avoidable admissions for each PQI by recipient status. Avoidable admissions are the number of admissions that were identified by each particular PQI (numerator). At risk admissions are the number of admissions that met the inclusion criteria to be considered for the PQI (denominator). An admission could have more than one PQI, so the total number of avoidable admissions, if summed, is more than the total avoidable admissions in Table 2. Statewide, the most frequent avoidable admissions were admissions for adult asthma, bacterial pneumonia and congestive heart failure. For managed care admissions, avoidable admissions were most frequently identified by admissions for adult asthma, pediatric asthma and low birth weight. The most frequent prevention quality indicators for fee for service admissions were congestive heart failure, bacterial pneumonia and adult asthma. Perforated appendix and pediatric asthma admissions were the prevention quality indicators with the highest number of admissions per 100 admissions eligible, regardless of recipient status. Also frequent were low birth weight admissions for FFS recipients and pediatric gastroenteritis for managed care admissions.

A potentially avoidable hospitalization was classified as any hospital admission that was either a potentially preventable readmission or an avoidable admission as identified by the PQIs. Table 3 contains all the hospital inpatient discharges and cost for Medicaid in 2009 by recipient status and region.

Table 4 also contains the same information for the potentially avoidable hospitalizations. For NYC residents, 18% of their discharges in 2009 were potentially avoidable hospitalizations, compared to 16% in the rest of the state.

In managed care, 13% of discharges were potentially avoidable whereas 20% of FFS were potentially avoidable hospitalizations. The total cost of the 152,589 potentially avoidable hospitalizations statewide was slightly over $1.4 billion ($1.1 billion for fee for service admissions and $335 million for managed care admissions). NYC recipients accounted for 67% of all the potentially avoidable hospitalizations and 72% of the total cost.

The data upon which these analyses were performed were extracted from New York State´s Medicaid OHIP Data Mart. The data set contained 871,496 inpatient hospital discharges from article 28 facilities during 2009.

The first step was to define those admissions that were potentially preventable readmissions. The PPR software, created by 3M, version 28.0 was used, with the readmission window set at 30 days. The results in this brief cannot be compared to the PPR results presented in Statistical Brief #2, as version 28.0 was used for these analyses and version 26.1 of the PPR software was used for the 2007 analyses. There have been changes to the logic (particularly the types of events to include and exclude) so the PPR rates are not comparable.

Then the remaining admissions were run through the PQI numerator logic to determine if the admission was for an ambulatory care sensitive condition and therefore the admission could have been avoided. The PQI logic from version 4.2 (September 2010 release) was used. All the PQIs were evaluated, along with the 4 pediatric quality indicators listed above. The PQI numerator logic was used to identify PQI admissions. The denominator was defined as those hospital inpatient admissions that were not excluded by any of the numerator or denominator exclusion criteria. For example, in PQI 1, Diabetes Short-term Complications, the denominator was those admissions not already defined as a potentially preventable readmission, age 18 and over, and the MDC was not 14 or missing. Transfers were not excluded (as the PQI logic suggests) because this information was not in the data set. The numerator was the admissions in the at-risk population that had one of the primary diagnosis codes for diabetes short-term complications.

The admission costs were determined using the paid amount on the claim for FFS, which had the GME portion of the bill factored into the paid amount. For managed care records, the cost was estimated using the shadow pricing algorithm. The GME portion of the bill was not included in the shadow price cost.

Number and Cost of 30 Day Potentially Preventable Readmissions, by Medicaid Type and Region

  Fee for Service Admissions Fee for Service Cost Managed Care Admissions Managed Care Cost Total Admissions Total Cost
NYC 31,342 $349,071,190 11,640 $87,747,192 42,982 $436,818,382
ROS 13,339 $116,650,955 5,722 $36,029,959 19,061 $152,680,914
Statewide 44,681 $465,722,145 17,362 $123,777,151 62,043 $589,499,296

