Is mortality readmissions bias a concern for readmission rates under the Hospital Readmissions Reduction Program?
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ABSTRACT: Objective
To determine whether the exclusion of patients who die from adjusted 30-day readmission rates influences readmission rate measures and penalties under the Hospital Readmission Reduction Program (HRRP).Data sources/study setting
100% Medicare fee-for-service claims over the period July 1, 2012, until June 30, 2015.Study design
We examine the 30-day readmission risk across the three conditions targeted by the HRRP: acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. Using logistic regression, we estimate the readmission risk for three samples of patients: those who survived the 30-day period after their index admission, those who died over the 30-day period, and all patients who were admitted to see how they differ.Data collection/extraction methods
We identified and extracted data for Medicare fee-for-service beneficiaries admitted with primary diagnoses of AMI (N = 497 931), CHF (N = 1 047 552), and pneumonia (N = 850 552).Results
The estimated hospital readmission rates for the survived and nonsurvived patients differed by 5%-8%, on average. Incorporating these estimates into overall readmission risk for all admitted patients changes the likely penalty status for 9% of hospitals. However, this change is randomly distributed across hospitals and is not concentrated amongst any one type of hospital.Conclusions
Not accounting for variations in mortality may result in inappropriate penalties for some hospitals. However, the effect of this bias is low due to low mortality rates amongst incentivized conditions and appears to be randomly distributed across hospital types.
SUBMITTER: Papanicolas I
PROVIDER: S-EPMC7080391 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BackgroundHospital readmission rates decreased for myocardial infarction (AMI), heart failure (CHF), and pneumonia with implementation of the first phase of the Hospital Readmissions Reduction Program (HRRP). It is not established whether readmissions fell for chronic obstructive pulmonary disease (COPD), an HRRP condition added in 2014.ObjectiveWe sought to determine whether HRRP penalties influenced COPD readmissions among Medicare, Medicaid, or privately insured patients.DesignWe analyzed a retrospective cohort, evaluating readmissions across implementation periods for HRRP penalties ("pre-HRRP" January 2010-April 2011, "implementation" May 2011-September 2012, "partial penalty" October 2012-September 2014, and "full penalty" October 2014-December 2016).PatientsWe assessed discharged patients ≥ 40 years old with COPD versus those with HRRP Phase 1 conditions (AMI, CHF, and pneumonia) or non-HRRP residual diagnoses in the Nationwide Readmissions Database.InterventionsHRRP was announced and implemented during this period, forming a natural experiment.MeasurementsWe calculated differences-in-differences (DID) for 30-day COPD versus HRRP Phase 1 and non-HRRP readmissions.Key resultsCOPD discharges for 1.2 million Medicare enrollees were compared with 22 million non-HRRP and 3.4 million HRRP Phase 1 discharges. COPD readmissions decreased from 19 to 17% over the study. This reduction was significantly greater than non-HRRP conditions (DID - 0.41%), but not HRRP Phase 1 (DID + 0.02%). A parallel trend was observed in the privately insured, with significant reduction compared with non-HRRP (DID - 0.83%), but not HRRP Phase 1 conditions (DID - 0.45%). Non-significant reductions occurred in Medicaid (DID - 0.52% vs. non-HRRP and - 0.21% vs. Phase 1 conditions).ConclusionsIn Medicare, HRRP implementation was associated with reductions in COPD readmissions compared with non-HRRP controls but not versus other HRRP conditions. Parallel findings were observed in commercial insurance, but not in Medicaid. Condition-specific penalties may not reduce readmissions further than existing HRRP trends.
