The changing seasons of quality: The new IQR measures part 2

Nov. 4, 2019 / By Cheryl Manchenton, RN

As I noted in my previous blog on the changes to the IQR program, fall brings joy to some and sadness to others. With the fall comes changes to the IPPS, as well to the various CMS quality reporting programs.

I previously discussed the new Safe Use of Opioids eCQM and will now turn my attention to the Hybrid Hospital-Wide All-Cause Readmission (HWR) Measure.

CMS notes that hospital readmission rates are affected by complex and critical aspects of care such as:

  • Communication between providers and patients
  • Prevention of and response to complications
  • Patient safety
  • Coordinated transitions to the outpatient environment

They note some readmissions are unavoidable (such as due to inevitable progression of disease or worsening of chronic conditions).  However, they note that readmissions may occur from poor quality of care or inadequate transitional care.

CMS noted for the time period of July 1, 2016 through June 30, 2017, the all-cause readmission rate ranged from 10.6 percent to 20.3 percent. Per CMS, this is a performance gap with wide variation and an opportunity to improve quality.

CMS created the Hybrid HWR measure to capture all unplanned readmission that arise from acute clinical events requiring urgent rehospitalization within 30 days of discharge. Planned readmissions (generally not a signal of quality of care) are not considered readmissions in the measure outcome. CMS also notes that all unplanned readmissions are considered an outcome, regardless of cause.

This Hybrid HWR aligns with the Meaningful Measures Initiative quality priority “Promoting Effective Communication and Coordination of Care.” The Hybrid HWR was endorsed by the National Quality Forum (NQF) in 2016. After further development and testing it is NQF-endorsed based on the current criteria. It began as a voluntary reporting program not affecting reimbursement under IQR reporting for the first two quarters of CY2018. Approximately 150 hospitals voluntarily reported data for the Hybrid HWR measure. Hospitals received feedback on their performance in the summer of 2019.

The Hybrid HWR is modeled on the current Hospital-Wide Readmissions IQR program and uses the same methodology to calculate a risk-standardized readmission rate (RSSR). The single summary RSSR is derived from volume-weighted results of five different models, one for each of the following mutually-exclusive specialty cohorts based on groups of discharge condition categories or procedure categories:

  • Surgery/gynecology
  • General medicine
  • Cardiorespiratory
  • Cardiovascular
  • Neurology

The Hybrid HWR is also similar in how it measures the hospital-level standardized readmission ratios (SSR) for each of these cohorts. The SSR is calculated as the ration of the number of “predicted” readmissions to the number of “expected” readmission at a given hospital. For each hospital, the numerator of the ratio is the number of readmissions predicted based on the hospital’s performance with its observed case mix and service mix. The denominator for each hospital is the number of readmissions expected based on the nation’s performance with each hospital’s case mix and service mix. The composite SSR is multiplied by the national observed readmission rate to produce the RSSR.

The targeted population is the same as the HWR program and includes Medicare fee-for service (FFS) beneficiaries:  

  • Enrolled in Medicare FFS Part A for the 12 months prior to the date of admission and during the index admission
  • Aged 65 or over
  • Discharged alive from a non-federal short-term acute care hospital
  • Not transferred to another acute care facility

Excluded from the readmission measure are patients:

  • Admitted to Prospective Payment System (PPS)-exempt cancer hospitals
  • Without at least 30 days of post-discharge enrollment in Medicare FFS
  • Discharged against medical advice
  • Admitted for primary psychiatric diagnoses
  • Admitted for rehabilitation
  • Admitted for medical treatment of cancer

The Hybrid HWR varies from the current HWR program in that it uses more than just the administrative claims data. The Hybrid HWR measure uses a combination of administrative data and a set of core clinical data elements extracted from hospital EHRs. It requires a set of six linking variables which must be present in both the EHR and claims data so each patient’s core clinical data elements can be matched to the claim for the relevant admission (patient unique identifier date of birth, admission and discharge dates, sex and Medicare Beneficiary Identifier). Also note that hybrid measure results must be calculated by CMS to determine hospitals’ risk-adjusted rates relative to national rates using data from all reporting hospitals.

CMS notes that Hybrid HWR rates are adjusted for case-mix differences and service-mix differences as well as patients’ ages and comorbidities (based on the index admission, the admission included in the measure cohort and a full year of prior history) but also laboratory test results and vital signs.

The core clinical data includes the following:

  • Heart rate
  • Systolic blood pressure
  • Respiratory rate
  • Temperature
  • Oxygen saturation
  • Weight
  • Hematocrit
  • White blood cell count
  • Potassium
  • Bicarbonate
  • Creatinine
  • Glucose

Note, to be able to calculate the Hybrid HWR measure results, each hospital will need to report vital signs and laboratory results for 90 percent or more of the hospital discharges for the measured patients. For patients admitted following elective surgery, there are no laboratory values available in the appropriate time window, so laboratory results are not used in the risk adjustment of the surgical cohort. Hospitals must also report the linking variables for 100 percent of discharges in the measurement period.

During the voluntary reporting periods, Hybrid HWR data will not be reported on the Hospital Compare website. At the same time the Hybrid HWR reporting program moves from voluntary to mandatory reporting, the HWR measure will be removed.

Look for future blogs on other finalized changes to the quality programs as well as a proposed eCQM that was not finalized.

Cheryl Manchenton is a senior inpatient consultant and project manager for 3M Health Information Systems.

View our November Quality webinar: Preventing the Preventables.


1Centers for Medicare & Medicaid Services. (2018). 2018 All-Cause Hospital-Wide Measure Updates and Specifications Report: Hospital-Wide Readmission. Available at:

2 Electronic Clinical Quality Improvement (eCQI) Resource Center. Hybrid Hospital-Wide Readmission. Available at:

3Hybrid 30-day Risk-standardized Acute Myocardial Infarction Mortality Measure with Electronic Health Record Extracted Risk Factors (Version 1.1); Hybrid Hospital-Wide Readmission Measure with Electronic Health Record Extracted Risk Factors (Version 1.1); 164 2013 Core Clinical Data Elements Technical Report (Version 1.1); all available at:

4 Centers for Medicare & Medicaid Services. (2018). 2018 All Cause Hospital Wide Measure Updates and Specifications Report. Available at: