Death rates for heart failure, pneumonia rise as readmissions targeted

Another study has found a rise in mortality for patients with certain conditions as hospitals are encouraged to lower 30-day readmissions through CMS' penalty program.

The new study, released Friday in JAMA, found death rates rose slightly among heart failure and pneumonia patients as hospitals were motivated to reduce 30-day readmission rates under the CMS' Hospital Readmissions Reduction Program, or HRRP. This is the second study that has been published finding a correlation between the readmissions penalty program and a rise in death among patients with conditions the program targets.

The most recent study compared mortality rates for hospitalizations for heart failure, heart attack and pneumonia from before the readmissions program began to a few years after the program's implementation. The authors found death rates for heart failure patients rose by 0.52% after the readmissions program was implemented compared to a 0.27% rise in mortality in the few years before the program. Furthermore, mortality rates from pneumonia were stable before the readmissions program went into effect with a 0.04% increase from 2005 to 2010 but rose by 0.44% from 2012 to 2015, after the program began.

Dr. Rishi Wadhera, lead author of the study and an investigator in the Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center, said that although it's difficult to know if the rises in mortality were directly related to the readmissions program, the findings alone are enough for the CMS to re-evaluate it.

"It's really hard to know whether the policy is directly responsible for the acceleration in mortality, but in the face of uncertainty I think we should err on the side of caution," he said.

Dr. Robert Yeh, co-author of the study and director of the Smith Center for Outcomes Research, said he doesn't think the readmissions program should be expanded "until we have a better understanding of why these trends are occurring."

A study released last November also published in JAMA found mortality rose among Medicare beneficiaries with heart failure after implementation of the readmissions program. That study eventually led to a report by the Medicare Payment Advisory Commission, which concluded there was "no compelling evidence to suggest that the readmission reduction policy has had a negative effect on mortality. To the extent that there is a small effect, our data as a whole suggest the HRRP may have done more to improve than harm mortality rates."

CMS Chief Medical Officer Dr. Kate Goodrich said in a statement that the Medicare Payment Advisory Commission studied the same data and didn't find an indication of higher mortality for heart failure patients.

"CMS monitors the impact of our programs, including looking at the input from peer-reviewed research and other sources, as we work to improve health outcomes while ensuring Americans are receiving safe, quality healthcare," she said.

The readmissions program currently includes six conditions: heart attack, pneumonia, chronic obstructive pulmonary disease, hip and knee replacements and coronary artery bypass graft surgery.

Wadhera and Yeh choose to evaluate heart attack, heart failure and pneumonia because those are the initial three conditions the program started with in 2012.

The study didn't find heart attack patients experienced rises in mortality compared to before the program was implemented and after. Yeh said that may be because heart attack is a single acute event that can be treated with less likelihood for complications that lead to readmissions. Heart failure is a chronic condition that is harder to treat whereas pneumonia is usually diagnosed in frail, sickly and older adults.

Since the JAMA study last year, quality experts raised concerns that hospitals may be denying patients necessary admissions in order to avoid a readmission penalty, which is up to 3% of their Medicare payments.