Appropriate use of quality measures: Response to “risk factors for hospital readmission within 30 days: A new quality measure for children with sickle cell disease”

To the Editor: The recent article, ‘‘Risk Factors for Hospital Readmission Within 30 Days: A New Quality Measure for Children with Sickle Cell Disease’’ by Frei-Jones et al. [1] and Highlight by Quinn [2] raise important considerations for identifying risk factors and valid quality measures for children with SCD. We agree with the concerns raised and would like to correct a misunderstanding regarding what is described as a ‘‘new quality measure’’ issued as an ‘‘edict by NACHRI.’’ It is important to consider the origin and intended use of the 30-day readmission measure for SCD, which is neither new nor decreed. The authors are correct that the measure was ‘‘originally developed as an ORYX non-core measure,’’ proposed by the National Association of Children’s Hospitals and Related Institutions (NACHRI) in 1996 in response to the Joint Commission’s (TJC) call for Performance Measurement Systems in TJC’s quest to integrate performance measurement into the accreditation process. As TJC rolled out its ORYX requirements, this measure was one of many available to hospitals serving children. Approximately 80 of NACHRI’s 216 member hospitals submit inpatient discharge abstract data to an aggregate data base, which they use to look at their own case mix and utilization data as well as aggregate data from other institutions. Because some hospitals were already submitting data through NACHRI and because of the relative dearth of measures for pediatric care, several member hospitals worked with NACHRI to identify six initial performance measures that could be generated through this system without additional data collection. Selection of the 30-day readmission rate for SCD as one of these non-core measures for ORYX requirements was and is entirely voluntary. The use of performance measures has evolved. It is notable that the ORYX initiative initially sought to encourage hospitals to demonstrate the use of data in improving performance, not for public reporting or for comparing performance across hospitals. All of the initial NACHRI proposed ORYX non-core measures were utilization measures, either length of stay or readmissions, and geared to high volume pediatric admissions where there might be sufficient volume to permit pattern analysis. These measures were not subjected to a scientific validation process and, therefore, we do not agree with the SCD readmission being listed as a measure of ‘‘accountability’’ in the Quality Measures Compendium compiled by the Centers for Medicare and Medicaid Services without further study and validation. Similarly, as it convened an expert panel to develop a core measure set for children’s asthma care, TJC did not include proposed readmission measures in the final core set. As measures are used to compare performance across hospitals, validation is critical. We agree wholeheartedly with Dr. Quinn that the ‘‘SCD community needs to critically assess this measurement,’’ and we would further argue that the SCD community should consider identifying and assessing other measures that best assess quality of care for these children. Readmission is a subject of increased interest among policy-makers and payers, and the professional community should take an active role in validating measures of quality.