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• W2904476163 abstract "HomeCirculation: Cardiovascular Quality and OutcomesVol. 11, No. 12Effects of the Hospital Readmissions Reduction Program Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBEffects of the Hospital Readmissions Reduction ProgramThe MedPAC Report Rohan Khera, MD and Harlan M. Krumholz, MD, SM Rohan KheraRohan Khera Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (R.K.). Search for more papers by this author and Harlan M. KrumholzHarlan M. Krumholz Harlan M. Krumholz, MD, SM, Department of Internal Medicine, Yale School of Medicine, 1 Church St, Suite 200, New Haven, CT 06510. Email E-mail Address: [email protected] Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (H.M.K.). Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT (H.M.K.). Department of Health Policy and Management, Yale School of Public Health, New Haven, CT (H.M.K.). Search for more papers by this author Originally published17 Dec 2018https://doi.org/10.1161/CIRCOUTCOMES.118.005083Circulation: Cardiovascular Quality and Outcomes. 2018;11:e005083This article is commented on by the following:Making Health Policy More AccessiblePOLICY STATEMENT TITLEUnited States Congressionally mandated report: The effects of the Hospital Readmissions Reduction Program.ORGANIZATIONMedicare Payment Advisory Committee, a nonpartisan US federal body that advises the US Congress on the administration of the Medicare program.RELEASE DATEJune 15, 2018.See Editor’s Perspective by Borden and NallamothuReadmission risk has emerged as a means to infer quality over the past decade.1 Preventable hospital readmissions represent the emergence of medical conditions sufficiently severe in the recovery period that acute care is necessary. Although some short-term health declines resulting in the need for readmission are inevitable, there is evidence that 30-day readmission risk can be reduced through higher quality care.2,3In recent years, the Centers for Medicare and Medicaid Services created incentives to reduce preventable readmissions for certain key health conditions. The public reporting of readmission rates for 3 common conditions (acute myocardial infarction [AMI], heart failure, and pneumonia) across US hospitals began in 2009,4 and, under the Hospital Readmissions Reduction Program (HRRP) enacted by the US Congress under the Patient Protection and Affordable Care Act, began in 2010 to create a financial incentive to improve care and reduce the risk of readmission by penalizing hospitals for readmission rates above the national average for these conditions.4 According to published literature, there has been a meaningful and significant reduction in readmissions after the introduction of the program.5–7 The program subsequently expanded to include hospitalizations because of chronic obstructive pulmonary disease and for planned knee and hip replacement procedures.Some experts, however, have maintained that the policy has had unintended adverse consequences.8,9In December 2017, the US Congress, under the 21st Century Cures Act, mandated that MedPAC provide an independent assessment of the impact of the HRRP on the care and outcomes for conditions targeted in the program.10 MedPAC is a nonpartisan, independent, federal agency established in 1997 to advise the US Congress on the administration of the Medicare program. It conducts periodic assessments of access and quality of care received by Medicare beneficiaries, as well as the costs associated with administering the program. The intent of the mandate under the 21st Century Cures Act was to determine if the reduction in readmissions observed under the HRRP was offset by a higher utilization of observation-only visits and emergency department (ED) healthcare encounters. The report also evaluated whether there was an unintended increase in mortality as a result of the program.10MethodologyMedPAC conducted an independent assessment of trends in readmissions, ED visits, observation stays and mortality among Medicare beneficiaries at least 65 years of age who were covered by both part A and part B for 12 months before their index hospitalization. This sample represents the entire population that is examined for excess readmissions under the HRRP. Notably, mortality included any deaths occurring either during the hospitalization or within 30 days of hospital discharge to account for shifting of patterns of mortality across care settings. The report did not restrict the assessment of mortality to the postdischarge setting11 but instead evaluated for changes across the entire episode of care. They evaluated these trends for 3 conditions targeted under the HRRP from its outset—AMI, heart failure, and