Association of Changing Hospital Readmission Rates With Mortality Rates After Hospital Discharge

Importance The Affordable Care Act has led to US national reductions in hospital 30-day readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. Whether readmission reductions have had the unintended consequence of increasing mortality after hospitalization is unknown. Objective To examine the correlation of paired trends in hospital 30-day readmission rates and hospital 30-day mortality rates after discharge. Design, Setting, and Participants Retrospective study of Medicare fee-for-service beneficiaries aged 65 years or older hospitalized with HF, AMI, or pneumonia from January 1, 2008, through December 31, 2014. Exposure Thirty-day risk-adjusted readmission rate (RARR). Main Outcomes and Measures Thirty-day RARRs and 30-day risk-adjusted mortality rates (RAMRs) after discharge were calculated for each condition in each month at each hospital in 2008 through 2014. Monthly trends in each hospital’s 30-day RARRs and 30-day RAMRs after discharge were examined for each condition. The weighted Pearson correlation coefficient was calculated for hospitals’ paired monthly trends in 30-day RARRs and 30-day RAMRs after discharge for each condition. Results In 2008 through 2014, 2 962 554 hospitalizations for HF, 1 229 939 for AMI, and 2 544 530 for pneumonia were identified at 5016, 4772, and 5057 hospitals, respectively. In January 2008, mean hospital 30-day RARRs and 30-day RAMRs after discharge were 24.6% and 8.4% for HF, 19.3% and 7.6% for AMI, and 18.3% and 8.5% for pneumonia. Hospital 30-day RARRs declined in the aggregate across hospitals from 2008 through 2014; monthly changes in RARRs were −0.053% (95% CI, −0.055% to −0.051%) for HF, −0.044% (95% CI, −0.047% to −0.041%) for AMI, and −0.033% (95% CI, −0.035% to −0.031%) for pneumonia. In contrast, monthly aggregate changes across hospitals in hospital 30-day RAMRs after discharge varied by condition: HF, 0.008% (95% CI, 0.007% to 0.010%); AMI, −0.003% (95% CI, −0.005% to −0.001%); and pneumonia, 0.001% (95% CI, −0.001% to 0.003%). However, correlation coefficients in hospitals’ paired monthly changes in 30-day RARRs and 30-day RAMRs after discharge were weakly positive: HF, 0.066 (95% CI, 0.036 to 0.096); AMI, 0.067 (95% CI, 0.027 to 0.106); and pneumonia, 0.108 (95% CI, 0.079 to 0.137). Findings were similar in secondary analyses, including with alternate definitions of hospital mortality. Conclusions and Relevance Among Medicare fee-for-service beneficiaries hospitalized for heart failure, acute myocardial infarction, or pneumonia, reductions in hospital 30-day readmission rates were weakly but significantly correlated with reductions in hospital 30-day mortality rates after discharge. These findings do not support increasing postdischarge mortality related to reducing hospital readmissions.

[1]  Leora I. Horwitz,et al.  Association Between Hospital Penalty Status Under the Hospital Readmission Reduction Program and Readmission Rates for Target and Nontarget Conditions. , 2016, JAMA.

[2]  K. Carey,et al.  Hospital Readmissions Reduction Program: Safety-Net Hospitals Show Improvement, Modifications To Penalty Formula Still Needed. , 2016, Health affairs.

[3]  Amy Deutschendorf,et al.  Associations between hospital-wide readmission rates and mortality measures at the hospital level: Are hospital-wide readmissions a measure of quality? , 2016, Journal of hospital medicine.

[4]  D. Himmelstein,et al.  The Hospital Readmissions Reduction Program. , 2016, The New England journal of medicine.

[5]  A. Jha,et al.  Public Reporting of Mortality Rates for Hospitalized Medicare Patients and Trends in Mortality for Reported Conditions , 2016, Annals of Internal Medicine.

[6]  A. Jha,et al.  Opinions on the Hospital Readmission Reduction Program: results of a national survey of hospital leaders. , 2016, The American journal of managed care.

[7]  E. Bradley,et al.  What Works in Readmissions Reduction: How Hospitals Improve Performance , 2016, Medical care.

[8]  A. Jha,et al.  Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study , 2016, British Medical Journal.

[9]  E John Orav,et al.  Readmissions, Observation, and the Hospital Readmissions Reduction Program. , 2016, The New England journal of medicine.

[10]  Leora I. Horwitz,et al.  Development and Validation of an Algorithm to Identify Planned Readmissions From Claims Data. , 2015, Journal of hospital medicine.

