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Reducing Heart Failure Readmissions Has Risks
Study finds mortality rates may increase as readmission rates drop.
A
federal program designed
to reduce heart failure (HF)
readmission rates may
achieve that goal, but possibly at
the expense of increasing HF death
rates, according to a new study
published in JAMA Cardiology.
The study compares 30-day and
one-year readmission and mortal
ity rates in 115,245 fee-for-service
Medicare beneficiaries ages 65
years and older who were treated
for HF at 416 U.S. hospitals before
and after implementation of the
Hospital Readmissions Reduction
Program (HRRP). The HRRP was
established by the Affordable Care
Act to reduce readmission rates for
HF (the most common reason for
readmission among Medicare ben
eficiaries), acute myocardial infarc
tion, and pneumonia.
Between January 1, 2006,
and March 31, 2010-before
HRRP implementation-the 30
day all-cause risk-adjusted HF re
admission rate was 20%, dropping
to 18.4%, from October 1, 2012,
through December 31, 2014-the
period of time hospitals began to
be penalized for excessive HF read
missions. This reduction was sig
nificant. But 30-day risk-adjusted
mortality rates between these two
time periods increased significantly
as well, from 7.2% to 8.6%, re
spectively. A similar pattern was
noted at one year, with a drop in
the risk-adjusted readmission rate
and an increase in the risk-adjusted
mortality rate, both statistically sig
nificant.
The findings "raise concerns
that the HRRP, while achieving
desired reductions in readmissions,
may have incentivized hospitals in
a way that has compromised the
survival of patients with HF," the
authors conclude, noting possible
hospital strategies to "game" the
system, such as delaying readmis
sions past 30 days, monitoring
patients in observation units, or
treating them in EDs instead of
inpatient units.
For nurses and other health
care professionals, the study's
results serve as a reminder that
"like drugs and devices, public
health policies should be tested
in a rigorous fashion-most
preferably in randomized trials-
before their widespread adop
tion," the authors write. They
add that if confirmed by addi
tional studies, the findings "may
require reconsideration of [im
plementing] the HRRP in HF."-
Elizabeth Mechcatie, BSN, MA
Gupta A, et al. JAMA Cardiol 2017 Nov 12
[Epub ahead of print].
ajn@wolterskluwer.com
AJN  February 2018  Vol. 118, No. 2
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