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Increase in post-discharge mortality in heart failure, pneumonia follows readmission reduction program

Implementation of the Hospital Readmissions Reduction Program was followed by an increase in 30-day post-discharge mortality for patients hospitalized for heart failure and pneumonia, according to data published in JAMA. Researchers reported that they could not determine that the program resulted in the increased mortality.

“The Hospital Readmissions Reduction Program has been associated with a reduction in readmission rates for heart failure, acute myocardial infarction and pneumonia,” Rishi K. Wadhera, MD, MPP, MPhil, clinical fellow in medicine at Brigham and Women’s Hospital, and colleagues wrote. “It is unclear whether the [Hospital Readmissions Reduction Program] has been associated with change in patient mortality.”

Wadhera and colleagues conducted a retrospective cohort study to investigate whether implementing the Hospital Readmissions Reduction Program affects patient-level mortality. The researchers studied 8.3 million hospitalizations for heart failure, acute MI and pneumonia among Medicare fee-for-service beneficiaries aged at least 65 years.

Baseline trends were established from April 2005 to September 2007 (period 1) and October 2007 to March 2010 (period 2). The Hospital Readmissions Reduction Program was announced between April 2010 and September 2012 (period 3) and implemented between October 2012 and March 2015 (period 4).

The researchers measured inverse probability-weighted mortality within 30 days of discharge following hospitalization for heart failure, acute MI and pneumonia, as well as mortality within 45 days of initial hospital admission.

There were 7.9 million hospitalizations in which patients were alive at discharge (mean age, 79.6 years; 53.4% women).

About 3.2 million hospitalizations were for heart failure, 1.8 million were for acute MI and 3 million were for pneumonia. A total of 270,517 deaths within 30 days of discharge occurred in patients with heart failure, 128,088 occurred in patients with acute MI and 246,154 occurred in patients with pneumonia.

Before the announcement of the readmissions program, there was an 0.27% increase in 30-day post-discharge mortality from period 1 to period 2 among patients with heart failure. An increase in post-discharge mortality was significantly associated with the readmissions program announcement (0.49% increase from period 2 to period 3; difference in change, 0.22%; P = .01) and implementation (0.52% increase from period 3 to period 4; difference in change, 0.25%; P = .001).

Conversely, there was an association between the announcement of the readmissions program and a decline in post-discharge mortality among patients with acute MI (0.18% pre-announcement increase vs. 0.08% post-announcement decrease; difference in change, –0.26%; P = .01)). Post-discharge mortality rate did not significantly change after implementation of the program among these patients.

During baseline, post-discharge mortality was stable among patients with pneumonia (0.04% increase from period 1 to period 2). However, post-discharge mortality significantly increased in these patients after the program announcement (0.26% post-announcement increase; difference in change, 0.22%) and implementation (0.44% post-implementation increase; difference in change, 0.4%).

According to the researchers, the increase in mortality among patients with heart failure and pneumonia was primarily due to outcomes in those who were not readmitted to the hospital but died within 30 days of discharge.

Overall, there was no significant association between implementing the readmissions program and an increase in mortality within 45 days of admission.

“Given the study design and the lack of significant association of the Hospital Readmissions Reduction Program implementation with mortality within 45 days of hospital admission, further research is needed to understand whether the increase in 30-day post-discharge mortality is a result of the Hospital Readmissions Reduction Program,” Wadhera and colleagues concluded. – by Alaina Tedesco

Disclosures: Wadhera reports receiving support from the National Institutes of Health Training and previously serving as a consultant for Regeneron. Please see study for all other authors’ relevant financial disclosures.