Advocates for Evidence-Based Health Policy Speakers
Readmission Program may worsen Mortality
When the Affordable Care Act (ACA) was enacted, a large majority of the subsequent attention focused on the obvious topic: increasing insurance coverage. While the main goal of the ACA was to increase access to care, the law also took a multifaceted approach to healthcare quality improvement. One such suggested improvement was the Hospital Readmission Reduction Program (HRRP), a program that penalized hospitals with readmission rates higher than the national average. Politicians and policy-makers hinged HRRP on a belief that readmissions rates were a proxy for the quality of care. This notion was received with mixed emotions by the healthcare community, to say the least. With many years of the HRRP behind us, studies are now uncovering a worrying connection: decreased hospital readmission rates correlate to an increase in mortality.
In a recent study focused on readmissions related to heart failure, there is convincing evidence of an increase in both short term and long-term mortality outcomes following implementation of HRRP. The study cross referenced data from hospitals participating in the American Heart Association’s Get with the Guidelines-Heart Failure (GWTG-HF) database with Medicare Part A claims files. The study attempted to minimize confounding by adjusting for several factors relating to both the hospitals and to patient demographics. While HRRP was successful in reducing hospital readmission from 20.0% to 18.4%, it came alongside a spike in 30-day mortality from 7.2% to 8.6%. The 1-year risk of readmission showed congruent trends with a decrease from 61.0% to 57.9% in readmissions coupled to a mortality rate increase from 34.5% to 38.1%.
While no single physician might feel pressured to change their clinical judgement because of this policy, it remains to be seen whether or not HRRP creates a dangerous culture. Are the spikes in mortality linked to strategies that put patients at risk? Shifting in-patient burdens to the emergency department, delaying readmission beyond 30 days, and taking advantage of observational stays could all impact American lives. However, studies such as this reinforce the notion that physicians must play a critical role in policy formation and should be present to guide policies that could potentially cause patients undue harm.
This Policy Prescriptions® review is written by Sydney Sachse as part of our collaboration with the Health Policy Journal Club at Baylor College of Medicine where she is a medical student.
Abstract
IMPORTANCE: Public reporting of hospitals’ 30-day risk-standardized readmission rates following heart failure hospitalization and the financial penalization of hospitals with higher rates have been associated with a reduction in 30-day readmissions but have raised concerns regarding the potential for unintended consequences.
OBJECTIVE: To examine the association of the Hospital Readmissions Reduction Program (HRRP) with readmission and mortality outcomes among patients hospitalized with heart failure within a prospective clinical registry that allows for detailed risk adjustment.
DESIGN, SETTING, AND PARTICIPANTS: Interrupted time-series and survival analyses of index heart failure hospitalizations were conducted from January 1, 2006, to December 31, 2014. This study included 115?245 fee-for-service Medicare beneficiaries across 416 US hospital sites participating in the American Heart Association Get With The Guidelines-Heart Failure registry. Data analysis took place from January 1, 2017, to June 8, 2017.
EXPOSURES: Time intervals related to the HRRP were before the HRRP implementation (January 1, 2006, to March 31, 2010), during the HRRP implementation (April 1, 2010, to September 30, 2012), and after the HRRP penalties went into effect (October 1, 2012, to December 31, 2014).
MAIN OUTCOMES AND MEASURES: Risk-adjusted 30-day and 1-year all-cause readmission and mortality rates.
RESULTS: The mean (SD) age of the study population (n = 115?245) was 80.5 (8.4) years, 62 927 (54.6%) were women, and 91 996 (81.3%) were white and 11 037 (9.7%) were black. The 30-day risk-adjusted readmission rate declined from 20.0% before the HRRP implementation to 18.4% in the HRRP penalties phase (hazard ratio (HR) after vs before the HRRP implementation, 0.91; 95% CI, 0.87-0.95; P?<?.001). In contrast, the 30-day risk-adjusted mortality rate increased from 7.2% before the HRRP implementation to 8.6% in the HRRP penalties phase (HR after vs before the HRRP implementation, 1.18; 95% CI, 1.10-1.27; P?<?.001). The 1-year risk-adjusted readmission and mortality rates followed a similar pattern as the 30-day outcomes. The 1-year risk-adjusted readmission rate declined from 57.2% to 56.3% (HR, 0.92; 95% CI, 0.89-0.96; P?<?.001), and the 1-year risk-adjusted mortality rate increased from 31.3% to 36.3% (HR, 1.10; 95% CI, 1.06-1.14; P?<?.001) after vs before the HRRP implementation.
CONCLUSIONS AND RELEVANCE: Among fee-for-service Medicare beneficiaries discharged after heart failure hospitalizations, implementation of the HRRP was temporally associated with a reduction in 30-day and 1-year readmissions but an increase in 30-day and 1-year mortality. If confirmed, this finding may require reconsideration of the HRRP in heart failure.
PMID: 29128869
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