Overview
Measure Overview
The goal of this measure is to improve patient outcomes. Measurement of patient outcomes allows for a broad view of quality of care that encompasses more than what can be captured by individual process-of-care measures. Safely transitioning patients from hospital to home requires a complex series of tasks which would be cumbersome to capture individually as process measures: timely and effective communication between providers, prevention of and response to complications, patient education about post-discharge care and self-management, timely follow-up, and more. Suboptimal transitions contribute to a variety of adverse events post-discharge, including emergency department (ED) evaluation, need for observation, and readmission.
This MUC submission includes an updated version of the HF EDAC measure currently reported in the Hospital Inpatient Quality Reporting (Hospital IQR) program. The updates include the addition of Medicare Advantage (MA) beneficiaries to the cohort, counting ED visits as 1 day and observation stays in rounded hours, using individual ICD-10 codes for risk adjustment, and adopting a binomial model for estimating days in acute care.
Excess days in acute care after a hospitalization is an issue that affects patient outcomes and impacts the quality of care provided to patients. Measuring and reporting excess days in acute care provides transparency for consumers and informs health care providers about opportunities to improve care, strengthen incentives for quality improvement, and ultimately improve the quality of care (including better inpatient management of diabetes as well as better peri-discharge care quality) received by Medicare patients.
Measure currently used in a Medicare program, but the measure is undergoing substantive change.
Initial endorsement in 2016. Endorsed during maintenance review with All-Cause Admissions and Readmissions Committee in Spring 2021.
The updates include the addition of MA beneficiaries to the cohort, counting ED visits as 1 day and observation stays in rounded hours, using individual ICD-10 codes for risk adjustment, and adopting a binomial model for estimating days in acute care.
Measure Specification
The outcome of the measure is a count of the number of days the patient spends in acute care within 30 days of discharge from an eligible index HF hospitalization. We define days in acute care as days spent in an ED, or an observation stay, or admitted as an unplanned readmission for any cause to a short-term acute care hospital, within 30 days from the date of discharge from the index HF hospitalization.
Not applicable
Not applicable
To be included in the measure cohort used in public reporting, patients must meet the following inclusion criteria:
- Have a principal discharge diagnosis of HF;
- Enrolled in Medicare FFS Part A and Part B or MA for 12-months prior to the date of admission and enrolled in Part A or MA during the index admission. [For VA beneficiaries hospitalized in VA hospitals, there are no Medicare FFS or MA enrollment requirements. For VA beneficiaries hospitalized in non-VA hospitals, they must be concurrently enrolled in Medicare FFS Part A or MA at the time of the index admission, to be eligible for cohort inclusions, but the 12-month Part A and B or MA enrollment prior to admission is not required];
- Aged 65 or older;
- Discharged alive from a non-federal short-term acute care hospital or VA hospital; and
- Not transferred to another acute care facility.
Not applicable
The measure excludes index hospitalizations that meet any of the following exclusion criteria:
- Without at least 30 days of post-discharge enrollment in Medicare FFS or MA (in the case of patients who are not VA beneficiaries);
- Discharged against medical advice;
- HF admissions within 30 days of discharge from a prior HF index admission;
- With a procedure code for left ventricular assist device (LVAD) implantation or heart transplantation either during the index admission or up to 12 months prior to the index admission.
- Digital-Administrative systems: Administrative Data (non-claims)
- Digital-Administrative systems: Claims Data
Meaningfulness
Importance
The developer presents empirical data showing wide variability in days spent in acute care within 30 days after hospital discharge for patients with heart failure. Evidence from a literature review and standards of care review show hospitals can take interventional strategies to reduce days of acute care after discharge for patients with heart failure. Reducing the need for acute care post discharge in patients with heart failure aligns with national health priorities and demonstrates potential for improving outcomes. The importance of this measure was found sufficient during prior endorsement in 2021.
The evidence supporting the importance of this measure was found to be sufficient during CBE endorsement review in 2021.
