Gaming hospital-level pneumonia 30-day mortality and readmission measures by legitimate changes to diagnostic coding.
OBJECTIVE
Risk-standardized 30-day mortality and hospital readmission rates for pneumonia are increasingly being tied to hospital reimbursement to incentivize the delivery of high-quality care. Such measures may be susceptible to gaming by recoding patients with pneumonia to a primary diagnosis of sepsis or respiratory failure. We sought to determine the degree to which hospitals can game mortality or readmission measures and change their rankings by recoding patients with pneumonia.


METHODS
Simulated experimental study of 2,906 U.S. acute care hospitals with at least 25 admissions for pneumonia using 2009 Medicare data.


METHODS
Elderly (age ≥ 65 yr) Medicare fee-for-service beneficiaries hospitalized with pneumonia. Patients eligible for recoding to sepsis or respiratory failure were those with a principal International Classification of Diseases, 9th Edition, Clinical Modification, discharge code for pneumonia and secondary codes for respiratory failure or acute organ dysfunction.


METHODS
None.


RESULTS
We measured the number of hospitals that improved their pneumonia mortality or readmission rates after recoding eligible patients. When a sample of 100 hospitals with pneumonia mortality rates above the 50th percentile recoded all eligible patients to sepsis or respiratory failure, 90 hospitals (95% CI, 84-95) improved their mortality rate (mean improvement, 1.09%; 95% CI, 0.94-1.28%) and 41 hospitals dropped below the 50th percentile (95% CI, 33-52). When a sample of 100 hospitals with pneumonia readmission rates above the 50th percentile recoded all eligible patients, 66 hospitals (95% CI, 54-75) improved their readmission rate (mean improvement, 0.34%; 95% CI, 0.19-0.45%) and 15 hospitals (95% CI, 9-22) dropped below the 50th percentile.


CONCLUSIONS
Hospitals can improve apparent pneumonia mortality and readmission rates by recoding pneumonia patients. Centers for Medicare and Medicaid Services should consider changes to their methods used to calculate hospital-level pneumonia outcome measures to make them less susceptible to gaming.
1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI. 2VA Center for Clinical Management Research, Ann Arbor, MI. 3Institute for Social Research, Ann Arbor, MI. 4Department of Surgery, University of Michigan, Ann Arbor, MI. 5Center for Healthcare Outcomes and Policy, Institute for Healthcare Innovation & Policy, University of Michigan, Ann Arbor, MI.
Michael W
MW
Sjoding
Theodore J
TJ
Iwashyna
Justin B
JB
Dimick
Colin R
CR
Cooke
D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D005260:Female; D006739:Hospital Administration; D017052:Hospital Mortality; D006801:Humans; D038801:International Classification of Diseases; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data*; D010359:Patient Readmission / Q000706:statistics & numerical data; D011014:Pneumonia / Q000401:mortality*; D019984:Quality Indicators, Health Care; D018805:Sepsis / Q000401:mortality*; D014481:United States