Research on Readmissions, Death Rates, Minorities

A 2018 JAMA summary of research says, "there is now independently corroborated evidence that the HRRP [hospital readmissions reduction program] was associated with increased postdischarge mortality among patients with heart failure and new evidence that the HRRP was associated with increased mortality among patients hospitalized for pneumonia. In light of these findings, it is incumbent upon Congress and CMS to initiate an expeditious reconsideration and revision of this policy."

Correlation between Low Readmissions and High Death Rates

Heidenreich et al. pubmed.gov/20650356
(2010) Journal of the American College of Cardiology, 56(5), 362-368. 

• In a study of 50,000 patients at Veterans Affairs hospitals over 5 years, "Heart failure admission rates remained constant at about 5 per 1,000 veterans. Mortality at 30 days decreased (7.1% to 5.0%, p < 0.0001), whereas rehospitalization for heart failure at 30 days increased (5.6% to 6.1%, p = 0.11)" italics added

Gorodeski, et al. pubmed.gov/20647209
(2010) New England Journal of Medicine, 363(3), 297-298.

• "A higher occurrence of readmissions after index admissions for heart failure was associated with lower risk-adjusted 30-day mortality."

American Hospital Association aha.org/research/reports/tw/11sep-tw-readmissions.pdf
(2011) Trendwatch September 2011

• "analysis using Hospital Compare data conducted by the Greater New York Hospital Association also concluded that mortality is inversely related to readmissions. (Chart 3)"

• Chart shows that states with lowest mortality, MA, CT, DC, DE, MN, NJ, IL, OH, MI, PA, all have above average readmissions, and all but two of these states are in the 70th percentile of readmissions or higher.

Krumholz et al. pubmed.gov/23403683
(2013) Journal of the American Medical Association. 2013 Feb.13; 309(6): 587–593.

• They find 17% correlation between lower readmissions and higher deaths among heart failure patients. These are the same Yale authors who develop Medicare's official readmission data:
• "The analyses included ... 4767 hospitals for HF [heart failure] ... The correlations ... [of mortality and readmission rates] were ...−0.17" for heart failure.

Gilman et al. pubmed.gov/25092831
(2014) Health Affairs, 33, no.8 (2014):1314-1322

• "safety-net hospitals were more likely than other hospitals to be penalized under the... Hospital Readmissions Reduction Program... 
• "[M]ortality outcomes in safety-net hospitals were better than those in other hospitals for patients with acute myocardial infarction, heart failure, or pneumonia. 
• "Third, the adjusted cost per Medicare discharge was virtually identical at safety-net and non-safety-net hospitals. 
• "Taken together, these results indicate that safety-net hospitals provided better health outcomes than other hospitals at a similar cost level yet were more likely to be penalized under programs that are intended to improve and reward high performance."

Higher Deaths after the Readmission Penalties Started

A 2015 CDC study found higher death rates from heart failure after the readmission penalties started. Their data cover both hospitalized and non-hospitalized patients, so they include the effect of less hospital treatment for heart failure, driven by penalties.

A 2018 JAMA study found higher death rates after the readmission penalties started, primarily in heart failure patients, and to some extent in pneumonia patients treated in hospitals. The paper's findings are strong, but the summary hides those findings: The paper says, "45-Day Postadmission Mortality... HRRP announcement was significantly associated with an increase in mortality" but the summary says, "Given the study design and the lack of significant association of
the HRRP with mortality within 45 days of admission, further research is needed." Then they refuse to say what kind of research would be more conclusive than the research so far. I asked, "Would you support removing penalties for a large random sample of hospitals for 20 years? Something else?" and they were silent.

Deaths Caused by a Program to Avoid Readmissions:

Fan et al. pubmed.gov/22586006
(2012) Annals of Internal Medicine 2012 May 15; 156(10):673-83

• 20 Veterans Affairs hospitals measured a "comprehensive care management program" for emphysema and chronic bronchitis (COPD). "Improving a patient's ability to self-monitor and manage changes"
• "data monitoring committee terminated the intervention before the trial's planned completion... There were 28 deaths from all causes in the intervention group versus 10 in the usual care group"

Minorities

Joynt et al. pubmed.gov/21325183
(2011) Journal of the American Medical Association. 2011 Feb 16;305(7):675-81

• "black patients were more likely to be readmitted after hospitalization"

Rodriguez et al. pubmed.gov/21835285
(2011) American Heart Journal. 2011 Aug;162(2):254-261.e3

• "Elderly Hispanic patients are more likely to be readmitted for HF and AMI [heart failure and heart attack] than whites"

Joynt et al. pubmed.gov/23340629
(2013) Journal of the American Medical Association. 2013 Jan 23;309(4):342-3

• "We found that large hospitals, teaching hospitals, and SNHs [safety net hospitals] are more likely to receive payment cuts under the HRRP [readmissions penalties]. It is unclear exactly why these hospitals have higher readmission rates than their smaller, nonteaching, non-SNH counterparts, but prior research suggests that differences between hospitals are likely related to both case mix (medical complexity) and socioeconomic mix of the patient population.2-3 There is less evidence that differences in readmissions are related to measured hospital quality.6"

Interviews

Dr Ashish Jha, of Harvard's School of Public Health, told PBS, "If you look at, for instance, the U.S. News [and World Report] publishes its list of top 50 hospitals. Those hospitals tend to have very low infection rates, very low mortality rates, very low death rates. Guess what? They tend to have very high readmission rates, because they do such a good job of keeping their patients alive that many of them are readmitted."

Dr. Sunil Kripalani, of Vanderbilt University Medical Center told Fox News, "Among patients with heart failure, hospitals that have higher readmission rates actually have lower mortality rates. So, which would we rather have -- a hospital readmission or a death?"