Did the Hospital Readmissions Reduction Program Impact Heart Failure Readmission or Mortality? Comparison of the change in heart failure readmission and mortality rates between hospitals subject to hospital readmission reduction program penalties and critical access hospitals

An article by Sandhu et al. published in the American Heart Journal reported that on using critical access hospitals (CAHs) as a control group, the introduction of financial penalties was only associated with modest reductions in readmissions and an uncertain association with mortality.

As the Hospital Readmission Reduction Program (HRRP), announced in 2010, penalized hospitals with high readmissions for multiple conditions including heart failure, a comparison was made of heart failure readmission and mortality rates between hospitals exposed to HRRP financial penalties vs critical access hospitals (CAHs) not subject to the penalty between 2005 and 2016 using 3-year moving averages from Hospital Compare. The investigators reported that following the start of HRRP, a 0.60% annual decrease in heart failure readmissions was noted in CAHs. Moreover, an additional 0.13% annual decrease was noted in HRRP-exposed hospitals vs CAHs. Only modest reductions in readmissions were associated with the introduction of financial penalties. The association between HRRP penalties and mortality was noted to vary with model specifications.

A similar study was conducted by Wadhera and his colleagues and published in JAMA recently. In this retrospective cohort study that included approximately 8 million Medicare beneficiary fee-for-service hospitalizations from 2005 to 2015, the results showed that among Medicare beneficiaries, the HRRP was significantly associated with an increase in 30-day postdischarge mortality after hospitalization for HF and pneumonia, but not for AMI. Given the study design and the lack of significant association of the HRRP with mortality within 45 days of admission, further research was deemed necessary to understand whether the increase in 30-day postdischarge mortality is a result of the policy.

Interpreting the results of these different studies, Dr. Atul Gupta, an Assistant Professor of Health Care Management at the Wharton School, University of Pennsylvania stated, “So what is the ‘final word’ on the effects of the HRRP? It will probably take some more time and other independent studies before the consensus truly forms. There is room for many studies on a policy issue as important as performance pay in health care. This episode illustrates one of the frustrations of empirical research, particularly observational studies – research design choices are consequential and can lead to differing conclusions. However, differing studies also play a critical role in generating informed debate and moving science forward. As researchers, it is important for us to analyze these differences and clearly communicate to stakeholders.” Dr. Alexander Sandhu and his colleagues believe that cluster-randomized rollouts of health care policy interventions will allow a better evaluation of the impact of their interventions.