Excess Days in Acute Care (EDAC) After Hospitalization for Diabetes

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.

New measure for high risk population, diabetes, and supporting same conceptual build as done for HF, COPD and Pneumonia.  The criteria to include Medicare and Medicare Advantage patients and two years data makes sense. 

I am not opposed to this measure, but I do fear that medically-under-served and rural hospitals may be at a disadvantage due to lack of post-discharge community resources such as skilled care, primary care providers,  proximally-convenient pharmacies, etc. I saw that the measure developer looked as socio-economic differences (dual eligibility), but did they explore potential differences for rural or medically-under-served communities to ensure that this measure does not show higher outcomes than urban areas? Thank you. 

SHM is opposed to the measure being included in CMS programs at this time, and asks CMS to narrow the measure window, clarify measure specifications, and consider alternative programs for the measure. 

SHM asks for the measure specification to more clearly state how diabetes is defined in this measure, as it is a common chronic condition for many Americans. 

We also have concerns this measure may be better suited for an ACO-type environment, since much of the performance on this measure may be driven by availability of post-discharge resources, such as durable medical equipment or pharmacy availability. 

We also continue 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.

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.

CMS outlines several new measures that align with Make America Health Again (MAHA) priorities, including MUC2025-053: Excess Days in Acute Care (EDAC) After Hospitalization for Diabetes. Vizient appreciates CMS’s interest in identifying measures that can help address quality issues related to diabetes. 

In addition, Vizient recognizes the value of identifying opportunities to reduce avoidable acute care utilization for patients with diabetes. However, as this is a newly developed measure, we have concerns regarding adoption of the measure and believe additional testing, validation and stakeholder review are needed before the measure is considered for use in the Hospital Inpatient Quality Reporting (IQR) program. 

In 2024, a Technical Expert Panel (TEP) released a summary of its meetings on the development of a similar 30-day risk-standardized EDAC Following Hospitalization for Diabetes Measure, where TEP members raised concerns regarding the reliability of diagnosis coding for diabetes, the complexity of risk adjustment and the feasibility of accurately capturing the full range of acute care encounters for patients with diabetes, among other concerns.¹ The TEP suggested additional refinement and indicated additional testing would be necessary to ensure the measure’s validity and reliability. Considering the concerns raised by the TEP and the limited testing information currently available, Vizient recommends that CMS continue to refine and evaluate this measure before it is included in the Hospital IQR program. 

Vizient also encourages sharing additional information regarding how the measure aligns with existing diabetes‑related quality initiatives and whether it has been evaluated for overlap or redundancy with existing measures. Understanding how this measure fits within the broader diabetes care landscape is essential to avoiding unnecessary burden and ensuring that new measures add meaningful value.

1. TEP Meetings Summary Report for 30-Day Risk-Standardized Excess Days in Acute Care (EDAC) following Hospitalization for Diabetes

We request transparent model specifications, transition periods, and social risk adjustment to avoid penalizing hospitals serving vulnerable populations. 

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. With respect to the EDAC measure for Diabetes, Premier is concerned that the volume may be low for smaller hospitals and therefore they would not report this measure due to minimum volume thresholds. 

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.   

Do not support: Recommend phased implementation to ensure fair MA comparrison. Recommend focus on TRC and PCR vs. adding another measure.

Mehmet Oz, MD, MBA

Administrator

Centers for Medicare and Medicaid Services

200 Independence Avenue, SW

Washington, DC 20201

RE: Excess Days in Acute Care (EDAC) After Hospitalization for Diabetes (MUC2025-053)

Dear Administrator Oz,

Glytec appreciates the opportunity to comment on the Excess Days in Acute Care (EDAC) After

Hospitalization for Diabetes measure (MUC2025-053), which assesses excess days spent in

acute care settings – including inpatient readmissions, observation stays, and emergency

department visits – within 30 days following discharge from a diabetes-related hospitalization.

We applaud CMS’s continued leadership in advancing outcomes-based quality measurement and

improving care transitions for patients hospitalized with diabetes. Glytec strongly supports the

adoption of the Diabetes EDAC measure as a mandatory reporting measure in the Hospital

Inpatient Quality Reporting (IQR) Program.

About Glytec

Since our founding in 2006, Glytec has been a pioneer in insulin management technology. We

provide advanced insulin management software as a medical device (SaMD), cleared by the

Food and Drug Administration, that delivers personalized insulin treatment across the full

spectrum of inpatient glycemic care. Glytec’s software is grounded in peer-reviewed clinical

guidelines and supported by advanced, intelligent, computer-based algorithms that optimize

glycemic management across a wide range of clinical conditions and severities. These include

patients with and without diabetes, complex inpatient populations (e.g., ICU, stroke, and cardiac

surgery patients), and acute metabolic presentations such as ketoacidosis related to diabetes and

hyperosmolar states.

