Evidenced Based- Analyzing articles
Association of the Hospital Readmissions Reduction Program With Mortality Among Medicare Beneficiaries Hospitalized for Heart Failure, Acute Myocardial Infarction, and Pneumonia Rishi K. Wadhera, MD, MPP, MPhil; Karen E. Joynt Maddox, MD, MPH; Jason H. Wasfy, MD, MPhil; Sebastien Haneuse, PhD; Changyu Shen, PhD; Robert W. Yeh, MD, MSc
IMPORTANCE The Hospital Readmissions Reduction Program (HRRP) has been associated with a reduction in readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. It is unclear whether the HRRP has been associated with change in patient mortality.
OBJECTIVE To determine whether the HRRP was associated with a change in patient mortality.
DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of hospitalizations for HF, AMI, and pneumonia among Medicare fee-for-service beneficiaries aged at least 65 years across 4 periods from April 1, 2005, to March 31, 2015. Period 1 and period 2 occurred before the HRRP to establish baseline trends (April 2005-September 2007 and October 2007-March 2010). Period 3 and period 4 were after HRRP announcement (April 2010 to September 2012) and HRRP implementation (October 2012 to March 2015).
EXPOSURES Announcement and implementation of the HRRP.
MAIN OUTCOMES AND MEASURES Inverse probability–weighted mortality within 30 days of discharge following hospitalization for HF, AMI, and pneumonia, and stratified by whether there was an associated readmission. An additional end point was mortality within 45 days of initial hospital admission for target conditions.
RESULTS The study cohort included 8.3 million hospitalizations for HF, AMI, and pneumonia, among which 7.9 million (mean age, 79.6 [8.7] years; 53.4% women) were alive at discharge. There were 3.2 million hospitalizations for HF, 1.8 million for AMI, and 3.0 million for pneumonia. There were 270 517 deaths within 30 days of discharge for HF, 128 088 for AMI, and 246 154 for pneumonia. Among patients with HF, 30-day postdischarge mortality increased before the announcement of the HRRP (0.27% increase from period 1 to period 2). Compared with this baseline trend, HRRP announcement (0.49% increase from period 2 to period 3; difference in change, 0.22%, P = .01) and implementation (0.52% increase from period 3 to period 4; difference in change, 0.25%, P = .001) were significantly associated with an increase in postdischarge mortality. Among patients with AMI, HRRP announcement was associated with a decline in postdischarge mortality (0.18% pre-HRRP increase vs 0.08% post-HRRP announcement decrease; difference in change, −0.26%; P = .01) and did not significantly change after HRRP implementation. Among patients with pneumonia, postdischarge mortality was stable before HRRP (0.04% increase from period 1 to period 2), but significantly increased 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). The overall increase in mortality among patients with HF and pneumonia was mainly related to outcomes among patients who were not readmitted but died within 30 days of discharge. For all 3 conditions, HRRP implementation was not significantly associated with an increase in mortality within 45 days of admission, relative to pre-HRRP trends.
CONCLUSIONS AND RELEVANCE Among Medicare beneficiaries, the HRRP was significantly associated with an increase in 30-day postdischarge mortality after hospitalization for HF and pneumonia, but not for AMI. Given the study design and the lack of significant association of the HRRP with mortality within 45 days of admission, further research is needed to understand whether the increase in 30-day postdischarge mortality is a result of the policy.
JAMA. 2018;320(24):2542-2552. doi:10.1001/jama.2018.19232
Editorial page 2539
Supplemental content
Author Affiliations: Author affiliations are listed at the end of this article.
Corresponding Authors: Robert W. Yeh, MD, MSc, and Changyu Shen, PhD, Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, 375 Longwood Ave, Boston, MA 02215 (ryeh@bidmc.harvard.edu).
Research
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T he Hospital Readmissions Reduction Program (HRRP)was established under the Affordable Care Act (ACA) in2010 and required that the Centers for Medicare & Med- icaid Services (CMS) impose financial penalties on hospitals with higher-than-expected 30-day readmission rates for pa- tients with heart failure, acute myocardial infarction, and pneu- monia, beginning in 2012.1 After the announcement of the HRRP, readmission rates among Medicare beneficiaries de- clined for target conditions nationwide.2,3 Recently, how- ever, policy makers and physicians have raised concern that the HRRP may have also had unintended consequences that adversely affected patient care, potentially leading to in- creased mortality.4,5 For instance, the financial penalties im- posed by the HRRP may have inadvertently pushed some phy- sicians to avoid indicated readmissions, potentially diverted hospital resources and efforts away from other quality im- provement initiatives, or worsened quality of care at resource- poor hospitals that are often penalized by the program. How- ever, it is also possible that the same mechanisms by which some hospitals have reduced readmissions, such as im- proved coordination and transitions of care, resulted in reduc- tions in mortality.