| S-EPMC7728926 | biostudies-literature
Project description:Background:Whether hospitals with the highest risk-standardized readmission rates (RSRRs) subsequently experienced the greatest improvement after passage of the Medicare Hospital Readmissions Reduction Program (HRRP) is unknown. Objective:To evaluate whether passage of the HRRP was followed by acceleration in improvement in 30-day RSRRs after hospitalizations for acute myocardial infarction (AMI), congestive heart failure (CHF), or pneumonia and whether the lowest-performing hospitals had faster acceleration in improvement after passage of the law than hospitals that were already performing well. Design:Pre-post analysis stratified by hospital performance groups. Setting:U.S. acute care hospitals. Patients:15 170 008 Medicare patients discharged alive from 2000 to 2013. Intervention:Passage of the HRRP. Measurements:30-day readmission rates after hospitalization for AMI, CHF, or pneumonia for hospitals in the highest-performance (0% penalty), average-performance (>0% and <0.50% penalty), low-performance (?0.50% and <0.99% penalty), and lowest-performance (?0.99% penalty) groups. Results:Of 2868 hospitals serving 1 109 530 Medicare discharges annually, 30.1% were highest performers, 44.0% were average performers, 16.8% were low performers, and 9.0% were lowest performers. After controlling for prelaw trends, an additional 67.6 (95% CI, 66.6 to 68.4), 74.8 (CI, 74.0 to 75.4), 85.4 (CI, 84.0 to 86.8), and 95.1 (CI, 92.6 to 97.5) readmissions per 10 000 discharges were found to have been averted per year in the highest-, average-, low-, and lowest-performance groups, respectively, after passage of the law. Limitation:Inability to distinguish between improvement caused by the magnitude of the penalty or by different levels of health improvement in different patient populations. Conclusion:After passage of the HRRP, 30-day RSRRs for myocardial infarction, heart failure, and pneumonia decreased more rapidly than before the law's passage. Improvement was most marked for hospitals with the lowest prelaw performance. Primary Funding Source:National Institutes of Health.
| S-EPMC5507076 | biostudies-literature
Project description:Since the implementation of the Hospital Readmissions Reduction Program (HRRP), readmissions have declined for Medicare patients with conditions targeted by the policy (acute myocardial infarction, heart failure, and pneumonia). To understand whether HRRP implementation was associated with a readmission decline for patients across all insurance types (Medicare, Medicaid, and private), we conducted a difference-in-differences analysis using information from the Nationwide Readmissions Database. We compared how quarterly readmissions for target conditions changed before (2010-12) and after (2012-14) HRRP implementation, using nontarget conditions as the control. Our results demonstrate that readmissions declined at a significantly faster rate after HRRP implementation not just for Medicare patients but also for those with Medicaid, both in the aggregate and for individual target conditions. However, composite Medicaid readmission rates remained higher than those for Medicare. Throughout the study period privately insured patients had the lowest aggregate readmission rates, which declined at a similar rate compared to nontarget conditions. The HRRP was associated with nationwide readmission reductions beyond the Medicare patients originally targeted by the policy. Further research is needed to understand the specific mechanisms by which hospitals have achieved reductions in readmissions.
