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Observational Study
. 2018 Jan 1;3(1):44-53.
doi: 10.1001/jamacardio.2017.4265.

Association of the Hospital Readmissions Reduction Program Implementation With Readmission and Mortality Outcomes in Heart Failure

Ankur Gupta  1 , Larry A Allen  2 , Deepak L Bhatt  1 , Margueritte Cox  3 , Adam D DeVore  3 , Paul A Heidenreich  4 , Adrian F Hernandez  3   5 , Eric D Peterson  3 , Roland A Matsouaka  3 , Clyde W Yancy  6   7 , Gregg C Fonarow  8   9
Affiliations
Observational Study

Association of the Hospital Readmissions Reduction Program Implementation With Readmission and Mortality Outcomes in Heart Failure

Ankur Gupta et al. JAMA Cardiol. .

Abstract

Importance: Public reporting of hospitals' 30-day risk-standardized readmission rates following heart failure hospitalization and the financial penalization of hospitals with higher rates have been associated with a reduction in 30-day readmissions but have raised concerns regarding the potential for unintended consequences.

Objective: To examine the association of the Hospital Readmissions Reduction Program (HRRP) with readmission and mortality outcomes among patients hospitalized with heart failure within a prospective clinical registry that allows for detailed risk adjustment.

Design, setting, and participants: Interrupted time-series and survival analyses of index heart failure hospitalizations were conducted from January 1, 2006, to December 31, 2014. This study included 115 245 fee-for-service Medicare beneficiaries across 416 US hospital sites participating in the American Heart Association Get With The Guidelines-Heart Failure registry. Data analysis took place from January 1, 2017, to June 8, 2017.

Exposures: Time intervals related to the HRRP were before the HRRP implementation (January 1, 2006, to March 31, 2010), during the HRRP implementation (April 1, 2010, to September 30, 2012), and after the HRRP penalties went into effect (October 1, 2012, to December 31, 2014).

Main outcomes and measures: Risk-adjusted 30-day and 1-year all-cause readmission and mortality rates.

Results: The mean (SD) age of the study population (n = 115 245) was 80.5 (8.4) years, 62 927 (54.6%) were women, and 91 996 (81.3%) were white and 11 037 (9.7%) were black. The 30-day risk-adjusted readmission rate declined from 20.0% before the HRRP implementation to 18.4% in the HRRP penalties phase (hazard ratio (HR) after vs before the HRRP implementation, 0.91; 95% CI, 0.87-0.95; P < .001). In contrast, the 30-day risk-adjusted mortality rate increased from 7.2% before the HRRP implementation to 8.6% in the HRRP penalties phase (HR after vs before the HRRP implementation, 1.18; 95% CI, 1.10-1.27; P < .001). The 1-year risk-adjusted readmission and mortality rates followed a similar pattern as the 30-day outcomes. The 1-year risk-adjusted readmission rate declined from 57.2% to 56.3% (HR, 0.92; 95% CI, 0.89-0.96; P < .001), and the 1-year risk-adjusted mortality rate increased from 31.3% to 36.3% (HR, 1.10; 95% CI, 1.06-1.14; P < .001) after vs before the HRRP implementation.

Conclusions and relevance: Among fee-for-service Medicare beneficiaries discharged after heart failure hospitalizations, implementation of the HRRP was temporally associated with a reduction in 30-day and 1-year readmissions but an increase in 30-day and 1-year mortality. If confirmed, this finding may require reconsideration of the HRRP in heart failure.

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Conflict of interest statement

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Allen reported receiving funding from the National Institutes of Health (NIH), PCORI, and American Heart Association (AHA) as well as consulting fees from Novartis and Janssen. Dr Bhatt reported being on the advisory board of Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; being on the board of directors of Boston VA Research Institute and Society of Cardiovascular Patient Care; being chair of the AHA Quality Oversight Committee; serving on the Data Monitoring Committees of the Cleveland Clinic, Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine, and Population Health Research Institute; receiving honoraria from the American College of Cardiology, Belvoir Publications, Duke Clinical Research Institute, Harvard Clinical Research Institute, HMP Communications, Journal of the American College of Cardiology, Slack Publications, Society of Cardiovascular Patient Care, WebMD, Clinical Cardiology, NCDR-ACTION Registry Steering Committee, and VA CART Research and Publications Committee; receiving research funding from Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Ironwood, Ischemix, Lilly, Medtronic, Pfizer, Roche, Sanofi Aventis, and The Medicines Company; receiving royalties from Elsevier; being a site coinvestigator for Biotronik, Boston Scientific, and St. Jude Medical (now Abbott); being a trustee for the American College of Cardiology; and conducting unfunded research for FlowCo, Merck, PLx Pharma, and Takeda. Dr DeVore reported receiving research support from the AHA, Amgen, and Novartis as well as being a consultant with Novartis. Dr Fonarow reported receiving research support from the NIH; consulting with Abbott, Amgen, Novartis, and Medtronic; and serving as a member of the AHA Get With The Guidelines-Heart Failure (GWTG-HF) Steering Committee. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Temporal Trends in 30-Day Risk-Adjusted Readmission and Mortality Rates by the Hospital Readmissions Reduction Program Periods
Each dot represents the mean rate for a calendar month weighted by the number of index hospitalizations in that month. The solid trend lines of the risk-adjusted rates are generated by linear splines from a linear regression model using generalized estimating equations and thus may not correspond exactly to the distribution of the points. Slope of the trend lines represents yearly change in predicted rates within each of the Hospital Readmissions Reduction Program (HRRP) periods. The vertical solid lines represent changes in the HRRP period (pre-HRRP implementation phase: January 1, 2006, to March 31, 2010; penalty-free HRRP implementation phase: April 1, 2010, to September 30, 2012; and the HRRP penalties phase: October 1, 2012, to December 31, 2014). A significant decline in 30-day risk-adjusted readmission rate was observed in the HRRP penalties phase, compared with the pre-HRRP implementation phase (change in slope: −0.039; 95% CI, −0.076 to −0.003) (A). In contrast, a significant increase in 30-day risk-adjusted mortality rate was observed in the HRRP penalties phase compared with the pre-HRRP implementation phase (change in slope, 0.039; 95% CI, 0.024-0.053) (B).
Figure 2.
Figure 2.. Event Probability Curves for 30-Day and 1-Year Readmissions and Mortality by the Hospital Readmissions Reduction Program (HRRP) Periods
The event probability of all-cause 30-day (A) and 1-year (B) risk-adjusted readmission rates decreased and the 30-day (C) and 1-year (D) risk-adjusted mortality rates increased in the HRRP penalties phase (orange curve; October 1, 2012, to December 31, 2014), compared with the pre-HRRP implementation phase (blue curve; January 1, 2006, to March 31, 2010): hazard ratio (HR), 0.91; 95% CI, 0.87-0.95; P < .001 for 30-day readmission rates; HR, 0.92; 95% CI, 0.89-0.96; P < .001 for 1-year readmission rates; HR, 1.18; 95% CI, 1.10-1.27; P < .001 for 30-day mortality rates; and HR, 1.10; 95% CI, 1.06-1.14; P < .001 for 1-year mortality rates.
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