Understanding whether the HRRP has been associated with changes in mortality at the patient level is important as policy makers evaluate this program, particularly given the ongoing expansion of the HRRP to include other conditions6
and the almost $2 billion in financial penalties that have been imposed on hospitals since 2012.7 This study aims to answer 3 questions. First, compared with past trends, was the announcement or implementation of the HRRP associated with a change in mortality within 30 days of discharge fol- lowing hospitalization for heart failure, acute myocardial infarction, or pneumonia? Second, was the HRRP associated with a change in the distribution of patients who experienced death and no readmission, readmission and no death, read- mission and death, or no death and no readmission during the 30 days after discharge? Third, was the HRRP associated with a change in mortality within 45 days of hospital admis- sion for target conditions?
Methods Institutional review board approval, including waiver of the requirement of participant informed consent because the data were deidentified, was provided by the Beth Israel Deacon- ess Medical Center.
Study Cohort We used Medicare Provider Analysis and Review files to iden- tify hospital admissions and discharges at short-term acute care hospitals from April 1, 2005, through March 31, 2015, with a principal discharge diagnosis of heart failure, acute myo- cardial infarction, or pneumonia. Study cohorts were de- fined using International Classification of Diseases, Ninth Revision, Clinical Modification codes used in the publicly re- ported CMS readmission and mortality measures.8-10 We in- cluded Medicare beneficiaries aged 65 years or older in the
analysis. We excluded patients who were discharged against medic al advice, were not enrolled in Medic are fee-for- service for at least 30 days after discharge (absent death), or were enrolled in Medicare fee-for-service for less than 1 year before hospitalization. Transfers to other hospitals were linked to a single index hospitalization. To examine 30-day postdischarge outcomes, we also excluded patients who died during hospitalization. Comorbidities were defined using CMS hierarchical condition categories based on Medicare claims up to 1 year before hospitalization.11 Specifically, we used covariates in the CMS risk-adjustment models for heart fail- ure, acute myocardial infarction, and pneumonia,12-14 as has been done in previous studies.2,15 The race/ethnicity of all pa- tients was identified based on claims files and was desig- nated into the following fixed categories: white, black, or other. Race/ethnicity was included as a covariate in the analysis be- cause it is associated with mortality for target conditions.16
Study Periods We identified 4 nonoverlapping study periods of equal dura- tion for index hospitalization. We chose to evaluate differ- ences in outcomes between time periods, rather than annual trends, for 2 reasons. First, we were interested in changes in outcomes among time periods defined by their relationship to the announcement and implementation of the HRRP, rather than within-period trends. Second, this strategy avoids as- sumptions on how the HRRP imposes its effect on different pa- tient groups (eg, assumptions on main effects and interaction terms) and of a linear relationship between outcomes and time and continuous confounders in a conventional logistic or mul- tinominal regression model.
We identified 2 study periods before the HRRP was estab- lished to examine baseline trends in outcomes. The first study period included hospitalizations from April 2005 to Septem- ber 2007 (period 1) and the second included hospitalizations from October 2007 to March 2010 (period 2). Two periods af- ter the HRRP was established were also included: 1 following the initial announcement of HRRP with passage of the ACA from April 2010 through September 2012 (period 3) and the other between October 2012 and March 2015 (period 4), which
Key Points Question Was the announcement and implementation of the Hospital Readmissions Reduction Program (HRRP) associated with an increase in patient-level mortality?
Findings In this retrospective cohort study that included approximately 8 million Medicare beneficiary fee-for-service hospitalizations from 2005 to 2015, implementation of the HRRP was associated with a significant increase in trends in 30-day postdischarge mortality among beneficiaries hospitalized for heart failure and pneumonia, but not for acute myocardial infarction.
Meaning There was a statistically significant association with implementation of the HRRP and increased post-discharge mortality for patients hospitalized for heart failure and pneumonia, but whether this finding is a result of the policy requires further research.
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is when the HRRP was implemented and hospitals were sub- jected to financial penalties. For patients with multiple hos- pitalizations within a time period, 1 index hospitalization was randomly selected for each condition.
