Reducing US hospital readmission not increasing death rates

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Reducing US hospital readmission rates for three key medical conditions occurred without causing an increase in death rates, according to a Yale University-led study.

US hospitals have made significant reductions in rates of readmission 30 days after a patient’s discharge in response to rules established by the Affordable Care Act. The health reform law imposed financial penalties for hospitals with high readmission rates for common medical conditions, including heart attack, heart failure, and pneumonia. However, questions rose about whether efforts to keep patients out of the hospital would negatively impact mortality rates.

To examine the issue, the Yale research team, who developed the readmission measures, studied data on Medicare recipients hospitalised for heart attack, heart failure, or pneumonia between 2008 and 2014. They analysed trends for readmissions and mortality at individual hospitals over time to determine whether there was a link between the two factors. The team reviewed the data for different time periods within the study period, and at hospitals where readmission rates were high, average, or low.

The researchers found a small but positive correlation between reduced readmissions and reduced mortality rates for the three conditions. “We can say that readmission reductions did not result in increased mortality. If anything, they may have decreased mortality,” said first author Dr Kumar Dharmarajan, assistant professor of medicine.

The correlation between reduced rates for readmissions and mortality may be due to steps that hospitals have taken to improve hospital and post-hospital care, he said. Those strategies include: better preparing patients and families for discharge; more timely follow-up; and improved communication with outpatient providers.

Dharmarajan and his colleagues also found that the link between reduced readmissions and reduced mortality was even stronger at 90 days compared to 30 days after hospital discharge, he said.

The findings may inform health policy. “Based on this evidence, there is no reason to revise policies to address unintended consequences of reducing hospital readmissions,” he said.

“Our study validates that the national focus on readmissions improved outcomes without causing unintended harm,” said senior author Dr Harlan Krumholz. “Thousands and thousands of readmissions are being avoided every year without any evidence of people being harmed – that is a victory of improving the quality of care,” he said.

Abstract
Importance: The Affordable Care Act has led to US national reductions in hospital 30-day readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. Whether readmission reductions have had the unintended consequence of increasing mortality after hospitalization is unknown.
Objective: To examine the correlation of paired trends in hospital 30-day readmission rates and hospital 30-day mortality rates after discharge.
Design, Setting, and Participants: Retrospective study of Medicare fee-for-service beneficiaries aged 65 years or older hospitalized with HF, AMI, or pneumonia from January 1, 2008, through December 31, 2014.
Exposure: Thirty-day risk-adjusted readmission rate (RARR).
Main Outcomes and Measures: Thirty-day RARRs and 30-day risk-adjusted mortality rates (RAMRs) after discharge were calculated for each condition in each month at each hospital in 2008 through 2014. Monthly trends in each hospital’s 30-day RARRs and 30-day RAMRs after discharge were examined for each condition. The weighted Pearson correlation coefficient was calculated for hospitals’ paired monthly trends in 30-day RARRs and 30-day RAMRs after discharge for each condition.
Results: In 2008 through 2014, 2 962 554 hospitalizations for HF, 1 229 939 for AMI, and 2 544 530 for pneumonia were identified at 5016, 4772, and 5057 hospitals, respectively. In January 2008, mean hospital 30-day RARRs and 30-day RAMRs after discharge were 24.6% and 8.4% for HF, 19.3% and 7.6% for AMI, and 18.3% and 8.5% for pneumonia. Hospital 30-day RARRs declined in the aggregate across hospitals from 2008 through 2014; monthly changes in RARRs were −0.053% (95% CI, −0.055% to −0.051%) for HF, −0.044% (95% CI, −0.047% to −0.041%) for AMI, and −0.033% (95% CI, −0.035% to −0.031%) for pneumonia. In contrast, monthly aggregate changes across hospitals in hospital 30-day RAMRs after discharge varied by condition: HF, 0.008% (95% CI, 0.007% to 0.010%); AMI, −0.003% (95% CI, −0.005% to −0.001%); and pneumonia, 0.001% (95% CI, −0.001% to 0.003%). However, correlation coefficients in hospitals’ paired monthly changes in 30-day RARRs and 30-day RAMRs after discharge were weakly positive: HF, 0.066 (95% CI, 0.036 to 0.096); AMI, 0.067 (95% CI, 0.027 to 0.106); and pneumonia, 0.108 (95% CI, 0.079 to 0.137). Findings were similar in secondary analyses, including with alternate definitions of hospital mortality.
Conclusions and Relevance: Among Medicare fee-for-service beneficiaries hospitalized for heart failure, acute myocardial infarction, or pneumonia, reductions in hospital 30-day readmission rates were weakly but significantly correlated with reductions in hospital 30-day mortality rates after discharge. These findings do not support increasing postdischarge mortality related to reducing hospital readmissions.

Authors
Kumar Dharmarajan, Yongfei Wang, Zhenqiu Lin, Sharon-Lise T Normand, Joseph S Ross, Leora I Horwitz, Nihar R Desai, Lisa G Suter, Elizabeth E Drye, Susannah M Bernheim, Harlan M Krumholz

Yale University material
JAMA abstract
JAMA editorial


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