Acute Care Measure Could Reduce Hospital Readmission Penalties

About one in four hospitals would see their penalty status change under the Hospital Readmissions Reduction Program (HRRP) if penalties were determined using “excess days in acute care” (EDAC), a more comprehensive measure of hospital use after discharge, instead of looking only at 30-day readmissions.

The EDAC measure captures all days spent in acute care settings within 30 days of discharge, including emergency department (ED) visits, observation stays, and unplanned readmissions.

In the study, published online October 13 in Annals of Internal Medicine, half of hospitals in the highest-performing group under the more blunt 30-day readmissions measure would fall to a lower-performing group if EDAC were used.

Conversely, a similar number of low-performing hospitals would jump to a higher stratum.

“We know that linking the 30-day readmission measure to penalties under the HRRP has led to intensified efforts to treat patients in the ED or as observation stays,” said lead author Rishi Wadhera, MD, MPP, MPhil Beth Israel Deaconess Medical Center, Boston. “While this makes hospitals’ readmission rates look lower, it’s not clear that these shifts are actually good for patient care.”

Given the $3 billion in penalties assessed by Centers for Medicare & Medicaid Services (CMS) under the HRRP since its implementation in 2012, a switch to EDAC could help pull some struggling hospitals back from the brink.

Of particular concern, said Wadhera, is evidence showing that small rural and less resourced hospitals might be taking the brunt of those penalties.

“Large hospitals have the capacity and infrastructure to treat patients in the ER or place them in observation status, such that these encounters won’t count as readmissions. Small rural hospitals don’t have that capacity and may be unfairly penalized,” he suggested.

This new study compared the impact of the standard 30-day readmissions measure with the EDAC measure in 3173 hospitals that participated in the HRRP in 2019.

Because of ongoing concerns regarding unintended consequences associated with the 30-day readmissions measure, including a possibility of increased mortality among patients admitted with heart failure and pneumonia, there have been numerous calls from the clinician and health policy communities, including a recent one in JAMA from Ashish K. Jha, MD, MPH, Brown University School of Public Health, Providence, Rhode Island, to replace the metric with a more comprehensive measure of hospital use.

EDAC was developed for CMS and has been publicly reported since 2017, but is not included in the HRRP. Like the 30-day readmissions measure, however, it does not fully adjust for risk factors like frailty and medical complexity.

The EDAC measure would diminish the perverse incentive to avoid readmitting patients who come back to the hospital.

“One advantage of the EDAC measure is that it’s comprehensive and less gameable, because it counts all hospital encounters after discharge, including ED visits, observation stays, and/or readmissions. The EDAC measure would diminish the perverse incentive to avoid readmitting patients who come back to the hospital and allow for fairer comparisons of hospital performance,” said Wadhera.

“But at best, switching from 30-day

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