The Hospital Readmissions Reduction Program (HRRP) — which requires the Centers for Medicare & Medicaid Services to impose penalties on hospitals with high 30-day readmission rates in specific patients with cardiovascular disease — appears to increase the risk for 30-day post-discharge mortality in Medicare beneficiaries hospitalized for heart failure (HF) and pneumonia, according to study results published in JAMA.
Researchers retrospectively reviewed hospitalizations for HF, pneumonia, and acute myocardial infarction (AMI) in Medicare fee-for-service beneficiaries age ≥65. The study included 4 temporal categories in their analysis: periods 1 and 2, which occurred prior to HRRP establishment of baseline trends (April 2005 to September 2007 and October 2007 to March 2010); periods 3 and 4, which occurred after the HRRP announcement (April 2010 to September 2012) and HRRP implementation (October 2012 to March 2015). Investigators analyzed mortality within a 30-day period of hospital discharge and stratified results according to whether or not an associated readmission occurred. Mortality within 45 days of initial hospital admission was included as an additional end point.
A total of 8.3 million hospitalizations for HF (n=3.2 million), AMI (n=1.8 million), and pneumonia (n=3.0 million) were included in the analysis. Of these, approximately 7.9 million patients were still alive at hospital discharge. Mortality within 30 days of discharge occurred in 270,517, 128,088, and 246,154 patients with HF, AMI, and pneumonia, respectively. Post-discharge mortality increased prior to the announcement of the HRRP in patients hospitalized for HF (0.27% increase from period 1 to period 2). In addition, the announcement of the HRRP (0.49% increase from period 2 to period 3; difference in change, 0.22%; P =.01), as well as its implementation (0.52% increase from period 3 to period 4; difference in change, 0.25%; P =.001) were associated with increases in mortality after discharge.
In patients hospitalized with AMI, the announcement of HRRP was associated with a decrease in post-discharge mortality (0.18% pre-HRRP increase vs 0.08% post-HRRP announcement decrease; difference in change, −0.26%; P =.01). Conversely, an increase in 30-day mortality was observed in patients hospitalized with pneumonia after HRRP announcement (0.26% post-HRRP announcement increase; difference in change, 0.22%; P =.01) and implementation (0.44% post-HPPR implementation increase; difference in change, 0.40%, P <.001).
Limitations of the study include its observational design, which reduced the ability to make causal inferences, and the lack of data regard patients’ disease severity.
“Given the study design and the lack of significant association of the HRRP implementation with mortality within 45 days of hospital admission,” the researchers concluded, “further research is needed to understand whether the increase in 30-day post-discharge mortality is a result of the HRRP.”
Wadhera RK, Joynt Maddox KE, Wasfy JH, et al. Association of the hospital readmissions reduction program with mortality among Medicare beneficiaries hospitalized for heart failure, acute myocardial infarction, and pneumonia. JAMA. 2018;320(24):2542-2552.