Association of the Hospital Readmissions Reduction Program With Mortality Among Medicare Beneficiaries Hospitalized for Heart Failure, Acute Myocardial Infarction, and Pneumonia

Abstract

Importance: The Hospital Readmissions Reduction Program (HRRP) has been associated with a reduction in readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. It is unclear whether the HRRP has been associated with change in patient mortality.

Objective: To determine whether the HRRP was associated with a change in patient mortality.

Design, setting, and participants: Retrospective cohort study of hospitalizations for HF, AMI, and pneumonia among Medicare fee-for-service beneficiaries aged at least 65 years across 4 periods from April 1, 2005, to March 31, 2015. Period 1 and period 2 occurred before the HRRP to establish baseline trends (April 2005-September 2007 and October 2007-March 2010). Period 3 and period 4 were after HRRP announcement (April 2010 to September 2012) and HRRP implementation (October 2012 to March 2015).

Exposures: Announcement and implementation of the HRRP.

Main outcomes and measures: Inverse probability-weighted mortality within 30 days of discharge following hospitalization for HF, AMI, and pneumonia, and stratified by whether there was an associated readmission. An additional end point was mortality within 45 days of initial hospital admission for target conditions.

Results: The study cohort included 8.3 million hospitalizations for HF, AMI, and pneumonia, among which 7.9 million (mean age, 79.6 [8.7] years; 53.4% women) were alive at discharge. There were 3.2 million hospitalizations for HF, 1.8 million for AMI, and 3.0 million for pneumonia. There were 270 517 deaths within 30 days of discharge for HF, 128 088 for AMI, and 246 154 for pneumonia. Among patients with HF, 30-day postdischarge mortality increased before the announcement of the HRRP (0.27% increase from period 1 to period 2). Compared with this baseline trend, HRRP announcement (0.49% increase from period 2 to period 3; difference in change, 0.22%, P = .01) and implementation (0.52% increase from period 3 to period 4; difference in change, 0.25%, P = .001) were significantly associated with an increase in postdischarge mortality. Among patients with AMI, HRRP announcement was associated with a decline in postdischarge mortality (0.18% pre-HRRP increase vs 0.08% post-HRRP announcement decrease; difference in change, -0.26%; P = .01) and did not significantly change after HRRP implementation. Among patients with pneumonia, postdischarge mortality was stable before HRRP (0.04% increase from period 1 to period 2), but significantly increased after HRRP announcement (0.26% post-HRRP announcement increase; difference in change, 0.22%, P = .01) and implementation (0.44% post-HPPR implementation increase; difference in change, 0.40%, P < .001). The overall increase in mortality among patients with HF and pneumonia was mainly related to outcomes among patients who were not readmitted but died within 30 days of discharge. For all 3 conditions, HRRP implementation was not significantly associated with an increase in mortality within 45 days of admission, relative to pre-HRRP trends.

Conclusions and relevance: Among Medicare beneficiaries, the HRRP was significantly associated with an increase in 30-day postdischarge mortality after hospitalization for HF and pneumonia, but not for AMI. Given the study design and the lack of significant association of the HRRP with mortality within 45 days of admission, further research is needed to understand whether the increase in 30-day postdischarge mortality is a result of the policy.

Figure 1.. Study Periods and Analytic Approach in a Study of the Association Between the Hospital Readmissions Reduction Program (HRRP) and Mortality

Figure 2.. Observed 30-Day Postdischarge Mortality for Target Conditions Before and After the Announcement and Implementation of the Hospital Readmissions Reduction Program (HRRP)

Trends in observed overall 30-day postdischarge mortality and 30-day postdischarge mortality stratified by whether there was an associated readmission for (A) heart failure (B) acute myocardial infarction, and (C) pneumonia. Given the large sample size, CIs for all point estimates are very narrow and therefore not depicted.

Figure 3.. Inverse Probability-Weighted 30-Day Postdischarge Mortality for Target Conditions Before and After the Announcement and Implementation of the Hospital Readmissions Reduction Program (HRRP)

Trends in inverse probability-weighted overall 30-day postdischarge mortality and 30-day postdischarge mortality stratified by whether there was an associated readmission. Given the large sample size, CIs for all point estimates were narrow and therefore not depicted (eg, overall mortality for heart failure in period 1 was 8.3% [95% CI, 8.2%-8.4%]).

Figure 4.. Inverse Probability-Weighted 45-Day Postadmission Mortality for Target Conditions Before and After the Announcement and Implementation of the Hospital Readmissions Reduction Program (HRRP)

Trends in inverse probability-weighted 45-day postadmission mortality for (A) heart failure, (B) acute myocardial infarction, and (C) pneumonia. Given the large sample size, CIs for all point estimates are very narrow and therefore not depicted.