麻豆传媒

Medicare penalties for above-average readmission rates among patients admitted with acute myocardial infarction, heart failure, and pneumonia do not seem to have affected mortality rates either in-hospital or after discharge, researchers said.

In the 2006-2014 period spanning the U.S. Hospital Readmissions Reduction Program's (HRRP) rollout during 2010-2012, in-hospital mortality rates decreased among Medicare beneficiaries hospitalized for acute MI (from 10.4% to 9.7%), heart failure (4.3% to 3.5%), and pneumonia (5.3% to 4.0%).

Rates of 30-day post-discharge also fell for acute MI (10.4% to 9.7%), but increased for heart failure (7.4% to 9.2%) and pneumonia (7.6% to 8.6%), according to Harlan Krumholz, MD, SM, of Yale School of Medicine in New Haven, Conn., and colleagues in a report published online in .

But the readmission penalties were not a factor, they argued.

"While post-discharge mortality for [heart failure] and pneumonia rose over the study period, these increases began in 2007 and 2006, respectively, over 3 years before the announcement of the HRRP and 5 years before the implementation of its associated financial penalties," Krumholz and colleagues wrote.

"Moreover, neither the announcement of the HRRP nor its implementation was associated with an increase in the changes in post-discharge mortality rates," they noted, whereas there was a substantial decrease in readmissions across the board.

Ultimately, the HRRP was associated with reduced readmissions without any harm done with respect to mortality, Krumholz's group concluded.

Their report responds to a study presented at the American Heart Association meeting last fall, which found increases in 30-day and 1-year mortality that offset the reduced readmissions from the HRRP.

Nevertheless, a major benefit of the HRRP is yet to be seen, said Ashish Jha, MD, MPH, of Harvard Global Health Institute in Cambridge, Mass., in an .

He emphasized the significant shift in trend for acute MI and heart failure inpatient mortality after the HRRP announcement.

While the monthly rate of change in acute MI in-hospital mortality was still downward in the post-HRRP announcement period (April 2010 to September 2012) it lost significance for that period (-0.001%, 95% CI -0.010 to 0.009) and the change in slope was significantly upward (0.020%, 95% CI 0.006 to 0.035).

For heart failure inpatient mortality, the month-over-month change likewise lost significance in its downward trend for that post-announcement period (-0.002%, 95% CI -0.008 to 0.005) with a significant change in slope (0.012%, 95% CI 0.003 to 0.022).

"Inpatient mortality, by definition, shapes the population of patients who are discharged and eligible to be readmitted. If there is an uptick in inpatient mortality -- or even if there is simply a slowing of the long-term gains in mortality -- the patient population discharged alive will be healthier than they would have been otherwise," according to Jha. This makes the lack of rise in post-discharge mortality "far less reassuring than it would be otherwise."

However, co-author Rohan Khera, MD, of UT Southwestern Medical Center in Dallas, countered in an email to 麻豆传媒: “The transient reduction in rate of decline in in-hospital mortality noted around the period of announcement of the HRRP was never associated with an actual rise in mortality, and even the rate of decline in in-hospital mortality for most of the post-HRRP period was similar to the pre-HRRP period.”

The new study covered the entire fee-for-service Medicare population hospitalized in 2006-2014, which included 1.7 million acute MI, 4 million heart failure, and 3.5 million pneumonia hospitalizations.

The Medicare claims data they used didn't typically include information about cause of death or end-of-life care, the authors noted.

Jha said that Krumholz and colleagues showed some of the potentially deleterious effects of the program and highlighted where some of the concerns may be less of an issue.

"But this hardly settles the issue. If thousands of hospitals and tens of thousands of clinicians are going to be asked to change the way they provide care, adequate resources and a robust set of efforts are needed to fully evaluate the program from a variety of perspectives to ensure that we continually improve the program," according to the editorialist.

Two changes are needed, Jha urged, the first being an adjustment in the financial penalties for centers with more readmissions.

"Right now, a high-readmission, low-mortality hospital will be penalized at 6 to 10 times the rate of a low-readmission, high-mortality hospital. The signal from policy makers is clear -- readmissions matter a lot -- and this signal needs to stop," he wrote.

The other need is a comprehensive examination of the HRRP, focusing on whether it has made U.S. patients better off and how much it has saved, Jha wrote. He added that it should be conducted by "independent experts who have no vested interest in the results" -- a veiled dig at Krumholz's group, which had been funded to develop the program's readmissions measure.

The story was updated on Oct. 10 to clarify the in-patient mortality trends with additional detail and perspective.

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