Outcomes Patient mortality within 30 days of discharge after a hospital- ization (postdischarge mortality) for heart failure, acute myo- cardial infarction, and pneumonia was evaluated, which has been done in previous hospital-level analyses.17-19 The follow- ing 30-day postdischarge outcome subgroups were also ex- amined: (1) death and no readmission, (2) readmission and death, (3) readmission and no death, and (4) no readmission and no death. These subgroup outcomes were examined to try to provide mechanistic insights on the relationship between readmission and mortality. To fully assess trends in mortality related to a complete clinical episode, 45-day patient mortal- ity rates following admission (postadmission mortality) were also evaluated, because efforts to reduce readmissions could potentially encompass care during hospitalization and might influence discharge timing and location of death. This mea- sure included varying hospital lengths of stay and captured both in-hospital and 30-day postdischarge deaths for the ma- jority of the cohort.
Statistical Analysis To account for a potential imbalance in case mix between study periods, a propensity score approach (ie, the probability of being in a specific period given the demographics and comor- bidities of the patient and calendar month of hospitalization) was used to standardize populations among periods. Patient demographics, comorbidities, and seasonal indicators (calen- dar month) from period 4 were used as a reference to re- weight observed outcomes in all other study periods. Logis- tic regression models were fit on data from periods 1 and 4 to obtain a propensity score for period 1. The propensity score was then used to weight the outcomes in period 1, generating event rates through inverse probability weighting (IPW) that would
have been observed if period 1 had the same case mix as pe- riod 4. Similarly, separate logistic regression models were fit to data from periods 2 and 4 and periods 3 and 4 to provide IPW-adjusted event rates in periods 2 and 3, respectively. This approach allowed the calculated distribution of each out- come in each of the 4 periods to be based on the same case mix (ie, the case mix from period 4).20 Because the primary aim was to understand the association of the HRRP with mortal- ity at the individual level, we did not examine hospital-level effects in the analysis.
To establish the change in rates of outcomes after the an- nouncement of the HRRP, the change in event rates between periods 2 and 3 was calculated. Similarly, the change in rates of outcomes between periods 3 and 4 was also calculated to examine the change in outcomes between the announce- ment and the implementation of the HRRP (Figure 1).
To isolate the association between the HRRP and the out- comes, we sought to remove secular trends for each out- come. To do so, the change in outcomes between periods 1 and 2 was computed to establish a baseline trend in outcomes be- fore the announcement and implementation of the HRRP. This difference was then subtracted from the change in outcomes after the announcement of the HRRP (between periods 2 and 3) to account for trends that were unrelated to the HRRP. Simi- larly, the baseline difference was also subtracted from the change in outcomes after the implementation of the HRRP, be- tween periods 3 and 4.
Additional Analyses Several sensitivity analyses were performed. First, patients enrolled in hospice were excluded because greater use of hospice care at the end of life might shift deaths that previ- ously occurred within a hospital to the postdischarge setting over time.21,22 Second, because 1 hospitalization was ran- domly selected for patients that experienced multiple hospi- talizations in a given study period, the main analysis was repeated using the first hospitalization for each patient in each study period as well as all hospitalizations for each
Figure 1. Study Periods and Analytic Approach in a Study of the Association Between the Hospital Readmissions Reduction Program (HRRP) and Mortality
Period 1 (April 2005-
September 2007)
Period 2 (October 2007-
March 2010)
Period 3 (April 2010-
September 2012)
Period 4 (October 2012-
April 2015)
Baseline change in mortality before HRRP announcement
Difference in change in mortality prior to HRRP (A) compared with change after HRRP announcement (B)
Difference in change in mortality before HRRP (A) compared with change after HRRP implementation (C)
Change in mortality after HRRP announcement
Change in mortality after HRRP implementation
HRRP Announcement (April 2010)
HRRP Implementation (October 2012)
Calculation A
Calculation
Calculation
Calculation B Calculation C
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patient. Third, the entire analysis for postdischarge mortality was repeated using outcome regression within each study period to generate predicted outcomes for the case-mix in period 4, which were then directly compared across periods to ensure the results were not sensitive to the analytic approach used.
More details on the methodologic approach are provided in the Supplement. Significance testing was performed using z tests, with standard error estimates that accounted for in- verse probability weighting. Statistical tests were 2-sided at a significance level of .05. The false discovery rate (FDR) based multiple comparison procedure was used to assess the statis- tical significance of the difference in the change in mortality- related end points (eg, aggregate mortality, mortality with or without readmission) at the FDR level of 0.05.23,24 Analyses were performed using SAS version 9.4 (SAS Institute).
