Readmissions Reductions and Unintended Consequences

A number of methodological and other criticisms have been lobbed at the Medicare hospital readmissions reduction program.  New research suggests it may also be causing greater mortality among its supposed beneficiaries.   (JAMA Article)   The program began in 2012 and was designed to penalize hospitals with higher than expected readmission rates for heart failure, pneumonia and heart attack patients.  Hospitals have incurred about $2 billion in lost revenue since the start of the program, which probably doesn’t help them have resources to improve care.  The researchers looked at readmission and mortality trends before and after the start of the reduction program.  As usual, there were numerous demographic and health status adjustments to the analysis to ensure accurate identification of potential associations.  The primary end-point was mortality within 30 days after hospital discharge, but a secondary analysis at 45 days after admission was also performed.  About 8 million hospitalizations were included in the analysis.  Surprisingly to me, among these hospitalizations, there were 270,000 deaths within 30 days after heart failure admission discharges, 128,000 after heart attack admissions and 246,000 after pneumonia ones.  Mortality increased following heart failure admissions after initiation of the readmissions reduction program.  This increase appeared to be associated solely with deaths following a hospitalization for which there was no readmission.  For heart attack patients, there was no apparent change in mortality.  Although rates of mortality declined, they did so at a rate consistent with the trend prior to implementation of the program.  In regard to pneumonia, there was again an increase in mortality which appears associated with patients who did not have a readmission.  So it appears that while hospitals may have reduced readmissions, one result may be that more patients died, presumably patients who might have benefited from a readmission.  It could also be that since in-hospital deaths were declining over this period, the analysis partly reflects a shift from in-hospital to out-of-hospital deaths.  There could be other explanations as well, but given the prominence of the readmissions reduction program and penalties associated with it, it seems likely that it played some role in the mortality increases.