November 21, 2017

A new study reignites debate: Did the Hospital Readmissions Reduction Program lead to more deaths?

Daily Briefing

    Heart failure readmissions declined, but mortality rates increased, after the Hospital Readmissions Reduction Program (HRRP) took effect, according to a new JAMA study—but the research has drawn pushback from authors of a prior study that reached different conclusions.  

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    The Affordable Care Act's HRRP was established in April 2010, and the program began enforcing penalties in October 2012. It aims to reduce the number of patients who are readmitted to the hospital within 30 days of discharge for several conditions.

    Study details

    For the latest study, researchers assessed data on 115,245 Medicare beneficiaries with heart failure who were discharged between Jan. 1, 2006, and Dec. 31, 2014, from 416 hospital sites participating in the American Heart Association's "Get with the Guidelines" initiative.

    The researchers assessed readmissions and mortality rates in three periods: from Jan. 1, 2006, to March 31, 2010, prior to HRRP implementation; from April 1, 2010, to Sept. 30, 2012, during implementation; and Oct. 1, 2012, to Dec. 21, 2014, post-implementation. The authors noted that their study is observational and "cannot establish cause and effect among the HRRP implementation, readmissions reduction, and increased mortality risk."

    Key findings

    The researchers found that the 30-day readmission rate among study participants fell from 20% before HRRP's penalties were implemented to 18.4% after they were implemented. However, over that same time period, the 30-day risk-adjusted mortality rate among participants increased from 7.2% to 8.6%—equivalent to about 5,400 additional deaths annually for Medicare beneficiaries not enrolled in managed care plans, the Wall Street Journal reports.

    Further, while the one-year risk-adjusted readmissions rate declined from 57.2% before the program's penalties took effect to 56.3% afterward, the one-year risk-adjusted mortality rate increased from 31.3% to 36.3%, the researchers found. The authors said the one-year risk-adjusted mortality increase was significant even when they accounted for patients discharged to hospice. "Thus, the policy directed at reducing readmissions was still associated with increased long-term mortality risk, even after accounting for hospice use," the authors wrote.

    Ankur Gupta, lead author of the study and research fellow at Brigham and Women's Hospital, said it's hard to know whether the program directly influenced heart failure mortality rates. However, he noted that heart failure mortality was falling prior to the program's implementation.

    Comments

    Gupta called the new findings "alarming." He suggested that CMS should remove heart failure from the readmissions program and called for further research into HRRP. According to Modern Healthcare, heart failure is the most common reason for readmissions among Medicare beneficiaries.

    Separately, Ashish Jha—a professor of health policy at Harvard University, who was not involved in the study—said the findings were significant, noting that HRRP has long drawn concerns from providers and other stakeholders. He explained that hospitals who provide quality care for very ill people are more likely to accept those people as returning patients if they require hospitalization for their illness. According to Jha, such hospitals shouldn't be penalized by Medicare for consequently high readmissions rates.

    Jha added that in his opinion, the program also errs by prioritizing readmissions over other measures of quality, including mortality. According to Jha, hospitals in the program that have high readmission rates can see up to 3% of their Medicare reimbursements cut. In comparison, a hospital with a high mortality rate would see only a 0.5% cut to their Medicare reimbursements.

    Meanwhile, in response to the new paper, a CMS spokesperson said the agency "continuously monitors the impact of the measures used in our programs, including input from peer reviewed research and other sources." The spokesperson added, "Studies like this are important inputs as we continuously assess our programs."

    Paper draws pushback

    Separately, the lead author of a study published in JAMA earlier this year on the same topic pushed back against the findings, HealthLeaders Media reports.

    For the earlier study, published in July, researchers reviewed more than six million Medicare beneficiary hospitalizations for heart failure, heart attack, and pneumonia at about 4,000 hospitals between 2008 and 2014. They found that efforts to curb readmissions under HRRP did not increase the risk of death after discharge for heart attack, heart failure, and pneumonia patients.

    In an interview with HealthLeaders Media, Kumar Dharmarajan, chief science officer at Clover Health and lead author of the July study, discussed how the new study is "technically limited."

    Dharmarajan cited the observational nature of the study, saying that "just because two things are changing over time, it's hard to know if they're related." 

    Citing how his own research looked at both national trends and individual hospital performance, he added, "If readmission declines are harming patients, we would expect to see that the hospitals with the greatest decrease in admissions would have the greatest increase in mortality." According to Dharmarajan, the researchers found no such relationship—and in fact, "to the extent that there was a relationship, it was the opposite," with hospitals that had lower readmission rates also having lower mortality rates. 

    In addition, Dharmarajan said the hospitals in the new study are not nationally representative, but rather comprise a self-selected group of hospitals that wanted to participate in the "Get with the Guidelines" initiative. According to Dharmarajan, the new paper found that most readmission declines occurred after 2013—even though, at the national level, the bulk of declines over the last decade occurred between 2010 and 2012. He added that nationally, admissions have been declining over time, while the new paper found they'd increased. "They are clearly working with a different data set," Dharmarajan said.

    Further, Dharmarajan said while the new study assessed only heart failure patients, the older study examined "heart failure, pneumonia, and heart attacks, and the national data sets." He added, "We had 30X the number of hospitalizations in our study. What we found was consistent across all three conditions. They are more heart-failure centric as opposed to trying to understand what is happening across conditions" (Evan, Wall Street Journal, 11/12; Susman, MedPage Today, 11/12; Castelluci, Modern Healthcare, 11/13, Paavola, Becker's Clinical Leadership & Infection Control, 11/13; Commins, HealthLeaders Media, 11/16; Gupta et al., JAMA, 11/12).

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