Readmissions reduction program linked to increased mortality for heart failure patients

A program that financially penalizes hospitals for excess readmissions for heart failure may have an unintended consequence: higher rates of 30-day and one-year mortality in those patients.

Researchers studied 115,245 Medicare beneficiaries across 416 U.S. hospitals to determine readmission and mortality rates for heart failure hospitalizations both before and after the Hospital Readmissions Reduction Program (HRRP) was implemented as part of the Affordable Care Act. They published their findings online in JAMA Cardiology and presented them Nov. 12 at the American Heart Association’s scientific sessions.

Risk-adjusted, 30-day readmission rates declined from 20 percent before HRRP penalties were assessed to 18.4 percent after they were assessed. Similarly, one-year readmission rates dropped from 57.2 percent to 56.3 percent.

But following HRRP implementation, risk-adjusted mortality increased from 7.2 to 8.6 percent at 30 days, and from 31.3 to 36.3 percent at one year.

“These findings raise concerns that the HRRP, while achieving desired reductions in readmissions, may have incentivized hospitals in a way that has compromised the survival of patients with HF (heart failure),” wrote lead researcher Ankur Gupta, MD, PhD, with Harvard Medical School, and colleagues.

The authors said some hospitals may attempt to “game the system” to avoid paying penalties.

“Incentives to reduce readmissions can potentially encourage inappropriate care strategies, such as discouraging appropriate triage for emergency care, delaying hospital readmissions beyond discharge day 30, or increasing observation stays without admitting patients,” they wrote.

Gupta et al. said the financial penalties from the HRRP had previously been shown to fall disproportionately on academic medical centers (more complex cases) and “safety-net” hospitals that treat a higher number of patients with a low socioeconomic status. However, they didn’t detect a significant difference in this study’s results based on the teaching status of the hospital, and they weren’t able to determine whether safety-net hospitals were affected more adversely by the HRRP than other centers.

Still, the researchers’ main finding—that incentivizing fewer readmissions could come at the expense of patients’ health—should be heeded by policymakers, they wrote.

“Our findings have substantial public health and policy implications given that HF is the leading diagnosis associated with readmissions in Medicare beneficiaries with high associated costs,” Gupta and colleagues wrote. “Our study is also a reminder that, like drugs and devices, public health policies should be tested in a rigorous fashion—most preferably in randomized trials—before their widespread adoption.”