pneumonia—and contrasted them to others not included in the program.Major Findings/RecommendationsThe report,10 based on the MedPAC analysis, made the following observations.Substantial reduction in readmissions for target conditions: While there were no changes in readmission rates between 2008 and 2010, a period before the HRRP was announced, in the 6-year period following its announcement (2010–2016), unadjusted rates of unplanned 30-day readmission decreased from 19.0% to 15.4% for AMI, 23.6% to 20.6% for heart failure, and from 18.7% to 16.4% for pneumonia. This change was accompanied by a smaller, but statistically significant, decrease in readmissions for conditions not covered in the HRRP (16.3% to 14.9% over the same period). For HRRP conditions, there was also a decline in potentially preventable readmissions, representing hospitalizations related to the primary hospitalizations. Bottom line: The HRRP was associated with a decrease in readmission that was more pronounced and significant for the conditions targeted.Number of total hospitalizations decreased less for target conditions than for the overall Medicare population: Between 2010 and 2016, per capita Medicare admissions decreased by 17% overall. This reduction was in the context of changes to the Medicare Recovery Audit Contractor program in 2010, which challenged hospital claims for short hospital stays, typically 1-day hospitalizations, and frequently deemed them medically unnecessary and withheld reimbursement. The report contended that despite pressures from the Medicare Recovery Audit Contractor program to reduce hospitalizations across conditions, the conditions targeted under the HRRP actually had a smaller decrease in number of hospitalizations, with a per capita decrease of 9% for AMI, 14% for heart failure, and 11% for pneumonia, compared with 19% for non-HRRP conditions. Bottom line: The HRRP was not associated with evidence of a reduction in hospital access for patients with the targeted conditions.Increased observation stays and ED use less for target conditions than for the overall Medicare population: The increased use in observation and ED services coincides with the changes in the Medicare Recovery Audit Contractor program, whereby lower acuity patients were more frequently managed in these alternative care systems. MedPAC, however, found that the overall rate of use of observation stays and ED visits after an index hospitalization was small and their rate of increase in the 30-day postdischarge period was lower in the targeted conditions than the increase observed in the Medicare population overall. Moreover, while HRRP conditions had a larger decrease in readmission rates than non-HRRP conditions, between 2010 and 2016 the rate of postdischarge observation stays and ED use was the same for both groups. The report noted that while postdischarge readmission and observation stays decreased consistently across the 3 conditions relative to the non-HRRP conditions, there was heterogeneity in ED use between heart failure and AMI. After accounting for ED use, postdischarge healthcare utilization to be lower than non-HRRP conditions for heart failure but was equivalent for AMI. However, the report also highlighted that there has been a measurable increase in ED utilization during this period unrelated to the primary hospitalization. Bottom line: The readmission reductions associated with HRRP are not a result of the use of observation stays or shifting utilization to the ED, and the HRRP was not associated with a greater rise in observation stays and ED use.Medicare program costs declined in association with HRRP: The Medicare program spent $2.28 billion less on readmissions in 2016 compared with 2010 because of the lower number of readmissions in 2016. The increases in postdischarge observation stays and ED visits were associated with net higher spending of $170 million and $70 million, respectively, which was still associated with a net saving of $2.04 billion in 2016. Notably, the financial effects of readmission penalties are expected to be much smaller, with the Medicare program projected to withhold $556 million in the form of penalties based on excess readmissions in 2018, based on patterns of readmissions in July 2013 to June 2016, the 3-year period forming the basis of these penalties in 2018. Bottom line: The HRRP was associated with substantial cost savings to Medicare as a result of the reduction in readmissions.No increase in mortality in association with HRRP: To investigate any impact on mortality, the report focused on mortality associated with hospitalization defined as death either during the hospitalization or in the 30-day period following discharge. It found that