Thirty-Day Hospital Readmission Metric Linked to Increased Mortality for HF and Pneumonia

Debra L. Beck

December 28, 2018

Implementation of the 30-day readmission rules has been linked to increased 30-day post-discharge mortality for those hospitalized for heart failure (HF) and pneumonia, but not acute myocardial infarction (AMI), a new report shows.

This signal of unintended harm has led policy experts to make the case for better evaluation of new health policy before widespread implementation.

"Post-discharge deaths have increased by 0.25% for patients hospitalized with heart failure and by 0.40% for patients with pneumonia since implementation of the 30-day readmission rules, compared with trends in mortality before the program was put in place," said cardiologist and health policy researcher Rishi K. Wadhera, MD, MPP, MPhil, Harvard Medical School, Boston, Massachusetts.

"These are small increases in mortality in percentage terms, but when you consider there were approximately 8 million hospitalizations over our study period, those small increases can translate into large numbers," he explained.

The findings, published online in JAMA, come from a retrospective cohort study that compared mortality rates among 8.3 million Medicare beneficiaries hospitalized for these common conditions before and after implementation of the Hospital Readmissions Reduction Program (HRRP).

The Centers for Medicare & Medicaid Services (CMS) established HRRP under the Affordable Care Act in 2010, with financial penalties starting in 2012 for hospitals with higher than acceptable 30-day readmission rates.

After implementation of HRRP, readmission rates for target conditions declined nationwide, and there have been calls to expand the program to include other conditions.

Although it's been acknowledged that the program may contribute to greater use of outpatient observation stays and emergency department services, according to recent estimates, Medicare is currently saving about $2 billion per year on hospital admissions.

"Some policy makers have called for expansion of the HRRP to all hospitalized conditions, and for now, we think they should be more cautious. We need to do a deep dive to really understand the factors driving these increases in deaths and whether they are truly related to the policy," Wadhera told | Medscape Cardiology.

Taking the Data to a Wider Audience

In an unusual move, several of the article's authors wrote an opinion piece for the New York Times, which was published simultaneously with the JAMA article on December 21.

Wadhera explained the move: "We wanted to place our findings in the context of prior research on the HRRP and emphasize that the evidence to date on the relationship between the HRRP and increased deaths is mixed. We also suggest a path forward for the HRRP in the face of this uncertainty. Our hope was to spur honest and thoughtful dialogue between policy makers, physicians, and patients," he said.

"As a result of the article, many physicians across the country who work in different settings, from safety-net to academic to rural hospitals, have provided frontline descriptions of how the HRRP has impacted the care of their patients. These perspectives are invaluable, and it's critical that we engage physicians and patients when developing and implementing new policies," he added.

"At first, the reduction program seemed like the win-win that policymakers had hoped for," wrote Wadhera and coauthors Karen Joynt-Maddox, MD, MPH, Washington University School of Medicine, St. Louis, Missouri, and Robert Yeh, MD, Beth Israel Deaconess Medical Center, Boston, Massachusetts, in the Times. But these new data indicate that all is not as rosy as it seems.

"In the long term, the Centers for Medicare and Medicaid Services should conduct an investigation into the patterns we and others report. All possibilities should be considered, from coding changes to inappropriately turning patients away from the emergency room to changes in risk factors among Medicare patients. The agency must also engage physicians and patients to understand how this program has influenced 'on the ground' care."

This call to reconsider the 30-day readmission metric as it currently stands was repeated in a JAMA editorial by Gregg C. Fonarow, MD, Ronald Reagan UCLA Medical Center, Los Angeles, California.

"In light of these findings, it is incumbent upon Congress and CMS to initiate an expeditious reconsideration and revision of this policy. Alternative strategies can be deployed to more effectively achieve the goal of reducing avoidable readmissions, improve patient-prioritized outcomes like health status, while better protecting patients from unintentional harms, including preventable deaths," Fonarow writes.

Increased Mortality at 30 Days

The patient-level cohort study included 8.3 million hospitalizations overall (mean age of patients, 79.6 years; 53.4% women).

