Study links HRRP to mortality increases for heart failure, pneumonia

Another study has linked the Hospital Readmissions Reduction Program (HRRP) to increased mortality among patients hospitalized for heart failure, prompting at least one cardiologist to urge policymakers to revise the policy.

Established in 2010 and implemented in 2012, the HRRP imposed financial penalties on hospitals with higher-than-expected 30-day readmission rates for Medicare beneficiaries hospitalized with heart failure, acute myocardial infarction (AMI) or pneumonia. Because some of these readmissions were costly and considered avoidable, the policy was intended to incentivize better performance and lower healthcare costs.

But while the national readmission rates for all three conditions have dropped since the HRRP was implemented, recent research has prompted a debate about whether the program actually twisted the incentives of hospitals and physicians—potentially leading to worse care and lower survival.

“The financial penalties imposed by the HRRP may have inadvertently pushed some physicians to avoid indicated readmissions, potentially diverted hospital resources and efforts away from other quality improvement initiatives, or worsened quality of care at resource-poor hospitals that are often penalized by the program,” wrote senior author Robert W. Yeh, MD, MSc, with Beth Israel Deaconess Medical Center and Harvard Medical School, and colleagues.

“However, it is also possible that the same mechanisms by which some hospitals have reduced readmissions, such as improved coordination and transitions of care, resulted in reductions in mortality.”

Previous reports on this topic have been conflicting, Yeh et al. noted in their new study, which was published in the Dec. 25 edition of JAMA. One study pointed to worse 30-day and one-year survival among discharged heart failure patients after the policy was implemented, while another suggested mortality was already trending upward and the slope of the increase didn’t change after the HRRP, indicating the policy itself wasn’t to blame.

To evaluate this potential association further, Yeh and coauthors studied about 8 million hospitalizations among Medicare beneficiaries over four time periods. The first two periods were before the HRRP was announced, the third was between its announcement and implementation, and the fourth was after the financial penalties took effect.

The researchers found there was a slight decline in risk-adjusted 30-day mortality for AMI after the policy was implemented compared to before its announcement, but there was a 0.25 percent increase in post-discharge mortality among heart failure patients and a 0.40 percent increase in deaths for patients with pneumonia. The analysis featured about 3 million hospitalizations for both heart failure and pneumonia, and the mortality increases for each condition were deemed statistically significant.

Yeh et al. found that most of the mortality increase was among patients who weren’t readmitted but died within 30 days of discharge.

“Financial incentives aimed at reducing readmissions were up to 10- to 15-fold greater under the HRRP than incentives to improve mortality through pay-for-performance programs, and some hospitals may have focused more resources and efforts on reducing or avoiding readmissions than on prioritizing survival,” they wrote. “Studies have found little evidence that standard measures of care quality for acute myocardial infarction and heart failure are correlated with readmission rates, suggesting that as hospitals face choices about which quality improvement efforts to prioritize, readmissions could be at odds with other goals.”

The authors acknowledged they couldn’t prove that the HRRP was directly responsible for the mortality increases, as their study was observational and reliant on claims data. They also said other factors could have increased the 30-day, post-discharge death rates associated with these conditions, such as shifts in coding practices or hospitals admitting increasingly sick patients over time.

In a press release, study coauthor Changyu Shen, PhD, said if the policy is the cause of this mortality bump, it “may have resulted in an additional 10,000 deaths among patients with heart failure and pneumonia during the five-year period after the HRRP announcement.”

“Nearly $2 billion in financial penalties have been imposed on hospitals by the HRRP since 2012, and this national policy has affected nearly all hospitals in a significant way,” Yeh added. “This is an example of how we can’t always predict the consequences of applying external incentives to medical care. It’s important that we disseminate this data while continuing to evaluate and discuss the future of policies that financially incentivize the prevention of readmissions to a greater extent than other patient-centered outcomes.”

Gregg C. Fonarow, MD, who authored an accompanying editorial in JAMA, noted the HRRP was implemented without any prospective testing of the policy or any evidence-based guidance on how to meet the readmission goals.

“Irrespective of the intent of the policy, there is no evidence that patients have benefited from the HRRP,” wrote Fonarow, with Ronald Reagan UCLA Medical Center in Los Angeles. “Yet, taken together with previous studies, there is now independently corroborated evidence that the HRRP was associated with increased post-discharge mortality among patients with heart failure and new evidence that the HRRP was associated with increased mortality among patients hospitalized for pneumonia.

“In light of these findings, it is incumbent upon Congress and CMS to initiate an expeditious reconsideration and revision of this policy.”