Becker's Clinical Quality & Infection Control

21 QUALITY IMPROVEMENT & MEASUREMENT Are hospital readmissions an accurate quality measure? These 2 researchers aren't so sure By Mackenzie Bean C MS rolled out its Hospital Read- missions Reduction Program in 2012, transforming hospital re- admissions into a widely accepted mea- sure of hospitals' care quality among payers and other policymakers. While improvement efforts have helped lower readmissions for various conditions, current readmission measures do not consider obser- vation stays, which two healthcare researchers describe as a crucial component missing from the quality equation in an op-ed published May 31 in e New England Journal of Medicine. Here are the article's authors: • Amber K. Sabbatini, MD, an emer- gency physician at Seattle-based Harbor view Medical Center and an assistant professor in the department of emergency medicine at Seattle-based University of Washington • Brad Wright, PhD, an assistant pro- fessor of health management and policy at the University of Iowa's College of Public Health in Iowa City Hospitals are increasingly using observation stays as an alternative to short inpatient hospitalizations, which payers discourage, according to Drs. Sabbatini and Wright. ey believe the increased reliance on obser- vation stays holds important implications for using hospital readmissions to assess quality, since hospitals do not track readmissions for patients admitted under observation, and these stays are not included in calculations for hospitals' 30-day readmission rate. "erefore, unscheduled hospitalizations billed as observation stays are missing from both the numerator and the denominator of the readmission-rate equation, which omits critical information about the quality of care transi- tions for many patients hospitalized for acute conditions," Drs. Sabbatini and Wright wrote. To assess the effect of observation stays on readmission measures, they analyzed 2007- 15 claims data from about 250 commercial payers nationwide housed in the Truven Health Analytics MarketScan Commercial Claims and Encounters Database. e data contained information on about 5 million emergency department visits per year. Drs. Sabbatini and Wright found the 30-day readmission rate for inpatients decreased from 17.8 percent in 2007 to 15.5 percent in 2015. However, readmission rates for pa- tients admitted under observation increased from 10.9 percent to 14.8 percent over the same time period. e authors noted this increase was likely driven by repeat observa- tion stays, which jumped from 3.6 percent in 2007 to 6.9 percent in 2015. Drs. Sabbatini and Wright suggested this increase may be due to hospitals admitting increasingly sicker patient populations for observation stays, rather than inpatient stays. Observation patients may also have less access to care coordination resources than those admitted as inpatients. "Although additional research is needed to understand and address the effect of obser- vation stays on readmission measures, our findings indicate that a large and increasing proportion of hospital care transitions are falling out of the current quality equation," the authors concluded. n 'Time's up': California exchange insurers to drop in-network hospitals missing safety marks By Morgan Haefner C overed California, the state's health insurance exchange established under the ACA, will require participating payers to kick hospitals out of their network if they don't reach certain safety and quality mea- sures, WBUR reported. Here are five things to know about the policy: 1. In less than two years, hospitals will lose in-network status with Covered California insurers if they don't cut back on unnecessary C-sections, prescribe fewer opioids, and perform fewer X-ray, MRI and CT scans to diagnose back pain. 2. The new policy poses significant consequences for California hospitals missing the target. 1.4 million Califor- nians purchase their health insurance through the state exchange from 11 health insurers. 3. Lance Lang, MD, CMO of Covered California, told WBUR, "We're saying 'time's up.' We've told health plans that by the end of 2019, we want networks to only include hospitals that have achieved that target." 4. For C-section rates, Covered California is setting the target rate at 23.9 percent for low-risk births. Several Cali- fornia hospitals are delivering 40 percent of low-risk births by C-section, and at one hospital, the rate is 78 percent. Leah Binder, CEO of the Leapfrog Group, told WBUR Covered California's impending policy is "probably the boldest move we've seen in maternity care ever." 5. Most of California's 243 maternity hospitals are on board with the C-section goal, with 40 percent already meeting the target, according to the report. Health plans can also request exemption from Covered California's new rule, and keep noncompliant hospitals in network, if they document their reasoning. n

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