Heart failure readmissions not targeted by HRRP also declined after policy announcement

Even though the Hospital Readmission Reduction Program (HRRP) targeted principal heart failure admissions, a new analysis in the Journal of the American College of Cardiology showed readmissions also declined for patients with a secondary diagnosis of heart failure.

The HRRP, which began financially penalizing hospitals for higher-than-expected 30-day readmission rates for heart failure, pneumonia and myocardial infarction in 2012, has led to multiple strategies to reduce readmissions for those conditions. But it’s also fueled an argument about whether there are unintended consequences and the gaming of the system through changing coding practices, particularly for heart failure, as studies have linked the HRRP to an increase in mortality among heart failure patients.

To track these trends with respect to different heart failure diagnoses, Saul Blecker, MD, MHS, with NYU School of Medicine, and colleagues studied nearly 13 million hospitalizations among Medicare patients with a principal or secondary diagnosis of heart failure between January 2008 and June 2015.

They divided patients into three groups: those with a principal heart failure diagnosis, those with a principal diagnosis of acute MI or pneumonia (the other conditions targeted by the HRRP) and secondary heart failure, and those hospitalized for any other reason with a secondary diagnosis of HF.

“We hypothesized that readmissions would decrease for all HF-related hospitalizations because of the HRRP-driven incentives for patients hospitalized principally for HF and presumed spillover effect for HF patients hospitalized for other causes,” Blecker and co-authors wrote. “However, because incentives targeted only principal HF hospitalizations, we further hypothesized that readmissions following these hospitalizations would decrease faster than hospitalizations for other causes.”

It turns out the 30-day readmission rates for all three cohorts declined after the passage of the Affordable Care Act in March 2010, when the HRRP was first announced. Readmissions declined by 1.09 percent for those with principal heart failure, 1.24 percent with a primary diagnosis of AMI or pneumonia and 1.05 percent for all other hospitalizations with heart failure. Readmission rates largely stabilized and plateaued for all three groups following the implementation of the HRRP in October 2012.

Even with these reductions, though, 30-day readmission rates exceeded 20 percent for all three cohorts at the end of the study.

“The fact that readmission rates for patients with a secondary HF were nearly the same as the rates for patients with principal diagnosis of HF in our study suggests that any diagnosis of HF may be a more important risk factor for readmission than the principal discharge diagnosis,” the researchers wrote. “Although other studies have shown HF to be a risk factor for readmission and it is included in the CMS readmission risk model, our findings specifically suggest that hospitalized patients with HF represent a high-risk group that may be an appropriate target for readmission reduction efforts.”

Blecker et al. noted the readmission reduction they observed was similar to previously reported studies on the topic, which may be related to “a spillover effect of policy changes that had hospitals more focused on readmissions both generally and specifically for HF patients.”

The authors said the specific strategies that have effectively reduced readmissions for multiple conditions, including heart failure, warrant further investigation.

Writing in a related editorial, Gregg C. Fonarow, MD, and Boback Ziaeian, MD, PhD, said recent evidence suggests not all of these strategies are in the best interests of patients.

“Even though the financial penalties were intended to incentive hospitals to invest in improved transitions of care, it now appears that these penalties may have instead encouraged restriction of clinically indicated inpatient care and inappropriate triage strategies,” they wrote. “Developing payment policies that reflect the relative value that patients place on averting mortality over hospital days may make for a more coherent patient-centered policy. For HRRP, the evidence for potential harms and gamification of health care metrics should give us pause.”