Potentially Preventable Hospitalizations (PPH) Among Persons With Diabetes Mellitus

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If you’re expecting your newly established Patient Centered Medical Home (PCMH), Accountable Care Organization (ACO) or Population-Care Management Program to reduce hospitalizations among persons with diabetes, you may want to sprinkle the acronym “PPH” into your business plans, talking points and meeting pitches. It stands for “potentially preventable hospitalizations.”  It’s not only a timely topic, but by brandishing the term “PPH,” compared to all those unfortunate knuckleheads who don’t read the Disease Management Care Blog, you’ll once again remind everyone about your health industry chops.

That’s why a look at this AJMC article examining “PPH” in a population of persons with diabetes may be worth your time.  555,538 California ’05-’06 hospitalizations for 361,858 persons aged 65 years or greater were examined for the presence of an "ambulatory care sensitive condition" or "ACSC".  The science underlying the use of ACSC metrics in this study has shown that the effective outpatient care of persons with certain concurrent ACSCs can reduce hospitalizations. The ACSCs used by the researchers in the AJMC article were bacterial pneumonia, dehydration, urine infection, COPD, heart failure, hypertension, diabetes complications and uncontrolled diabetes. 

In addition to ACSCs, the the authors looked at the impact of age, gender, race, neighborhood, income, insurance type (Medicare, Medicaid or commercial) and the number of other chronic conditions (as determined by insurance claims).

The results?  More than 112,000 (about 20%) of the hospitalizations were due to an ACSC and therefore were PPHs.   The most common conditions were pneumonia and heart failure; the length of stay averaged 5 days with a per hospitalization cost of approximately $9900.  The authors estimated that PPHs resulted in 570,000 hospital days and a cost of more than $1.1 billion  Being female, Medicaid, rural dwelling, low income, having multiple co-morbidities and having to be admitted via the emergency room were all associated with PPHs.

How can this information help the PCMH-savvy, ACO-adroit and care management cognoscenti?  While the authors of the AJMC article vaguely suggest that better vaccination rates against flu and pneumonia may work, the DMCB offers up some additional observations:

1. Baseline:  Now readers have an idea of the extent of the problem in a diabetes population.  20% is a lot of PPHs, a lot of hospital days and a lot of money.

2. Reality Check:  In this study, 80% of the admissions for persons with diabetes were NOT potentially preventable.  This should give pause to anyone believing that their initiative can precipitously reduce hospitalization rates.  Doctors (the kind that actually take care of patients) will also tell you that many PPHs are not truly preventable also: many people get acute pneumonia and heart failure exacerbations despite the best of care. As a result, more than 90% of hospitalizations among elderly persons with diabetes may not be preventable.

3. Generalist Care Management, not just diabetes care: your organization's nursing care plans have to not only address blood glucose control, but a host of other co-morbidities that are the real short term drivers of inpatient use.

4. But, Cake and Eat It Too: There are scant data on this, but the DMCB believes that good blood glucose control leads to fewer infections and atherothrombotic complications.  If it is correct, good care management not only has to manage multiple co-morbidities (the cake) but achieve good blood sugar control (the eats).

5. ER Chicken and Egg:  Does becoming very ill with an ACSC make ER visits more likely which, in turn, makes a PPH more likely?  The DMCB agrees that that is one causal pathway accounting for the data above.  However, it also wonders if presenting to an ER with any ACSC at any stage of illness is more likely to lead to an admission.  If the DMCB is correct, it stands to reason that 1) developing initiatives that keep patients away from the ER (with outpatient care options) may materially reduce admissions and 2) putting care management resources in the ER to assist with discharge planning is an option because it may divert patients to the outpatient setting.