For HF, there were 3.2 million hospitalizations and 270,517 deaths within 30 days of discharge. For AMI, there were 1.8 million hospitalizations and 128,088 deaths. Of 3.0 million hospitalizations for pneumonia, there were 246,154 deaths.

For patients with HF, 30-day post-discharge mortality was already on the rise before the announcement of the HRRP (a 0.27% increase from April 2005–September 2007 to October 2007–March 2010) but increased by 0.49% after the HRRP announcement (April 2010 to September 2012; difference in change, 0.22%; P = .01) and by 0.52% during HRRP implementation (October 2012 to March 2015; difference in change, 0.25%; P = .001).

For AMI, the HRRP announcement period (from 2010 to 2012) was associated with a decline in 30-day mortality (0.18% pre-HRRP increase vs 0.08% post-HRRP announcement decrease; difference in change, −0.26%; P = .01) and did not significantly change after HRRP implementation.

Thirty-day mortality was stable during the baseline periods for patients with pneumonia but significantly increased after the HRRP announcement by 0.26% (difference in change, 0.22%; P = .01) and increased again by 0.44% post implementation (difference in change, 0.40%; P < .001).

"For both heart failure and pneumonia, the increase in deaths after HRRP were concentrated in those patients who had not been readmitted to the hospital after discharge," said Wadhera.

The study is limited by its observational nature and by reliance on administrative data, which limits inferences about causality, note the authors.

However, in the accompanying editorial, Fonorow hints that causality might be suggested by the finding that the overall increase in mortality appeared to be driven mainly by patients who were not readmitted to the hospital but who died within 30 days of discharge.

"This finding, in particular, enhances the likelihood of a causal relationship between the HRRP financially incentivized restricting of inpatient readmissions and the harm observed," he said.

Decoupling Readmissions From Mortality

The new findings lend support to other reports suggesting there are unintended consequences associated with focusing on readmissions as a quality metric. These studies appear to directly contradict a recent observational study published in JAMA Network Open that showed that for more than 115,000 fee-for-service Medicare beneficiaries hospitalized with HF at 416 US sites, implementation of the 30-day re-admit rules was associated with a subsequent decrease in 30-day and 1-year risk-adjusted readmissions, but there was no evidence of an increase in post-discharge risk-adjusted mortality.

"If you look at the numerical trends in their study and ours, they both indicate that 30-day post-discharge mortality has increased for heart failure and pneumonia, which has important implications both clinically and for public health. Where we disagree is how these increases related to HRRP," explained Wadhera.

This is confirmed by Fonorow: "Khera et al reported an increase in unadjusted and risk-adjusted 30-day post-discharge mortality rates for patients with heart failure; however, the authors concluded that the increase in mortality began before the HRRP implementation in 2010 without significant slope change and thus was unrelated to the policy."

Health policy experts continue to rail against the HRRP's decoupling of 30-day readmissions and mortality and instead promote the need for "precision policy making" that employs systematic study of new measures before widespread rollout.

Ashish K. Jha, MD, MPH, director of the Harvard Global Health Institute, Cambridge, Massachusetts, wrote in an editorial that accompanied the JAMA Network Open article: "The signal from policy makers is clear — readmissions matter a lot more than mortality — and this signal needs to stop.

"The HRRP was a well-intentioned effort to get hospitals to focus on transitions of care, an area in desperate need of improvement. However, 8 years after the passage of this program, we still do not understand whether it has met its primary goal and at what costs."

In their New York Times article, Wadhera and coauthors take this argument to the general public: "Eight years after the Hospital Readmissions Reduction Program was created, we remain uncertain about whether it has had unintentionally deadly consequences. That should be a bracing reminder that before we are seduced by promising but untried ideas, we need to first demand robust evidence that they will not harm patients."

The study was supported by the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology. Dr Fonorow has received research support from the National Institutes of Health, has consulted for Abbott, Amgen, Janssen, Novartis, and Medtronic, and has served as a Get With The Guidelines Steering Committee member. Dr Wadhera is supported by a National Institutes of Health training grant and previously served as a consultant for Regeneron.

JAMA. Published online December 25, 2018. Abstract, Editorial


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