Inpatient Rehabilitation Facility Quality Measure Flawed

Marcia Frellick

December 13, 2019

The Centers for Medicare & Medicaid Services (CMS) measure that calculates potentially preventable 30-day hospital readmissions of patients coming from inpatient rehabilitation facilities (IRFs) does not discern which facilities are performing well or poorly and should not be part of the IRF quality reporting program, say the authors of a new study.

Matt P. Malcolm, PhD, OTR/L, of the Department of Occupational Therapy at Colorado State University in Fort Collins, and colleagues studied claims for 454,378 Medicare beneficiaries discharged from 1162 IRFs between June 1, 2013, and July 1, 2015. They published their findings online December 13 in JAMA Network Open.

The researchers found that using the recently mandated CMS measure "resulted in risk-standardized readmission rates above or below the mean national rate for just 1% to 2% of 1162 Medicare-eligible IRFs."

The Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) of 2014, as part of the movement toward value-based care, included measuring IRFs' quality and linking payments accordingly.

A 2019 report from the Medicare Payment Advisory Commission indicated that between 2012 and 2017, rates of potentially preventable rehospitalizations (PPRs) within 30 days of discharge from IRFs ranged from 4.3% to 4.8%. The authors note that addressing readmissions after an IRF stay has the potential to significantly cut healthcare costs and avoid exposing patients to additional risks.

Ideally, IRFs prepare patients for resuming independent living by offering equipment and education and building patient engagement in performing activities of daily living. The goal is for patients to transition from there to home or to supported living.

The authors sought to examine variations by facility in all-cause unplanned and potentially preventable 30-day rehospitalizations after patients left an IRF.

They looked at the CMS outcome measure for PPRs, which was part of the IMPACT Act of 2014. Public reporting for the measure began for IRFs in fiscal year 2019.

The hope was that the study would show how the measure was able to differentiate "between well-performing and poorly performing IRFs and could help guide next steps in health care quality initiatives targeting readmissions," the authors write.

But they found individual facilities deviated little from the national average.

Multiple Factors Explain Lack of Difference

The researchers offer several reasons for the small difference. One is that algorithms do not consider sociodemographic variables. Also, cognitive functioning is not adequately accounted for in the risk models, which are largely based on motor function, they write. Additionally, some historically have argued the 30-day risk window is arbitrary. The authors note that previous studies have shown a large proportion of those returning to hospitals did so within 14 days.

In an invited commentary, Andrea Gilmore-Bykovskyi, PhD, RN, with the School of Nursing at University of Wisconsin–Madison, and colleagues warn against misinterpreting the study's findings.

"The lack of variation in IRF performance in the current study is certainly not an indication that further improvements in care continuity are unneeded. On the contrary, these findings remind us that developing practical, clinically sensitive, and meaningful performance measures always is (or should be) an iterative process," they write.

The editorialists say CMS quality measures should be able to motivate improvement.

This study adds to the debate about such measures, they write. Experts have long said the measures don't account for things such as social support, living arrangements, and socioeconomic factors.

They also note there is debate around definitions of "preventable" and "avoidable."

"Prior work has demonstrated variation in IRF readmission rates by geography, region, and institutional profit status. Any or all of these factors may be contributing to the findings observed in this study," they explain.

Gilmore-Bykovskyi and colleagues add that it's unclear from the study whether improvement measures for IRFs have hit a ceiling or whether the current readmission measures are not sensitive enough to meaningfully gauge care quality.

CMS, before accepting the current quality measures, should continue to monitor performance and consider adjustments that might make them better able to discern good and poor performers, the editorialists conclude.

The study was supported in part by a grant from the Eunice K. Shriver National Institute of Child Health and Human Development (National Center for Medical Rehabilitation Research); the National Institute for Neurological Disorders and Stroke; and the National Institute of Biomedical Imaging and Bioengineering. A coauthor of the study reported grants from the Foundation for Physical Therapy during the conduct of the study. Another coauthor reported personal fees from the Kessler Foundation outside the submitted work. Coauthors of the invited commentary reported grants from the state of Wisconsin, Agency for Healthcare Research and Quality, and the US Department of Veterans Affairs outside the submitted work.

JAMA Netw Open. Published online December 13, 2019. Full text, Editorial

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