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Original Investigation
Innovations in Health Care Delivery
December 27, 2016

Association Between Hospital Penalty Status Under the Hospital Readmission Reduction Program and Readmission Rates for Target and Nontarget Conditions

Author Affiliations
  • 1Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
  • 2Center for Outcomes Research and Evaluation, New Haven, Connecticut
  • 3Section of General Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
  • 4Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
  • 5Department of Health Policy and Management, Yale University School of Public Health, New Haven, Connecticut
  • 6Health Research and Educational Trust, Chicago, Illinois
  • 7Division of Healthcare Delivery Science, Department of Population Health, NYU School of Medicine, New York, New York
  • 8Center for Healthcare Innovation and Delivery Science, NYU Langone Medical Center, New York, New York
  • 9Department of Medicine, NYU School of Medicine, New York, New York
JAMA. 2016;316(24):2647-2656. doi:10.1001/jama.2016.18533
Key Points

Question  Was the Hospital Readmission Reduction Program (HRRP) associated with different changes in readmission rates for target and nontarget conditions among penalized and nonpenalized hospitals?

Findings  In this longitudinal cohort study of 48 137 102 hospitalizations among 20 351 161 Medicare fee-for-service patients across 3497 hospitals, announcement of the HRRP was associated with significant reductions in readmissions at hospitals later subject to penalties, with significantly larger reductions for target conditions. Hospitals not subject to financial penalties experienced comparable reductions in readmissions for target and nontarget conditions. Readmission rates plateaued across all hospitals after implementation of the HRRP.

Meaning  Hospitals subject to penalties under the HRRP had greater reductions in readmission rates compared with nonpenalized hospitals. Changes were greater for target vs nontarget conditions at the penalized hospitals, but not at nonpenalized hospitals.

Abstract

Importance  Readmission rates declined after announcement of the Hospital Readmission Reduction Program (HRRP), which penalizes hospitals for excess readmissions for acute myocardial infarction (AMI), heart failure (HF), and pneumonia.

Objective  To compare trends in readmission rates for target and nontarget conditions, stratified by hospital penalty status.

Design, Setting, and Participants  Retrospective cohort study of Medicare fee-for-service beneficiaries older than 64 years discharged between January 1, 2008, and June 30, 2015, from 2214 penalty hospitals and 1283 nonpenalty hospitals. Difference-interrupted time-series models were used to compare trends in readmission rates by condition and penalty status.

Exposure  Hospital penalty status or target condition under the HRRP.

Main Outcomes and Measures  Thirty-day risk adjusted, all-cause unplanned readmission rates for target and nontarget conditions.

Results  The study included 48 137 102 hospitalizations of 20 351 161 Medicare beneficiaries. In January 2008, the mean readmission rates for AMI, HF, pneumonia, and nontarget conditions were 21.9%, 27.5%, 20.1%, and 18.4%, respectively, at hospitals later subject to financial penalties and 18.7%, 24.2%, 17.4%, and 15.7% at hospitals not subject to penalties. Between January 2008 and March 2010, prior to HRRP announcement, readmission rates were stable across hospitals (except AMI at nonpenalty hospitals). Following announcement of HRRP (March 2010), readmission rates for both target and nontarget conditions declined significantly faster for patients at hospitals later subject to financial penalties compared with those at nonpenalized hospitals (for AMI, additional decrease of −1.24 [95% CI, −1.84 to −0.65] percentage points per year relative to nonpenalty discharges; for HF, −1.25 [95% CI, −1.64 to −0.86]; for pneumonia, −1.37 [95% CI, −1.80 to −0.95]; and for nontarget conditions, −0.27 [95% CI, −0.38 to −0.17]; P < .001 for all). For penalty hospitals, readmission rates for target conditions declined significantly faster compared with nontarget conditions (for AMI, additional decline of −0.49 [95% CI, −0.81 to −0.16] percentage points per year relative to nontarget conditions [P = .004]; for HF, −0.90 [95% CI, −1.18 to −0.62; P < .001]; and for pneumonia, −0.57 [95% CI, −0.92 to −0.23; P < .001]). In contrast, among nonpenalty hospitals, readmissions for target conditions declined similarly or more slowly compared with nontarget conditions (for AMI, additional increase of 0.48 [95% CI, 0.01-0.95] percentage points per year [P = .05]; for HF, 0.08 [95% CI, −0.30 to 0.46; P = .67]; for pneumonia, 0.53 [95% CI, 0.13-0.93; P = .01]). After HRRP implementation in October 2012, the rate of change for readmission rates plateaued (P < .05 for all except pneumonia at nonpenalty hospitals), with the greatest relative change observed among hospitals subject to financial penalty.

Conclusions and Relevance  Medicare fee-for-service patients at hospitals subject to penalties under the HRRP had greater reductions in readmission rates compared with those at nonpenalized hospitals. Changes were greater for target vs nontarget conditions for patients at the penalized hospitals but not at the other hospitals.

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