Table Of ContentAll-Cause Admissions and
Readmissions 2015-2017
TECHNICAL REPORT
April 24, 2017
This report is funded by the Department of Health
and Human Services under contract HHSM-500-
2012-00009I Task Order HHSM-500-T0008.
Contents
Executive Summary ............................................................................................................................4
Introduction ......................................................................................................................................6
Trends and Performance ....................................................................................................................... 6
NQF Portfolio of Performance Measures for All-Cause Admissions and Readmissions Conditions .........7
Table 1. NQF Admissions and Readmissions Portfolio of Measures ..................................................... 7
NQF’s All-Cause Admissions and Readmissions Portfolio ..................................................................... 9
All-Cause Admissions and Readmissions Measure Evaluation ............................................................ 11
Comments Received Prior to Standing Committee Evaluation .......................................................... 11
Refining the NQF Measure Evaluation Process ................................................................................... 12
Standing Committee Evaluation ......................................................................................................... 12
Overarching Issues .............................................................................................................................. 13
Summary of Measure Evaluation ........................................................................................................ 20
Comments Received After Committee Evaluation ............................................................................. 29
References ....................................................................................................................................... 30
Appendix A: Details of Measure Evaluation ...................................................................................... 32
Endorsed Measures ............................................................................................................................. 32
0171 Acute Care Hospitalization During the First 60 Days of Home Health ................................... 32
0173 Emergency Department Use Without Hospitalization During the First 60 Days of Home
Health ....................................................................................................................................... 35
0330 Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following
Heart Failure (HF) Hospitalization ........................................................................................... 38
0506 Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following
Pneumonia Hospitalization ...................................................................................................... 46
1789 Hospital-Wide All-Cause Unplanned Readmission Measure (HWR) ...................................... 53
1891 Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following
Chronic Obstructive Pulmonary Disease (COPD) Hospitalization........................................... 61
2827 PointRight® Pro Long Stay(TM) Hospitalization Measure ....................................................... 65
2858 Discharge to Community .......................................................................................................... 71
2860 Thirty-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in
an Inpatient Psychiatric Facility (IPF) ....................................................................................... 77
2879 Hybrid Hospital-Wide Readmission Measure with Claims and Electronic Health Record
Data........................................................................................................................................... 81
2880 Excess Days in Acute Care (EDAC) After Hospitalization for Heart Failure ............................. 86
2881 Excess Days in Acute Care (EDAC) After Hospitalization for Acute Myocardial Infarction
(AMI) ......................................................................................................................................... 92
2882 Excess Days in Acute Care (EDAC) After Hospitalization for Pneumonia ............................... 98
2886 Risk-Standardized Acute Admission Rates for Patients with Heart Failure .......................... 103
2
2887 Risk-Standardized Acute Admission Rates for Patients with Diabetes ................................. 108
2888 Risk-Standardized Acute Admission Rates for Patients with Multiple Chronic
Conditions ...............................................................................................................................1 14
Measure Not Recommended ............................................................................................................ 120
2884 30-Day Unplanned Readmissions For Cancer Patients .........................................................1 20
Appendix B: NQF All-Cause Admissions and Readmissions Portfolio and Related Measures ............. 122
Appendix C: All-Cause Admissions and Readmissions Portfolio—Use in Federal Programs ............... 125
