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 Measures Under Consideration (MUC) submission includes an updated version of the Pneumonia EDAC measure currently reported in the Hospital Inpatient Quality Reporting (Hospital IQR) Program. 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.
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 changes.
Initial endorsement in 2016. Endorsed during maintenance review in 2021.
Integration of MA beneficiaries into the cohort, modifying performance period from 3 years to 2 years, and changes to outcome weighting (ED visits counted as 1 day and observation stays counted by hours and rounded up to 1 day). Updates to this measure also include non-substantive changes using individual ICD-10 codes for risk adjustment and adopting a binomial model for estimating days in acute care.
Measure Specification
The outcome of this measure is a count of the number of days the patient spends in acute care within 30 days of discharge from an eligible index pneumonia 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 pneumonia hospitalization.
N/A
N/A
The cohort includes admissions for patients that meet all of the following inclusion criteria:
Diagnosis coding that meets one of the two following requirements:
- Principal discharge diagnosis of pneumonia; or
- (i). Principal discharge diagnosis of sepsis (that is not severe); and
- (ii). A secondary diagnosis of pneumonia coded as present on admission (POA); and
- (iii). No secondary diagnosis of sepsis that is both severe and coded as POA;
- Enrolled in Medicare FFS Part A and Part B or MA for the 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 inclusion, but the 12-month Part A and B or MA enrollment prior to admission is not required.];
- Aged 65 or over;
- Discharged alive from a non-federal short-term acute care hospital or VA hospital;
- Not transferred to another acute care facility.
N/A
This measure excludes index admissions for patients 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; or
- Pneumonia admissions within 30 days of discharge from a prior pneumonia index admission.
Meaningfulness
Importance
The developer presents empirical data that states pneumonia leads to over 1 million hospitalizations per year in the United States, incurring billions of dollars in health care costs. Evidence suggests that safely transitioning patients from hospital to home involves a complex set of tasks—such as provider communication, complication management, patient education, and timely follow-up—that are difficult to capture individually through process measures. Suboptimal transitions are linked to adverse outcomes, including emergency department visits, observation stays, and readmissions. These findings support the need for comprehensive measures that reflect the full scope of post-discharge care quality. Evidence from the literature review has raised concerns that current readmission measures do not capture the full range of unplanned acute care in the post-discharge period. This measure aligns with national health care priorities and demonstrates potential for improving outcomes, such as interventions during and after hospitalizations.
During CBE endorsement review in 2021, the committee found the evidence supporting the importance of this measure was to be sufficient.
Conformance
This measure intends to estimate days spent in acute care within 30 days post discharge from an inpatient hospitalization for pneumonia. The measure numerator, denominator, and exclusions are clearly defined and directly support the intent of the measure. Specifically, the numerator is a count of the number of days the patient spends in acute care within 30 days of discharge from an eligible index pneumonia hospitalization.The denominator includes patients aged 65 and older with a principal discharge diagnosis of pneumonia and no secondary diagnosis of sepsis. Including MA enrollees increases the cohort size and more accurately reflects the quality of care for fee-for-service and MA beneficiaries compared to the previous version of the measure.
This measure aligns with the Hospital IQR Program objectives to improve the quality of care that hospitals provide and to distribute clearly defined and objective data about hospital performance.
Feasibility
No, not an eCQM
Data elements for this measure come from administrative data and claims data. These data sources are standardized and widely available across settings. The measure can be implemented without significant workflow changes. No major technical barriers are associated with this measure.
During CBE endorsement review in 2021, the committee found the feasibility of this measure to be sufficiently demonstrated.
Validity
Empiric Validity; Face Validity [MERIT Submission Form, Supplemental Attachment]
Facility
Yes
The developer assessed the empiric validity of the measure by comparing the correlations between the Pneumonia 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 Pneumonia 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 Pneumonia EDAC measure and Star Rating-related measures.
Pneumonia EDAC measure showed negative correlations with the Star Rating Adjusted Readmission Group Scores (r=-0.248, p < .0001), the Star Rating Adjusted Summary Scores (r=-0.347, p < .0001), and the Star Rating Adjusted Summary Scores excluding the Readmission Measure Group Score (r=-0.207, p < .0001). These findings are consistent with expectations, reinforcing the relationship between lower Pneumonia 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, the following 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 years to 2 years.
Testing in populations representative of the CMS program population supports the external validity of the measure.
During CBE endorsement review in 2021, the committee found the validity of this measure to be sufficiently demonstrated.
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 developer performed model discrimination using the c-statistic and predictive ability and assessed model calibration using the risk decile plot. During measure development, the sample of 617,442 persons produced a c-statistic of 0.66, with predictive ability ranging from 0.60 in the lowest decile to 3.40 in the highest decile. The validation sample of 616,187 persons produced the same c-statistic of 0.66, with predictive ability ranging from 0.59 to 3.38. The risk decile plot showed that deciles with a higher predicted risk of EDAC after hospitalization for pneumonia were associated with higher observed EDAC. These results suggest that the model effectively differentiates EDAC after hospitalization for pneumonia levels and adequately adjusts for differences in patient characteristics. The measure is not recommended to be stratified.