raw rates of mortality following hospitalization for AMI decreased throughout the period from 15.4% in 2008 to 12.1% in 2016. For heart failure, mortality after discharge increased from 11.1% in 2008 to 11.4% in 2010 to 12.4% in 2013 and decreased thereafter to 11.9% in 2016. For pneumonia, in hospital or postdischarge mortality decreased from 18.9% in 2008 to 16.9% in 2016. However, after accounting for the increased patient severity over time, risk-adjusted mortality declined for all 3 conditions, from 15.8% to 11.9% for AMI, 13.6% to 9.4% for heart failure, and 21.7% to 13.8% for pneumonia (Figure). In an assessment of whether the increased risk profile of patients was a function of the intensity of coding, the report found those hospitalized in later years had greater intensive care unit use, were less likely to be discharged home for self-care, and were high-risk even based on the diagnoses in the preceding years. Moreover, between 2010 and 2016, as discussed above, short stay index hospitalizations that were low risk decreased, and fewer hospitalizations in 2016, compared with 2010, were 1-day inpatient hospitalizations. Finally, the report also found that hospitals that reduced readmissions for any of the HRRP conditions, on average, also had lower mortality for that condition. These observations were also confirmed in a recent study specifically evaluating for changes in mortality around the period of the announcement and implementation of the program.12 Bottom line: The HRRP was not associated with an increase in mortality for any of the 3 targeted conditions, once case-mix was considered.Download figureDownload PowerPointFigure. Calendar-year trends in observed (A) and risk-adjusted (B) mortality for conditions included in the Hospital Readmissions Reduction Program (HRRP). Mortality during hospitalization through 30-day postdischarge for 3 conditions—acute myocardial infarction (AMI), heart failure, and pneumonia—included in the program, compared with those not included in the program. Based on the data presented in the MedPAC report.10 PPACA indicates Patient Protection and Affordable Care Act.DiscussionThe MedPAC report on HRRP addressed several critical aspects relevant to its implementation. The report categorically identifies HRRP as a program that successfully reduced the burden of readmissions on patients and the health system, with continued improvement in readmission rates despite increasing patient complexity over time. The report specifically addressed concerns about benefits and harms associated with the HRRP and the focus on readmission. The MedPAC concluded that the HRRP contributed to a significant decline in readmission rates without causing a material increase in either ED visits or observation stays, or a net adverse effect on mortality rates. Their report also concluded that while the HRRP was largely successful, there continue to be opportunities to improve hospitals’ financial incentives under the program.This independent group’s findings can be interpreted as a resounding endorsement of what was accomplished.Application to Cardiovascular Disease CareQuality ImprovementThe MedPAC report is particularly salient for the cardiovascular community as both AMI and heart failure, 2 cardiovascular conditions affecting millions of Americans, have been critical components of the HRRP since its inception. The HRRP has been associated with improved outcomes of patients and spurred the transformation of transitional care services that emphasize safe hospital discharge and high quality postdischarge outpatient care.13,14 Through a focus on benchmarking performance to other hospitals, rather than predefined thresholds, the HRRP also incentivizes continued innovation of strategies to prevent readmissions. The MedPAC report also serves as a further acknowledgement of efforts of hospitals to improve care quality as opposed to strategies to circumvent the principles of the program. The MedPAC has used the evaluation of HRRP as a platform to lay out future strategies to blunt the potential long-term negative impact of financial penalties through suggestions on lowering the magnitude of penalties associated with excess readmission. Finally, the multifaceted MedPAC report serves as a model for postimplementation surveillance of other health policies to ensure that they are successful in achieving their intended outcomes.ResearchSeveral observations from the report are primed for further investigation by the cardiovascular research community. First, while the HRRP has been associated with improved outcomes, there is a critical need to identify the causes for continued high rates of readmissions for these important cardiovascular conditions.12 This may