Appendix D: Project Standing Committee and NQF Staff ................................................................. 127
Appendix E: Measure Specifications ............................................................................................... 130
0171 Acute Care Hospitalization During the First 60 Days of Home Health ................................. 130
0173 Emergency Department Use Without Hospitalization During the First 60 Days of Home
Health .....................................................................................................................................1 37
0330 Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following
Heart Failure (HF) Hospitalization .........................................................................................1 42
0506 Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following
Pneumonia Hospitalization ....................................................................................................1 51
1789 Hospital-Wide All-Cause Unplanned Readmission Measure (HWR) ....................................1 60
1891 Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following
Chronic Obstructive Pulmonary Disease (COPD) Hospitalization.........................................1 68
2827 PointRight® Pro Long Stay(TM) Hospitalization Measure .....................................................1 76
2858 Discharge to Community ........................................................................................................1 82
2860 Thirty-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in
an Inpatient Psychiatric Facility (IPF) .....................................................................................1 88
2879 Hybrid Hospital-Wide Readmission Measure with Claims and Electronic Health Record
Data.........................................................................................................................................1 95
2880 Excess Days in Acute Care (EDAC) After Hospitalization for Heart Failure ........................... 204
2881 Excess Days in Acute Care (EDAC) After Hospitalization for Acute Myocardial Infarction
(AMI) .......................................................................................................................................2 11
2882 Excess Days in Acute Care (EDAC) After Hospitalization for Pneumonia ............................. 218
2886 Risk-Standardized Acute Admission Rates for Patients with Heart Failure .......................... 225
2887 Risk-Standardized Acute Admission Rates for Patients with Diabetes ................................. 231
2888 Risk-Standardized Acute Admission Rates for Patients with Multiple Chronic
Conditions ...............................................................................................................................2 37
Appendix F1: Related and Competing Measures (Tabular Format) ................................................... 245
Appendix F2: Related and Competing Measures (Narrative Format) ................................................ 314
Appendix G: Review of Previously Endorsed Measures for Risk Adjustment for Sociodemographic
Factors .......................................................................................................................................... 396
3
All-Cause Admissions and Readmissions 2015-2017
TECHNICAL REPORT
Executive Summary
Reducing avoidable admissions and readmissions to acute care facilities continues to be an important
focus of quality improvement across the healthcare system. Unnecessary hospitalizations can prolong
the illness of patients, increase their time away from home and family, expose them to potential harms,
and add to their costs. Avoidable admissions and readmissions also significantly contribute to the high
rate of healthcare spending in the United States. One estimate puts the cost of all-cause adult hospital
readmissions at over $40 billion annually. While there is no clear evidence on how many of these
readmissions are avoidable, estimates suggest that anywhere from 5 percent to 79 percent may be
preventable.1 A 2013 MedPAC report suggests that reducing avoidable readmissions by 10 percent could
achieve a savings of $1 billion or more.2
Currently, there are more than 46 NQF-endorsed admissions and readmissions measures. These
measures have been adopted into various federal quality programs with the aim of reducing
unnecessary admissions and readmissions by fostering improved care coordination across the
healthcare system.
The impact of sociodemographic status (SDS) on readmission measures continues to be an ongoing
question. As payment penalties attached to the use of readmission measures increase, questions have
arisen about how to improve performance without disproportionately affecting safety net facilities
serving the most vulnerable populations. To better understand these issues, NQF launched a two-year
trial period in April 2015 in which measures can be evaluated for the potential need for SDS adjustment
based on both conceptual and empirical evidence.
While admission and readmission rates continue to drop, it is imperative to ensure that they decrease
safely and without adverse consequences for patients. In particular, reducing admission and
readmission rates should be balanced with monitoring of unintended consequences to ensure that
patients are getting the care that they need.