| S-EPMC7137289 | biostudies-literature
Project description:Importance:Public reporting of hospitals' 30-day risk-standardized readmission rates following heart failure hospitalization and the financial penalization of hospitals with higher rates have been associated with a reduction in 30-day readmissions but have raised concerns regarding the potential for unintended consequences. Objective:To examine the association of the Hospital Readmissions Reduction Program (HRRP) with readmission and mortality outcomes among patients hospitalized with heart failure within a prospective clinical registry that allows for detailed risk adjustment. Design, Setting, and Participants:Interrupted time-series and survival analyses of index heart failure hospitalizations were conducted from January 1, 2006, to December 31, 2014. This study included 115?245 fee-for-service Medicare beneficiaries across 416 US hospital sites participating in the American Heart Association Get With The Guidelines-Heart Failure registry. Data analysis took place from January 1, 2017, to June 8, 2017. Exposures:Time intervals related to the HRRP were before the HRRP implementation (January 1, 2006, to March 31, 2010), during the HRRP implementation (April 1, 2010, to September 30, 2012), and after the HRRP penalties went into effect (October 1, 2012, to December 31, 2014). Main Outcomes and Measures:Risk-adjusted 30-day and 1-year all-cause readmission and mortality rates. Results:The mean (SD) age of the study population (n = 115?245) was 80.5 (8.4) years, 62 927 (54.6%) were women, and 91 996 (81.3%) were white and 11 037 (9.7%) were black. The 30-day risk-adjusted readmission rate declined from 20.0% before the HRRP implementation to 18.4% in the HRRP penalties phase (hazard ratio (HR) after vs before the HRRP implementation, 0.91; 95% CI, 0.87-0.95; P?<?.001). In contrast, the 30-day risk-adjusted mortality rate increased from 7.2% before the HRRP implementation to 8.6% in the HRRP penalties phase (HR after vs before the HRRP implementation, 1.18; 95% CI, 1.10-1.27; P?<?.001). The 1-year risk-adjusted readmission and mortality rates followed a similar pattern as the 30-day outcomes. The 1-year risk-adjusted readmission rate declined from 57.2% to 56.3% (HR, 0.92; 95% CI, 0.89-0.96; P?<?.001), and the 1-year risk-adjusted mortality rate increased from 31.3% to 36.3% (HR, 1.10; 95% CI, 1.06-1.14; P?<?.001) after vs before the HRRP implementation. Conclusions and Relevance:Among fee-for-service Medicare beneficiaries discharged after heart failure hospitalizations, implementation of the HRRP was temporally associated with a reduction in 30-day and 1-year readmissions but an increase in 30-day and 1-year mortality. If confirmed, this finding may require reconsideration of the HRRP in heart failure.
| S-EPMC5833526 | biostudies-literature
Project description:Readmission rates declined after announcement of the Hospital Readmission Reduction Program (HRRP), which penalizes hospitals for excess readmissions for acute myocardial infarction (AMI), heart failure (HF), and pneumonia.To compare trends in readmission rates for target and nontarget conditions, stratified by hospital penalty status.Retrospective cohort study of Medicare fee-for-service beneficiaries older than 64 years discharged between January 1, 2008, and June 30, 2015, from 2214 penalty hospitals and 1283 nonpenalty hospitals. Difference-interrupted time-series models were used to compare trends in readmission rates by condition and penalty status.Hospital penalty status or target condition under the HRRP.Thirty-day risk adjusted, all-cause unplanned readmission rates for target and nontarget conditions.The study included 48?137?102 hospitalizations of 20?351?161 Medicare beneficiaries. In January 2008, the mean readmission rates for AMI, HF, pneumonia, and nontarget conditions were 21.9%, 27.5%, 20.1%, and 18.4%, respectively, at hospitals later subject to financial penalties and 18.7%, 24.2%, 17.4%, and 15.7% at hospitals not subject to penalties. Between January 2008 and March 2010, prior to HRRP announcement, readmission rates were stable across hospitals (except AMI at nonpenalty hospitals). Following announcement of HRRP (March 2010), readmission rates for both target and nontarget conditions declined significantly faster for patients at hospitals later subject to financial penalties compared with those at nonpenalized hospitals (for AMI, additional decrease of -1.24 [95% CI, -1.84 to -0.65] percentage points per year relative to nonpenalty discharges; for HF, -1.25 [95% CI, -1.64 to -0.86]; for pneumonia, -1.37 [95% CI, -1.80 to -0.95]; and for nontarget conditions, -0.27 [95% CI, -0.38 to -0.17]; P?<?.001 for all). For penalty hospitals, readmission rates for target conditions declined significantly faster compared with nontarget conditions (for AMI, additional decline of -0.49 [95% CI, -0.81 to -0.16] percentage points per year relative to nontarget conditions [P?=?.004]; for HF, -0.90 [95% CI, -1.18 to -0.62; P?<?.001]; and for pneumonia, -0.57 [95% CI, -0.92 to -0.23; P?<?.001]). In contrast, among nonpenalty hospitals, readmissions for target conditions declined similarly or more slowly compared with nontarget conditions (for AMI, additional increase of 0.48 [95% CI, 0.01-0.95] percentage points per year [P?=?.05]; for HF, 0.08 [95% CI, -0.30 to 0.46; P?=?.67]; for pneumonia, 0.53 [95% CI, 0.13-0.93; P?=?.01]). After HRRP implementation in October 2012, the rate of change for readmission rates plateaued (P?<?.05 for all except pneumonia at nonpenalty hospitals), with the greatest relative change observed among hospitals subject to financial penalty.Medicare fee-for-service patients at hospitals subject to penalties under the HRRP had greater reductions in readmission rates compared with those at nonpenalized hospitals. Changes were greater for target vs nontarget conditions for patients at the penalized hospitals but not at the other hospitals.
