Heart Failure, MI, Pneumonia Readmissions Down Without Higher Mortality

Megan Brooks

July 18, 2017

NEW HAVEN, CT — Recent efforts to reduce readmission did not result in higher rates of death after discharge among patients with heart failure (HF), acute MI, and pneumonia, a new study suggests[1].

"If anything, readmission reductions were associated with concomitant reductions in mortality," which is "very encouraging," Dr Kumar Dharmarajan (Yale New Haven Health, CT) told theheart.org | Medscape Cardiology.

"In hindsight, this finding should not be that surprising," said Dharmarajan. "Interventions to lower readmissions have largely focused on integrating and coordinating care for patients as they transition from the hospital to home. These strategies include getting the medications right, setting up follow-up medical appointments, and properly educating patients and family members prior to discharge.

"It may be that these interventions resulted in broader collateral benefits for patients besides readmission reduction," he explained.

The study was published online July 18, 2017 in the Journal of  the American Medical Association.

Readmissions Reduction a Success?

The Affordable Care Act established the Hospital Readmissions Reduction Program (HRRP), which penalizes hospitals with higher-than-expected readmission rates based on the clinical risk of their patient population. The program has led to reductions in 30-day hospital readmission rates for HF, AMI, and pneumonia. But whether hospitals' increased attention to curbing readmissions have led to the unintended consequence of increasing mortality after discharge has been unknown.

Dharmarajan and colleagues took a look at Medicare beneficiaries hospitalized with HF, AMI, or pneumonia between 2008 and 2014. They analyzed trends in 30-day hospital readmission rates and 30-day mortality rates after discharge.

During the 7-year study period, there were roughly 2.96 million hospitalizations for HF, 1.3 million for AMI, and 2.5 million for pneumonia.

Hospital 30-day risk-adjusted readmission rates per month declined for all three conditions (−0.053% for HF, −0.044% for AMI, and −0.033% for pneumonia, respectively).  

At the same time, 30-day risk-adjusted mortality rates per month increased for HF (0.008%), declined for AMI (−0.003%), and were stable for pneumonia (0.001%).

For HF, AMI, and pneumonia, reductions in 30-day hospital readmission rates were "weakly but significantly" correlated with reductions in 30-day death rates after hospital discharge (correlation coefficients 0.066, 0.067, and 0.108, respectively). "These findings do not support increasing postdischarge mortality related to reducing hospital readmissions," the authors write.

"This analysis was important to do, as researchers and advocacy groups were concerned that penalizing hospitals for excess readmissions would result in their deterring necessary care for patients and higher rates of death," Dharmarajan said.

"While concerns about unintended consequences of incentivizing readmission reduction have been frequently raised, study findings strongly suggest that mortality has not increased. Results extend previous work showing no harm and possible additional benefits from the HRRP," he and his colleagues write in their article.

The fact that the analysis included only three conditions is a limitation of the study and means the findings may not apply to readmission reductions for conditions not targeted by the HRRP, they note. The study was also observational and therefore can't determine causality between hospitals' efforts to lower readmissions and mortality outcomes after discharge.

"Nevertheless, the finding of a weak positive correlation in most cases between changes in hospital readmission and mortality rates makes it extremely unlikely that readmission reductions worsened mortality after hospitalization, as has been hypothesized," they conclude.

In an accompanying editorial[2], Dr Karen E Joynt Maddox (Washington University School of Medicine, St Louis, MO) says the results are "certainly good news."

She notes that hospitals are now using a variety of strategies to reduce readmissions and most focus on improving coordination, communication, and cooperation among physicians and other healthcare professionals and across care settings. 

"These strategies are patient centered and, when successful, should be adopted by all hospitals, regardless of baseline readmission rates. The fact that these strategies do not inadvertently increase mortality rates and may even have some positive effects is even more reason to continue this important work helping patients transition safely from hospital to home," concludes Joynt Maddox, who is also associate editor for JAMA.

The study had no commercial funding. Dharmarajan has served as a consultant and scientific advisory board member for Clover Health. Disclosures for the coauthors are listed in the paper. Joynt Maddox has served as a senior advisor to the US Department of Health and Human Services.

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