Conformance
This measure estimates days spent in acute care within 30 days post discharge from an inpatient hospitalization for HF. The numerator includes emergency department visits, observation stays, and unplanned readmissions. The denominator includes patients age 65 and older discharged from a hospital with a diagnosis of HF. The measure aligns with the Hospital Inpatient Quality Reporting Program goal of improving the quality of inpatient care.
Feasibility
No, not an eCQM
Data for this measure come from administrative data and claims data. These data sources are standardized and widely available across care settings. The measure can be implemented without significant workflow changes. No major technical barriers were identified.
The feasibility of this measure was found sufficiently demonstrated during CBE endorsement review in 2021.
Validity
Face Validity, Empiric Validity [MERIT Submission Form]
Facility
Yes
The developer assessed the empiric validity of the measure by comparing the correlations between the Heart Failure EDAC measure and components of the Overall Hospital Quality Star Rating, including the Readmission Group Score (with and without the Hospital-Wide Readmission measure), the Summary Score (with and without the entire Readmission Group), and the Patient Experience Group Score. Because the Heart Failure EDAC measure follows a lower-is-better scale while Star Rating measures follow a higher-is-better scale, the developer hypothesized a weak-to-moderate negative correlation between the Heart Failure EDAC measure and Star Rating-related measures.
The Heart Failure EDAC measure showed negative correlations with the Star Rating Adjusted Readmission Group Scores (-0.256, p <.0001), the Star Rating Adjusted Summary Scores (-0.340, p < .0001), and the Star Rating Adjusted Summary Scores excluding the Readmission Measure Group Score (-0.185, p < .0001). These findings are consistent with expectations, reinforcing the relationship between lower Heart Failure EDAC scores and higher Star Ratings as indicators of better quality of care.
The developer assessed the face validity of the measure score as an indicator of quality by surveying the technical expert panel (TEP) on their agreement on the following statement: the risk-standardized acute care days obtained from the measures as specified can be used to distinguish between better- and worse-quality hospitals. Eleven of the 12 members of the TEP agreed with the statement. However, three changes have been made to the measure since the TEP convened: the outcome weighting was simplified by assigning rounded times to observation stays and counting ED visits as 1 day, MA patients were added to the cohort, and the reporting period was shortened from 3 to 2 years.
Testing in populations representative of the CMS program population supports the external validity of the measure.
The validity of this measure was found sufficiently demonstrated during CBE endorsement review in 2021.
The developer considered threats to validity during measure development and testing. The measure is risk adjusted for patient functional status (frailty indicator), patient-level demographics (age), and patient-level health status and clinical conditions (case-mix adjustment, comorbidities, and severity of illness). The results of model discrimination testing and calibration using the c-statistic and examining predictive ability suggest that the model effectively differentiates excess days in acute care after hospitalization for heart failure levels and adequately adjusts for differences in patient characteristics.
The measure is not recommended to be stratified.
Reliability
Random Split-Half Correlation [MERIT Submission Form]
Facility
The developer conducted permutation resampling to calculate the intraclass correlation coefficient (ICC) at the accountable entity level. The overall ICC for hospitals with at least 25 admissions was 0.831. When at least 70% of the entities have a reliability >0.6, a measure is considered capable of differentiating entities by quality of performance.
During collaboration on this PA, the developer shared that they calculated reliability results using 2 years of data (2022-2023) from 3,268 facilities with at least 25 admissions. The developer also provided the minimum, maximum, median, and 25th and 75th percentiles. Among hospitals with at least 25 admissions, the minimum reliability was 0.823, the median reliability was 0.831 (IQR: 0.829-0.833), and the maximum reliability was 0.841. All facilities exceeded the recommended minimum reliability threshold of 0.6.
The reliability of this measure was found sufficiently demonstrated during CBE endorsement review in 2021.
No additional analyses were conducted.
Usability
Yes, the submission materials briefly discuss the measure’s usability within the current program.