| S-EPMC5599851 | biostudies-literature
Project description:Importance:The Hospital Readmissions Reduction Program (HRRP) is a Centers for Medicare and Medicaid Services policy that levies hospital reimbursement penalties based on excess readmissions of patients with 4 medical conditions and 3 surgical procedures. A greater understanding of factors associated with the 3 surgical reimbursement penalties is needed for clinicians in surgical practice. Objective:To investigate the first year of HRRP readmission penalties applied to 2 surgical procedures-elective total hip arthroplasty (THA) and total knee arthroplasty (TKA)-in the context of hospital and patient characteristics. Design, Setting, and Participants:Fiscal year 2015 HRRP penalization data from Hospital Compare were linked with the American Hospital Association Annual Survey and with the Healthcare Cost and Utilization Project State Inpatient Database for hospitals in the state of Florida. By using a case-control framework, those hospitals were separated based on HRRP penalty severity, as measured with the HRRP THA and TKA excess readmission ratio, and compared according to orthopedic volume as well as hospital-level and patient-level characteristics. The first year of HRRP readmission penalties applied to surgery in Florida Medicare subsection (d) hospitals was examined, identifying 60?663 Medicare patients who underwent elective THA or TKA in 143 Florida hospitals. The data analysis was conducted from February 2016 to January 2017. Exposures:Annual hospital THA and TKA volume, other hospital-level characteristics, and patient factors used in HRRP risk adjustment. Main Outcomes and Measures:The HRRP penalties with HRRP excess readmission ratios were measured, and their association with annual THA and TKA volume, a common measure of surgical quality, was evaluated. The HRRP penalties for surgical care according to hospital and readmitted patient characteristics were then examined. Results:Among 143 Florida hospitals, 2991 of 60?663 Medicare patients (4.9%) who underwent THA or TKA were readmitted within 30 days. Annual hospital arthroplasty volume seemed to follow an inverse association with both unadjusted readmission rates (r?=?-0.16, P?=?.06) and HRRP risk-adjusted readmission penalties (r?=?-0.12, P?=?.14), but these associations were not statistically significant. Other hospital characteristics and readmitted patient characteristics were similar across HRRP orthopedic penalty severity. Conclusions and Relevance:This study's findings suggest that higher-volume hospitals had less severe, but not significantly different, rates of readmission and HRRP penalties, without systematic differences across readmitted patients.
