Changes in hospital safety following penalties in the US Hospital Acquired Condition Reduction Program: retrospective cohort study

Abstract

Objective: To evaluate the association between hospital penalization in the US Hospital Acquired Condition Reduction Program (HACRP) and subsequent changes in clinical outcomes.

Design: Regression discontinuity design applied to a retrospective cohort from inpatient Medicare claims.

Setting: 3238 acute care hospitals in the United States.

Participants: Medicare fee-for-service beneficiaries discharged from acute care hospitals between 23 July 2014 and 30 November 2016 and eligible for at least one targeted hospital acquired condition (n=15 470 334).

Intervention: Hospital receipt of a penalty in the first year of the HACRP.

Main outcome measures: Episode level count of targeted hospital acquired conditions per 1000 episodes, 30 day readmissions, and 30 day mortality.

Results: Of 724 hospitals penalized under the HACRP in fiscal year 2015, 708 were represented in the study. Mean counts of hospital acquired conditions were 2.72 per 1000 episodes for penalized hospitals and 2.06 per 1000 episodes for non-penalized hospitals; 30 day readmissions were 14.4% and 14.0%, respectively, and 30 day mortality was 9.0% for both hospital groups. Penalized hospitals were more likely to be large, teaching institutions, and have a greater share of patients with low socioeconomic status than non-penalized hospitals. HACRP penalties were associated with a non-significant change of -0.16 hospital acquired conditions per 1000 episodes (95% confidence interval -0.53 to 0.20), -0.36 percentage points in 30 day readmission (-1.06 to 0.33), and -0.04 percentage points in 30 day mortality (-0.59 to 0.52). No clear patterns of clinical improvement were observed across hospital characteristics.

Conclusions: Penalization was not associated with significant changes in rates of hospital acquired conditions, 30 day readmission, or 30 day mortality, and does not appear to drive meaningful clinical improvements. By disproportionately penalizing hospitals caring for more disadvantaged patients, the HACRP could exacerbate inequities in care.

Fig 1

Implementation of program to reduce hospital acquired conditions and study timeline. Performance period (Domain 1) ranges from 1 July 2011 to 30 June 2013. Performance period (Domain 2) ranges from 1 January 2012 to 31 December 2013. Study period ranges from 23 July 2014 to 30 November 2016. Penalty period ranges from 1 October 2014 to 30 September 2015. Penalties were announced on 23 July 2014. FY=fiscal year

Fig 2

Distribution of total hospital acquired condition scores under the Hospital Acquired Condition Reduction Program for first penalty period. Dashed line=penalty threshold; CMS=Centers for Medicare and Medicare Services

Fig 3

Discontinuities in the association between Centers for Medicare and Medicare Services (CMS) hospital acquired condition score and rate of hospital acquired conditions per 1000 discharges (top), rate of readmission at 30 days (middle), and rate of mortality at 30 days (bottom). Graph shows local linear regression within data-driven bandwidths used to compute point estimates presented in Results and figure 4. Bins are evenly spaced and designed to mimic underlying variance in the data

Fig 4

Change in rate of hospital acquired condition per 1000 discharges (top), rate of readmission at 30 days (middle), and rate of mortality at 30 days (bottom) associated with financial penalization under the Hospital Acquired Condition Reduction Program. Robust, bias corrected estimates of the treatment effect obtained through a regression discontinuity model using local linear regression and data driven bandwidth selection. Heterogeneous effects derived from subgroup analysis in which discharges were restricted to the subgroup of interest. Teaching hospitals in subgroup analyses defined as those hospitals that had residents (resident-to-bed ratio >0.00). Small hospitals defined as hospitals with fewer than 200 beds, and large hospitals defined as hospitals with more than 500 beds. Standard errors and confidence intervals were robust to hospital level clustering. P values were two sided with a threshold for significance of less than 0.05. HAC=hospital acquired condition; DSH=disproportionate share hospital; CMI=case mix index; RN=registered nurse; HRRP=Hospital Readmissions Reduction Program