The measure is currently used in the Hospital Inpatient Quality Reporting Program and has demonstrated actionable insights for providers in the intended setting. The measure developer reported that they have not seen any unintended consequences from implementing the measure within the program. The developer briefly discussed usability implications of the substantive changes to this measure. The measure is highly usable from both clinical and patient perspectives. It captures all acute care events within 30 days of discharge—an adverse outcome for patients—and reflects the full post-discharge experience, including ED visits, observation stays, and readmissions. This broader scope, combined with updates like inclusion of Medicare Advantage beneficiaries and refined risk adjustment, makes the measure clinically meaningful, actionable for providers, and aligned with CMS goals to improve safety, reduce readmissions, and enhance care coordination.
The use/usability of this measure was found sufficiently demonstrated during CBE endorsement review in 2021.
Appropriateness of Scale
Overview
Excess Days in Acute Care (EDAC) after Hospitalization for Pneumonia is a related measure in the Hospital IQR Program and Hospital Readmissions Reduction Program.
Excess Days in Acute Care (EDAC) after Hospitalization for AMI is a related measure in the Hospital IQR Program and Bundled Payment for Care Improvement Advanced Model
Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Heart Failure (HF) Hospitalization is a related measure in the Hospital IQR Program and the Hospital Value-Based Purchasing Program.
Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Heart Failure (HF) Hospitalization is a related measure in the Hospital Readmission Reduction Program.
The measure is well-suited for use across diverse populations and care settings, with minimal burden and high value. While there are several similar measures in the program, there are no competing measures. The measure captures EDAC from ED visits and observation stays as well as readmissions. This represents an important construct to patients. The EDAC measures each capture excess days in acute care following hospitalizations for different conditions. The 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Heart Failure (HF) Hospitalization measure captures mortality outcomes. These measures complement one another to achieve program goals.
Considerations for the committee: Based on clinical and professional experience, the committee should consider how different populations might benefit from use of the measure, and whether the measure will have the same impact in rural or low-resource settings.
Time to Value Realization
Overview
The submission materials briefly discuss near-term impacts.
From a patient perspective, days in acute care from any cause is an adverse event. The purpose of this measure is to encourage hospitals to collaborate with their communities to reduce days in acute care. The measure also supports CMS’s goals of enhancing patient safety, reducing readmissions, and improving overall health care efficiency.
Considerations for the committee:
- What are the potential near- and long-term impacts of this measure on measured entities, the Hospital IQR Program, and patient populations?
- Will benefits and burdens associated with this measure be realized within an appropriate implementation time frame?
- How will this measure continue to mature through revisions in the Hospital IQR Program?
Public Comments
MUC2025-031
The Kansas Hospital Association has concerns regarding the substantive changes identified in this measure.
The inclusion of Medicare Advantage (MA) beneficiaries raises concern, as hospitals have limited ability to account for or influence MA plan utilization management policies, including prior authorization requirements, network limitations, and post-acute care restrictions. These plan-level factors may affect utilization outcomes in ways that are unrelated to hospital performance and could introduce variability that is outside the hospital’s control.
We also have concerns regarding the inclusion and weighting of emergency department (ED) visits and observation stays. Counting ED visits as a full day and observation stays based on hours, rounded up to one day, may overstate utilization and inadvertently penalize hospitals for clinically appropriate care delivered in lower-acuity settings. ED and observation services should not be treated as equivalent to inpatient days, as this may discourage appropriate care pathways and conflict with CMS goals related to care efficiency and right-site care.
We recommend reconsideration of the inclusion of MA beneficiaries in the cohort and exclusion of ED and observation stays from utilization calculations to ensure the measure more accurately reflects hospital performance.
EDAC HF
Agree with decision to include Medicare Advantage patients in the population cohort. HF data including observation and ED stays in addition to raw admissions is especially important with this diagnostic population.
