Dataset Information

Thirty-Day Postdischarge Mortality Among Black and White Patients 65 Years and Older in the Medicare Hospital Readmissions Reduction Program.

ABSTRACT:

Importance

The Medicare Hospital Readmissions Reduction Program (HRRP) has disproportionately penalized hospitals that treat many black patients, which could worsen health outcomes in this population.

Objective

To determine whether short-term mortality rates increased among black and white adults 65 years and older after initiation of the HRRP and whether trends differed by race.

Design, setting, and participants

In a cohort study using an interrupted time-series analysis conducted from March 15, 2018, to January 23, 2019, in 3263 eligible acute care hospitals nationally, risk-adjusted mortality rates observed after Medicare started to impose penalties (October 1, 2012, to November 30, 2014) were compared with projections based on pre-HRRP trends (January 1, 2007, to March 31, 2010) among adults 65 years and older with acute myocardial infarction (AMI), heart failure (HF), or pneumonia. Observed-to-projected differences were then compared between racial groups.

Exposures

Hospital discharge during pre-HRRP and HRRP penalty periods.

Main outcomes and measures

Thirty-day postdischarge all-cause mortality.

Results

In the 3263 acute care hospitals included in the analysis, black patients (627?373 index discharges) were more likely than white patients (5?845?130 index discharges) to be younger (mean [SD] age, 77.8 [8.3] vs 80.5 [8.2] years; P?Conclusions and relevanceIn this study of patients 65 years and older, short-term postdischarge mortality did not appear to increase for black patients under the HRRP, suggesting that certain value-based payment policies can be implemented without harming black populations. However, mortality seemed to increase for white patients with HF and this situation warrants investigation.

SUBMITTER: Huckfeldt P

PROVIDER: S-EPMC6484660 | biostudies-literature | 2019 Mar

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Thirty-Day Postdischarge Mortality Among Black and White Patients 65 Years and Older in the Medicare Hospital Readmissions Reduction Program.

Huckfeldt Peter P Escarce José J Sood Neeraj N Yang Zhiyou Z Popescu Ioana I Nuckols Teryl T

JAMA network open 20190301 3

<h4>Importance</h4>The Medicare Hospital Readmissions Reduction Program (HRRP) has disproportionately penalized hospitals that treat many black patients, which could worsen health outcomes in this population.<h4>Objective</h4>To determine whether short-term mortality rates increased among black and white adults 65 years and older after initiation of the HRRP and whether trends differed by race.<h4>Design, setting, and participants</h4>In a cohort study using an interrupted time-series analysis c ...[more]

PMID: 30874780

Similar Datasets

Project description:ImportanceExcess 30-day readmissions have declined substantially in hospitals initially penalized for high readmission rates under the Medicare Hospital Readmissions Reduction Program (HRRP). Although a possible explanation is that the policy incentivized penalized hospitals to improve care processes, another is regression to the mean (RTM), a statistical phenomenon that predicts entities farther from the mean in one period are likely to fall closer to the mean in subsequent (or preceding) periods owing to random chance.ObjectiveTo quantify the contribution of RTM to declining readmission rates at hospitals initially penalized under the HRRP.Design, setting, and participantsThis study analyzed data from Medicare Provider and Analysis Review files to assess changes in readmissions going forward and backward in time at hospitals with high and low readmission rates during the measurement window for the first year of the HRRP (fiscal year [FY] 2013) and for a measurement window that predated the FY 2013 measurement window for the HRRP among hospitals participating in the HRRP. Hospital characteristics are based on the 2012 survey by the American Hospital Association. The analysis included fee-for-service Medicare beneficiaries 65 years or older with an index hospitalization for 1 of the 3 target conditions of heart failure, acute myocardial infarction, or pneumonia or chronic obstructive pulmonary disease and who were discharged alive from February 1, 2006, through June 30, 2014, with follow-up completed by July 30, 2014. Data were analyzed from January 23, 2018, through March 29, 2019.ExposuresHospital Readmission Reduction Program penalties.Main outcome and measuresThe excess readmission ratio (ERR), calculated as the ratio of a hospital's readmissions to the readmissions that would be expected based on an average hospital with similar patients. Hospitals with ERRs of greater than 1.0 were penalized.ResultsA total of 3258 hospitals were included in the study. For the 3 target conditions, hospitals with ERRs of greater than 1.0 during the FY 2013 measurement window exhibited decreases in ERRs in the subsequent 3 years, whereas hospitals with ERRs of no greater than 1.0 exhibited increases. For example, for patients with heart failure, mean ERRs declined from 1.086 to 1.038 (-0.048; 95% CI, -0.053 to -0.043; P < .001) at hospitals with ERRs of greater than 1.0 and increased from 0.917 to 0.957 (0.040; 95% CI, 0.036-0.044; P < .001) at hospitals with ERRs of no greater than 1.0. The same results, with ERR changes of similar magnitude, were found when the analyses were repeated using an alternate measurement window that predated the HRRP and followed up hospitals for 3 years (for patients with heart failure, mean ERRs declined from 1.089 to 1.044 [-0.045; 95% CI, -0.050 to -0.040; P < .001] at hospitals with below-mean performance and increased from 0.915 to 0.948 [0.033; 95% CI, 0.029 to 0.037; P < .001] at hospitals with above-mean performance). By comparing actual changes in ERRs with expected changes due to RTM, 74.3% to 86.5% of the improvement in ERRs for penalized hospitals was explained by RTM.Conclusions and relevanceMost of the decline in readmission rates in hospitals with high rates during the measurement window for the first year of the HRRP appeared to be due to RTM. These findings seem to call into question the notion of an HRRP policy effect on readmissions.