Results There were 8 326 688 Medicare fee-for-service hospitaliza- tions for heart failure, acute myocardial infarction, and pneu- monia from April 1, 2005, to March 31, 2015, among which 7 948 937 patients were alive at hospital discharge. The mean (SD) age of the study population was 79.6 (8.7) years, 4 246 45 4 partic ipants (53.4%) were women, 6 802 296 (85.6%) were white, and 738 198 (9.3%) were black. There were 3.2 million hospitalizations for heart failure, 1.8 million for acute myocardial infarction, and 3.0 million for pneumo- nia and, overall, there were 270 517 deaths from heart failure, 128 088 deaths from ac ute myoc ardial infarction, and 246 154 deaths from pneumonia within 30 days of discharge. Baseline patient demographics were similar among the 4 study periods; comorbidities are shown in Table 1 for patients alive at discharge. Observed trends in 30-day postdischarge and 45-day postadmission outcomes for target conditions are shown in Figure 2 and eTables 1 and 2 in the Supplement.
HRRP and 30-Day Postdischarge Mortality Among patients with heart failure, IPW-adjusted postdis- charge mortality (Figure 3A and eTable 3 in the Supplement) increased before the announcement or implementation of the HRRP (0.27% increase from period 1 to period 2; Table 2). Relative to this baseline trend, the announcement of the HRRP was significantly associated with an increase in postdischarge mortality (0.49% increase from period 2 to period 3; 0.22% difference between the change from period 1 to period 2 and period 2 to period 3; P = .01). An analysis stratified by whether there was an associated readmission showed that this change was entirely driven by a significant increase in mortality without readmission (0.27% increase from period 1 to period 2 vs 0.53% increase from period 2 to period 3; 0.26% difference between the change from period 1 to period 2 and period 2 to period 3; P < .001). In addition, HRRP implementation was significantly associated with an increase in postdischarge mortality overall relative to base- line trends (0.52% increase from period 3 to period 4; 0.25% difference between the change from period 1 to period 2 and
period 3 to period 4; P = .001), which was also explained by an increase in death without readmission.
In contrast, among patients with acute myocardial infarc- tion (Figure 3B), HRRP announcement was significantly asso- ciated with a decline in postdischarge mortality (Table 2; 0.18% increase from period 1 to period 2 vs 0.08% decrease from period 2 to period 3; −0.26% difference between the change from period 1 to period 2 and period 2 to period 3; P = .01). Compared with baseline trends, HRRP implementa- tion was not associated with a significant change in mortality (0.15% increase from period 3 to period 4; −0.03% difference between the change from period 1 to period 2 and period 3 to period 4; P = .69).
Postdischarge mortality among patients with pneumonia (Figure 3C) was relatively stable before the HRRP (0.04% increase from period 1 to period 2), but increased signifi- cantly after announcement of the HRRP (Table 2; 0.26% increase from period 2 to period 3; 0.22% difference between the change from period 1 to period 2 and period 2 to period 3; P = .01). This overall change was driven by an increase in patients who were not readmitted but died within 30 days of discharge (0.09% increase from period 1 to period 2 vs 0.32% increase from period 2 to period 3; 0.23% difference between the change from period 1 to period 2 and period 2 to period 3; P = .003). In addition, compared with baseline trends, HRRP implementation was also significantly associated with an increase in mortality overall (0.44% increase from period 3 to period 4; 0.40% difference between the change from period 1 to period 2 and period 3 to period 4; P < .001) and among stratified mortality outcomes of death and no readmission (0.09% from period 1 to period 2 vs 0.38% from period 3 to period 4; 0.30% difference between the change from period 1 to period 2 and period 3 to period 4; P < .001) and readmis- sion and death (0.05% decrease from period 1 to period 2 vs 0.05% increase from period 3 to period 4; 0.11% difference between the change from period 1 to period 2 and period 3 to period 4; P = .003).
All P values less than .05 for the 18 comparisons involv- ing 3 end points (total mortality, mortality without readmis- sion, and mortality with readmission), 2 differences in change (post-HRRP announcement trends and post-HRRP implemen- tation trends compared with pre-HRRP trends) and 3 condi- tions (heart failure, acute myocardial infarction, and pneu- monia) were also significant at the FDR level of 0.05 (Table 2).
Other 30-Day Postdischarge Outcomes Inverse probability-weighted readmissions without death within 30 days declined significantly following the announce- ment and implementation of the HRRP compared with the years preceding the HRRP for all 3 target conditions (Table 2). Trends across study periods in rates of patients who were not readmitted and were alive within 30 days of discharge are also shown in Table 2 and eTable 3 in the Supplement.