Glytec’s solutions have demonstrated meaningful improvements in safety, clinical outcomes, and

cost savings for more than 350 health systems nationwide, including academic medical centers,

community hospitals, accountable care organizations, and health plans. With an estimated 40 to

50 percent of hospitalized patients requiring insulin therapy in some settings, hospitals

increasingly rely on SaMD to improve glycemic management. Glytec’s clients have achieved

measurable reductions in hypoglycemia, hyperglycemia, length of stay, readmissions, A1C

levels, and overall cost of care. By improving inpatient glycemic control and supporting safer

transitions of care, Glytec delivers both clinical and economic value to patients and health

systems.

As a leading health care technology company, Glytec welcomes the opportunity to share its

experience and insights and appreciates CMS’s efforts to advance quality measurement that

meaningfully reflects patient outcomes.

Support for the Diabetes EDAC Measure

Glytec strongly supports the Diabetes EDAC measure as a meaningful and appropriate approach

to evaluating post-discharge outcomes for patients hospitalized with diabetes. Patients with

diabetes face an elevated risk of emergency department visits, observation stays, and unplanned

readmissions following hospitalization, often due to challenges related to glycemic management,

medication adjustments, patient education, and care coordination at discharge. By aggregating

emergency department visits, observation stays, and unplanned readmissions into a single, risk-

adjusted outcome measure, the EDAC framework provides a more comprehensive and clinically

relevant assessment of post-discharge acute care utilization than readmission-only measures.

Glytec believes this approach more accurately reflects the patient experience and aligns with

CMS’s goals of improving care transitions, reducing avoidable utilization, and advancing value-

based care. We also support the measure’s use of risk adjustment for age, comorbidities, and

exposure time, which helps ensure fair comparisons across hospitals serving complex patient

populations.

Importance of Mandatory Inclusion in the Hospital IQR Program

Glytec strongly urges CMS to adopt the Diabetes EDAC measure as a mandatory measure within

the IQR Program. Mandatory reporting increases hospital engagement, elevates leadership

accountability for patient safety, and drives investment in quality improvement strategies focused

on diabetes care transitions. CMS’s experience with other mandatory inpatient quality measures

demonstrates that public reporting and accountability frameworks catalyze the adoption of

standardized clinical protocols, strengthen discharge planning processes, and support

implementation of tools and workflows that reduce preventable adverse outcomes. Making the

Diabetes EDAC measure mandatory would clearly signal CMS’s commitment to improving

patient safety for patients with diabetes.

Including the Diabetes EDAC measure in the IQR Program would further reinforce the

importance of continuity of care beyond the inpatient setting and encourage hospitals to

implement interventions that reduce post-discharge acute care utilization, improve patient safety,

and lower the cost of care. A growing body of evidence demonstrates that effective inpatient

glycemic management – specifically the avoidance of hypoglycemia and hyperglycemia and the

reduction of glucose variability – is associated with lower rates of emergency department visits

and hospital readmissions after discharge.1 These findings underscore the importance of

addressing glycemic control during the inpatient stay as a foundational strategy for improving

post-discharge outcomes.

Alignment with Outcomes-Based Quality Measurement

The Diabetes EDAC measure aligns with CMS’s broader shift toward outcomes-based quality

measurement, including recent efforts to improve inpatient glycemic management through

electronic clinical quality measures, by promoting accountability for both inpatient care and

downstream outcomes following discharge. In addition to holding hospitals accountable for post-

discharge acute care utilization, the measure will drive a transition toward more technology-

enabled care during the critical 30-day post-discharge period, when patients hospitalized with

diabetes face heightened risk for adverse events.

Hospitals have access to a range of emerging solutions that can help modulate the post-discharge

experience for patients with diabetes, including models like Glytec’s artificial intelligence-

powered Command Center and other technology-enabled approaches that support monitoring,

coordination, and timely intervention following discharge. Glytec’s Command Center uses AI-

driven analytics to transform electronic health record and glycemic data into actionable insights

for risk surveillance, performance benchmarking, and care coordination across the enterprise,

helping health systems prioritize high-risk discharges and intervene early.

Effective inpatient glycemic management remains a critical determinant of post-discharge

outcomes, underscoring the importance of optimizing glucose control during hospitalization to

reduce downstream acute care utilization. We expect hospitals to prioritize improvements to care

protocols and adopt technology-enabled approaches that strengthen care transitions, reduce

avoidable emergency department visits and readmissions, and advance CMS’s goals for patient-

centered, value-driven care. Hospitals already have access to a range of technology-enabled

solutions that support effective glycemic management and coordinated transitions of care, and

the EDAC measure provides a meaningful incentive to adopt and scale these approaches to

reduce excess days in acute care.

Conclusion

Glytec appreciates CMS’s leadership in advancing meaningful quality measures and strongly

supports the adoption of the Diabetes EDAC measure as a mandatory reporting measure in the

IQR Program. We believe this measure represents a significant step forward in enhancing care

transitions and outcomes for patients with diabetes.

Thank you for the opportunity to provide comment. We look forward to continued engagement

as this measure advances.

Sincerely,

Deborah Dean

[email protected]

The American Occupational Therapy Association (AOTA) supports the intention of the Excess Days in Acute Care after Hospitalization for Diabetes measure. Seeking care after hospitalization for diabetes 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.

Capturing MA data for excess days in acute care after hospitalization for diabetes 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.