番茄社区

ANAHEIM -- Among fee-for-service Medicare patients discharged after heart failure hospitalizations, implementation of a national readmissions reduction program was temporally tied to a reduction in 30-day and 1-year readmissions, researchers reported here, but was also linked to an increase in 30-day and 1-year mortality.

The 30-day risk-adjusted readmission rate declined from 20.0% before the Hospital Readmissions Reduction Program (HRRP) to 18.4% during the program penalties phase (HR 0.91, 95% CI 0.87-0.95, P<0.001). Similarly, the 1-year risk-adjusted readmission rate declined from 57.2% pre-HRRP to 56.3% (HR 0.92, 95%CI 0.89-0.96, P<0.001) during the penalties phase of the study, according to Ankur Gupta, MD, PhD, of Brigham and Women's Hospital Heart & Vascular Center in Boston, and colleagues.

However, the reductions achieved in reducing readmissions to the hospital were offset by increases in mortality. The 30-day risk-adjusted mortality rate increased from 7.2% before program implementation to 8.6% during the penalties phase (HR 1.18, 95%CI, 1.10-1.27, P<0.001). The 1-year risk-adjusted mortality rate increased from 31.3% to 36.3% (HR 1.10, 95%CI 1.06-1.14, P<0.001), they reported at the American Heart Association (AHA) meeting and simultaneously in JAMA Cardiology.

"The results persisted despite extensive risk adjustment with prospectively captured clinical data and consideration of hospice use," the authors noted. "These findings raise concerns that the Hospital Readmissions Reduction Program, while achieving desired reductions in readmissions, may have incentivized hospitals in a way that has compromised the survival of patients with heart failure."

The Affordable Care Act established HRRP, which involved public reporting of hospitals' 30-day risk-standardized readmission rates and created financial penalties for hospitals with higher readmissions.

Gupta's group identified fee-for-service Medicare beneficiaries, ages ≥65, who were discharged from the hospital with heart failure from Jan. 1, 2006, to Dec. 31, 2014, at one of 416 hospital sites participating in AHA Get with the Guidelines protocols. The final study cohort consisted of 115,245 index hospitalizations. The mean study population age was 80.5, more than half (54.6%) were women, and the majority (81.3%) were white.

Patients with index hospitalization length of stay >30 days or who died in the hospital were excluded, as were those who underwent placement of a left ventricular assist device or heart or heart-lung transplant within 30 days of index hospitalization.

The study period was divided into three phases: Pre-implementation (Jan. 1, 2006 to March 31, 2010), during implementation (April 1, 2010 to Sept. 30, 2012), and during the penalty phase (Oct. 1, 2012 to Dec. 31, 2014).

"In a secondary analysis, after excluding patients who were discharged to hospice, we found similar but attenuated temporal trends of decrease in readmissions and increase in mortality following the program implementation," the authors stated. "The attenuation was most prominent in the increased 30-day risk-adjusted mortality.

"We also observed a trend toward increasing use of home and in-patient hospice in the program penalties phase, compared with the pre-program implementation phase. Whether this trend reflects honoring of patients'wishes among those with otherwise poor quality of life or reflects an incentive for coercion toward hospice discharge to reduce any readmissions penalty is not known," they noted.

"Regardless, the 1-year risk-adjusted mortality was significantly increased even after excluding patients discharged to hospice. Thus, the policy directed at reducing readmissions was still associated with increased long-term mortality risk, even after accounting for hospice use," the authors added.

Mary Norine Walsh, MD, president of the American College of Cardiology, told 番茄社区 that "Ever since the [Centers for Medicare and Medicaid Services or CMS] mandate came out, hospitals have really turned their attention to this measure, and have put into place systems of care so they can reduce readmissions; many hospitals in the United States have made great strides to reducing readmissions."

But Walsh, who is with St. Vincent Heart Center in Indianapolis, noted that "the concern has been -- and the authors of this study have really proved it with the Get with the Guidelines data -- that along with a reduction in readmission comes an increase in mortality...The most important part of this paper is that they call for CMS to reconsider the readmission penalties."

Walsh, who was not involved in the study, said that the reasons may be that patients are admitted for "observation" rather than a full admission. Or patients may be treated in the emergency department, rather than being admitted "and there is even some concern that physicians, and other clinicians, sort of wait out the 30-day period and only admit patients after 30 days."

For example, if a patient was near the end of the 30-day period and had symptoms, she suggested a doctor might call the patient into the office for a follow-up. "But the focus on readmission has been so strong that the doctor may be calculating the time since discharge, be very cognizant of readmission, and say to the patient 'Let's do everything we can with medication,' where clinically the plan might have been to have the patient come back into the hospital where we can treat with intravenous therapy and other measures."

Study limitations included the lack of generalizability to hospitals that are not in the Get with the Guidelines registry. Also, because it is an observational analysis, the study "cannot establish cause and effect among the HRRP implementation, readmissions reduction, and increased mortality risk."

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