HRRP and 45-Day Postadmission Mortality Trends in IPW-adjusted postadmission mortality rates are shown in Figure 4 and eTable 4 in the Supplement. Among pa- tients hospitalized for heart failure, postadmission mortality
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rates steadily increased before the announcement of the HRRP (Table 2; 0.15% increase from period 1 to period 2). Compared with this baseline trend, the HRRP announcement was sig- nificantly associated with an increase in mortality (0.42% in- crease from period 2 to period 3; 0.27% difference between the change from period 1 to period 2 and period 2 to period 3; P = .01). However, mortality did not significantly change af- ter HRRP implementation (0.32% increase from period 3 to pe- riod 4; 0.17% difference between the change from period 1 to period 2 and period 3 to period 4; P = .06).
Postadmission mortality declined among patients hospi- talized for acute myocardial infarction before the announce- ment of the HRRP (0.24% decline from period 1 to period 2), a trend that did not significantly change after the HRRP an- nouncement (0.35% decline from period 2 to period 3; −0.12%
difference between the change from period 1 to period 2 and period 2 to period 3; P = .39). Following the HRRP implemen- tation, postadmission mortality continued to decline (0.44% from period 3 to period 4), but did not significantly differ from baseline trends (−0.21% difference between the change from period 1 to period 2 and period 3 to period 4: P = .06).
Among patients hospitalized for pneumonia, postadmis- sion mortality was relatively stable before the HRRP (0.05% increase from period 1 to period 2), and did not significantly change after the HRRP announcement (0.15% decline from pe- riod 2 to period 3; −0.20% difference between the change from period 1 to period 2 and period 2 to period 3; P = .07) and imple- mentation (0.14% increase from period 3 to period 4; 0.09% difference between the change from period 1 to period 2 and period 3 to period 4; P = .30).
Table 1. Baseline Characteristics of Patients Discharged After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumoniaa
Participants, % Period 1 (April 2005- September 2007)
Period 2 (October 2007- March 2010)
Period 3 (April 2010- September 2012)
Period 4 (October 2012- March 2015)
Hospitalizations 2 283 774 2 011 915 1 857 337 1 795 911
Demographics
Age, mean (SD), y 79.5 (8.5) 79.7 (8.7) 79.7 (8.9) 79.6 (9.0)
Women 54.4 53.7 53.1 52.2
Men 45.6 46.3 46.9 47.8
Race/ethnicity
White 85.9 85.8 85.4 85.1
Black 9.2 9.2 9.4 9.4
Otherb 4.9 5.0 5.2 5.5
Cardiovascular comorbidities
Chronic atherosclerosis 53.0 52.6 52.4 50.0
Diabetes 33.9 34.1 35.3 36.0
Hypertension 60.6 66.3 69.1 67.6
History of acute myocardial infarction 5.1 5.2 5.2 5.1
History of heart failure 27.2 26.4 26.8 26.1
Peripheral vascular disease 8.6 8.7 8.4 7.7
Unstable angina 3.4 2.9 2.7 2.6
Valvular heart disease 22.7 17.6 17.2 17.0
Other comorbidities
Anemia 28.5 30.2 32.3 32.0
COPD 39.6 34.8 34.5 33.8
Cancer 9.5 9.8 9.9 9.7
Cerebrovascular disease 5.1 5.0 4.9 4.5
Dementia 13.7 14.2 12.9 6.8
Depression 8.4 8.1 8.5 8.2
Functional disability 2.9 3.2 3.4 3.3
Liver disease 1.0 1.0 1.1 1.3
Malnutrition 4.6 6.5 7.7 8.2
Psychiatric disorder 2.8 3.2 3.3 3.2
Kidney failure 14.0 18.2 21.2 21.9
Respiratory failure 6.6 8.7 10.2 11.5
Substance abuse 6.9 6.6 7.0 7.3
Trauma 7.5 7.4 7.2 6.6
Length of stay, mean (SD), d 5.6 (4.9) 5.5 (4.8) 5.2 (4.5) 5.1 (4.4)
Abbreviation: COPD, chronic obstructive pulmonary disease. a Data are reported as percentages
unless otherwise noted. HRRP announcement was in April 2010 and implementation was in October 2012.
b Race/ethnicity denoted as Asian, Hispanic, North American Native, other, or unknown.
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Additional Analyses As a sensitivity analysis, we excluded patients receiving hos- pice care and observed patterns in postdischarge mortality that paralleled our primary analysis (eTable 5 in the Supplement). After excluding patients receiving hospice care, postdis- charge mortality among patients hospitalized for heart fail- ure and pneumonia were declining before the announce- ment and implementation of the HRRP, but significantly increased after the announcement and implementation due to an increase in mortality without readmission (eTable 6 in the Supplement). Trends in hospice deaths within 30 days of discharge by condition are shown in eTables 7 and 8 in the Supplement. Trends in postdischarge mortality also re- mained similar when the analysis was restricted to the first hos- pitalization for each patient in each period (eTables 9 and 10 in the Supplement) or included all hospitalizations for each pa-
tient (eTables 11 and 12 in the Supplement). In addition, find- ings were consistent using the outcome regression-based ap- proach (eTables 13 and 14 in the Supplement).
