QUALITY CORNER: Readmissions Study on Mortality vs. Rehospitalization

 A study released last week in JAMA Cardiology confirmed what many previous studies have proposed: for certain conditions there may be unintended consequences associated with the effort to reduce readmissions – namely, increased mortality. 

The article – Association of the Hospital Readmissions Reduction Program Implementation With Readmission and Mortality Outcomes in Heart Failure – based its findings on a study group of more than 115,0000 patients at 416 U.S. hospitals participating in the American Heart Association Get With The Guidelines Heart Failure registry.

Among fee-for-service Medicare beneficiaries discharged after heart failure hospitalizations, implementation of the federal Hospital Readmissions Reduction Program (HRRP) was associated with a reduction in 30-day and 1-year readmissions, but an increase in 30-day and 1-year patient mortality, according to the study.

“These findings raise concerns that the HRRP, while achieving desired reductions in readmissions, may have incentivized hospitals in a way that has compromised the survival of patients with [heart failure],” the authors wrote.

The authors asked if the high financial penalties associated with readmissions caused hospitals to focus more on observation stays or shifting inpatient-type care to emergency departments.  The readmission penalties have been shown in numerous studies to unfairly target disproportionate share hospitals and academic medical centers “where higher readmission rates in these hospitals are associated with the higher case-mix complexity and lower socioeconomic status.”  If these hospitals are penalized financially, they find it harder to care for more vulnerable and sicker populations, the researchers said. In a secondary analysis, the authors “observed a trend toward increasing the use of home and inpatient hospice” in the readmission penalty program phase compared to the pre-implementation phase.

The authors didn’t form a definitive conclusion about why heart failure mortality may increase while readmissions decrease, but said their study shows that the Hospital Readmissions Reduction Program as it relates to heart failure patients “may require reconsideration.”

The Massachusetts State Senate recently passed a sweeping healthcare reform bill that contains a series of aggressive readmissions reduction goals and harsh penalties for not meeting the benchmarks.  While Massachusetts has a higher-than-national average in hospital readmissions, the state’s heart failure mortality rate is the second lowest  in the U.S., according to the federal government’s influential Hospital Compare website.