Mortality rates for heart failure patients rise as readmissions decline

As hospitals are motivated by the CMS' penalty program to reduce readmissions among heart failure patients, quality of care could suffer, a new study suggests.

The report, published Sunday in JAMA, found mortality rates increased slightly among heart failure patients as hospitals reduced 30-day and one-year readmission rates as part of the CMS' Hospital Readmissions Reduction program.

The findings underscore concerns expressed by some health policy experts that in an effort to reduce readmissions, quality of care could be compromised. The CMS program was implemented under the Affordable Care Act as a way to incentivize hospitals to improve outcomes while lowering costs. All acute-care hospitals that treat Medicare beneficiaries are required to participate in the program.

"We all respond to incentives ... those incentives could also lead hospitals to adopt policies that could harm patients," said Dr. Ankur Gupta, lead author of the study and research fellow at Brigham and Women's Hospital in Boston.

There have been concerns that in order to avoid a Medicare penalty, hospitals won't readmit patients or will put them on observation status. Gupta said recent studies of Medicare beneficiaries have found the percentage of patients on observation status has increased since the implementation of the CMS' readmissions program.

HHS has steadfastly denied that the program has encouraged hospitals to put patients on observation status instead of admitting them to the hospital.

In a statement in response to the study, the CMS said it "continuously monitors the impact of the measures used in our programs, including input from peer-reviewed research and other sources. Studies like this are important inputs as we continuously assess our programs."

Gupta and his co-authors analyzed readmission and mortality rates for 115,245 Medicare beneficiaries treated at 416 hospitals across the country. The study found 30-day readmissions rates for heart failure patients dropped from 20% before the CMS program to 18.4% after the program went into effect. At the same time, the 30-day mortality rate for those patients rose from 7.2% to 8.6%. Mortality rates among heart failure patients one-year after an inpatient stay increased from 31.3% before the program to 36.3% after the program.

Gupta called the results "alarming."

The findings are in line with previous research that found mortality rates have increased for heart failure patients since the start of the CMS' readmissions program.

Gupta said it's difficult to know if the program has directly influenced heart failure mortality rates, but before the program went into effect, heart failure mortality rates were on the decline.

Research hasn't found a connection between readmission rate declines and an increase in mortality rates for pneumonia or heart attack patients, which are also part of the CMS' program.

Gupta suggested that the CMS omit heart failure patients from the readmissions program given the findings. The condition is the most common cause of readmissions among Medicare beneficiaries. Gupta said he conducted the recent study because he wanted to follow up on previous research that also found an adverse association between a decrease in readmission rates for heart failure patients and a rise in mortality.

Gupta questioned the value of the readmissions program in general, calling readmissions a "utilization measure," not a quality measure.

"In the likelihood that (the program is related to adverse mortality rates), we shouldn't subject our patients to harm. We need more studies on the subject," he said.

Gupta's comments echo others who say readmission rates don't provide a worthwhile depiction of the quality of care given at a facility. Some have even called for the CMS to retire the program.