Incorporating Present-on-Admission Indicators in Medicare Claims to Inform Hospital Quality Measure Risk Adjustment Models

Importance: Present-on-admission (POA) indicators in administrative claims data allow researchers to distinguish between preexisting conditions and those acquired during a hospital stay. The impact of adding POA information to claims-based measures of hospital quality has not yet been investigated to better understand patient underlying risk factors in the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision setting. Objective: To assess POA indicator use on Medicare claims and to assess the hospital- and patient-level outcomes associated with incorporating POA indicators in identifying risk factors for publicly reported outcome measures used by the Centers for Medicare mean SD age, 78.2 8.3 years) for the acute myocardial infarction mortality outcome measure to 1 395 870 admissions (677 158 48.5% men; mean SD age, 80.3 8.7 years) for the pneumonia readmission measure. Use of POA indicators was associated with improvements in risk adjustment model performance, particularly for mortality measures (eg, the C statistic increased from 0.728 95% CI, 0.726-0.730 to 0.774 95% CI, 0.773-0.776 when incorporating POA indicators into the acute myocardial infarction mortality measure). Conclusions and Relevance: The findings of this quality improvement study suggest that leveraging POA indicators in the risk adjustment methodology for hospital quality outcome measures may help to more fully capture patients' risk factors and improve overall model performance. Incorporating POA indicators does not require extra effort on the part of hospitals and would be easy to implement in publicly reported quality outcome measures.