Policy Changes Have Done Little for Heart Failure Readmission Rates in US

Even with the passage of the 2012 Hospital Readmissions Reduction Program (HRRP), the US and Canada saw similar reductions in readmissions rates for patients hospitalized with heart failure (HF), despite no such program existing in Canada, according to a recent study.

In the US, 30-day all-cause readmission rates dropped by 2.7% and the rate of HF-specific readmissions dropped by 1.9%, while those rates dropped by 2.1% and 1.5% in Canada from 2005 to 2015.

The study included 265,165 individuals from Canada and 2,794,579 individuals from the US who were admitted to hospital for a primary diagnosis of HF. Of the Canadian cohort, investigators focused on 239,031 individuals with a mean age of 77 years and the group was 50.1% male. Investigators focused on 2,781,829 individuals from the US group with a mean age of 78 and the group was 45.4% male. Investigators examined patients admitted between April 1, 2005 and Dec. 31, 2015.

Outcomes of the study were index hospitalization length of stay (LOS), 30-day all-cause readmission rates, and 30-day HF-specific readmission rates. Investigators did not have access to out-of-hospital deaths after discharge in either US or Canadian data.

In the Canadian cohort of 239,031 patients, 43,498 (18.2) were readmitted within 30 days. Patients who were readmitted were older than those who were not and had higher comorbidity burdens, more hospitalizations in the prior 6 months, and longer length of stays during the index hospitalization. Patients who were not readmitted were more likely to have a cardiologist as their attending physician (17.9%) than those who were readmitted (14.6%).

Between 2005 and 2015, both index hospitalization LOS and total inpatient days within the first 30 days declined, with index LOS dropping from a mean of 7.5 days in 2005 to 7.3 days in 2015 and total inpatient days fell from a 9.1 to 8.9. All cause 30-day readmission rates declined from 19.7% to 17.6% during the same time period. The HF-specific 30-day readmission rates declined from 8.4% to 6.9%.

In the US cohort, 552,608 (19.9%) were readmitted within 30 days. Those who were readmitted had higher comorbidity burdens than those who were not readmitted, longer length of stay during the index hospitalization, and more hospitalizations in the prior 6 months. Patients who were readmitted were less often discharged to home than those who were not readmitted (72% versus 77.3%).

Between 2005 and 2015, index hospitalization LOS remained stable with a mean stay of 4.9 days in 2005 and 4.9 days in 2015. Total inpatients days of care in the first 30 days declined from 5.9 days to 5.7 days. The all-cause 30-day readmission rate declined from 21.2% to 18.5% and the HF-specific readmission rate dropped from 7.6% to 5.7%.

A comparison revealed that LOS, in regard to index hospitalization and total inpatient days of care in the first 30 days, was longer and in-hospital mortality was higher, but all-cause 30-day readmission rates were lower in Canada than the US. Investigators determined that readmission rates declined over the decade in question to a similar extent in both Canada and the US and no significant acceleration in the US was noted despite the HRRP implementation in Oct. 2012.

Investigators concluded that the similar declines in 30-day all-cause readmission rates in both countries show no significant difference after the implementation of penalties in the US in Oct. 2012, which suggests any benefits of the HRRP are modest at best.

In an invited commentary, Ashish Jha, MD, MPH, director of the Harvard Global Health Institute, said that this study supports evidence from previous studies that the effects HRRP may have been more limited than originally expected.

“We are now approaching the ninth anniversary of the passage of the HRRP, and there is mounting evidence that the program is failing to live up to expectations,” Jha wrote. “Three studies have found an increase in mortality because of the program. Two studies have concluded that coding changes were the primary driver of the decrease in readmissions.”

This study, “Trends in Readmissions and Length of Stay for Patients Hospitalized With Heart Failure in Canada and the United States,” was published in the Journal of the American Medical Association.