For this project, the Standing Committee evaluated 11 newly submitted measures and six measures
undergoing maintenance review against NQF’s standard evaluation criteria. Sixteen measures were
endorsed:
• 0171 Acute Care Hospitalization During the First 60 Days of Home Health (Centers for Medicare
& Medicaid Services)
• 0173 Emergency Department Use without Hospitalization During the First 60 Days of Home
Health (Centers for Medicare & Medicaid Services)
• 0330 Hospital 30-day, all-cause, risk-standardized readmission rate (RSRR) following heart
failure (HF) hospitalization (Centers for Medicare & Medicaid Services/Yale New Haven Health
Services Corporation/Center for Outcomes Research and Evaluation [YNHHSC/CORE])
4
• 0506 Hospital 30-day, all-cause, risk-standardized readmission rate (RSRR) following pneumonia
hospitalization (Centers for Medicare & Medicaid Services/Yale New Haven Health Services
Corporation/Center for Outcomes Research and Evaluation [YNHHSC/CORE])
• 1789 Hospital-Wide All-Cause Unplanned Readmission Measure (HWR) (Centers for Medicare &
Medicaid Services/Yale New Haven Health Services Corporation/Center for Outcomes Research
and Evaluation [YNHHSC/CORE])
• 1891 Hospital 30-day, all-cause, risk-standardized readmission rate (RSRR) following chronic
obstructive pulmonary disease (COPD) hospitalization (Centers for Medicare & Medicaid
Services/Yale New Haven Health Services Corporation/Center for Outcomes Research and
Evaluation [YNHHSC/CORE])
• 2827 PointRight® Pro Long Stay(TM) Hospitalization Measure (PointRight)
• 2858 Discharge to Community (American Health Care Association)
• 2860 Thirty-Day All-Cause Unplanned Readmission Following Psychiatric Hospitalization in an
Inpatient Psychiatric Facility (IPF) (Health Services Advisory Group, Inc.)
• 2879 Hybrid Hospital-Wide Readmission Measure with Claims and Electronic Health Record Data
(Centers for Medicare & Medicaid Services/Yale New Haven Health Services Corporation/Center
for Outcomes Research and Evaluation [YNHHSC/CORE])
• 2880 Excess Days in Acute Care (EDAC) After Hospitalization for Heart Failure (Centers for
Medicare & Medicaid Services/Yale New Haven Health Services Corporation/Center for
Outcomes Research and Evaluation [YNHHSC/CORE])
• 2881 Excess Days in Acute Care (EDAC) After Hospitalization for Acute Myocardial Infarction
(AMI) (Centers for Medicare & Medicaid Services/Yale New Haven Health Services
Corporation/Center for Outcomes Research and Evaluation [YNHHSC/CORE])
• 2882 Excess Days in Acute Care (EDAC) After Hospitalization for Pneumonia (Centers for
Medicare & Medicaid Services/Yale New Haven Health Services Corporation/Center for
Outcomes Research and Evaluation [YNHHSC/CORE])
• 2886 Risk-Standardized Acute Admission Rates for Patients with Heart Failure (Centers for
Medicare & Medicaid Services/Yale New Haven Health Services Corporation/Center for
Outcomes Research and Evaluation [YNHHSC/CORE])
• 2887 Risk-Standardized Acute Admission Rates for Patients with Diabetes (Centers for Medicare
& Medicaid Services/Yale New Haven Health Services Corporation/Center for Outcomes
Research and Evaluation [YNHHSC/CORE])
• 2888 Risk-Standardized Acute Admission Rates for Patients with Multiple Chronic Conditions
(Centers for Medicare & Medicaid Services/Yale New Haven Health Services Corporation/Center
for Outcomes Research and Evaluation [YNHHSC/CORE])
The following measure was not endorsed:
• 2884 30-Day Unplanned Readmissions for Cancer Patients (Alliance of Dedicated Cancer Centers
[ADCC])
Brief summaries of the measures reviewed are included in the body of the report; detailed summaries of
the Standing Committee’s discussion and ratings of the criteria for each measure are in Appendix A.
5
Introduction
Reducing unnecessary admissions and readmissions to acute care facilities has been a focus of
healthcare quality improvement efforts. The Agency for Healthcare Research and Quality (AHRQ)
Healthcare Cost and Utilization Project (HCUP) estimated that in 2011, there were approximately 3.3
million adult 30-day all-cause hospital readmissions in the United States.3 It has been estimated that
one in five Medicare beneficiaries are readmitted within 30 days of discharge.
These excess hospitalizations can negatively impact a patient’s quality of life, forcing them to spend
more time away from home and their families. Avoidable admissions and readmissions cause patients
prolonged illness and pain, potential unnecessary exposure to harm, loss of productivity, inconvenience
and added cost. Avoidable admissions and readmissions also burden the healthcare system with
unnecessary costs. HCUP estimated that in 2011, 30-day adult all-cause hospital readmissions were
associated with about $41.3 billion in hospital costs.
