Hospital Readmission Rate and Mortality – The Effect of the HRRP

The Affordable Care Act, among many other
things, created the Hospital Readmission Reduction Program, which penalized Medicare reimbursement
to hospitals with higher 30-day readmission rates for three common diseases: heart failure,
acute myocardial infarction, and pneumonia. The motivation for the program was pretty
clear: improve the quality of care by tying reimbursement to good care practices. Of course, any policy like this may have unintended
consequences. A hospital might try to avoid readmitting
people that really need to be hospitalized – sending them home from the ER, for example. Or a hospital might hold on to patients longer
in the first place, prolonging length of stay to be sure that the patients are really 100%
ready for discharge, which would drive up costs and potentially increase the risk of
nosocomial disasters. Most concerningly, individuals who die during
the first hospitalization can’t be readmitted. You don’t want to inadvertently incentivize
practices that trade deaths for readmissions. This week, a study appearing in the Journal
of the American Medical Association gives us the best look yet into the real effects
the HRRP has had on patient outcomes. Researchers, largely based at Yale, examined
individuals on Medicare admitted to US hospitals from 2008 to 2014.This amounted to roughly
3 million heart failure admissions, 1.3 million acute MIs, and 2.5 million cases of pneumonia. They then examined the link, on a hospital-by-hospital
basis, between changes in readmission rates and changes in 30-day mortality. In epidemiology, our version of “let’s
go to the video tape” is “let’s go to the scatter plot”. So here it is: I’m showing you the data for heart failure
here, but the results were pretty similar for acute MI and pneumonia. Basically, each dot represents a hospital,
and you’re seeing the relationship between a hospital’s change in readmission rate, and
change in 30-day mortality rate. The statistics suggest that hospitals that
reduced readmission had a slight reduction in 30-day mortality too, but the signal was
pretty small – visible only to statistical software and not the human eye. But have all of the hypothetical concerns
been addressed in this study design? In the primary analysis, part of the risk-adjustment
formula used to measure how sick patients were included length of stay. I was worried that if a hospital enacted a
program to stretch out length of stay – avoiding discharge for fear of readmission – adjusting
for length of stay would bias the results. I asked lead author Kumar Dharmarajan about
that issue. He noted that they did not examine the relationships
between length of stay, readmission rate, and mortality, but that they did examine inpatient
mortality in a secondary analysis and again found no increased risk among hospitals with
better readmission rates. So even if hospitals are keeping patients
longer, it doesn’t seem like this is killing them. The critical thing to take from this paper
is that examining off-target effects of policy decisions are critical. In this case, we have no evidence of unintended
consequences from the HRRP. But this is but one policy of many, and in
a health system as complicated as ours, prediction of the effects of policy will never be a match
for measurement of those effects.

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