require implementing mixed-methods research strategies that engage the patient and all medical stakeholders to understand why the successful transition to outpatient care still fails in 1 of every 8 patients with AMI and heart failure. This may help identify care practices that somehow contribute to the debility of patients and lead to posthospitalization syndrome in this period of vulnerability following discharge.15 Next, there is a need to develop methods that incorporate the greater granularity of information about clinical encounters available in the electronic health record to better characterize individual risk of readmissions. Moreover, we would need to evaluate if including diverse sources of information available in the electronic medical record is better able account for patient risk in profiling hospital performance. Finally, it is essential that continuous surveillance of the program and its outcomes guides iterative improvements in the policy and its implementation.Sources of FundingDr Khera is supported by the National Center for Advancing Translational Sciences (UL1TR001105) of the National Institutes of Health.DisclosuresDr Krumholz is a recipient of research agreements from Medtronic and Johnson & Johnson (Janssen), through Yale, to develop methods of clinical trial data sharing; was the recipient of a grant from Medtronic and the Food and Drug Administration, through Yale, to develop methods for postmarket surveillance of medical devices; works under contract with the Centers for Medicare & Medicaid Services to develop and maintain performance measures that are publicly reported; chairs a cardiac scientific advisory board for UnitedHealth; is a participant/participant representative of the IBM Watson Health Life Sciences Board; is a member of the Advisory Board for Element Science and the Physician Advisory Board for Aetna; and is the founder of Hugo, a personal health information platform. Dr Khera reports no conflicts.FootnotesHarlan M. Krumholz, MD, SM, Department of Internal Medicine, Yale School of Medicine, 1 Church St, Suite 200, New Haven, CT 06510. Email harlan.[email protected]eduReferences1. Centers for Medicare and Medicaid Services. Hospital Readmissions Reduction Program (HRRP).https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HRRP/Hospital-Readmission-Reduction-Program.html. Accessed October 11, 2018.Google Scholar2. Bradley EH, Curry L, Horwitz LI, Sipsma H, Wang Y, Walsh MN, Goldmann D, White N, Piña IL, Krumholz HM. Hospital strategies associated with 30-day readmission rates for patients with heart failure.Circ Cardiovasc Qual Outcomes. 2013; 6:444–450. doi: 10.1161/CIRCOUTCOMES.111.000101LinkGoogle Scholar3. Krumholz HM, Wang K, Lin Z, Dharmarajan K, Horwitz LI, Ross JS, Drye EE, Bernheim SM, Normand ST. Hospital-readmission risk - isolating hospital effects from patient effects.N Engl J Med. 2017; 377:1055–1064. doi: 10.1056/NEJMsa1702321CrossrefMedlineGoogle Scholar4. Khera R, Horwitz LI, Lin Z, Krumholz HM. Publicly reported readmission measures and the hospital readmissions reduction program: a false equivalence?Ann Intern Med. 2018; 168:670–671. doi: 10.7326/M18-0536CrossrefMedlineGoogle Scholar5. Zuckerman RB, Sheingold SH, Orav EJ, Ruhter J, Epstein AM. Readmissions, observation, and the hospital readmissions reduction program.N Engl J Med. 2016; 374:1543–1551. doi: 10.1056/NEJMsa1513024CrossrefMedlineGoogle Scholar6. Wasfy JH, Zigler CM, Choirat C, Wang Y, Dominici F, Yeh RW. Readmission rates after passage of the hospital readmissions reduction program: a pre-post analysis.Ann Intern Med. 2017; 166:324–331. doi: 10.7326/M16-0185CrossrefMedlineGoogle Scholar7. Angraal S, Khera R, Zhou S, Wang Y, Lin Z, Dharmarajan K, Desai NR, Bernheim SM, Drye EE, Nasir K, Horwitz LI, Krumholz HM. Trends in 30-day readmission rates for Medicare and non-Medicare patients in the era of the Affordable Care Act.Am J Med. 2018; 131:1324–1331.e14. doi: 10.1016/j.amjmed.2018.06.013CrossrefMedlineGoogle Scholar8. Gupta A, Fonarow GC. The hospital readmissions reduction program-learning from failure of a healthcare policy.Eur J Heart Fail. 2018; 20:1169–1174. doi: 10.1002/ejhf.1212CrossrefMedlineGoogle Scholar9. Chatterjee P, Joynt Maddox KE. US national trends in mortality from acute myocardial infarction and heart failure: policy success or failure?JAMA Cardiol. 