[11]  S. Nuti,et al.  Mortality, Hospitalizations, and Expenditures for the Medicare Population Aged 65 Years or Older, 1999-2013. , 2015, JAMA.

[12]  D. Cutler,et al.  Recent national trends in acute myocardial infarction hospitalizations in Medicare: shrinking declines and growing disparities. , 2015, Epidemiology.

[13]  L. Allen,et al.  Hospital readmissions reduction program. , 2015, Circulation.

[14]  Harlan M Krumholz,et al.  Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study , 2015, The Lancet.

[15]  Leora I. Horwitz,et al.  Hospital Strategy Uptake and Reductions in Unplanned Readmission Rates for Patients with Heart Failure: A Prospective Study , 2014, Journal of General Internal Medicine.

[16]  L. Koenig,et al.  The Medicare Hospital Readmissions Reduction Program: potential unintended consequences for hospitals serving vulnerable populations. , 2014, Health services research.

[17]  J. Ouslander,et al.  The Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program: an overview for medical directors and primary care clinicians in long term care. , 2014, Journal of the American Medical Directors Association.

[18]  Harlan M. Krumholz,et al.  Hospital Strategies Associated With 30-Day Readmission Rates for Patients With Heart Failure , 2013, Circulation. Cardiovascular quality and outcomes.

[19]  A. Jha,et al.  A path forward on Medicare readmissions. , 2013, The New England journal of medicine.

[20]  H. Krumholz,et al.  National trends in heart failure hospital stay rates, 2001 to 2009. , 2013, Journal of the American College of Cardiology.

[21]  Harlan M Krumholz,et al.  Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. , 2013, JAMA.

[22]  Ashish K. Jha,et al.  Characteristics of hospitals receiving penalties under the Hospital Readmissions Reduction Program. , 2013, JAMA.

[23]  I. Piña,et al.  National Survey of Hospital Strategies to Reduce Heart Failure Readmissions: Findings From the Get With the Guidelines-Heart Failure Registry , 2012, Circulation. Heart failure.

[24]  M. Naylor,et al.  Unintended consequences of steps to cut readmissions and reform payment may threaten care of vulnerable older adults. , 2012, Health affairs.

[25]  S. Normand,et al.  Comparison of Hospital Risk-Standardized Mortality Rates Calculated by Using In-Hospital and 30-Day Models: An Observational Study With Implications for Hospital Profiling , 2012, Annals of Internal Medicine.

[26]  Harlan M Krumholz,et al.  National and regional trends in heart failure hospitalization and mortality rates for Medicare beneficiaries, 1998-2008. , 2011, JAMA.

[27]  Harlan M Krumholz,et al.  Development, validation, and results of a measure of 30-day readmission following hospitalization for pneumonia. , 2011, Journal of hospital medicine.

[28]  Harlan M. Krumholz,et al.  An Administrative Claims Measure Suitable for Profiling Hospital Performance Based on 30-Day All-Cause Readmission Rates Among Patients With Acute Myocardial Infarction , 2011, Circulation. Cardiovascular quality and outcomes.

[29]  E. Blackstone,et al.  Are all readmissions bad readmissions? , 2010, The New England journal of medicine.

[30]  Eric T. Bradlow,et al.  Public reporting on hospital process improvements is linked to better patient outcomes. , 2010, Health affairs.

[31]  Alan S. Go,et al.  Population trends in the incidence and outcomes of acute myocardial infarction. , 2010, The New England journal of medicine.

[32]  C. Yancy,et al.  Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. , 2010, JAMA.

[33]  R. Bhalla,et al.  Could Medicare Readmission Policy Exacerbate Health Care System Inequity? , 2010, Annals of Internal Medicine.

[34]  Sharon-Lise T. Normand,et al.  An Administrative Claims Measure Suitable for Profiling Hospital Performance on the Basis of 30-Day All-Cause Readmission Rates Among Patients With Heart Failure , 2008, Circulation. Cardiovascular quality and outcomes.

[35]  Sung-joon Min,et al.  The care transitions intervention: results of a randomized controlled trial. , 2006, Archives of internal medicine.

[36]  Harlan M Krumholz,et al.  An Administrative Claims Model Suitable for Profiling Hospital Performance Based on 30-Day Mortality Rates Among Patients With Heart Failure , 2006, Circulation.

[37]  S. Normand,et al.  An Administrative Claims Model Suitable for Profiling Hospital Performance Based on 30-Day Mortality Rates Among Patients With an Acute Myocardial Infarction , 2006, Circulation.

[38]  M. Naylor,et al.  Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. , 1994, Annals of internal medicine.