Hospital Readmissions Reduction Program Increases Mortality in Heart Failure Patients

Gregg Fonarow MD

Gregg Fonarow, MD

A new analysis of the Hospital Readmissions Reduction Program (HRRP) suggests that while the program may decrease rehospitalizations, it may bring another, more sinister result — an increase in mortality in patients hospitalized for heart failure.

The goal of HRRP is to reduce the number of rehospitalizations and decrease cost to the health care system, which sounds great at face value, but becomes dubious when put into practice, according to Gregg C Fonarow, MD, professor of cardiovascular medicine at UCLA, and the study’s corresponding author.

“This policy of reducing readmissions is more focused on reducing utilization for hospitals than improving quality of patient care and outcomes,” Fonarow told MD Magazine. “Due to the perverse financial incentives that this policy has created to keep patients out of the hospital, there has been concern for unintended consequence on worsening patient outcomes, which our study uncovered.”

Fonarow and colleagues conducted interrupted time-series and survival analyses of index heart failure hospitalizations from January 1, 2006 to December 31, 2014. The study included 115,245 fee-for-service Medicare beneficiaries across 416 US hospital sites participating in the American Heart Association (AHA) Get With The Guidelines-Heart Failure registry.

The 30-day risk-adjusted hospital readmission rate declined from 20% before HRRP implementation, to 18.4% in the HRRP penalties phase (HR after vs before HRRP implementation, 0.91;95% CI, 0.87-0.95; p,0.001). In contrast, the 30-day risk-adjusted mortality rate increased from 7.2% before HRRP implementation, to 8.6% in the HRRP penalties phase (HR after vs before the HRRP implementation, 1.18; 95% CI, 1.10-1.27; p<0.001).

The 1-year risk-adjusted readmission and mortality rates followed a similar pattern, according to the results. One year readmission rates declined by roughly 1%, from 57.2% to 56.3%, and 1-year mortality rates increased by 5%, from 31.3% to 36.3% (HR 1.10; 95% CI, 1.06-1.14; p<0.001).

Based on the results, Fonarow argued that while HRRP policy reduces readmissions from heart failure, it also reversed a decades-long trend of reduced mortality from heart failure, despite the many advances in the management of heart failure that have taken place since the program’s 2010 implementation alongside the Affordable Care Act (ACA).

For Fonarow, it boils down to dollars and cents. Through HRRP, Medicare financially penalizes approximately two-thirds of US hospitals based on their 30-day readmission rates. He pointed to these penalties as a primary driver of the study’s outcomes.

“This public reporting of hospital 30-day readmission rates and financial penalties may have incentivized strategies that unintentionally harmed patients with heart failure,” he said. “The penalties hit hospitals that care for the most vulnerable heart failure patients the hardest, denying them vital resources to provide care. To avoid the penalties, hospitals have incentives to keep patients out of hospitals longer, which they would have otherwise readmitted on clinical grounds prior to this policy.”

According to study authors, further research is needed to confirm the findings, but if confirmed, the results should warrant reconsideration of the HRRP in heart failure.

“This is of major public health importance due to the large number of people in the US affected by this disease,” Fonarow said. “The policy should focus on incentivizing improving quality and outcomes of patients with heart failure and not on a misguided utilization metric of rehospitalizations.”

The study, Association of the Hospital Readmissions Reduction Program Implementation with Readmission and Mortality Outcomes in Heart Failure, was published November 13, 2017 in JAMA Cardiology.

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