Did the HRRP cause a rise in post-discharge heart failure mortality? Experts take sides

A pair of point/counterpoint articles published online June 25 in JACC: Heart Failure debated whether the Hospital Readmissions Reduction Program (HRRP) has resulted in greater mortality for heart failure patients or whether those observations stem from incomplete or misconstrued evidence.

The HRRP financially penalizes hospitals for higher-than-expected 30-day readmission rates for common conditions such as heart failure, acute myocardial infarction (AMI) and pneumonia. But in a study published in JAMA Cardiology in November, a team of researchers found that while readmissions for heart failure did, in fact, decrease after the policy took effect, risk-adjusted mortality increased from 7.2 percent to 8.6 percent at 30 days post-discharge and from 31.3 percent to 36.3 percent at one year. This dataset included 416 U.S. hospitals and 115,245 Medicare beneficiaries.

Two of the authors of that study, Gregg C. Fonarow, MD, and Ankur Gupta, MD, PhD, reiterated their belief that the HRRP may have incentivized care strategies that reduced 30-day readmissions at the expense of patient health.

“Penalizing hospitals financially with limited resources may have directly undermined patient safety efforts and exacerbated disparities in the quality of care delivered,” Fonarow and Gupta wrote in their JACC: Heart Failure viewpoint piece. “Incentives to reduce readmissions may also have potentially encouraged ‘gaming’ of the system, including inappropriate triage strategies in emergency departments, increased use of observation stays when admissions would have been warranted, and delaying readmissions beyond discharge day 30. Further, a very narrow focus on reducing readmissions may have diverted the attention and resources of hospitals from meaningful heart failure quality-improvement efforts and patient safety.”

The researchers added there has been evidence of upcoding post-HRRP to make patients’ conditions appear more severe, making the true reduction in risk-adjusted readmissions more modest than the statistics show.

“A re-evaluation is needed on how best to achieve the goal of reducing avoidable readmissions in heart failure while improving care quality, health status, and preventable deaths, and mitigating the harm accrued because of the implementation of this penalty-based policy,” Fonarow and Gupta wrote. “Is it ethical to continue a policy where there is significant concern for substantial ongoing patient harm?”

But in an opposing viewpoint, Rohan Khera, MD, Kimar Dharmarajan, MD, MBA, and Harlan M. Krumholz, MD, SM, noted post-hospitalization mortality rates were already rising at least six years before the HRRP was implemented. For this reason, continuing increases shouldn’t be attributed to the policy, they said.

Khera et al. pointed out there haven’t been mortality increases for pneumonia and AMI, which were also included in the HRRP.

“If the penalties under HRRP were leading clinicians and hospitals to reduce readmissions at the cost of increased mortality, a similar effect would be expected across all conditions, especially because patients with AMI and pneumonia would also be vulnerable to an increased risk of death when necessary hospitalizations are avoided,” they wrote.

The authors said limitations of Fonarow and colleagues’ JAMA Cardiology study include voluntary reporting from the hospitals that “is not guaranteed to be complete.”

“The factors driving the rise in post-discharge mortality merit a thorough evaluation that would likely require information not currently included in administrative or registry data, such as cause of death and end-of-life goals,” Khera, Dharmarajan and Krumholz wrote. “Efforts to discredit the HRRP with limited evidence from small and non-representative datasets undermine a program that has led clinicians and hospitals to improve outcomes beyond hospital discharge through teamwork, integration and coordination of care for our most vulnerable patients.”