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Risk-standardized Acute Admission Rates Among Patients With Diabetes and Heart Failure as a Measure of Quality of Accountable Care Organizations

Rationale, Methods, and Early Results

Spatz, Erica S., MD, MHS; Lipska, Kasia J., MD, MHS; Dai, Ying, PhD; Bao, Haikun, PhD; Lin, Zhenqiu, PhD; Parzynski, Craig S., MS; Altaf, Faseeha K., MPH; Joyce, Erin K., BA; Montague, Julia A., MPH; Ross, Joseph S., MD, MHS; Bernheim, Susannah M., MD, MHS; Krumholz, Harlan M., MD, SM; Drye, Elizabeth E., MD, SM

doi: 10.1097/MLR.0000000000000518
Original Articles

Background: Population-based measures of admissions among patients with chronic conditions are important quality indicators of Accountable Care Organizations (ACOs), yet there are challenges in developing measures that enable fair comparisons among providers.

Methods: On the basis of consensus standards for outcome measure development and with expert and stakeholder input on methods decisions, we developed and tested 2 models of risk-standardized acute admission rates (RSAARs) for patients with diabetes and heart failure using 2010–2012 Medicare claims data. Model performance was assessed with deviance R2; score reliability was tested with intraclass correlation coefficient. We estimated RSAARs for 114 Shared Savings Program ACOs in 2012 and we assigned ACOs to 3 performance categories: no different, worse than, and better than the national rate.

Results: The diabetes and heart failure cohorts included 6.5 and 2.6 million Medicare Fee-For-Service beneficiaries aged 65 years and above, respectively. Risk-adjustment variables were age, comorbidities, and condition-specific severity variables, but not socioeconomic status or other contextual factors. We selected hierarchical negative binomial models with the outcome of acute, unplanned hospital admissions per 100 person-years. For the diabetes and heart failure measures, respectively, the models accounted for 22% and 12% of the deviance in outcomes and score reliability was 0.89 and 0.81. For the diabetes measure, 51 (44.7%) ACOs were no different, 45 (39.5%) were better, and 18 (15.8%) were worse than the national rate. The distribution of performance for the heart failure measure was 61 (53.5%), 37 (32.5%), and 16 (14.0%), respectively.

Conclusion: Measures of RSAARs for patients with diabetes and heart failure meet criteria for scientific soundness and reveal important variation in quality across ACOs.

*Section of Cardiovascular Medicine, Yale University School of Medicine

Center for Outcomes Research and Evaluation, Yale-New Haven Hospital

Sections of Endocrinology

§General Internal Medicine

Departments of Internal Medicine, Robert Wood Johnson Foundation Clinical Scholars Program

Health Policy and Management

#Pediatrics, Yale University School of Medicine, New Haven, CT

E.S.S. and K.J.L. contributed equally.

E.S.S. is supported by the Agency for Healthcare Research and Quality Patient Centered Outcomes Research (PCOR) Institutional Mentored Career Development Program (K12 HS023000). K.J.L. and J.S.R. are supported by the National Institute on Aging (K23 AG048359 and K08 AG032886) and by the American Federation for Aging Research through the Paul B Beeson Career Development Award Program. H.M.K. is supported by grant U01 HL105270-05 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute. Dr Krumholz is supported by grant U01 HL105270-05 (Center for Cardiovascular Outcomes Research at Yale University) from the National Heart, Lung, and Blood Institute.

All authors work under contract with the Centers for Medicare and Medicaid Services (CMS) to develop and maintain performance measures. The analyses on which this publication is based were performed under contract #HHSM-500-2012-00025I, Task Order HHSM-500-T0002, entitled, “Measure & Instrument Development and Support (MIDS)—Development and Reevaluation of the CMS Hospital Outcomes and Efficiency Measures,” funded by CMS, an agency of the US Department of Health and Human Services (HHS). The content of this publication does not necessarily reflect the views or policies of HHS. CMS reviewed and approved the use of its data for this work and approved submission of the manuscript. H.M.K. and J.S.R. disclose that they are the recipient of research agreements from Medtronic Inc. and Johnson & Johnson, through Yale University, to develop methods of clinical trial data sharing. J.S.R. also receives research support from the Food and Drug Administration (FDA) and Medtronic to develop methods for postmarket surveillance of medical devices. H.M.K. is chair of a cardiac scientific advisory board for UnitedHealth.

Reprints: Erica S. Spatz, MD, Section of Cardiovascular Medicine, Yale University School of Medicine, 330 Cedar Street, Dana 3, New Haven, CT 06520. E-mail:

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