Evaluation of Hospital Performance Using the Excess Days in Acute Care Measure in the Hospital Readmissions Reduction Program

Abstract

The Hospital Readmissions Reduction Program (HRRP) has penalized hospitals with higher 30-day readmission rates more than $3 billion to date. Clinicians and policy experts have raised concerns that the 30-day readmission measure used in this program provides an incomplete picture of performance because it does not capture all hospital encounters that may occur after discharge. In contrast, the excess days in acute care (EDAC) measure, which currently is not used in the HRRP, captures the full spectrum of hospital encounters (emergency department, observation stay, inpatient readmission) and their associated lengths of stay within 30 days of discharge. This study of 3173 hospitals that participated in the HRRP in fiscal year 2019 compared performance on the readmission and EDAC measures and evaluated whether using the EDAC measure would change hospitals' penalty status for 3 conditions targeted by the HRRP. Overall, only moderate agreement was found on hospital performance rankings by using the readmission and EDAC measures (weighted κ statistic: heart failure, 0.45 [95% CI, 0.42 to 0.47]; acute myocardial infarction [AMI], 0.37 [CI, 0.35 to 0.40]; and pneumonia, 0.50 [CI, 0.47 to 0.52]). Under the HRRP, the penalty status of 769 (27.0%) of 2845 hospitals for heart failure, 581 (28.3%) of 2055 for AMI, and 724 (24.9%) of 2911 for pneumonia would change if the EDAC measure were used instead of the readmission measure to evaluate performance. Fewer small and rural hospitals would receive penalties. The Centers for Medicare & Medicaid Services should consider using the EDAC measure, which provides a more comprehensive picture of postdischarge hospital use, rather than the 30-day readmission measure to evaluate health care system performance under federal quality, reporting, and value-based programs.

Figure 1.

Reclassification of hospital performance rankings on the basis of the EDAC measure for heart failure (top), AMI (middle), and pneumonia (bottom). Hospitals were ranked into performance quintiles, with group 1 representing “best-performing” and group 5 “worst-performing” hospitals. Each column shows hospitals falling within a specific group ranking on the basis of the readmission measure, and each row shows the number (%) of those hospitals that would (or would not) be reclassified on the basis of the EDAC measure. The dark gray cells show the number (%) of hospitals within a readmission performance group that would have no change in performance ranking if the EDAC measure were used. The light gray cells show the number (%) of hospitals within a readmission performance group that would shift into a lower performance group on the basis of the EDAC measure. The unshaded cells show the number (%) of hospitals within a readmission performance group that would shift into a higher performance group if the EDAC measure were used. The number of hospitals in each performance quintile is unequal because some hospitals had identical readmission rates. AMI = acute myocardial infarction; EDAC = excess days in acute care.

Figure 2.

Reclassification of hospital penalty status on the basis of the EDAC measure for heart failure (top), AMI (middle), and pneumonia (bottom). The gray cells show the number (%) of hospitals penalized (or not) under the HRRP readmission measure that would have no change in penalty status with the EDAC measure. The unshaded cells show the number (%) of hospitals that are penalized (or not) under the readmission measure that would have a change in penalty status with the EDAC measure. To assess changes in penalty status, we replicated the approach that the Centers for Medicare & Medicaid Services currently uses for the HRRP, which stratifies eligible hospitals into 5 peer group quintiles based on the proportion of Medicare hospital stays for which patients were dually enrolled in Medicare and Medicaid. Hospitals are evaluated relative to the median performance within their group, and financial penalties under the HRRP are levied on those with worse than median performance. AMI = acute myocardial infarction; EDAC = excess days in acute care; HRRP = Hospital Readmissions Reduction Program.