HCS 493 Week 4 Using Data to Address Quality Measures Example

A Ratio of 1.09 for Heart Failure: Reading a Hospital's Readmission Measures, Checking Them Against Balancing Data and Choosing Where to Improve

[Student Name]

University of Phoenix

HCS/493: Data Analytics for Health Care Managers

Week 4 Assignment

[Instructor Name]

[Date]

The hospital and its measure results are composites written for a model paper; program rules and research findings come from the sources listed.

The finance director of a composite 210-bed community hospital sent a short message to the quality committee: for the third year in a row, the hospital would lose part of its Medicare inpatient payments under the federal readmissions program. The committee asked the analytics team three questions. What do the readmission measures actually say? How much money is at stake? Where should the hospital focus to improve? This paper answers those questions and adds a fourth the committee did not ask: could reducing readmissions cause harm somewhere else?

The Program

The Hospital Readmissions Reduction Program reduces Medicare base payments to hospitals whose 30-day readmissions exceed what would be expected for their patients, for six conditions and procedures: heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease, coronary artery bypass surgery and elective hip and knee replacement. The reduction is capped at 3% of base operating payments (Centers for Medicare & Medicaid Services, n.d.). Because the penalty applies to all Medicare inpatient payments, not just the six conditions, a small ratio above one can cost far more than the readmissions themselves.

What the Measure Means

For each condition, the program calculates an excess readmission ratio. The numerator is the hospital's predicted readmissions, estimated from its own performance and its patients' age and illnesses. The denominator is the number expected if an average hospital had treated the same patients. A ratio of 1.00 means the hospital performs as expected; 1.09 means about 9% more readmissions than expected. The ratio is a comparison after risk adjustment, not a readmission rate.

The Hospital's Results

The six ratios for the most recent three-year period were:

Heart failure: 1.09, based on 612 eligible discharges.

Pneumonia: 1.03, based on 498 discharges.

Chronic obstructive pulmonary disease: 0.98, based on 301 discharges.

Heart attack: 0.96, based on 144 discharges.

Hip and knee replacement: 0.91, based on 402 procedures.

Coronary artery bypass surgery: too few cases to be measured.

Heart failure and pneumonia exceed one. Heart failure also rose from 1.04 three years earlier. The heart attack ratio rests on fewer cases, so it is less stable from year to year.

The Payment at Stake

The finance director estimated the payment reduction at 0.61% of base operating payments, about $412,000 for the year. For comparison, the hospital's 612 heart failure discharges over three years produced about 128 readmissions, roughly 43 a year. Each avoided readmission saves the patient a hospital stay, and together they would reduce the penalty.

The National Picture

Zuckerman et al. (2016) followed 3,387 hospitals and showed 30-day readmissions for the program's conditions falling from 21.5% in 2007 to 17.8% in 2015, with the fastest decline soon after the program was enacted. Over the same years, observation stays after discharge for targeted conditions rose from 2.6% to 4.7%, although within hospitals the increases in observation were not significantly associated with the decreases in readmissions. National success on readmissions leaves the hospital measured against a moving average; standing still now means falling behind.

A Warning From Research

Wadhera et al. (2018) examined 8.3 million Medicare hospitalizations for heart failure, heart attack and pneumonia and reported that, after the program was announced and again after penalties began, deaths within 30 days of leaving the hospital rose for heart failure and pneumonia, mostly among patients who were never readmitted, though deaths within 45 days of admission did not rise significantly. The finding is debated, but it gives a reason to watch deaths alongside readmissions.

Checking the Hospital's Balancing Data

Before recommending action, the team pulled two balancing measures from its own records. Observation stays within 30 days of a heart failure discharge rose from 3.1% to 4.4% over the three years, a trend worth watching but smaller than the rise in readmissions. The hospital's heart failure 30-day mortality measure was 11.2%, close to the national average in the public data. Neither measure suggested that readmissions were being hidden or that patients were being harmed by avoiding return visits.

Choosing a Target

Heart failure is the clear first target. Its ratio is the highest, it is rising, it rests on enough cases to be reliable and it carries the most discharges. Pneumonia is second. Chronic obstructive pulmonary disease, heart attack and joint replacement are performing as expected or better, and the heart attack ratio is too unstable to guide action.

Looking Inside the Heart Failure Data

The team linked readmissions to discharge records. Of the heart failure readmissions in the past year, 58% occurred within 10 days of discharge. Patients discharged on Fridays and Saturdays were readmitted more often than those discharged midweek, and 41% of readmitted patients had no follow-up appointment scheduled at discharge. Patients discharged home without home health were readmitted at a rate almost double that of patients with home health visits.

Recommendation

The improvement team will focus on the first 10 days after discharge: a scheduled clinic visit within seven days for every heart failure patient, a pharmacist medication review before discharge, a nurse phone call within 48 hours and home health referral criteria reviewed with cardiology.

Measures to Track Monthly

Because federal ratios arrive years late, the team will track process measures monthly: the share of heart failure patients with a visit scheduled at discharge, the share completing it within seven days, the share receiving a call within 48 hours and, from the hospital's own records, how many heart failure patients return for any reason within 30 days. Balancing measures, observation stays and 30-day mortality, will be reviewed quarterly.

Conclusion

The readmission measures showed that the hospital's problem is concentrated, not general. Heart failure, with a ratio of 1.09 on more than 600 discharges and a rising trend, drives most of the penalty. Balancing data showed no sign of hidden harm, and the hospital's own discharge records pointed to specific gaps in the first days at home. Reading the ratios correctly, checking what else might move and choosing one focused target turned a penalty notice into an improvement plan.

References

Centers for Medicare & Medicaid Services. (n.d.). Hospital Readmissions Reduction Program (HRRP). https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/hospital-readmissions-reduction-program-hrrp

Wadhera, R. K., Joynt Maddox, K. E., Wasfy, J. H., Haneuse, S., Shen, C., & Yeh, R. W. (2018). Association of the Hospital Readmissions Reduction Program with mortality among Medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumonia. JAMA, 320(24), 2542-2552. https://doi.org/10.1001/jama.2018.19232

Zuckerman, R. B., Sheingold, S. H., Orav, E. J., Ruhter, J., & Epstein, A. M. (2016). Readmissions, observation, and the Hospital Readmissions Reduction Program. The New England Journal of Medicine, 374(16), 1543-1551. https://doi.org/10.1056/NEJMsa1513024