The Opportunity

The unpredictable nature of a patient’s path once they are discharged from the hospital is a byproduct of a fragmented healthcare delivery system. This is especially true for patients who suffer from chronic and comorbid conditions. Previous studies have shown that nearly one in five Medicare patients are readmitted to the hospital within 30 days of discharge, including many patients returning via the emergency room, costing upwards of $26 billion annually.^1,2

The causes of readmissions are complex and not well understood. One report by the Robert Wood Johnson Foundation suggests that communities and health systems with higher underlying admission rates also have higher readmission rates, since patients in these communities are more like likely to rely on the hospital as a site of care in general.³ Other risk factors include environmental and patient characteristics, including socioeconomic status.^4,5 A 2013 MedPAC report suggests that to succeed in reducing readmissions, policies must encourage hospitals to look beyond their walls and improve care coordination (i.e. medication reconciliation, use of case managers, discharge planning) across providers. The report suggests that reducing avoidable readmissions by 10 percent could achieve a savings of $1 billion or more.⁶

NQF has undertaken a number of projects addressing admissions and readmissions that are condition or setting-specific. Past measure endorsement projects have included the consideration of six condition-specific readmission measures, as well as measures of acute care hospitalization from the home health and dialysis settings. NQF’s most recent work in this area, which concluded in April 2012, was the Readmissions Endorsement Maintenance project, which resulted in the endorsement of two new all-cause readmission measures.

In addition to measure endorsement projects, NQF has pursued other work related to admissions and readmissions. NQF’s Measure Applications Partnership (MAP) recommended that readmission measures should be part of a suite of measures promoting a system of patient-centered care coordination. This conclusion recognized that multiple entities and individuals are jointly accountable for reducing avoidable readmissions, that assessment of performance should include measures of both avoidable admissions and readmissions, and additionally should address important care coordination processes and readmissions.⁷

As we move towards a model of accountable care organizations using readmissions measures as part of a suite in conjunction with quality measures looking at admissions and length of stay, we can achieve greater efficiencies (Lower LOS) and improvements in quality (reductions in readmissions and mortality).

About the Project

This project will evaluate measures related to all-cause admissions and hospital readmissions that can be used for accountability and public reporting for all populations and in all settings of care. This project will address topic areas including but not limited to:

• Measures from applicable settings, such as skilled nursing facilities and inpatient rehabilitation facilities
• Unplanned admission-related measures from other settings (i.e., hospitalization for patients on dialysis)
• All-Cause and condition specific admission measures
• Condition-specific readmissions measures
• Measures examining length of stay

The Admissions and Readmissions project will also review six measures that are eligible for maintenance, including measures targeting readmissions of patients with heart failure, acute myocardial infarction (AMI), and pneumonia.

NQF Process

Candidate standards will be considered for NQF endorsement as national voluntary consensus standards. Consensus on the recommendations will be developed through NQF’s formal Consensus Development Process (CDP, Version 1.9). This project involves the active participation of representatives from across the spectrum of healthcare stakeholders and will be guided by a Steering Committee.

In an effort to test improvements to the CDP, this project will pilot a continuous commenting feature, enabling the public and NQF membership to submit comments on an ongoing basis throughout the project. NQF will solicit stakeholder and public comment throughout the consensus development process. This pilot is intended to eliminate finite timeframes for the submission of comments, which is traditionally only solicited for a single 30-day period after Steering Committee recommendations for endorsement, and enable earlier and more frequent public and member inputs to the evaluation process.

Update on Measure 1789: (Hospital-Wide, All-Cause Unplanned Readmissions)

This project will also include an update on Measure 1789 (Hospital-Wide, All-Cause Unplanned Readmissions (CMS/Yale)), including review of the following key issues:

• Results of the CMS dry run,
• Updates to the planned readmission exclusion, and
• Harmonization with measure #1768 (Plan All-Cause Readmissions (NCQA).

The review of CMS’s dry run results is expected to include an analysis of the distribution of performance between hospitals with varying proportions of low socio-economic status (SES) patients, and the proportion of measure result variation that is attributable to providers compared to patients.

Funding

This project is funded under NQF’s contract with the Department of Health and Human Services, Consensus-based Entities Regarding Healthcare Performance Measurement.

For information about the availability of auxiliary aids and services for NQF’s federally funded projects, please visit: http://www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html.

Related NQF Work

Patient Outcomes: All-Cause Readmissions Expedited Review Project 2011

Contact Info

For further information, contact Andrew Lyzenga, MPP or Adeela Khan, MPH, at 202-783-1300 or via email at readmissions@qualityforum.org.

Notes 

1. Dartmouth Atlas Project, PerryUndem Research & Communications. The Revolving Door: A Report on U.S. Hospital Readmissions. Princeton, NJ:Robert Wood Johnson Foundation; 2013. Available at http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/02/the-revolving-door--a-report-on-u-s--hospital-readmissions.html
2. Medicare Payment Advisory Committee (MEDPAC). Report to the Congress: Medicare and the Health Care Delivery System, DC: MedPAC; 2013. Available at http://medpac.gov/documents/Jun13_EntireReport.pdf
3. Dartmouth Atlas Project, PerryUndem Research & Communications. The Revolving Door: A Report on U.S. Hospital Readmissions. Princeton, NJ:Robert Wood Johnson Foundation; 2013. Available at http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/02/the-revolving-door--a-report-on-u-s--hospital-readmissions.html
4. Joynt KE, Orav EJ, Jha AK. Thirty-day readmission rates for Medicare beneficiaries by race and site of care. JAMA 2011 Feb 16;305(7):675-81
5. Arbaje AI, Wolff JL, Yu Q, Powe NR, Anderson GF, Boult C. Postdischarge environmental and socioeconomic factors and the likelihood of early hospital readmission among community-dwelling Medicare beneficiaries. Gerontologist 2008 Aug;48(4):495-504
6. Medicare Payment Advisory Committee (MEDPAC). Report to the Congress: Medicare and the Health Care Delivery System, DC: MedPAC; 2013. Available at http://medpac.gov/documents/Jun13_EntireReport.pdf
7. MAP Pre-Rulemaking Report: 2013 Recommendations on Measures Under Consideration by HHS. Washington, DC: National Quality Forum; 2013 Feb. Available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=72746