Small and rural hospitals take less heat with measure of excess days in acute care

A hospital performance metric that captures all encounters occurring within 30 days of discharge substantially changed performance rankings compared with the readmissions measure of Medicare’s Hospital Readmissions Reduction Program (HRRP), researchers reported.

In a study of 3,173 U.S. hospitals and under the HRRP, “the penalty status for more than a quarter of hospitals would change if the EDAC [excess days in acute care] measure, rather than the readmission measure, were used to evaluate performance. Small [<200 beds] and rural hospitals would see a marked reduction in the burden of financial penalties,” stated Rishi K. Wadhera, MD, MPP, MPhil, of the Beth Israel Deaconess Medical Center in Boston, and co-authors.

Looking specifically at three conditions – heart failure (HF), acute myocardial infarction (AMI), and pneumonia — the authors reported the following in the Annals of Internal Medicine:

  • Median readmissions rate: 21.6% for HF (range 15.9%-29.8%), 16.0% for AMI (range 12.0%-20.7%), 16.7% for pneumonia (range 12.5%-23.3%).
  • Median EDAC/100 discharges: 5.1 days (range 60.1-143.4 days), 4.8 days (range 59.0-174.3 days), 6.3 days (range 57.8-148.9 days).

Also, in terms of penalty status, under the HRRP, the penalty status of 27.0% of 2,845 hospitals for HF, 28.3% of 2,055 for AMI, and 24.9% of 2,911 for pneumonia would change if the EDAC measure were used instead of the readmission measure to evaluate hospital performance for each condition, the authors noted, with penalties either being “down classified” or “up-classified.”

Specifically, fewer small hospitals and rural hospitals, respectively, would be penalized under EDAC versus the readmission measure for:

  • HF: 40.5% versus 49.5%; 36.8% versus 46.9% (P<0.001 for both).
  • AMI: 43.9% versus 48.8% (P=0.009); 38.1% versus 45.3% (P=0.02).
  • Pneumonia: 38.5% versus 45.0%; 34.0% versus 40.3% (P<0.001 for both).

“Concern is growing that the 30-day readmission measure, which has been used increasingly by CMS to assess hospitals, provides an incomplete picture of performance,” Wadhera and co-authors stated. “The HRRP has imposed more than $3 billion in financial penalties to date but has been criticized because it does not fully risk adjust readmission performance for important clinical characteristics (such as frailty) and social factors (such as housing instability), which are associated with a higher risk for hospitalization.”

In fiscal year 2020, the Centers for Medicare & Medicaid (CMS) will penalize 2,583 hospitals for 30-day readmissions, according to Becker’s Hospital Review. What does that mean in dollars and cents? For example, those cuts totaled $563 million over a year for 22 Kansas City-area hospitals in 2019, reported the Kansas City Business Journal.

On the other hand, using EDAC “would reduce financial penalties imposed on small and rural hospitals… reducing financial penalties for rural hospitals is particularly important, because many of these health systems are facing financial instability and are closing at an alarming rate across the United States,” the authors stressed.

Indeed, HRRP “readmission measures as a reflection of quality of care in national rankings and pay-for-performance programs is empirically suspect and an ongoing source of frustration and confusion among health care leaders and researchers,” stated Saul N. Weingart, MD, MPP, PhD, of Tufts Medical Center and Tufts University School of Medicine in Boston, in an editorial accompanying the study.

“Wadhera and colleagues’ analysis is clearly a step in the right direction, at least as a measure of resource use…[the authors] make a compelling argument for replacing the HRRP’s 30-day readmissions measure with EDAC, given its enhanced ability to capture relevant information compared with the readmissions metric,” he wrote.

However, Weingart asserted that both EDAC and readmissions are inadequate as they “are poorly designed to measure quality of care and patient safety.” Even the version of EDAC proposed by the authors — incorporating patients who were dually enrolled in Medicare and Medicaid — “suffers from the same problem as the readmissions measure in its limited ability to adjust for frailty, medical complexity, and social determinants of health — major drivers of rehospitalization,” he argued, adding “We can do better.”

The authors used data from the CMS Hospital Compare files to find short-term acute care hospitals that participated in the HRRP in fiscal year 2019. They obtained their performance on the 30-day readmission and EDAC measures, all publicly reported by CMS for the three conditions. They included all discharges among Medicare fee-for-service beneficiaries (ages ≥65 years) from July 2014 to June 2019.

They noted that the “hospital-level 30-day readmission measure captures unplanned inpatient readmissions that occur within 30 days of discharge after an index hospitalization,” while EDAC “captures the total number of days a patient spends in an ED [emergency department], in observation status, or admitted as an unplanned readmission within 30 days of discharge after an index hospitalization.”

“The EDAC measure describes the difference (’excess’) between the average number of days patients spend in acute care per 100 discharges and the expected number of days given the case mix of that hospital,” the authors added [italics are their own].

They reported that, overall, there was only moderate agreement on hospital performance rankings by readmission and EDAC metrics for the three conditions:

  • HF: weighted κ statistic 0.45 (95% CI 0.42-0.47).
  • AMI: 0.37 (95% CI 0.35-0.40).
  • Pneumonia 0.50 (95% CI 0.47-0.52).

Study limitations included the fact that EDAC “does not address other limitations, including inadequate risk adjustment for social risk and the upcoding of comorbid conditions,” Wadhera’s group wrote.

Still, they advocated that “The CMS should consider using the EDAC measure, which provides a more comprehensive picture of hospital use within 30 days of discharge than the readmission measure, to evaluate health care system performance under federal quality, reporting, and value-based programs.”

  1. The 30-day readmissions penalty status of more than a quarter of U.S. hospitals would change if the excess days in acute care (EDAC) measure were used in the Hospital Readmissions Reduction Program.

  2. Small (<200 beds) and rural hospitals would be less likely to receive penalties.

Shalmali Pal, Contributing Writer, BreakingMED™

Wadhera disclosed research support from the National Heart, Lung, and Blood Institute (grant K23HL148525-1) at the National Institutes of Health. He previously served as a consultant for Regeneron, outside the submitted work.

Weingart disclosed no relationships relevant to the contents of this paper.

Cat ID: 791

Topic ID: 498,791,791,807,507,509,556,800,192,808,925