Medicare's Hospital Readmission Reduction Program reduced fall-related health care use: An unexpected benefit?

Abstract

Objective: To assess whether Medicare's Hospital Readmissions Reduction Program (HRRP) was associated with a reduction in severe fall-related injuries (FRIs).

Data sources and study setting: Secondary data from Medicare were used.

Study design: Using an event study design, among older (≥65) Medicare fee-for-service beneficiaries, we assessed changes in 30- and 90-day FRI readmissions before and after HRRP's announcement (April 2010) and implementation (October 2012) for conditions targeted by the HRRP (acute myocardial infarction [AMI], congestive heart failure [CHF], and pneumonia) versus "non-targeted" (gastrointestinal) conditions. We tested for modification by hospitals with "high-risk" before HRRP and accounted for potential upcoding. We also explored changes in 30-day FRI readmissions involving emergency department (ED) or outpatient care, care processes (length of stay, discharge destination, and primary care visit), and patient selection (age and comorbidities).

Data collection: Not applicable.

Principal findings: We identified 1.5 million (522,596 pre-HRRP, 514,844 announcement, and 474,029 implementation period) index discharges. After its announcement, HRRP was associated with 12%-20% reductions in 30- and 90-day FRI readmissions for patients with CHF (-0.42 percentage points [ppt], p = 0.02; -1.53 ppt, p < 0.001) and AMI (-0.35, p = 0.047; -0.97, p = 0.001). Two years after implementation, HRRP was associated with reductions in 90-day FRI readmission for AMI (-1.27 ppt, p = 0.01) and CHF (-0.98 ppt, p = 0.02) patients. Results were similar for hospitals at higher versus lower baseline risk of FRI readmission. After HRRP's announcement, decreases were observed in home health (AMI: -2.43 ppt, p < 0.001; CHF: -8.83 ppt, p < 0.001; pneumonia: -1.97 ppt, p < 0.001) and skilled nursing facility referrals (AMI: -5.95 ppt, p < 0.001; CHF: -3.19 ppt, p < 0.001; pneumonia: -10.27 ppt, p < 0.001).

Conclusions: HRRP was associated with reductions in FRIs, primarily for HF and pneumonia patients. These decreases may reflect improvements in transitional care including changes in post-acute referral patterns that benefit patients at risk for falls.

Keywords: HRRP; Medicare; fall injury; policy; readmissions.

FIGURE 1

Changes in 90‐day fall‐related injury (FRI) readmissions relative to Hospital Readmissions Reduction Program's (HRRP) announcement. Figures were created from event study analyses on a patient by quarter dataset spanning from 2008Q1 to 2014Q4. The figure plots the estimated coefficients of interest (a set of lag and lead indicators for the number of quarters before or after the HRRP announcement date [April 2010] and their 95% confidence intervals). Models controlled for patient‐ and market‐level factors and included hospital and quarter‐year fixed effects and standard errors clustered at the hospital level. AMI, acute myocardial infarction; CHF, congestive heart failure. [Color figure can be viewed at wileyonlinelibrary.com]