Discussion Overall, the announcement and implementation of the HRRP was associated with a significant increase in mortality within 30 days of discharge among Medicare beneficiaries hospi- talized for heart failure and pneumonia, but not for acute myocardial infarction. Although 30-day postdischarge mor- tality for heart failure was increasing before the HRRP, this increase accelerated after the announcement and implemen- tation of the program. In addition, postdischarge mortality for pneumonia was stable before the HRRP, but increased
Figure 2. Observed 30-Day Postdischarge Mortality for Target Conditions Before and After the Announcement and Implementation of the Hospital Readmissions Reduction Program (HRRP)
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No. of hospitalizations
Heart failureA HRRP
announcement HRRP
implementation
Period 1 (2005-2007)
911 244
Period 2 (2007-2010)
805 918
Period 3 (2010-2012)
734 675
Period 4 (2012-2015)
720 228
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PneumoniaC HRRP
announcement HRRP
implementation
Period 1 (2005-2007)
891 966
Period 2 (2007-2010)
763 378
Period 3 (2010-2012)
704 233
Period 4 (2012-2015)
659 274
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No. of hospitalizations
Acute myocardial infarctionB HRRP
announcement HRRP
implementation
Period 1 (2005-2007)
480 564
Period 2 (2007-2010)
442 619
Period 3 (2010-2012)
418 429
Period 4 (2012-2015)
419 409
Readmission and death
Death and no readmission
Aggregate death
Readmission and death
Death and no readmission
Aggregate death
Readmission and death
Death and no readmission
Aggregate death
Trends in observed overall 30-day postdischarge mortality and 30-day postdischarge mortality stratified by whether there was an associated readmission for (A) heart failure (B) acute myocardial infarction,
and (C) pneumonia. Given the large sample size, CIs for all point estimates are very narrow and therefore not depicted.
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after announcement and implementation of the program. The increase in mortality for heart failure and pneumonia were driven mainly by patients who were not readmitted within 30 days of discharge.
Postdischarge mortality was first evaluated because this is the period when many potential changes in care incentiv- ized by the HRRP, intended to lower readmissions, could manifest in terms of mortality.17 In addition, mortality within 45 days of initial admission was also evaluated, because efforts to reduce readmissions could potentially encompass care during the index hospitalization and might influence discharge timing and location of death. Although announce- ment of the HRRP was associated with a significant increase in mortality for patients with heart failure using this alternate end point, no association was observed between HRRP implementation and increased mortality for all conditions. The difference between findings for postdischarge and post- admission mortality could potentially be explained by in-hospital deaths, which were steadily declining for target
conditions in the decade before the announcement and implementation of the HRRP.25,26 The postadmission mortal- ity measure included both in-hospital and postdischarge deaths; thus secular declines in in-hospital deaths may have counterbalanced the increase in postdischarge mortality observed after the announcement and implementation of the HRRP. Hospitals may have also changed practices so that high-risk patients, over time, were discharged earlier, leading to a shift of some deaths from the inpatient to the outpatient setting that was unrelated to the HRRP. Such shifts, however, would need to have accelerated at the time of the announce- ment and implementation of the HRRP to explain the con- comitant increase in postdischarge mortality.
Most concerning, however, is the possibility that the relationship between the HRRP and postdischarge mortality for heart failure and pneumonia is causal, indicating that the HRRP led to changes in quality of care that adversely af- fected patients. Financial incentives aimed at reducing readmissions were up to 10- to 15-fold greater under the HRRP
Figure 3. Inverse Probability-Weighted 30-Day Postdischarge Mortality for Target Conditions Before and After the Announcement and Implementation of the Hospital Readmissions Reduction Program (HRRP)
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Heart failureA HRRP
announcement HRRP
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Period 1 (2005-2007)
Period 2 (2007-2010)
Period 3 (2010-2012)
Period 4 (2012-2015)
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Period 2 (2007-2010)
Period 3 (2010-2012)
Period 4 (2012-2015)
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PneumoniaC HRRP
announcement HRRP
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Period 1 (2005-2007)
Period 2 (2007-2010)
Period 3 (2010-2012)
Period 4 (2012-2015)
Readmission and death
Death and no readmission
Aggregate death
Readmission and death
Death and no readmission
Aggregate death
Readmission and death
Death and no readmission
Aggregate death
Trends in inverse probability-weighted overall 30-day postdischarge mortality and 30-day postdischarge mortality stratified by whether there was an associated readmission. Given the large sample size, CIs for all point estimates
were narrow and therefore not depicted (eg, overall mortality for heart failure in period 1 was 8.3% [95% CI, 8.2%-8.4%]).