Number and Cost of Avoidable Admissions, by Medicaid Type and Region

  Fee for Service Admissions Fee for Service Cost Managed Care Admissions Managed Care Cost Total Admissions Total Cost
NYC 37,917 $421,328,697 20,951 $156,012,812 58,868 $577,341,509
ROS 23,602 $190,985,693 8,076 $55,521,984 31,678 $246,507,677
Statewide 61,519 $612,314,390 29,027 $211,534,796 90,546 $823,849,186

Total Medicaid Inpatient Discharges, by Medicaid Type and Region

  Fee for Service Admissions Fee for Service Cost Managed Care Admissions Managed Care Cost Total Admissions Total Cost
NYC 317,926 $3,120,862,538 234,883 $1,372,025,905 552,809 $4,492,888,442
ROS 205,661 $1,414,718,947 113,026 $540,458,207 318,687 $1,955,177,154
Statewide 523,587 $4,535,581,484 347,909 $1,912,484,112 871,496 $6,448,065,596

Total Potentially Avoidable Hospitalizations, by Medicaid Type and Region

  Fee for Service Admissions Fee for Service Cost Managed Care Admissions Managed Care Cost Total Admissions Total Cost
NYC 69,259 $770,399,887 32,591 $243,760,004 101,850 $1,014,159,891
ROS 36,941 $307,636,648 13,798 $91,551,943 50,739 $399,188,591
Statewide 106,200 $1,078,036,535 46,389 $335,311,947 152,589 $1,413,348,482

Frequency and Rate of Avoidable Admission, by Prevention Quality Indicator and Medicaid Type

  Fee for Service Admissions Managed Care Admissions Total Admissions
  Avoidable Admissions At Risk Admissions Rate per 100 Avoidable Admissions At Risk Admissions Rate per 100 Avoidable Admissions At Risk Admissions Rate per 100
Prevention Quality Indicator
PQI #1 Diabetes Short- Term Complication Admissions 2,243 382,090 0.59 1,268 124,404 1.023,511 506,4940.69
PQI #2 Perforated Appendix Admissions 597 2,344 25.47 286 1,599 17.89883 3,94322.39
PQI #3 Diabetes Long- Term Complication Admissions 5,263 382,090 1.38 1,812 124,404 1.467,075 506,4941.40
PQI #5 Chronic Obstructive Pulmonary Disease Admissions 5,764 382,090 1.51 1,261 124,404 1.017,025 506,4941.39
PQI #7 Hypertension Admissions 2,926 371,713 0.79 1,060 119,565 0.893,986 491,2780.81
PQI #8 Congestive Heart Failure Admissions 9,688 371,901 2.60 1,945 119,603 1.6311,633 491,5042.37
PQI #9 Low Birth Weight Admissions 4,037 37,529 10.76 3,624 75,176 4.827,661 112,7056.80
PQI #10 Dehydration Admissions 2,267 382,090 0.59 532 124,404 0.432,799 506,4940.55
PQI #11 Bacterial Pneumonia Admissions 9,467 340,974 2.78 2,302 117,117 1.9711,769 458,0912.57
PQI #12 Urinary Tract Infection Admissions 6,630 342,959 1.93 1,618 118,097 1.378,248 461,0561.79
PQI #13 Angina Without Procedure Admissions 959 371,901 0.26 528 119,603 0.441,487 491,5040.30
PQI #14 Uncontrolled Diabetes Admissions 1,661 382,090 0.43 672 124,404 0.542,333 506,4940.46
PQI #15 Adult Asthma Admissions 7,338 381,785 1.92 4,523 124,316 3.6411,861 506,1012.34
PQI #16 Lower Extremity Amputation among diabetics Admissions 1,182 382,068 0.31 366 124,401 0.291,548 506,4690.31
Pediatric Prevention
>PDI #14 Pediatric Asthma Admissions 1,249 14,175 8.81 4,366 24,652 17.71 5,615 38,827 14.46
>PDI #15 Diabetes Short-Term Complication Admissions 111 10,337 1.07 278 14,343 1.94389 24,6801.58
PDI #16 Gastroenteritis Admissions 612 19,065 3.21 2,043 36,935 5.53 2,655 56,000 4.74
PDI #18 Urinary Tract Infection Admissions 251 19,520 1.29 802 38,665 2.07 1,053 58,185 1.81