The causes of avoidable admissions and readmissions are complex and multifactorial. Avoidable
admissions and readmissions can be related to a lack of care coordination and poor discharge planning.
However, environmental, community, and patient-level factors, including sociodemographic factors, can
also affect the risk of readmission. The complexity of what causes avoidable admissions and
readmissions means that providers across the healthcare continuum including hospitals, skilled nursing
facilities, and clinicians in the community must work together to ensure high-quality care transitions by
improving care coordination across providers and engaging patients and their families.
The National Quality Forum has actively worked to endorse and recommend the use of performance
measures to reduce avoidable admissions and readmissions. In 2012, NQF endorsed two all-cause
readmission measures. In 2015, NQF endorsed an additional 17 measures examining community-level
readmissions, pediatric readmissions, and readmission measures in post-acute care and long-term care
settings, in addition to hospital and health plan readmission measures. Past measure endorsement
projects endorsed six condition-specific readmission measures, as well as measures of acute care
hospitalization from home health and community settings. The NQF-convened Measure Applications
Partnership (MAP) has stressed the importance of measures addressing avoidable admissions and
readmissions when it recommends measures for use in federal quality initiative programs. MAP has
stressed that measures of readmissions should be part of a suite of measures promoting shared
accountability across the healthcare system.
Avoidable admissions and readmissions continue to put an unnecessary burden on patients and on the
resources of the healthcare system. Reducing the rates of these events will require all stakeholders to
work together to improve coordination of care between care settings. Performance measurement can
provide the necessary information to focus improvement efforts and drive change across the healthcare
system.
Trends and Performance
Hospital admission rates have been declining steadily. The American Hospital Association found an
inpatient admission rate of 103.7 per 1,000 in 2014, down from a high of 119.7 per 1,000 in 2002.4
6
Similarly, the Healthcare Cost and Utilization Project (HCUP) found that the rate of hospitalization
decreased an average of 1.9 percent per year between 2008 and 2012.5
Likewise, recent trends show improvement in 30-day hospital readmission rates among Medicare fee-
for-service beneficiaries. From 2007 to 2011 almost 20 percent of Medicare patients were readmitted
to the hospital within 30 days of discharge.6 This rate fell to 18.5 percent in 2012 and further decreased
to 17.5 percent in 2013, resulting in 150,000 fewer hospital readmissions between January 2012 and
December 2013.7
However, there are concerns that the increased focus on reducing avoidable admissions and
readmissions could lead to increased use of observation status and emergency department (ED) visits.
Potentially preventable ED visits rose by 11 percent from 2008 to 2012.8 Similarly, the use of
observation status may be rising. Researchers found a 34 percent increase in the use of observation
stays from 2007 to 2009.9 One analysis found that the top 10 percent of hospitals with the largest
decrease in readmission rates between 2011 and 2012 increased their use of observation status by an
average 25 percent for the same time period.10 However, other analyses have challenged the belief
that reductions in readmissions are related to changes in the use of observation status,11 and the
evidence on the association remains mixed.
NQF Portfolio of Performance Measures for All-Cause Admissions and
Readmissions Conditions
The All-Cause Admissions and Readmissions Standing Committee (see Appendix D) oversees NQF’s
Admissions and Readmissions portfolio of measures that includes all-cause and condition-specific
measures. (See Appendix B.) This portfolio contains 47 admission and readmission measures addressing
numerous healthcare settings (Table 1).
Table 1. NQF Admissions and Readmissions Portfolio of Measures
All-Cause Condition Specific
Hospital 4 13
Home Health 4 0
Skilled Nursing Facility 4 0
Long-Term Care Facility 1 0
Inpatient Rehab Facility 1 0
Inpatient Psychiatric Facility 1 0
Dialysis Facility 2 0
Health Plan 1 0
Population-Based 4 11
Hospital Outpatient/Ambulatory Surgery Center 0 1
Total 22 25
Additional measures related to admissions and readmissions may be reviewed by other Standing
Committees based on appropriate expertise. These measures address issues such as population level
7
admission rates and readmissions to specific subpopulations, such as the neonatal intensive care unit
(NICU).