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Association of the Hospital Readmissions Reduction Program With Heart Failure, AMI, and Pneumonia Mortality Original Investigation Research
jama.com (Reprinted) JAMA December 25, 2018 Volume 320, Number 24 2549
© 2018 American Medical Association. All rights reserved.
than incentives to improve mortality through pay-for- performance programs, and some hospitals may have fo- cused more resources and efforts on reducing or avoiding re- admissions than on prioritizing survival. Studies have found little evidence that standard measures of care quality for acute myocardial infarction and heart failure are correlated with re- admission rates,27,28 suggesting that as hospitals face choices about which quality improvement efforts to prioritize, read- missions could be at odds with other goals. Safety net hospi- tals and hospitals serving a high proportion of socioeconomi- cally disadvantaged patients were more likely to receive financial penalties under the HRRP, potentially impeding their ability to invest limited resources toward quality improve- ment efforts to better outcomes.29-32 In addition, the HRRP may have pushed some physicians and institutions to increas- ingly treat patients who would have benefited from inpatient care in emergency departments or observation units, which could be consistent with the finding that increases in postdis- charge mortality for heart failure and pneumonia were en- tirely driven by patients who were not readmitted within 30
days of discharge. This is also in line with analyses that have shown that following the HRRP, inpatient readmissions de- clined while emergency department and observation unit stays increased among patients returning to a hospital within 30 days for target conditions.33
Alternatively, factors unrelated to the HRRP could poten- tially explain the observed increases in postdischarge mortal- ity. Greater use of hospice care at the end of life might shift deaths that previously occurred within a hospital to the post- discharge setting over time.21,22 However, increases in aggre- gate death and death without readmission were similar even after excluding patients receiving hospice care, indicating that these trends were not explained by greater use of hos- pice after hospital discharge. Increases in mortality after the announcement and implementation of the HRRP could potentially reflect greater use of do-not-resuscitate orders among hospitalized beneficiaries. In a sample of hospitals in California, for example, the proportion of do-not-resuscitate orders among patients hospitalized for heart failure increased over time.34 If these patterns were similar on a national scale,
Figure 4. Inverse Probability-Weighted 45-Day Postadmission Mortality for Target Conditions Before and After the Announcement and Implementation of the Hospital Readmissions Reduction Program (HRRP)
16
14
12
10
8
6
4
2
0
45 -D
ay P
os ta
dm is
si on
M or
ta lit
y, %
Study Periods
Heart failureA HRRP
announcement HRRP
implementation
Period 1 (2005-2007)
Period 2 (2007-2010)
Period 3 (2010-2012)
Period 4 (2012-2015)
16
14
12
10
8
6
4
2
0
45 -D
ay P
os ta
dm is
si on
M or
ta lit
y, %
Study Periods
Acute myocardial infarctionB HRRP
announcement HRRP
implementation
Period 1 (2005-2007)
Period 2 (2007-2010)
Period 3 (2010-2012)
Period 4 (2012-2015)
16
14
12
10
8
6
4
2
0
45 -D
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Study Periods
PneumoniaC HRRP
announcement HRRP
implementation
Period 1 (2005-2007)
Period 2 (2007-2010)
Period 3 (2010-2012)
Period 4 (2012-2015)
Trends in inverse probability-weighted 45-day postadmission mortality for (A) heart failure, (B) acute myocardial infarction, and (C) pneumonia.
Given the large sample size, CIs for all point estimates are very narrow and therefore not depicted.
Research Original Investigation Association of the Hospital Readmissions Reduction Program With Heart Failure, AMI, and Pneumonia Mortality
2550 JAMA December 25, 2018 Volume 320, Number 24 (Reprinted) jama.com
© 2018 American Medical Association. All rights reserved.
trends in mortality might simply reflect greater focus on and attention to goals of care among hospitalized patients or on patients with advanced heart failure increasingly declining life-prolonging care after discharge. It is also possible that the overall increase in postdischarge mortality for heart failure reflects inc reasing severity of illness among admitted patients that is not captured in claims data. In incentivizing hospitals to not admit patients, the HRRP might have been associated with a change in patients who reached the thresh- old of admission, resulting in the healthiest portion of these encounters to be managed in the emergency department and observation units and leaving an increasingly higher risk population to be managed in the inpatient setting. Such a shift, if uncaptured in claims, could have led to an increase in mortality after hospitalization for heart failure. In contrast, for pneumonia, recent evidence suggests that shifts in coding practice may have resulted in a healthier cohort of patients over time, because hospitals have increasingly recoded severely ill patients with pneumonia to sepsis or respiratory failure with pneumonia.35,36 Such shifts in coding make the observed increase in postdischarge mortality among patients with pneumonia less likely to be due to increases in unmea- sured disease severity.