| S-EPMC6902819 | biostudies-literature
Project description:Importance:The strongest evidence for the effectiveness of Medicare's Hospital Readmissions Reduction Program (HRRP) involves greater reductions in readmissions for hospitals receiving penalties compared with those not receiving penalties. However, the HRRP penalty is an imperfect measure of hospitals' marginal incentive to avoid a readmission for HRRP-targeted diagnoses. Objectives:To assess the association between hospitals' condition-specific incentives and readmission performance and to examine the responsiveness of hospitals to condition-specific incentives compared with aggregate penalty amounts. Design, Setting, and Participants:This retrospective cohort analysis used Medicare readmissions data from 2823 US short-term acute care hospitals participating in HRRP to compare 3-year (fiscal years 2016-2019) follow-up readmission performance according to tertiles of hospitals' baseline (2016) marginal incentives for each of 5 HRRP-targeted conditions (acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, pneumonia, and hip and/or knee surgery). Main Outcomes and Measures:Linear regression models were used to estimate mean change in follow-up readmission performance, measured using the excess readmissions ratio, with baseline condition-specific incentives and aggregate penalty amounts. Results:Of 2823 hospitals that participated in the HRRP from baseline to follow-up, 2280 (81%) had more than 1 excess readmission for 1 or more applicable condition and 543 (19%) did not have any excess readmissions. The mean (SD) financial incentive to reduce readmissions for incentivized hospitals ranged from $8762 ($3699) to $58?158 ($26?198) per 1 avoided readmission. Hospitals with greater incentives for readmission avoidance had greater decreases in readmissions compared with hospitals with smaller incentives (45% greater for pneumonia, 172% greater for acute myocardial infarction, 40% greater for hip and/or knee surgery, 32% greater for chronic obstructive pulmonary disease, and 13% greater for heart failure), whereas hospitals with no incentives had increases in excess readmissions of 4% to 7% (median, 4% [percentage change for nonincentivized hospitals was 3.7% for pneumonia, 4.2% for acute myocardial infarction, 7.1% for hip and/or knee surgery, 3.7% for chronic obstructive pulmonary disease, and 3.7% for heart failure]; P?<?.001). During the study period, each additional $5000 in the incentive amount was associated with a 0.6- to 1.3-percentage point decrease, or up to a 26% decrease, in excess readmissions (P?<?.001). Regression to the mean explained approximately one-third of the results depending on the condition examined. Conclusions and Relevance:The findings suggest that improvements in readmission avoidance are more strongly associated with incentives from the HRRP than with aggregate penalty amounts, suggesting that the program has elicited sizeable changes. Worsened performance among hospitals with small or no incentives may indicate the need for reconsideration of the program's lack of financial rewards for high-performing hospitals.
| S-EPMC7125432 | biostudies-literature
Project description:ImportanceAlthough readmission rates are declining under Medicare's Hospital Readmissions Reduction Program (HRRP), concerns remain that the HRRP will harm quality at safety-net hospitals because they are penalized more often. Disparities between white and black patients might widen because more black patients receive care at safety-net hospitals. Disparities may be particularly worse for clinical conditions not targeted by the HRRP because hospitals might reallocate resources toward targeted conditions (acute myocardial infarction, pneumonia, and heart failure) at the expense of nontargeted conditions.ObjectiveTo examine disparities in readmission rates between white and black patients discharged from safety-net or non-safety-net hospitals after the HRRP began, evaluating discharges for any clinical condition and the subsets of targeted and nontargeted conditions.Design, setting, and participantsCohort study conducting quasi-experimental analyses of patient hospital discharges for any clinical condition among fee-for-service Medicare beneficiaries from 2007 to 2015 after controlling for patient and hospital characteristics. Changes in disparities were measured within safety-net and non-safety-net hospitals after the HRRP penalties were enforced and compared with prior trends. These analyses were then stratified by targeted and nontargeted conditions. Analyses were conducted from October 1, 2017, through August 31, 2018.Main outcomes and measuresTrends in 30-day readmission rates among white and black patients by quarter and differences in trends across periods.ResultsThe study sample included 58 237 056 patient discharges (black patients, 9.8%; female, 57.7%; mean age [SD] age, 78.8 [7.9] years; nontargeted conditions, 50 372 806 [86.5%]). Within safety-net hospitals, disparities in readmission rates for all clinical conditions widened between black and white patients by 0.04 percentage point per quarter in the HRRP penalty period (95% CI, 0.01 to 0.07; P = .01). This widening was driven by nontargeted conditions (0.05 percentage point per quarter [95% CI, 0.01 to 0.08]; P = .006), whereas disparities for the HRRP-targeted conditions did not change (with an increase of 0.01 percentage point per quarter [95% CI, -0.07 to 0.10]; P = .74). Within non-safety-net hospitals, racial disparities remained stable in the HRRP penalty period across all conditions, whether the conditions were HRRP-targeted or nontargeted.Conclusions and relevanceFindings from this study suggest that disparities are widening within safety-net hospitals, specifically for non-HRRP-targeted conditions. Although increases in racial disparities for nontargeted conditions were modest, they represent 6 times more discharges in our cohort than targeted conditions.
