Program to reduce readmission, mortality after MI fails to affect racial disparities
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After the Hospital Readmission Reduction Program was implemented, declines were seen in 30-day readmission rates for both black and nonblack patients with MI, according to an observational cohort analysis published in JAMA Cardiology.
Differences between rates for 30-day readmission rates persisted, although they may have been related to patient-level factors, according to the analysis.
“These findings potentially allay concerns that penalizing low-performing hospitals with reduced CMS payments under the Hospital Readmission Reduction Program has led to worsening racial disparities in clinical outcomes for acute MI,” Ambarish Pandey, MD, MSCS, cardiology fellow at University of Texas Southwestern Medical Center in Dallas, told Healio.
Chest Pain-MI Registry data
Researchers analyzed data from 155,397 patients (7.3% black) with acute MI from the Chest Pain-MI Registry who were treated at 753 hospitals. Patients were aged 65 years or older and had coverage through fee-for-service Medicare. Centers included in this study participated in the first cycle of the Hospital Readmission Reduction Program between 2008 and November 2016.
Performance status for hospitals was determined on the Hospital Readmission Reduction Program penalty status during the first cycle. Low-performing hospitals were defined as centers with an excess readmission ratio for MI greater than 1.
The primary outcomes were 30-day all-cause mortality and 30-day all-cause readmission from the day of hospital discharge.
Of the hospitals included in the study, 354 were low performing and 399 were high performing. Compared with nonblack patients, black patients treated at both high-performing and low-performing hospitals were more often women and had a younger mean age.
In 2009, declines were seen in nonblack and black patients for readmission rates at 30 days (17.94% vs. 20.84%, respectively).
Compared with nonblack patients, black patients had an increased risk for readmission at 30 days before the program was implemented at both low-performing (OR = 1.14; 95% CI, 1.03-1.26) and high-performing hospitals (OR = 1.17; 95% CI, 1.04-1.32). This continued after the program was implemented in low-performing (OR = 1.23; 95% CI, 1.13-1.34) and high-performing hospitals (OR = 1.25; 95% CI, 1.12-1.39). The link between race and 30-day readmissions was not significant once adjusted for patient-level variables.
Significant declines were seen over time for 30-day mortality rates for nonblack patients. There were stable temporal trends for black patients, although they were nonsignificant. After adjusting for patient-level characteristics, black patients had a lower rate of 30-day mortality in low-performing before (OR = 0.79; 95% CI, 0.63-0.97) and after the program was implemented (OR = 0.8; 95% CI, 0.68-0.95). This was not seen in high-performing hospitals.
The association between race and outcomes at 30 days did not differ after the program began in high-performing and low-performing hospitals.
Additional research
“Future studies are needed to determine if a more patient-focused approach aimed at optimizing guideline-directed medical therapies along with targeting readmission diversion programs to patients with a higher disease severity burden may lower racial differences in 30-day readmission rates, which are largely driven by differences in clinical factors,” Pandey said in an interview. “Studies are also needed to better understand how we can reduce the 30-day mortality rates among black patients, which has not changed much in the past years.”
In a related editorial, Martha J. Radford, MD, professor in the department of medicine and of population health at New York University School of Medicine, wrote: “Future inquiries into the genotypic and phenotypic variability in disease progression and treatment options are needed. In addition, we need to broaden the national quality measurement portfolio to better assess high-quality care so that the U.S. health care system may reward hospitals that exemplify the best care U.S. medicine has to offer rather than penalize hospitals for using resources that are likely to contribute to that care.” – by Darlene Dobkowski
For more information:
Ambarish Pandey, MD, MSCS, can be reached at Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390; email: ambarish.pandey@utsouthwestern.edu.
Disclosures: Pandey and Radford report no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
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