The current study builds upon a body of evidence regard- ing the intended and potential unintended consequences of the HRRP amid recent calls to restructure and improve the program.5,30,37 Previous work has shown mixed findings re- garding the relationship between the HRRP and mortality. A report by the Medicare Payment Advisory Commission dem- onstrated declines in risk-adjusted mortality since 2008 for all target conditions,33 which was inconsistent with a number of past analyses that have demonstrated an increase in heart fail- ure and pneumonia mortality rates over the same period.17-19,38
A 2018 study showed no significant association between the HRRP and increased mortality for target conditions.39 A third investigation observed a weakly positive correlation be- tween the HRRP and monthly changes in readmissions and postdischarge mortality at the hospital level for all target conditions.17 Although hospitals that reduce readmissions also appear to reduce mortality, this hospital-level concordance does not reflect the change in readmissions and mortality at
the level of the patient population, which is arguably of greater importance to individual patients and to public health. The cur- rent analysis is unique in that all Medicare inpatient claims data were used to examine both postadmission and postdischarge mortality at the patient level, stratified outcomes were evalu- ated to provide mechanistic insights, and an IPW approach was used to compare outcomes among similar patient popula- tions in exposure periods before and after the announcement and implementation of the HRRP.
Limitations This study has several limitations. First, given the observa- tional design, we are unable to make inferences about causal- ity or the mechanisms that explain the increase in mortality associated with the HRRP for some target conditions. Never- theless, we attempted to account for secular trends in mortal- ity using baseline years during which the HRRP was not in ef- fect, making it unlikely that observed associations between the HRRP and mortality were due to preexisting trends alone. Sec- ond, patient severity of illness may have differed in ways that were not captured by claims data. But, to minimize confound- ing, we used inverse probability weighting, an approach that is less susceptible to biased estimates of the HRRP’s associa- tion with mortality due to imbalances in covariates over time. Third, recent studies have demonstrated up-coding associ- ated with the HRRP, although such changes would have attenuated the observed relationship between the HRRP and increased mortality.40
Conclusions Among Medicare beneficiaries, announcement and imple- mentation of the HRRP were significantly associated with an increase in 30-day postdischarge mortality following hospi- talization for heart failure and pneumonia, but not for acute myocardial infection. Given the study design and the lack of significant association of the HRRP implementation with mor- tality within 45 days of hospital admission, further research is needed to understand whether the increase in 30-day post- discharge mortality is a result of the HRRP.
ARTICLE INFORMATION
Author Affiliations: Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, Massachusetts (Wadhera, Shen, Yeh); Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts (Wadhera); Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri (Joynt Maddox); Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Wasfy); Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (Haneuse).
Author Contributions: Drs Wadhera and Yeh had full access to all the data in the study and take
responsibility for the integrity of the data and the accuracy of the data analysis.
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Wadhera is supported by National Institutes of Health Training grant T32HL007604-32, and previously served as a consultant for Regeneron. Dr Joynt Maddox receives research support from the National Heart, Lung, and Blood Institute (K23HL109177-03) and provides contract work for the US Health and Human Services. Dr Wasfy receives research support from the National Institutes of Health KL2 Grant (TR001100) and American Heart Association (18CDA34110215). Dr Yeh receives research support from the National Heart, Lung, and Blood Institute (R01HL136708) and the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology and received
grants and personal fees from Abbott Vascular, grants from Abiomed, personal fees from Asahi Intecc, grants from AstraZeneca, grants and personal fees from Boston Scientific, personal fees from Medtronic, and personal fees from Teleflex outside the submitted work. The other authors report nothing to disclose.
Funding/Support: This work was supported by the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Association of the Hospital Readmissions Reduction Program With Heart Failure, AMI, and Pneumonia Mortality Original Investigation Research
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© 2018 American Medical Association. All rights reserved.
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Research Original Investigation Association of the Hospital Readmissions Reduction Program With Heart Failure, AMI, and Pneumonia Mortality
2552 JAMA December 25, 2018 Volume 320, Number 24 (Reprinted) jama.com
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