Diagnosis Related Group-Based Readmission Profiling

By Arushi Khurana and Sumeet Vashishta

29 August 2019

Practical Analytic Approaches to Healthcare Challenges


High rates of unplanned readmissions indicate poor quality of care or gaps in care coordination, and bring an increased financial burden on the healthcare system.[i] The major reasons for unplanned readmissions include premature discharge from initial hospitalization, gaps in post-operative care, unnecessary inpatient admissions from the Emergency Department, no integrated system for patient records leading to incomplete information sharing, and misunderstandings of patient discharge instructions.[ii]

A study published by the Healthcare Cost and Utilization Project (HCUP) in 2014, found that 3.3 million 30-day readmissions occurred in the United States in 2011 and cost $41 billion.[iii] Healthcare policy makers, payers, and providers are making efforts to reduce hospital readmissions. The Centers for Medicaid and Medicare Services (CMS) in 2012 initiated the Hospital Readmissions Reduction Program (HRRP) to bring attention to unnecessary readmissions. Since then, readmissions within 30 days of an acute inpatient discharge have become a key indicator for healthcare quality.[iv]

Penalties imposed by Medicare for high readmission rates increased by $108 million from 2015 to 2016, putting the total withheld reimbursements for 2016 at $528 million.1 However, between 2007 and 2015, the overall readmission rate for the targeted diseases of HRRP decreased from 21.5% to 17.8% and rates for non-targeted conditions decreased from 15.3% to 13.1%.[v]

MedInsight provides a number of evidence-based measures to assess the quality of inpatient care such as the Plan All-Cause Readmissions (PCR) Healthcare Effectiveness Data and Information Set (HEDIS®[1])measure which provides a comparison between the expected and observed readmission rate. We analyzed a MedInsight client’s 2016 data containing over 3.9 million Medicaid, Medicare Advantage, and Commercial plan members, to explore the most common conditions resulting in readmissions within 7, 15, and 30 days of an acute inpatient discharge.

Diagnosis Related Group-Based Summarization
Out of all reported admissions in the year 2016, 3.2%, 6.3% and 10.3% of cases resulted in unplanned readmissions within 7, 15, and 30 days, respectively. Table 1 displays the percentage of index admissions that had an unplanned readmission within 7,15, and 30 days, for ten Medicare Severity-Diagnosis Related Groups (MS-DRGs) families with high admission counts and significant readmission rates. Instead of individual DRGs we used DRG families created by Milliman’s New York health practice which groups together clinically related DRGs. We found that not all DRG families with high index admission counts have high readmission counts. For example, the DRG family ‘Lower Extremity Arthroplasty’ had the highest admission count but a low readmission count.

A 2017 statistical brief by the HCUP showed the top 20 index admission primary diagnoses for 7- and 30-day all-cause readmission rates in 2014. The top 10 primary diagnoses for 30-day readmission rates were congestive heart failure, schizophrenia, respiratory failure, alcohol related disorders, anemia, hypertension, diabetes, renal failure, chronic obstructive pulmonary disease, and implant/graft complications.[vi] The findings of our analysis are shown in Table 1.

Table 1: DRG Families with High Index Admission Counts and Significant Readmission Rates

Same DRG Family Readmissions for the Top 10 DRG Families by Index Admission Count
Approximately 22% of the 7-, 15-, and 30-day readmissions had the same DRG family as the index admission. For the top 10 DRG families with the highest number of inpatient index admissions in 2016, the bar plot below (Figure 1) shows the percentage of unplanned readmissions within 7,15, and 30 days with the same DRG family. The values range from very low (below 2%) for lower extremity arthroplasty to very high (80% and above) for mental disorders.

Figure 1: Same DRG Family Readmission Rates for the Top 10 DRG Families by Index Admission Count

Same MDC Readmissions for the Top 10 MDCs by Index Admission Count
We further examined the major diagnosis category (MDC) of the index admissions and readmissions. Figure 2 shows the percentage of readmissions within 7, 15, and 30 days for the top 10 MDCs with the highest number of index admissions in 2016.

  • For each of the top 10 MDCs, more than 25% of unplanned readmissions had the same MDC as the index admission.
  • About 80% of all unplanned mental health disorder readmissions had the same MDC as the index admission.
  • Musculoskeletal disorders index admissions had the lowest percentage of readmissions with the same MDC.

  • Figure 2: Same MDC Readmission Rates for the Top 10 MDCs by Index Admission Count


    A high percentage of unplanned readmissions that we reviewed in our analysis had the same DRG family or MDC as their corresponding index admission. This observation might be attributed to possible gaps in the quality of care or the care delivery process. Plans and providers can choose from several inpatient quality measures provided in MedInsight to get an overview of their respective standing in comparison to national/regional benchmarks and design interventions to improve the quality of inpatient care.


    [1] HEDIS® is a registeredtrademark of the National Committee for Quality Assurance (NCQA).

    [i] National Quality Forum, All-Cause Admissions and Readmissions Technical report, September, 2017. Available at: https://www.qualityforum.org/Publications/2017/09/All-Cause_Admissions_and_Readmissions_2017_Technical_Report.aspx.

    [ii]T. Edelman, 2016. Center for Medicare Advocacy, Reducing Hospital Readmissions by Addressing the Causes, April 18, 2016. Available at: https://www.medicareadvocacy.org/reducing-hospital-readmissions-by-addressing-the-causes/.

    [iii] Anika L. Hines et al, 2014. Conditions with the Largest Number of Adult Hospital Readmissions by Payer, 2011. Published: April, 2014. Available at: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb172-Conditions-Readmissions-Payer.pdf.

    [iv] Center for Medicare and Medicaid Services- Readmissions Reduction Program (HRRP). Last Modified: April, 2018. Available at: https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html.

    [v] Rachael Zuckerman et al, 2016. The New England Journal of Medicine, Readmissions, Observation, and the Hospital Readmissions Reduction Program. Published: April 21, 2016. Available at: https://www.nejm.org/doi/full/10.1056/NEJMsa1513024.

    [vi] Kathryn R. Fingar et al, 2017. A Comparison of All-Cause 7-Day and 30-Day Readmissions, 2014. Published: October 2017. Available at: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb230-7-Day-Versus-30-Day-Readmissions.jsp?utm_source=ahrq&utm_medium=en1&utm_term=&utm_content=1&utm_campaign=ahrq_en11_7_2017.

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