Benefits of financial penalties imposed by Hospital Readmissions Reduction Program "modest at best"
Implementation of the Hospital Readmissions Reduction Program (HRRP), which cuts Medicare payments to hospitals with high readmission rates, was followed by a drop in readmissions in the U.S. -- yet the same phenomenon could be observed during the same time in Canada where there was no equivalent to the HRRP, researchers showed.
A cohort study of more than 3 million adults admitted for heart failure found that 30-day readmission rates fell to a similar extent from 2005 through 2015 in both the U.S. (21.2% to 18.5%, P<0.001) and in Canada (19.7% to 17.6%, P<0.001), according to Finlay McAlister, MD, of the University of Alberta in Edmonton, and colleagues.
There was no change in readmission rates in either country before and after the HRRP took effect in the U.S. in October 2012, nor was there any difference in the rates of change, the authors reported online in JAMA Cardiology.
From 2005 to 2015, mean length of stay in the hospital went down marginally in Canada from 7.5 to 7.3 days (P<0.001), whereas it stayed stable at 4.9 days in the U.S. There was a small but statistically positive correlation between length of stay and 30-day readmissions in both countries, the authors noted.
Based on these findings, "any benefits of the HRRP are modest at best," they concluded. "Our finding that all-cause readmission rates in the United States have declined to the same extent over the past decade as those in Canada would suggest that the implementation of financial payment penalties in October 2012 under the HRRP may not have had as large an influence as was previously thought."
It will take more than public reporting and these financial penalties to achieve better outcomes for heart failure patients, they said.
The HRRP lets CMS withhold money from hospitals when they have higher-than-expected readmission rates for heart failure, MI, and pneumonia. Several studies had reported a drop in readmissions for these conditions after the program was implemented, but these were all done without external controls, according to McAlister and colleagues.
Their study adds to the "mounting evidence that the program is failing to live up to expectations" as three studies have already linked HRRP to an increase in mortality and two have concluded that coding changes were the primary driver of the decrease in readmissions, wrote Ashish Jha, MD, MPH, of the Harvard Global Health Institute in Cambridge, Massachusetts, in an accompanying editorial.
McAlister's group conducted the study using data gathered from Medicare Hospitalization files and the Canadian Institute of Health Information Discharge Abstract Database.
Among the limitations of this approach were the missing out-of-hospital death information and the lack of granular clinical data that would provide insight about the severity of illness, they acknowledged.
"Looking at the bigger picture, this study casts new and important doubt onto whether the HRRP has had any benefit at all. The fact that readmission rates decreased comparable amounts in Canada and the United States suggests that underlying changes in clinical practice (broader secular trends) in both countries are likely at play," Jha said.
"What might those factors be? There have been ongoing improvements in both pharmaceutical and nonpharmaceutical approaches to caring for patients with heart failure, including new treatments, greater use of electronic health records, and improvements in transitions to primary care. These changes, which have taken place in both the United States and Canada, likely explain more of the drop in readmissions than the HRRP," he noted.
The study was supported by a National Heart, Lung, and Blood Institute grant and the Alberta Health Services Chair in Cardiovascular Outcomes.
McAlister and Jha disclosed no relevant relationships with industry.
Source Reference: Samsky MD, et al "Trends in readmissions and length of stay for patients hospitalized with heart failure in Canada and the United States" JAMA Cardiol 2019; DOI: 10.1001/jamacardio.2019.0766.
Source Reference: Jha AK "What readmission rates in Canada tell us about the Hospital Readmissions Reduction Program" JAMA Cardiol 2019; DOI: 10.1001/jamacardio.2019.0846.
Read the original article on Medpage Today: Hospital Readmissions: Failing to Meet Expectations?