National Quality Strategy
NQF-endorsed measures for admission and readmissions support the National Quality Strategy (NQS).
The NQS serves as the overarching framework for guiding and aligning public and private efforts across
all levels (local, state, and national) to improve the quality of healthcare in the U.S. The NQS establishes
the "triple aim" of better care, affordable care, and healthy people/communities, focusing on six
priorities to achieve those aims: Safety, Person and Family Centered Care, Communication and Care
Coordination, Effective Prevention and Treatment of Illness, Best Practices for Healthy Living, and
Affordable Care.
Improvement efforts for admissions, readmissions, and length of stay are consistent with the NQS triple
aim and align with several of the NQS priorities, including:
• Making care safer by reducing harm caused in the delivery of care. The Centers for Medicare &
Medicaid Services reported in February 2013 that the 30-day, all-cause readmission rate
dropped to 17.8 percent, or 70,000 fewer readmissions in the last quarter of 2012, after
averaging 19 percent for the past five years.12 The MedPAC June 2013 Report to Congress
indicated that, at a national level, all-cause readmissions for the three reported conditions
(Heart Failure, AMI, and Pneumonia) had a larger decrease in readmissions over the three-year
measurement period than did all conditions, since implementation of the Hospital Readmissions
Reduction Program.13
• Promoting effective communication and coordination of care. Readmissions are events that are
associated with gaps in follow-up care. Researchers have estimated that inadequate care
coordination, including inadequate management of care transitions, was responsible for $25
billion to $45 billion in wasteful spending in 2011 as a result of avoidable complications and
unnecessary hospital readmissions.14
The Measurement Framework below lists each measure in the admissions and readmissions portfolio.
Use of Measures in the Portfolio
NQF’s endorsement of measures is valued not only because of its rigorous and transparent evaluation
process, but also because evaluations are conducted by multistakeholder committees. These
Committees comprise clinicians and other experts representing healthcare providers, employers, health
plans, public agencies, community coalitions, and patients—many of whom use measures on a daily
basis to ensure better care. Moreover, NQF-endorsed measures undergo routine "maintenance" (i.e., re-
evaluation) to ensure that they are still the best-available measures and reflect the current science.
Importantly, federal law requires that preference be given to NQF-endorsed measures for use in federal
public reporting and performance-based payment programs. A variety of stakeholders in the private
sector also use NQF measures, including hospitals, health plans, and communities.
The admissions and readmissions portfolio of measures continues to grow rapidly. The first admissions
and readmissions measures were endorsed by NQF in 2008, and in recent years, new measures have
8
been developed and endorsed to expand accountability for avoidable admissions and readmissions for
additional settings and conditions. As reducing avoidable admissions and readmissions continues to be a
key quality goal, the use of these measures continues to expand. In particular, the Improving Medicare
Post-Acute Care Transformation Act of 2014 (IMPACT Act) required CMS to implement quality measures
for potentially preventable readmission rates to long-term care hospitals, inpatient rehabilitation
facilities, skilled nursing facilities, and home health agencies. Currently, measures in the portfolio are
used in federal programs, including the Home Health Quality Reporting Program, Ambulatory Surgical
Center Quality Reporting Program, the Hospital Inpatient Quality Reporting Program, Hospital
Readmission Reduction Program, Medicare Shared Savings Program, Inpatient Rehabilitation Facility
Quality Reporting Program, Long-Term Care Hospital Quality Reporting Program, and the Skilled Nursing
Facility Value-Based Purchasing Program.
See Appendix C for details of federal program use for the measures in the portfolio.
