The Centers for Medicare and Medicaid Services’ (CMS) readmission after acute myocardial infarction (MI) ratio has no association with quality of care or clinical outcomes, according to results from a new analysis published in JAMA Cardiology.

The findings have important health-policy implications for the Hospital Readmission Reduction Program (HRRP), which offers financial incentives or penalties to hospitals based on their risk-standardized rates of readmission of MI patients after 30 days following hospital discharge, the researchers write. 

“The Hospital Readmission Reduction Program (HRRP) is intended to provide financial incentives to improve quality of care and clinical outcomes and to lower cost of care among hospitalized patients… [but] the present results suggest that this strategy may not in and of itself lead to improvements in quality of care, long-term mortality, or even long-term readmission rates,” writes James de Lemos, MD, associate director of the Cardiovascular Fellowship Program at The University of Texas Southwestern Medical Center in Dallas, and his colleagues.  

They noted that the HRRP was implemented in an effort to reduce the incidence of financially and clinically burdensome unplanned hospital readmissions. A key metric for HRRP is the excess readmission ratio after MI (MI-ERR), which calculates expected hospital admission rates adjusted for patient age, comorbidity burden, and certain measures of disease severity. 


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However, there are no data evaluating the association between this metric and quality-of-care measures or long-term clinical outcomes, explain the researchers. 

To fill that gap, Dr de Lemos and his team conducted an observational analysis of data collected from 176,644 acute MI patients admitted to 380 hospitals involved in HRRP between July 1, 2008, and June 30, 2011. Forty-three percent of these hospitals had higher-than-expected MI-ERR, but they did not have higher rates of mortality among the population studied at one year after discharge, the researchers found.  

Notably, hospitals with high MI-ERR had greater proportions of black patients and patients with more heart failure symptoms, lower ejection fraction and more bleeding events — for none of which does CMS adjust when calculating MI-ERR, explained Dr de Lemos and colleagues. 

“[O]ur findings raise questions of whether CMS readmissions penalties are equitably and justly applied for hospitals with a high prevalence of socially and/or medically complex patients,” they write.

Indeed, they warn that, “[H]ospitals that treat a greater proportion of black and other disadvantaged patients may be unfairly penalized, which could deplete resources from the hospitals that need them most.” 

Further, Dr de Lemos and his team offer two strategies to improve HRRP — update the MI-ERR to adjust for race and ethnicity and to include better measures of disease severity, and compare readmission rates between hospitals with similar patient populations. 

“Future studies are needed to determine whether 30-day readmission rates are associated with any other meaningful quality measures and the impact of penalties associated with readmission rates on hospital performance and patient outcomes over time,” they conclude.

Reference

Pandey A, Golwala H, Hall HM, et al. “Association of US Centers for Medicare and Medicaid Services Hospital 30-Day Risk-Standardized Readmission Metric With Care Quality and Outcomes After Acute Myocardial Infarction: Findings From the National Cardiovascular Data Registry/Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines.” JAMA Cardiol. 2017. doi: 10.1001/jamacardio.2017.1143 [Epub ahead of print]