SHM continues to oppose…
SHM continues to oppose using 30-day windows with the Excess Days in Acute Care measures. Current evidence suggests that the window of impact for preventing readmissions or returns to the ER is much shorter than 30 days, and may be as short as 7 days. Therefore, the measure as structured makes hospitals and clinicians accountable for factors well outside of their control. We urge CMS to narrow the episode window for these measures to focus on the modifiable factors within hospitals and clinician’s control to prevent or reduce excess days in acute care.
Chin DL, Bang H, Manickam RN, Romano PS. Rethinking Thirty-Day Hospital Readmissions: Shorter Intervals Might Be Better Indicators Of Quality Of Care. Health Aff (Millwood). 2016 Oct 1;35(10):1867-1875. doi: 10.1377/hlthaff.2016.0205. PMID: 27702961; PMCID: PMC5457284.
EDAC- HF
As the agency did in last year’s PRMR process, CMS included this updated measure on the MUC list because it intends to include MA beneficiaries in the denominator. We appreciate the general effects this change would have to improve accuracy of the measure, but it is unclear from the supporting documentation whether any analysis has been done to determine the implications of including these beneficiaries for the outcomes of the IQR program. We hope that the measure developer can provider additional insight into how the change to the measure’s specifications would impact performance on the EDAC measures.
Excess Days in Acute Care (EDAC) after Hospitalization HF
The American Medical Association (AMA) is concerned of the potential unintended negative consequences to patients that may result from measures that include readmissions as they may not capture the appropriate patient population due to their structure and timeframe.[1],[2] For example, the literature is beginning to show that the 30-day readmission measures based on administrative claims in the Hospital Readmissions Reduction Program (HRRP) may lead to increased mortality.2
The AMA believes that additional analyses are needed before revised measures are implemented. For example, it remains unclear to what degree is the reported association of lower readmissions with higher mortality found over longer or shorter time periods such as, one year or one week, as compared to the first 30-days post discharge. Gupta and co-authors report that the inverse association was still evident at one year.2 To what degree are any positive or negative correlations related to all-cause mortality and/or readmissions versus the condition-specific outcome? It is also worth examining whether trends exist based on unadjusted data and adjusted data. Most of the studies identified through our search of the literature, including Dharmarajan, et al.[3], used risk-adjusted data. Most individual patient care decisions are not made with risk-adjustment in mind. To better understand the outliers (those who are readmitted), there is a need to investigate and determine whether there is small, but important associations between reduced readmissions rates with patient mortality. Therefore, are we masking the issue by only examining the adjusted rates? Examination of unadjusted and risk-adjusted rates could help address this concern. We also believe that the timeframe of the readmission measures and whether the post discharge period is appropriate must be reexamined.
In addition, this measure includes some of the same changes that CMS has made to the readmission measures in HRRP; specifically, the risk adjustment model was updated to use individual ICD-10 codes rather than the CMS Hierarchical Condition Category (HCC) model; the measure now includes Medicare Advantage (MA) beneficiaries; and the data collection timeframe is two years. How each of these changes impact the reliability and validity of the measure has not been provided in this submission and we are concerned that without a phased approach, it will be extremely difficult for hospitals to determine their impact (e.g., what is the effect of the expansion to MA beneficiaries as compared to the reduction in the number of years of data used to calculate the measure). We also recommend CMS provide data on how hospitals’ performance shift since the potential impact on each hospital is critical to ensure that the results can be used to drive further improvement in patient care.
Lastly, we also question the lack of socio-economic factors in the risk adjustment due to evidence that hospitals with larger populations of poor patients perform poorly on the measures. We recognize that some of the measures have been tested to consider economic related variables; however, we do not believe the appropriate risk models were tested. The traditional approach of risk adjusting at the patient level may not be appropriate for measures where the measurement period includes care that is outside of the control of the hospital and a 30-day post-acute phase where the availability of community supports, and other resources directly impact a patient’s care. We believe that there may be community-level variables that affect the risk of readmission during the days following hospital admission but are not currently addressed. Measures that extend beyond the hospital stay or outside the locus of control of the measured entity should continue to have socio-economic adjustments addressed and analyzed at different levels (e.g., patient, hospital, and community).