Reliability
Random Split-Half Correlation
Facility
Split-half reliability testing demonstrated strong consistency for the measure, with a corrected reliability score of 0.817 among hospitals meeting the minimum case volume of 25 admissions. This score, based on the mean intraclass correlation coefficient (ICC) across 100 random split samples, meets accepted standards for publicly reported measures and indicates that observed performance differences are likely to reflect true variation rather than random noise. Reliability results used 2 years of data (2022-2023) from 3,705 facilities with at least 25 admissions. During collaboration on this PA, the developer provided the minimum, maximum, median, and 25th and 75th percentiles. Among hospitals with at least 25 admissions, the minimum reliability was 0.809, the median reliability was 0.816 (IQR: 0.815-0.818), and the maximum reliability was 0.824. All facilities exceeded the recommended minimum reliability threshold of 0.6.
During CBE endorsement review in 2021, the committee found the reliability of this measure to be sufficiently demonstrated.
Additional analyses were not performed.
Usability
Yes, the submission materials briefly discuss the measure’s usability within relevant programs.
The measure is currently used in the Hospital IQR Program and has demonstrated actionable insights for providers in hospitals. The developer did not assess for any unintended consequences but will continue to monitor the measure’s use and assesses potential unintended consequences over time, such as the inappropriate shifting of care, increased patient morbidity and mortality, and other negative unintended consequences for patients.
During CBE endorsement review in 2021, the committee found the use/usability of this measure to be sufficiently demonstrated.
Appropriateness of Scale
Overview
- Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Pneumonia Hospitalization is a related measure within the Hospital Readmissions Reduction Program.
- Excess Days in Acute Care (EDAC) after Hospitalization for Heart Failure (HF) is a related measure in the Hospital IQR Program.
- Excess Days in Acute Care (EDAC) after Hospitalization for Acute Myocardial Infarction (AMI) is a related measure in the Hospital IQR Program and Bundled Payment for Care Improvement Advanced Model.
The developer noted that pneumonia is a priority condition and the target of readmission rate monitoring. The developer noted several existing measures for pneumonia or measures focused on EDAC. However, no directly competing measures are currently active in the Hospital IQR Program, indicating that this measure addresses a clear gap. This measure also supports CMS’s goals of enhancing patient safety, reducing readmissions, and improving overall health care efficiency. The developer’s literature review and analysis do not indicate a potential for differential benefit or harm to specific subgroups of participating entities or their patient populations.
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
None specified
Incorporating MA data will extend the measure to a broader group of Medicare beneficiaries, thereby improving representativeness and reducing potential selection bias. In the near term, some hospitals may experience modest changes in scores as MA beneficiaries are incorporated. Over the longer term, a single, comprehensive Medicare cohort will provide more consistent tracking of performance trends, enhance comparability across hospitals and regions, and better reflect true differences in hospital quality.
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 mature through revisions in the future if added to the Hospital IQR measure set?
Public Comments
MUC2025-039
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 Pneumonia
Agree with recommendation to include Medicare Advantage and reducing measurement period from 3 to 2 years.
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- PN
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.
EDAC after Hospitalization for Pneumonia
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.
Comments on MUC2025-039
Addition of Medicare Advantage Data
Vizient appreciates efforts to update the MUC2025-039: Excess Days in Acute Care (EDAC) after Hospitalization for Pneumonia 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 MUC2025-039: Excess Days in Acute Care (EDAC) after Hospitalization for Pneumonia 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.
MUC2025-039
American Thoracic Society (ATS)
Church Street Station
P.O. Box 3421
New York, NY 10008-3421
January 5, 2026
Dear Centers for Medicare & Medicaid Measures Under Consideration (MUC) Staff:
The American Thoracic Society (ATS) formally submits comments below in response to the call for public comments for 2025 MUC Measure #039 Excess Days in Acute Care after Hospitalization for Pneumonia (EDAC). Comments were sourced from ATS members who are clinical practice guideline authors and quality experts in pneumonia:
Overall impression: High clinical importance but concerns with measure specifications
Rationale:
Sincerely, Katie A. Artis, Committee Chair, Quality Improvement and Implementation, ATS
Comment re: MUC2025-039
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.
MUC2025-039 measure
Support with modification: Recommend minimum denominator thresholds and phased implementation. 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 Pneumonia
The American Occupational Therapy Association (AOTA) supports the updates to the Excess Days in Acute Care after Hospitalization for Pneumonia measure. Seeking care after hospitalization for pneumonia 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 pneumonia 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