Potentially Avoidable Complications

An Episode of Care definition includes all covered services across all providers that would typically treat a patient for a single illness or condition (hospital, physicians, laboratory, pharmacy, rehabilitation facility, etc.). Definitions are comprised of diagnosis, procedure and pharmacy code tables, which establish the episode’s triggers and boundaries.

These episode definitions can be used as the foundation for multiple purposes, including bundled payment and ACO payment programs, reference-pricing initiatives, and for cost and quality analysis of providers.

Key Features
Episode of Care definitions are a core element of the PROMETHEUS Analytics and one of their most distinct charecteristic is the ditinction of diagnosis codes included in the definitions that can be deemed typical or routine, from those deemed to indicate a potentially avoidable complication (PAC).

Ours are the only episode definitions that include this distinction. PACs were created to determine the amount of unexplainable variation in total costs of care that could be reasonably attributed to complications under the control of providers and can be used to create incentives for both cost-saving and for quality analysis. For example, in the figure below that represents the distribution of knee replacement episode costs, all of the higher cost episodes are the ones that include PACs. Without this crucial distinction, providers and payers would be hard-pressed to understand why some episodes are more expensive than others and work to reduce PACs.

There are two categories of PACs:

• Type 1 -- Related to the index condition or stay – for example, an emergency department (ED) visit for keto-acidosis by a diabetic patient, or a repeat acute Myocardial Infarction (MI) within 30 days of discharge for a patient hospitalized with an AMI.
• Type 2 -- Related to patient safety failures – for example, an adverse drug event for a patient with COPD, or a post-operative wound infection.

The following figure represents the frequency of PACs for hypertension episodes in a commercially insured population, by PAC type.

In January 2011, the National Quality Forum endorsed 4 PAC measures as comprehensive outcomes measures. These were for acute myocardial infarction (heart attack), pneumonia, stroke and six chronic conditions: diabetes, congestive heart failure (CHF), hypertension, chronic obstructive pulmonary disease (COPD), asthma and coronary artery disease (CAD).