Examining the Utility of 30-day Readmission Rates and Hospital Profiling in the Veterans Health Administration
BACKGROUND: The Veterans Health Administration (VA) reports hospital-specific 30-day risk-standardized readmission rates (RSRRs) using CMS-derived models.
OBJECTIVE: The aim of this study was to examine and describe the interfacility variability of 30-day RSRRs for acute myocardial infarction (AMI), heart failure (HF), and pneumonia as a means to assess its utility for VA quality improvement and hospital comparison.
RESEARCH DESIGN: A retrospective analysis of VA and Medicare claims data using one-year (2012) and three-year (2010-2012) data given their use for quality improvement or for hospital comparison, respectively.
SUBJECTS: This study included 3,571 patients hospitalized for AMI at 56 hospitals, 10,609 patients hospitalized for HF at 102 hospitals, and 10,191 patients hospitalized for pneumonia at 106 hospitals.
MEASURES: Hospital-specific 30-day RSRRs for AMI, HF, and pneumonia hospitalizations were calculated using hierarchical generalized linear models.
RESULTS: Of 164 qualifying VA hospitals, 56 (34%), 102 (62%), and 106 (64%) qualified for analysis based on CMS criteria for AMI, HF, and pneumonia cohorts, respectively. Using 2012 data, we found that two hospitals (2%) had CHF RSRRs worse than the national average (+95% CI), whereas no hospital demonstrated worse-than-average risk-stratified readmission Rate (RSRR; +95% CI) for AMI or pneumonia. After increasing the number of facility admissions by combining three years of data, we found that four (range: 3.5%-5.3%) hospitals had RSRRs worse than the national average (+95% CI) for all three conditions.
CONCLUSIONS: The Centers for Medicare and Medicaid Services-derived 30-day readmission measure may not be a useful measure to distinguish VA interfacility performance or drive quality improvement given the low facility-level volume of such readmissions.
© 2019 Society of Hospital Medicine
Using methodology created by the Centers for Medicare & Medicaid Services (CMS), the Department of Veterans Affairs (VA) calculates and reports hospital performance measures for several key conditions, including acute myocardial infarction (AMI), heart failure (HF), and pneumonia.1 These measures are designed to benchmark individual hospitals against how average hospitals perform when caring for a similar case-mix index. Because readmissions to the hospital within 30-days of discharge are common and costly, this metric has garnered extensive attention in recent years.
To summarize the 30-day readmission metric, the VA utilizes the Strategic Analytics for Improvement and Learning (SAIL) system to present internally its findings to VA practitioners and leadership.2 The VA provides these data as a means to drive quality improvement and allow for comparison of individual hospitals’ performance across measures throughout the VA healthcare system. Since 2010, the VA began using and publicly reporting the CMS-derived 30-day Risk-Stratified Readmission Rate (RSRR) on the Hospital Compare website.3 Similar to CMS, the VA uses three years of combined data so that patients, providers, and other stakeholders can compare individual hospitals’ performance across these measures.1 In response to this, hospitals and healthcare organizations have implemented quality improvement and large-scale programmatic interventions in an attempt to improve quality around readmissions.4-6 A recent assessment on how hospitals within the Medicare fee-for-service program have responded to such reporting found large degrees of variability, with more than half of the participating institutions facing penalties due to greater-than-expected readmission rates.5 Although the VA utilizes the same CMS-derived model in its assessments and reporting, the variability and distribution around this metric are not publicly reported—thus making it difficult to ascertain how individual VA hospitals compare with one another. Without such information, individual facilities may not know how to benchmark the quality of their care to others, nor would the VA recognize which interventions addressing readmissions are working, and which are not. Although previous assessments of interinstitutional variance have been performed in Medicare populations,7 a focused analysis of such variance within the VA has yet to be performed.
In this study, we performed a multiyear assessment of the CMS-derived 30-day RSRR metric for AMI, HF, and pneumonia as a useful measure to drive VA quality improvement or distinguish VA facility performance based on its ability to detect interfacility variability.