Due to these concerns and unanswered questions, the AMA does not support inclusion of this measure in the Hospital Inpatient Quality Reporting Program.
[1]Graham, Kelly. Et al (2018). Preventability of Early Versus Late Hospital Readmissions in a National Cohort of General Medicine Patients. Ann Intern Med. Doi. 10.7326/M17-1724.
[2]Gupta, Ankar, et al. Association of the Hospital Readmissions Reduction Program Implementation With Readmission and Mortality Outcomes in Heart Failure. JAMA Cardiol. 2017.
[3] Dharmarajan, Wang, Lin, et al. Association of Changing Hospital Readmission Rates With Mortality Rates After Hospital Discharge. JAMA. 2017;318:270-278.
MUC2025-031 EDAC after hospitalization for HF
On behalf of the American Heart Association, including the American Stroke Association (Association) and 35 million volunteers and supporters, we appreciate the opportunity to submit comments on MUC2025-031. The Association supports the updated specifications expanding measurement to MA beneficiaries to the cohort.
MUC2025-031, EDAC for HF
Heart failure is a chronic condition requiring ongoing monitoring and medication adjustments. Without additional safeguards, the HF EDAC measure risks penalizing evidence-based care, conflicting with other CMS value-based models, and widening health inequities.
Many post-discharge ED visits or observation stays reflect appropriate, proactive management such as IV diuresis, electrolyte monitoring during GDMT titration, or evaluation of new symptoms. These strategies prevent full readmissions and reduce mortality. Treating them as negative outcomes misclassifies high-quality care as poor performance. CMS should clarify whether EDAC aims to reduce all post-discharge acute care or only preventable utilization as these represent fundamentally different quality objectives.
The measure also conflicts with the Heart Failure Ambulatory Specialty Model, which explicitly encourages outpatient management and observation-based strategies to prevent hospitalizations. CMS should clarify how EDAC applies when cardiologists manage patients post-discharge but do not control the index admission and ensure ASM participation does not result in unintended penalties.
Advanced HF patients, those with severely reduced ejection fraction, recurrent hospitalizations, cardiogenic shock, or undergoing LVAD/transplant evaluation, have inherently higher post-discharge acute care needs regardless of discharge quality. We recommend enhanced risk adjustment using clinical indicators such as HFrEF vs. HFpEF status, prior HF hospitalizations, renal function, and cardiogenic shock.
Patients enrolled in remote monitoring programs are explicitly instructed to seek ED evaluation when alerts trigger. These encounters represent successful early intervention, not quality failures. CMS should exclude or separately stratify these patients. Social determinants, medication affordability, lab access, and outpatient cardiology capacity also strongly influence ED use and should be incorporated into risk adjustment or stratified reporting.
Finally, counting every ED visit as a full "day" overstates acute-care exposure for brief monitoring visits common during GDMT titration. CMS should consider weighting ED visits by duration or excluding brief visits without intervention. Device-related ED visits (e.g., ICDs) should also be excluded, as they are typically unrelated to discharge quality.
Comments on MUC2025-031
Addition of Medicare Advantage Data
Vizient appreciates efforts to update the MUC2025-031: Excess Days in Acute Care (EDAC) after Hospitalization for Heart Failure (HF) measure by adding Medicare Advantage (MA) population data as more than half of Medicare patients are covered through MA plans. While Vizient recognizes the importance of updating quality measures to reflect a broader range of Medicare beneficiaries, we continue to believe that additional steps are needed to ensure that MA data can be used reliably alongside fee-for-service (FFS) data. For example, as noted in Vizient’s FY 2026 IPPS Proposed Rule comments, there may be differences in how FFS claims and MA encounter data are recorded, yet it does not appear that an analysis to identify the impact of these types of differences has been completed. Vizient encourages P4QM to consider our recommendation that CMS analyze the data to ensure encounter data is accurate and comparable between FFS and MA before including MA beneficiaries in these measures.
