Hospital-Wide Readmission Measure: Hospital Inpatient Quality Reporting (IQR)

Readmissions are tracked by CMS (Center for Medicaid and Medicare Services) in two of their mandatory quality improvement programs for hospitals paid under the Inpatient Prospective Payment System (IPPS), also known as subsection (d) hospitals.

• The Hospital Readmission Reduction Program (HRRP)
• The Hospital Inpatient Quality Reporting Program (IQR)

The Hospital Inpatient Quality Program (IQR) includes a hybrid hospital-wide all-cause readmission measure (HWR). A hybrid measure incorporates both data pulled directly from the electronic medical record (EMR) and claims data, which is used to define the measure population.

HWR uses core clinical data elements (CCDE) from the EMR, such as laboratory tests and vital signs. This data will be used to improve case mix risk adjustment in conjunction with condition categories that are part of the Hierarchical Condition Categories methodology used to determine CMS payments to MA (Medicare Advantage) plans.

Like the HRRP measures, all unplanned readmissions are included regardless of cause. The HWR measure also uses the same algorithm as the HRRP to determine an unplanned readmission.

Core Clinical Data Elements

Abstraction of core clinical data elements will be automated through the EMR. Measure logic will extract the first set of HWR-specific CCDE differently for patients who receive hospital services prior to admission and those who are direct admits.

• If the patient was a direct admission, the logic supports extraction of the FIRST resulted.
  • Vital signs within 2 hours after the start of the inpatient admission.
  • Laboratory tests within 24 hours after the start of the inpatient admission.
• If the patient has values captured prior to admission, the logic supports extraction of the FIRST resulted vital signs and laboratory tests within 24 hours PRIOR to the start of the inpatient admission.

The specific values that will be extracted from the EMR, which varies by specialty cohort, include:

• Bicarbonate
• Creatinine
• Glucose
• Heart rate
• Hematocrit
• Oxygen saturation (by pulse oximetry)
• Potassium
• Respiratory rate
• Sodium
• Systolic blood pressure
• Temperature
• Weight
• White blood cell count

HWR Exclusions

This measure is different than those included in the HRRP because it is not limited to a few diagnoses or procedures. Potentially all Medicare patients could be included in the population unless one of the following exclusion criteria are met:

• Discharged against medical advice.
• The patient expires during the indexed admission.
• Admitted for:
  • Primary psychiatric diagnoses
  • Rehabilitation
  • Medical treatment of cancer
  • With a principal diagnosis of code of COVID-19 or a secondary diagnosis code of COVID-19 that is present on admission claim.
• Transferred from one short-term acute care hospital (STAC) to another.
  • Only the last admission in a series of transfers eligible for inclusion in the cohort so the measure will be associated with the receiving hospital.

Patients who have an unplanned readmission and expired within 30 days of discharge from the indexed admission will be included as long as they meet criteria.

Specialty Cohorts

A predicted readmission rate is calculated by cohort, which is then divided by the expected readmission rate resulting in a standardized readmission ratio (SRR) for each cohort. The cohorts are:

• Cardiorespiratory
• Cardiovascular
• Medicine
• Neurology
• Surgery/gynecology

The volume-weighted geometric mean of SRR for each cohort results in a combined SRR, which is compared to the national readmission rate to procedure the risk-standardized readmission rate (RSRR).

CMS assigns hospitals to a performance category for HWR by comparing each hospital’s RSRR interval estimate to the national observed readmission rate as follows:

• “Better than the National Rate” if the entire 95% interval estimate surrounding the hospital’s rate is lower than the national observed readmission rate.
• “No Different than the National Rate” if the 95% interval estimate surrounding the hospital’s rate includes the national observed readmission rate.
• “Worse than the National Rate” if the entire 95% interval estimate surrounding the hospital’s rate is higher than the national observed readmission rate.

There are several measures included within the IQR. Overall hospital performance under the IQR program can result in:

• Hospitals receiving full Annual Payment Update (APU) – hospitals that satisfactorily met the requirements.
• Hospitals not receiving full APU – hospitals that did not satisfactorily meet criteria or do not participate receive a reduction by one-fourth of the applicable market basket update.

The CMS annual market basket update payment refers to the adjustments made to Medicare payments based on the cost-of-living increases. The increase in IPPS operating payment rates for general acute care hospitals that successfully participate in the IQR program and are meaningful electronic health record users under the Medicare Promoting Interoperability Program is 2.6% for FY 2026.