Similar Post-HF Readmission Rates in US, Canada in Era of HRRP Reimbursement Penalties

April 10, 2019

Thirty-day readmission rates after heart failure (HF) hospitalization fell similarly from 2005 to 2015 in Canada and the United States, even after the October 2012 implementation of Medicare reimbursement penalties under the Hospital Readmissions Reduction Program (HRRP) in the US, researchers say.

Also in their new analysis, such readmissions in the US did not fall faster after the HRRP penalties kicked in, despite the program's goal of readmission reduction as part of the Patient Protection and Affordable Care Act of 2010.

Outcomes for Medicare fee-for-service patients, covered by a single-payer system, were compared with patients treated in Canada's universal single-payer system. Results were similar in a sensitivity analysis confined to patients 65 years and older in both countries.

"Unlike earlier before/after studies in the US, which suggested benefits from the HRRP as 30-day readmission rates were shown to be declining in the US, ours included a control arm, Canada," Finlay A. McAlister, MD, MSc, University of Alberta, Edmonton, Canda, told theheart.org | Medscape Cardiology in an email.

"Despite no equivalent to the HRRP in Canada, the same secular trend was observed," said McAlister, who is senior author on the study published online April 10 in JAMA Cardiology with lead author Marc D. Samsky, MD, Duke University Medical Center, Durham, North Carolina.

The HRRP, which uses Medicare reimbursement penalties as motivation for hospitals to lower readmission rates, has been credited with helping to push those rates down for patients in the US hospitalized with HF, myocardial infarction, or pneumonia.

But it has been challenging to pin down what effects, direct or indirect, the program was having on outcomes. It has many supporters, but some critics argue that 30-day readmission rates are a poor quality metric.

In one public debate centered on patients discharged after an HF hospitalization, 30-day mortality was seen to go up at the same time as, and arguably as a result of, falling 30-day HF readmissions under HRRP. Other research disputes that line of reasoning.

The current findings, based on 240,000 people in Canada and about 2,800,000 in the US discharged after hospitalization with a primary diagnosis of HF, suggest the program "may not have had as large an influence as was previously thought," and that "any benefits of the HRRP are modest at best," the authors contend.

"I think our study highlights the continued need for further efforts to improve postdischarge outcomes in both countries, since up to one-fifth of patients are still readmitted within a month of discharge," said McAlister.

"This study casts new and important doubt onto whether the HRRP has had any benefit at all," writes Ashish K. Jha, MD, MPH, Harvard Global Health Institute, Cambridge, Massachusetts, in an accompanying editorial.

"For those who believe in examining the totality of the evidence — and believe that policies must be responsive to data — the time for change has come," writes Jha. "Are we sure that the HRRP has failed to improve patient care or led to patient harm? Of course not, but the evidence is strong enough to suggest that this well-intentioned policy may not be as helpful to patients as intended."

The analysis "has a number of limitations, but certainly the finding that readmissions decreased similarly in Canada as in the US is provocative," said Karen Joynt Maddox, MD, MPH, Washington University School of Medicine, St. Louis, who isn't associated with the study.

"I think this study creates yet another question mark for the HRRP, which has been touted as an enormous policy success. It points out just how hard it is to make good policy, and in the absence of randomization, how hard it is to evaluate policy," she told theheart.org | Medscape Cardiology in an email.

All-Cause and Heart-Failure Readmission Rates in Canada and the US, 2005-2015 in Samsky et al.*
End Points 2005   2012 2013 2014 2015
30-day all-cause readmission
Canada (%) 19.7   18.4 18.1 18.0 17.6
United States (%) 21.2   19.5 18.6 18.6 18.5
30-day heart failure readmission
Canada (%) 8.4   7.2 7.0 6.9 6.9
United States (%) 7.6   5.8 5.6 5.6 5.7
*P < .001 for all 2005–2015 trends

No significant differences in all-cause readmission rates in either country were seen after vs before the October 2012 implementation of HRRP in the US in an "interrupted time-series analysis," report Samsky and colleagues.

Nor was there a significant change in the slope of the readmission-rate trend after vs before October 2012 in either country. In Canada, the group reports, the all-cause readmission rate declined 1.1% per year before and 1.3% per year after that time (P = .84); the corresponding rates of change in the US were 1.6% and 1.8% per year, respectively (P = .60).

The overall declines in all-cause readmission observed in the analysis probably in part derive from "underlying changes in clinical practice, broader secular trends, in both countries," the editorial proposes.

For example, "there have been ongoing improvements in both pharmaceutical and nonpharmaceutical approaches to caring for patients with heart failure, including new treatments, greater use of electronic health records, and improvements in transitions to primary care," Jha writes.

"These changes, which have taken place in both the United States and Canada, likely explain more of the drop in readmissions than the HRRP."

Samsky and McAlister reported no conflicts; disclosures for the other authors are in the report. Jha had no disclosures. Joynt Maddox has previously disclosed receiving research support from the National Heart, Lung, and Blood Institute and performing contract work for the US Department of Health and Human Services.

JAMA Cardiology. Published online April 10, 2019. Abstract, Editorial

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