| S-EPMC6324411 | biostudies-literature
Project description:ObjectivesExamine whether the introduction of the Hospital Readmissions Reduction Program (HRRP) is associated with changes in post-acute care (PAC) use and 30-day readmission.DesignA retrospective cohort study examined data prepassage, preimplementation, and postimplementation of the HRRP.Setting and participantsIn total, 7,851,430 Medicare beneficiaries discharged from 5116 acute hospitals to PAC settings including inpatient rehabilitation, skilled nursing, home health, or a long-term care hospital during 2007‒2015. We examined HRRP-targeted conditions (acute myocardial infarction, heart failure, and pneumonia) and nontargeted conditions (ischemic stroke, total hip arthroplasty/total knee arthroplasty, and hip/femur fractures).MeasuresThe hospital-level of quarterly PAC use and the association with 30-day risk-standardized readmission rates. Outcomes were calculated for HRRP-targeted and nontargeted conditions/diagnoses across 3 phases of HRRP implementation.ResultsAn increase in quarterly PAC use was significantly (P < .001) associated with a decrease in 30-day risk-standardized readmission rates for acute myocardial infarction, heart failure, and hip/femur fracture. In contrast, an increase in quarterly PAC use was significantly associated with an increase in readmission rate for total hip arthroplasty/total knee arthroplasty (P < 001). PAC quarterly use and readmission rates varied significantly during implementation periods for HRRP- targeted and nontargeted conditions.Conclusions and implicationsThe impact on readmission after PAC for selected impairment groups may be mediated by the type of PAC services received and whether the diagnoses is included in the HRRP. Additional research is necessary to determine if a reduction in readmission is associated with inclusion in the HRRP or is a side effect related to diagnostic group and/or type of PAC services received.
| S-EPMC7529906 | biostudies-literature
Project description:BackgroundThe Hospital Readmissions Reduction Program (HRRP) penalizes hospitals for higher-than-expected readmission rates. Almost 20% of Medicare fee-for-service (FFS) patients receive postacute care in skilled nursing facilities (SNFs) after hospitalization. SNF patients have high readmission rates.ObjectiveThe objective of this study was to investigate the association between changes in hospital referral patterns to SNFs and HRRP penalty pressure.DesignWe examined changes in the relationship between penalty pressure and outcomes before versus after HRRP announcement among 2698 hospitals serving 6,936,393 Medicare FFS patients admitted for target conditions: acute myocardial infarction, heart failure, or pneumonia. Hospital-level penalty pressure was the expected penalty rate in the first year of the HRRP multiplied by Medicare discharge share.OutcomesInformal integration measured by the percentage of referrals to hospitals' most referred SNF; formal integration measured by SNF acquisition; readmission-based quality index of the SNFs to which a hospital referred discharged patients; referral rate to any SNF.ResultsHospitals facing the median level of penalty pressure had modest differential increases of 0.3 percentage points in the proportion of referrals to the most referred SNF and a 0.006 SD increase in the average quality index of SNFs referred to. There were no statistically significant differential increases in formal acquisition of SNFs or referral rate to SNF.ConclusionsHRRP did not prompt substantial changes in hospital referral patterns to SNFs, although readmissions for patients referred to SNF differentially decreased more than for other patients, warranting investigation of other mechanisms underlying readmissions reduction.
| S-EPMC6944285 | biostudies-literature