Project description:BACKGROUND:The Hospital Readmissions Reduction Program (HRRP) was established by the 2010 Patient Protection and Affordable Care Act (ACA) in an effort to reduce excess hospital readmissions, lower health care costs, and improve patient safety and outcomes. Although studies have examined the policy's overall impacts and differences by hospital types, research is limited on its effects for different types of vulnerable populations. The aim of this study was to analyze the impact of the HRRP on readmissions for three targeted conditions (acute myocardial infarction, heart failure, and pneumonia) among four types of vulnerable populations, including low-income patients, patients served by hospitals that serve a high percentage of low-income or Medicaid patients, and high-risk patients at the highest quartile of the Elixhauser comorbidity index score. METHODS:Data on patient and hospital information came from the Nationwide Readmission Database (NRD), which contained all discharges from community hospitals in 27 states during 2010-2014. Using difference-in-difference (DD) models, linear probability regressions were conducted for the entire sample and sub-samples of patients and hospitals in order to isolate the effect of the HRRP on vulnerable populations. Multiple combinations of treatment and control groups and triple difference (DDD) methods were used for testing the robustness of the results. All models controlled for the patient and hospital characteristics. RESULTS:There have been statistically significant reductions in readmission rates overall as well as for vulnerable populations, especially for acute myocardial infarction patients in hospitals serving the largest percentage of low-income patients and high-risk patients. There is also evidence of spillover effects for non-targeted conditions among Medicare patients compared to privately insured patients. CONCLUSIONS:The HRRP appears to have created the right incentives for reducing readmissions not only overall but also for vulnerable populations, accruing societal benefits in addition to previously found reductions in costs. As the reduction in the rate of readmissions is not consistent across patient and hospital groups, there could be benefits to adjusting the policy according to the socioeconomic status of a hospital's patients and neighborhood.

Project description:OBJECTIVE: To examine the source of observed lower risk-adjusted mortality for blacks than whites within the Veterans Affairs (VA) system by accounting for hospital site where treated, potential under-reporting of black deaths, discretion on hospital admission, quality improvement efforts, and interactions by age group. DATA SOURCES: Data are from the VA Patient Treatment File on 406,550 hospitalizations of veterans admitted with a principal diagnosis of acute myocardial infarction, stroke, hip fracture, gastrointestinal bleeding, congestive heart failure, or pneumonia between 1996 and 2002. Information on deaths was obtained from the VA Beneficiary Identification Record Locator System and the National Death Index. STUDY DESIGN: This was a retrospective observational study of hospitalizations throughout the VA system nationally. The primary outcome studied was all-location mortality within 30 days of hospital admission. The key study variable was whether a patient was black or white. PRINCIPAL FINDINGS: For each of the six study conditions, unadjusted 30-day mortality rates were significantly lower for blacks than for whites (p<.01). These results did not vary after adjusting for hospital site where treated, more complete ascertainment of deaths, and in comparing results for conditions for which hospital admission is discretionary versus non-discretionary. There were also no significant changes in the degree of difference by race in mortality by race following quality improvement efforts within VA. Risk-adjusted mortality was consistently lower for blacks than for whites only within the population of veterans over age 65. CONCLUSIONS: Black veterans have significantly lower 30-day mortality than white veterans for six common, high severity conditions, but this is generally limited to veterans over age 65. This differential by age suggests that it is unlikely that lower 30-day mortality rates among blacks within VA are driven by treatment differences by race.

Dataset Information

Thirty-Day Postdischarge Mortality Among Black and White Patients 65 Years and Older in the Medicare Hospital Readmissions Reduction Program.

Importance

Objective

Design, setting, and participants

Exposures

Main outcomes and measures

Results

Publications

Thirty-Day Postdischarge Mortality Among Black and White Patients 65 Years and Older in the Medicare Hospital Readmissions Reduction Program.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets