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Healthcare Insights

Top 20 DRGs by highest readmission rates

One of the biggest priorities in hospital care today is identifying the risks of and avoiding preventable readmissions. Readmissions are estimated to cost the healthcare system more than $20 billion a year.

The U.S. healthcare industry is more often tying reimbursement rates to the quality of patient care. For example, the Centers for Medicare and Medicaid Services (CMS) tracks readmission rates through the Hospital Readmissions Reduction Program (HRRP) as well as Diagnostic Related Groups (DRGs), which are used to categorize patients based on their primary diagnosis, procedures received, and discharge status. DRGs ensure that Medicare reimbursements take into account the types and level of severity of patients typically seen at the hospital.

For this Healthcare Insight, we use data from the Definitive Healthcare HospitalView product to analyze the top DRGs at hospitals with the highest readmission rates.

First, we gathered the top DRG codes for more than 4,800 hospitals.

Next, we analyzed the all-cause readmission rates from about 4,300 hospitals. This number is slightly lower because some hospitals, such as critical access hospitals and psychiatric hospitals, don’t track readmissions with CMS due to their specialties. The national average readmission rate is 15.0% with a range of scores from 9.9% to 22.5%.

Then we filtered out the hospitals with the highest all-cause readmission rate, those above 16%.

Finally, we compared the lists to find the top DRG codes at the hospitals with some of the highest readmission rates. This list shows the percentage of the 423 hospitals with the highest all-cause readmission rate that reported the DRG in calendar year 2021.

Top DRGs at hospitals with the highest readmission rates

Rank DRG code Description Percent of highest readmission rate hospitals Explore dataset
871 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 OR MORE HOURS W MCC 74.2% Explore
177 RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC 68.6% Explore
291 HEART FAILURE & SHOCK W MCC 68.3% Explore
207 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 OR MORE HOURS 64.5% Explore
853 INFECTIOUS & PARASITIC DISEASES W O.R. PROCEDURE W MCC 64.5% Explore
870 SEPTICEMIA OR SEVERE SEPSIS W MV 96 OR MORE HOURS 62.2% Explore
208 RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT <96 HOURS 59.6% Explore
TRACH W MV 96 OR MORE HRS OR PDX EXC FACE, MOUTH & NECK W/O MAJ O.R. 54.6% Explore
193 SIMPLE PNEUMONIA & PLEURISY W MCC 53.7% Explore
10 392 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC 53.7% Explore
11 682 RENAL FAILURE W MCC 50.4% Explore
12 280 ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE W MCC 50.1% Explore
13 329 MAJOR SMALL & LARGE BOWEL PROCEDURES W MCC 48.5% Explore
14 65 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC 46.6% Explore
15 872 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96 OR MORE HOURS W/O MCC 45.6% Explore
16 377 G.I. HEMORRHAGE W MCC 45.4% Explore
17 64 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W MCC 45.2% Explore
18 246 PERC CARDIOVASC PROC W DRUG-ELUTING STENT W MCC OR 4 OR MORE VESSELS/STENTS 44.4% Explore
19 981 EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS W MCC 44.4% Explore
20 247 PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC 44.2% Explore

Fig 1. Data from the Definitive Healthcare HospitalView product and sourced from the Centers for Medicare and Medicaid Services (CMS) and the Medicare Standard Analytical Files (SAF). Data accessed October 2022.

The top DRG codes at hospitals with the highest readmission rates are sepsis, respiratory conditions, including those with ventilator support, heart failure, and infectious and parasitic diseases.

Sepsis is the result of a complication of an infection and can be life-threating. It is a healthcare associate infection (HAI) where early detection and treatment is necessary.

The appearance of respiratory conditions on list is likely associated with chronic conditions, such as COPD, as well as COVID-19.

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Healthcare Insights are developed with healthcare commercial intelligence from the Definitive Healthcare platform. Want even more insights? Start a free trial now and get access to the latest healthcare commercial intelligence on hospitals, physicians, and other healthcare providers.