NQF’s All-Cause Admissions and Readmissions Portfolio
All-Cause/All Condition-Specific Population-Based Measures
Measure Number Measure Title
1768 Plan All-Cause Readmissions [NCQA]
2504 30-day Rehospitalizations per 1000 Medicare Fee-for-Service (FFS) Beneficiaries [CMS]
2503 Hospitalizations per 1000 Medicare Fee-for-Service (FFS) Beneficiaries [Colorado
Foundation for Medical Care]
2888* Risk-Standardized Acute Admission Rates for Patients with Multiple Chronic Conditions
[Yale/CORE]
*Denotes measures reviewed in this current project.
Condition-Specific Population-Based Measures
Measure Number Measure Title
0272 Diabetes Short-Term Complications Admission Rate (PQI 1) [AHRQ]
0273 Perforated Appendix Admission Rate (PQI 2) [AHRQ]
0274 Diabetes Long-Term Complications Admission Rate (PQI 3) [AHRQ]
0277 Heart Failure Admission Rate (PQI 8) [AHRQ]
0279 Bacterial Pneumonia Admission Rate (PQI 11) [AHRQ]
0280 Dehydration Admission Rate (PQI 10) [AHRQ]
0281 Urinary Tract Infection Admission Rate (PQI 12) [AHRQ]
0283 Asthma in Younger Adults Admission Rate (PQI 15) [AHRQ]
0638 Uncontrolled Diabetes Admission Rate (PQI 14) [AHRQ]
Admissions Measures
Measure Number Measure Title
0727 Gastroenteritis Admission Rate (Pediatric) [AHRQ]
0728 Asthma Admission Rate (Pediatric) [AHRQ]
9
Measure Number Measure Title
2886* Risk-Standardized Acute Admission Rates for Patients with Heart Failure [Yale/CORE]
2887* Risk-Standardized Acute Admission Rates for Patients with Diabetes [Yale-CORE]
*Denotes measures reviewed in this current project
Hospital All-Cause/All-Condition Readmission Measures
Measure Number Measure Title
0335 PICU Unplanned Readmission Rate [Virtual PICU Systems, LLC]
1789* Hospital-Wide All-Cause Unplanned Readmission Measure (HWR) [CMS]
2393 Pediatric All-Condition Readmission Measure [Center of Excellence for Pediatric Quality
Measurement]
2879* Hybrid Hospital-Wide Readmission Measure with Claims and Electronic Health Record
Data [Yale/CORE]
*Denotes measures reviewed in this current project
Cardiovascular Condition-Specific Hospital Readmission Measures
Measure Number Measure Title
0330* Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate Following Heart Failure
Hospitalization for Patients 18 and Older [CMS]
0505 Thirty-Day All-Cause Risk Standardized Readmission Rate Following Acute Myocardial
Infarction (AMI) Hospitalization [CMS]
0695 Hospital 30-Day Risk-Standardized Readmission Rates following Percutaneous Coronary
Intervention (PCI) [American College of Cardiology]
2514 Risk-Adjusted Coronary Artery Bypass Graft (CABG) Readmission Rate [STS]
2515 Hospital 30-Day, All-Cause, Unplanned, Risk-Standardized Readmission Rate (RSRR) Following
Coronary Artery Bypass Graft (CABG) Surgery [CMS]
2880* Excess days in acute care (EDAC) after hospitalization for heart failure [Yale/CORE]
2881* Excess days in acute care (EDAC) after hospitalization for acute myocardial infarction (AMI)
[Yale/CORE]
*Denotes measures reviewed in this current project.
Pulmonary Condition-Specific Hospital Readmission Measures
Measure Number Measure Title
0506* Thirty-Day All-Cause Risk Standardized Readmission Rate Following Pneumonia
Hospitalization [CMS]
1891* Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) following Chronic
Obstructive Pulmonary Disease (COPD) Hospitalization [CMS]
2414 Pediatric Lower Respiratory Infection Readmission Measure [Center of Excellence for
Pediatric Quality Measurement]
2882* Excess Days in Acute Care (EDAC) After Hospitalization for Pneumonia
*Denotes measures reviewed in this current project.
10
Description:Table 1. NQF Admissions and Readmissions Portfolio of Measures 2887 Risk-Standardized Acute Admission Rates for Patients with Diabetes .