In addition, another important consideration is that MA populations can vary significantly across plans, and in some cases may be selectively healthier. Without careful attention to appropriate risk adjustment, these differences could unintentionally bias performance results. Ensuring that MA data are risk‑adjusted correctly is essential for fair and meaningful comparisons across hospitals.
Increasing Emergency Department and Observation Stays to One Day
CMS is also considering changing the MUC2025-031:Excess Days in Acute Care (EDAC) after Hospitalization for Heart Failure (HF) measure specifications to increase the count for Emergency Department (ED) visits from 0.5 days to one full day, and to calculate observation stays (OBSs), based on the total hours spent in observation, by rounding that time up to one full day. Vizient agrees with this change of counting ED visits and OBSs to one day and plans to use this timeframe for future benchmarking work. This update will also help improve consistency among measures.
Comment re: MUC2025-031
We request transparent model specifications, transition periods, and social risk adjustment to avoid penalizing hospitals serving vulnerable populations.
Premier supports the…
Premier supports the addition of Medicare Advantage (MA) members and the technical changes proposed for the Excess Days in Acute Care (EDAC) measures. Premier remains concerned that the EDAC measures may not be easily replicable using available data sources.
Premier also has concerns about the ability of these measures to improve hospital quality when the data lags by two years. This can impact both the observed performance by not reflecting today’s outcomes and risk adjustment by using older data to create expected values for more recent patients. Premier has also observed that the risk standardized results do not change much over time and may not reflect performance improvement because it is heavily driven by the random effect in the model. The use of the Predicted to Expected ratio rather than the Observed to Expected ratio, while helpful to reduce undue influence from outliers, does not provide a good reflection of actual performance. Consequently, CMS should emphasize that this methodology is best suited for payment purposes and not quality improvement purposes. The utility of the measure is further hindered by the facility level hierarchical methodology, which does not allow for drill downs into further subgroups, e.g. by physician grouping.
MUC2025-031
Support with modification: Recommend stratification and clear attibution. Recommend focusing on TRC and PCR vs adding new measure (seems duplicative). Would appreciate more information on why these diagnosis are split out (MI/HF/Pneumonia/Diabetes, etc.).
Excess Days in Acute Care after Hospitalization for HF
The American Occupational Therapy Association (AOTA) supports the updates to the Excess Days in Acute Care after Hospitalization for Heart Failure (HF) measure. Seeking care after hospitalization for HF increases healthcare costs and can be highly disruptive for patients. AOTA strongly supports the addition of the Medicare Advantage (MA) cohort to this measure. MA enrollment has steadily increased, and excluding this population fails to provide a complete picture for public reporting.
Patients and healthcare practitioners, including occupational therapy (OT) practitioners, consistently report that MA plans often delay, deny, or limit needed care to reduce hospital readmissions. Including MA data will improve the accuracy of public reporting, highlight discrepancies in outcomes based on coverage, and hold MA plans accountable to ensure patients receive necessary care.
OT services during a hospital stay and after a hospital discharge can be critical to avoiding hospital readmissions. OT practitioners address functional limitations, promote safe transitions, and support engagement in essential daily activities – factors that contribute to recovery and overall well-being.
An independent study found that OT services were the only spending category with a statistically significant association with lower readmission rates for heart failure, pneumonia, and AMI (Rogers et al., 2016). However, some MA policies may limit or exclude critical OT services. Capturing MA data for excess days in acute care after hospitalization for HF is an important step toward ensuring all Medicare beneficiaries, traditional and MA, have access to the services and tools needed to optimize recovery and well-being after a hospital stay.
Reference:
Rogers, A. T., Bai, G., Lavin, R. A., & Anderson, G. F. (2016, September 2). Higher hospital spending on occupational therapy is associated with lower readmission rates. Medical Care Research and Review, 1–19. https://doi.org/10.1177/1077558716666981