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. 2018 Sep 7;1(5):e182777.
doi: 10.1001/jamanetworkopen.2018.2777.

Association of the Hospital Readmissions Reduction Program With Mortality During and After Hospitalization for Acute Myocardial Infarction, Heart Failure, and Pneumonia

Rohan Khera  1 , Kumar Dharmarajan  2   3   4 , Yongfei Wang  3   4 , Zhenqiu Lin  3 , Susannah M Bernheim  3   5 , Yun Wang  6 , Sharon-Lise T Normand  6   7 , Harlan M Krumholz  3   4   8
Affiliations

Association of the Hospital Readmissions Reduction Program With Mortality During and After Hospitalization for Acute Myocardial Infarction, Heart Failure, and Pneumonia

Rohan Khera et al. JAMA Netw Open. .

Abstract

Importance: The US Hospital Readmissions Reduction Program (HRRP) was associated with reduced readmissions among Medicare beneficiaries hospitalized for acute myocardial infarction (AMI), heart failure (HF), and pneumonia. It is important to assess whether there has been a signal for concomitant harm with an increase in mortality.

Objective: To evaluate whether the announcement or the implementation of HRRP was associated with an increase in either in-hospital or 30-day postdischarge mortality following hospitalization for AMI, HF, or pneumonia.

Design, setting, and participants: In this cohort study, using Medicare data, all hospitalizations for AMI, HF, and pneumonia were identified among fee-for-service Medicare beneficiaries aged 65 years and older from January 1, 2006, to December 31, 2014. These were assessed for changes in trends for risk-adjusted rates of in-hospital and 30-day postdischarge mortality after announcement and implementation of the HRRP using an interrupted time series framework. Analyses were done in November 2017 and December 2017.

Exposures: Announcement of the HRRP in March 2010, and implementation of its penalties in October 2012.

Main outcomes and measures: Monthly risk-adjusted rates of in-hospital and 30-day postdischarge mortality.

Results: The sample included 1.7 million AMI, 4 million HF, and 3.5 million pneumonia hospitalizations. Between 2006 and 2014, in-hospital mortality decreased for the 3 conditions (AMI, from 10.4% to 9.7%; HF, from 4.3% to 3.5%; pneumonia, from 5.3% to 4.0%) while 30-day postdischarge mortality decreased from 7.4% to 7.0% for AMI (P for trend < .001), but increased from 7.4% to 9.2% for HF (P for trend < .001) and from 7.6% to 8.6% for pneumonia (P for trend < .001). Before the HRRP announcement, monthly postdischarge mortality was stable for AMI (slope for monthly change, 0.002%; 95% CI, -0.001% to 0.006% per month), and increased by 0.004% (95% CI, 0.000% to 0.007%) per month for HF and by 0.005% (95% CI, 0.002% to 0.008%) per month for pneumonia. There were no inflections in slope around HRRP announcement or implementation (P > .05 for all). In contrast, there were significant negative deflections in slopes for readmission rates at HRRP announcement for all conditions.

Conclusions and relevance: Among Medicare beneficiaries, there was no evidence for an increase in in-hospital or postdischarge mortality associated with HRRP announcement or implementation-a period with substantial reductions in readmissions. The improvement in readmission was therefore not associated with any increase in in-hospital or 30-day postdischarge mortality.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Krumholz is a recipient of research grants through Yale, from Medtronic and Johnson & Johnson (Janssen) to develop methods of clinical trial data sharing and from Medtronic and the US Food and Drug Administration to develop methods for postmarket surveillance of medical devices. Drs Krumholz, Dharmarajan, Bernheim, Lin, and Normand and Mr Yongfei Wang work under contract with the Centers for Medicare & Medicaid Services to develop and maintain performance measures that are publicly reported. Dr Krumholz chairs a Cardiac Scientific Advisory Board for UnitedHealth; is a participant and participant representative of the International Business Machines CorporationWatson Health Life Sciences Board; is a member of the Advisory Board for Element Science and the Physician Advisory Board for Aetna; and is the founder of Hugo, a personal health information platform. Dr Dharmarajan is chief scientific officer at Clover Health, a Medicare Advantage company. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Calendar-Year Trends in Number of Hospitalizations, Risk Factor Burden, and Length of Stay
A, Calendar-year trends in the number of hospitalizations for acute myocardial infarction (AMI), heart failure, and pneumonia. B, Cumulative burden of risk factors represented by the mean of the linear predictors (patient-level covariates combined with their corresponding regression coefficients from the risk-adjustment models for post–30-day mortality based on the 2006 data), with 2006 as the reference year. The dotted line indicates the reference level of risk score. C, Mean length of stay for hospitalizations.
Figure 2.
Figure 2.. Time Trends in Risk-Adjusted Mortality and Readmissions for Acute Myocardial Infarction (AMI)
A, Trend plot for risk-adjusted monthly in-hospital mortality, postdischarge 30-day mortality, and 30-day readmission. Trend lines represent nonparametric locally weighted regression (Loess) lines. B, C, and D, Trend lines with expanded axes. The gray band represents the 95% confidence interval for trend lines.
Figure 3.
Figure 3.. Time Trends in Risk-Adjusted Mortality and Readmissions for Heart Failure
A, Trend plot for risk-adjusted monthly in-hospital mortality, postdischarge 30-day mortality, and 30-day readmission. Trend lines represent nonparametric locally weighted regression (Loess) lines. B, C, and D, Trend lines with expanded axes. The gray band represents the 95% confidence interval for trend lines.
Figure 4.
Figure 4.. Time Trends in Risk-Adjusted Mortality and Readmissions for Pneumonia
A, Trend plot for risk-adjusted monthly in-hospital mortality, postdischarge 30-day mortality, and 30-day readmission. Trend lines represent nonparametric locally weighted regression (Loess) lines. B, C, and D, Trend lines with expanded axes. The gray band represents the 95% confidence interval for trend lines.
Figure 5.
Figure 5.. Time Trends in Risk-Adjusted Hospitalization-Related Mortality
A, C, and E, Trend plots for risk-adjusted monthly rates of mortality either during hospitalization or within 30 days of discharge following hospitalization for acute myocardial infarction (A), heart failure (C) and pneumonia (E). B, D, and F, Trend plots for corresponding trends for mortality within 30 days of admission. Trend lines represent nonparametric locally weighted regression (Loess) lines. The gray band represents the 95% confidence interval for trend lines.
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