Larry Allen, MD: The Problems With the Hospital Readmissions Reduction Program

Larry Allen, MD, is an associate professor of medicine at the University of Colorado, and a cardiologist that was part of a deeper look into the hospital readmissions reduction program (HRRP), and what the data that have been presented about it actually mean.

An analysis of the HRRP from November 2017 suggested that while the program may decrease rehospitalizations, it may bring an increase in mortality in patients hospitalized for heart failure. At the 67th American College of Cardiology Scientific Sessions in Orlando, Florida, Allen presented these data and revealed to many of his colleagues that while readmissions have been reduced, in fact, it appears that mortality has increased.

Larry Allen, MD: “I [had] the pleasure of speaking about the HRRP [at ACC 2018], which emphasizes reductions in 30-day rehospitalization for patients hospitalized with heart failure, as well as pneumonia and myocardial infarction. One of the questions that have been controversial is whether focusing on readmissions has actually led to an increase in 30-day mortality, so the talk really went into [the fact that] by focusing on readmissions: What are the implications for that, what are the unintended consequences, and how can we modify the program so that both readmissions and mortality are reduced rather than this—one going up and the other going down.”

Allen went on to describe the clinical consequences of this program, which appears to have been failing the very patients it sought to help.

In November, Gregg C. Fonarow, MD, a professor of cardiovascular medicine at UCLA, told MD Magazine, “This is of major public health importance due to the large number of people in the US affected by this disease. The policy should focus on incentivizing improving quality and outcomes of patients with heart failure and not on a misguided utilization metric of rehospitalizations.”

Larry Allen, MD: “The hospital readmissions reduction program (HRRP) went into effect in 2012, and essentially [began] penalizing hospitals that have a higher than expected 30-day readmission rate for heart failure and other conditions.

“What we've seen in looking at the data since 2012 is that there has been a significant reduction in the percent of patients that get readmitted with within 30 days after discharge. Among the Medicare population, this is dropped from about 25%, which is quite high, down to closer to 21—22%, and nationally the rates have dropped in other conditions as well.

“The problem that we see is that looking at the mortality rate over the next 30 days, there seems to be a small uptick in the percent of patients who now are dying.

“Some data that I was involved with combined Medicare billing data with [the AHA’s] Get With The Guidelines data, which includes clinical variables. We found that after adjustment for patient factors, it still appeared that there was about a 0.5% increase in the rate at which people were dying in the next 30 days.

“This is concerning because most patients would rather live than be then be readmitted to the hospital, so we've looked at why this may be the case and I think people don't know [that] it may be that patients are actually getting sicker—that we're only admitting patients to the hospital who have more severe disease. And if we don't adjust for those differences properly, perhaps the higher rate of mortality is just a reflection of these changes in who gets admitted to the hospital and it being a sicker population.

“But more concerning is maybe, in focusing on readmissions, we're doing things that are actually bad for patients such as discharging them and then not allowing them to come back into the hospital when they get sick—to the point that they're at home and not getting the care that they need. I think that's the real concern, that in focusing on readmissions as the primary outcome to be avoided, we're potentially taking our eye off some of the things that we could do to keep patients healthy and alive once they go home.”