January 31, 2019

There's 'no evidence' that HRRP increases patient deaths, former Obama official contends

Daily Briefing

    Weighing in on a heated controversy over the Hospital Readmissions Reduction Program (HRRP), Peter Orszag—who was director of the Office of Management and Budget (OMB) when HRRP was created during the Obama administration—argues in NEJM Catalyst that HRRP has "either no effect or a beneficial one on mortality."

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    Background

    Before HRRP's implementation in 2012, 20% of Medicare patients were readmitted to the hospital within 30 days of discharge. In an effort to reduce that rate, HRRP subjects hospitals to penalties if they have high readmissions rates for patients admitted for heart attacks, heart failure, or pneumonia, Orszag writes.

    Since the policy's implementation, readmissions rates have fallen to about 16%.

    Researchers debate impact of HRRP

    Recent research has raised questions, however, about whether HRRP was actually responsible for the decline in readmissions—and even whether it led to more patient deaths.  

    In particular, Orszag cites a controversial JAMA paper arguing—as Orszag describes it—that HRRP's "incentives are so strong that they cause hospitals to avoid readmitting patients so fiercely that they died instead."

    But Orszag argues that "three points tilt the weight of the evidence toward either no effect or a beneficial one on mortality."

    1. Past researchers have calculated mortality rates in a misleading way, according to Orszag

    2. Citing the Medicare Payment Advisory Commission, Orszag argues that "death rates should be measured from the point a patient is admitted to the hospital, rather than when they leave the hospital." For instance, if a sick patient "decid[es] to spend her final days at home...or [in] a hospice, the death rate following discharge would increase" but the death rate after initial admission would not be affected, Orszag writes.

      When death rates are measured from the point of admission, the authors of the JAMA paper "find little or no effect" on mortality, according to Orszag. Moreover, a separate study that measured mortality in this manner "found 'no evidence for an increase in in-hospital or post-discharge mortality associated' with" HRRP.

      Therefore, Orszag contends, "[m]uch of the debate is therefore resolved in favor of HRRP having no deleterious impact."

    3. It's difficult to identify trends in mortality rates—so it's tough to know whether HRRP changed those rates

    4. Because detecting any effect from HRRP requires comparing mortality rates from before and after the program was established, researchers must adjust for any change in mortality rates over time—and that's a tricky, treacherous task, Orszag argues.

      The research team behind the JAMA paper tackled the challenge by dividing data into four time periods within the April 2010 to September 2012 window: "two [periods] before the law was enacted, one from enactment until the policy went into effect, and the final one thereafter," Orszag writes.

      But their approach is far from foolproof. After all, "other important regulations changed" during that time, Orszag notes, which created "significant shifts in the populations being admitted to the hospital," such as an increase in sicker patients who were closer to death.

      Orszag also writes that the 2010 starting point of the researchers' analysis is "also possibly both too late and too early" for a reliable analysis. The readmission provision was included in public versions of the legislation in 2009—so an analysis period that begins in 2010 may be "too late" to capture hospitals' initial reaction to the proposal. But 2010 is also "too early in the sense that preliminary regulations to implement the policy were not even published until August 2011," Orszag writes.

    5. Not all hospitals were subject to HRRP—and when you zoom in on those that were, a better mortality trend emerges

    6. "[P]erhaps most importantly," Orszag writes, when assessing HRRP, researchers must account for the fact that "the penalty does not apply to all hospitals, only those with high readmission rates."

      With this in mind, hospitals with lower readmission rates "have little fear that the penalty will apply to them," Orszag writes. However, the research team that wrote the JAMA paper did not assess differences between hospitals who are subject to HRRP and those that are not, "which is an important source of potential information about the program's effects," he writes.

      In a separate analysis, Atul Gupta of the University of Pennsylvania, assesses these differences, and "effectively shows that hospitals at greater risk of having the penalty apply were more likely to see beneficial mortality trends compared to hospitals at lower risk of facing the penalty," which led Gupta to conclude that "[HRRP] reduced death rates," Orszag writes.  

    What's next?

    Given the conflicting and uncertain evidence, Orszag acknowledges that it's "complicated" to assess HRRP's effects—but even so, he argues that some articles in the popular press, like the New York Times op-ed, have been "unduly alarmist."

    On the whole, Orszag argues research "suggests some benefit from the policy in reducing readmissions and no harm in mortality," although he acknowledges these conclusions should be held "tentatively."

    To help researchers draw clearer conclusions in the future, he proposes that any adjustments to HRRP "should be rolled out first in some areas but not others ... to allow a clearer test of the effects ... [and] better-informed policy and fewer debates on Twitter—which seems like an attractive combination," he writes (Orszag, NEJM Catalyst, 1/24).

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    Knowing where to focus is half the battle. We've found that the best strategies target four stages of care with significant potential to influence cardiovascular patient outcomes. The other half is knowing what improvements to make.

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