2018; 3:336–340. doi: 10.1001/jamacardio.2018.0218CrossrefMedlineGoogle Scholar10. Medicare Payment Advisory Commission. Mandated Report: The Effects of the Hospital Readmissions Reduction Program.http://www.medpac.gov/docs/default-source/reports/jun18_ch1_medpacreport_sec.pdf?sfvrsn=0. Accessed October 11, 2018.Google Scholar11. Dharmarajan K, Wang Y, Lin Z, Normand ST, Ross JS, Horwitz LI, Desai NR, Suter LG, Drye EE, Bernheim SM, Krumholz HM. Association of changing hospital readmission rates with mortality rates after hospital discharge.JAMA. 2017; 318:270–278. doi: 10.1001/jama.2017.8444CrossrefMedlineGoogle Scholar12. Khera R, Dharmarajan K, Wang Y, Lin Z, Bernheim SM, Wang Y, Normand ST, Krumholz HM. Association of the hospital readmissions reduction program with mortality during and after hospitalization for acute myocardial infarction, heart failure, and pneumonia.JAMA Network Open. 2018; 1:e182777. doi: 10.1001/jamanetworkopen.2018.2777CrossrefMedlineGoogle Scholar13. Feltner C, Jones CD, Cené CW, Zheng ZJ, Sueta CA, Coker-Schwimmer EJ, Arvanitis M, Lohr KN, Middleton JC, Jonas DE. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis.Ann Intern Med. 2014; 160:774–784. doi: 10.7326/M14-0083CrossrefMedlineGoogle Scholar14. Bradley EH, Sipsma H, Horwitz LI, Curry L, Krumholz HM. Contemporary data about hospital strategies to reduce unplanned readmissions: what has changed?JAMA Intern Med. 2014; 174:154–156. doi: 10.1001/jamainternmed.2013.11574CrossrefMedlineGoogle Scholar15. Krumholz HM. Post-hospital syndrome–an acquired, transient condition of generalized risk.N Engl J Med. 2013; 368:100–102. doi: 10.1056/NEJMp1212324CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Kim Y, Feldman Z, Majumdar M, DeCarlo C, Pendleton A, Zacharias N, Mohapatra A and Dua A (2022) Factors Influencing Hospital Readmission after Lower Extremity Bypass for Chronic Limb-Threatening Ischemia, Vascular and Endovascular Surgery, 10.1177/15385744221144389, (153857442211443) Enumah S, Sundt T and Chang D (2022) Association of Measured Quality and Future Financial Performance Among Hospitals Performing Cardiac Surgery, Journal of Healthcare Management, 10.1097/JHM-D-21-00262, 67:5, (367-379), Online publication date: 1-Sep-2022. Boulos P, Messenger J and Waldo S (2022) Readmission After ACS: Burden, Epidemiology, and Mitigation, Current Cardiology Reports, 10.1007/s11886-022-01702-8, 24:7, (807-815), Online publication date: 1-Jul-2022. Dai T, Gleason K, Hwang C and Davidson P (2019) Heart analytics: Analytical modeling of cardiovascular care, Naval Research Logistics (NRL), 10.1002/nav.21880, 68:1, (30-43), Online publication date: 1-Feb-2021. Teo K, Wee Lai K, Wai Yong C, Pingguan-Murphy B, Huang Chuah J and Tee C (2020) Prediction of Hospital Readmission Combining Rule-based and Machine Learning Model 2020 International Computer Symposium (ICS), 10.1109/ICS51289.2020.00076, 978-1-7281-9255-0, (352-355) Khera R, Valero-Elizondo J and Nasir K (2020) Financial Toxicity in Atherosclerotic Cardiovascular Disease in the United States: Current State and Future Directions, Journal of the American Heart Association, 9:19, Online publication date: 6-Oct-2020. Khera R, Kondamudi N, Zhong L, Vaduganathan M, Parker J, Das S, Grodin J, Halm E, Berry J and Pandey A (2020) Temporal Trends in Heart Failure Incidence Among Medicare Beneficiaries Across Risk Factor Strata, 2011 to 2016, JAMA Network Open, 10.1001/jamanetworkopen.2020.22190, 3:10, (e2022190) Pandey A, Keshvani N, Vaughan-Sarrazin M, Gao Y and Girotra S (2020) Evaluation of Risk-Adjusted Home Time After Acute Myocardial Infarction as a Novel Hospital-Level Performance Metric for Medicare Beneficiaries, Circulation, 142:1, (29-39), Online publication date: 7-Jul-2020.Khera R (2020) Do or Do Not, There Is No Try, Circulation: Cardiovascular Quality and Outcomes, 13:5, Online publication date: 1-May-2020. Khera R, Wang Y, Bernheim S, Lin Z and Krumholz H (2020) Post-discharge acute care and outcomes following readmission reduction initiatives: national retrospective cohort study of Medicare beneficiaries in the United States, BMJ, 10.1136/bmj.l6831, (l6831) Weintraub W (2019) Reduce Acute Care Costs, and All Other Healthcare Costs Too, Journal of the American Heart Association, 8:8, Online publication date: 16-Apr-2019.Borden W and Nallamothu B (2018) Making Health Policy More Accessible, Circulation: Cardiovascular Quality and Outcomes, 11:12, Online publication date: 1-Dec-2018. Dai T, Gleason K, Hwang C and Davidson P Heart Analytics: Analytical Modeling of Cardiovascular Care, SSRN Electronic Journal, 10.2139/ssrn.3380716 Related articlesMaking Health Policy More AccessibleWilliam B. Borden, et al. Circulation: Cardiovascular Quality and Outcomes. 2018;11 December 2018Vol 11, Issue 12 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCOUTCOMES.118.005083PMID: 30562071 Originally publishedDecember 17, 2018 Keywordshospitalizationheart failurepneumoniamyocardial infarctionMedicarePDF download Advertisement SubjectsEthics and Policy" @default.
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