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Original Investigation
July 18, 2017

Association of Changing Hospital Readmission Rates With Mortality Rates After Hospital Discharge

Author Affiliations
  • 1Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut
  • 2Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 3Now with Clover Health, Jersey City, New Jersey
  • 4Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
  • 5Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts
  • 6Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 7The Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 8Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
  • 9Center for Healthcare Innovation and Delivery Science, NYU Langone Medical Center, New York, New York
  • 10Division of Healthcare Delivery Science, Department of Population Health, New York University School of Medicine, New York
  • 11Division of General Internal Medicine and Clinical Innovation, Department of Medicine, New York University School of Medicine, New York
  • 12Section of Rheumatology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
  • 13Section of General Pediatrics, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
JAMA. 2017;318(3):270-278. doi:10.1001/jama.2017.8444
Key Points

Question  Have hospital readmission reductions associated with the Affordable Care Act had the unintended consequence of increasing mortality after hospitalization?

Findings  In this cohort study of more than 5 million Medicare fee-for-service hospitalizations for heart failure, acute myocardial infarction, and pneumonia from 2008 to 2014, reductions in hospital 30-day readmission rates were weakly but significantly correlated with reductions in 30-day mortality rates after hospital discharge (correlation coefficients, 0.066, 0.067, and 0.108, respectively).

Meaning  These findings do not support increasing postdischarge mortality related to reducing hospital readmissions.

Abstract

Importance  The Affordable Care Act has led to US national reductions in hospital 30-day readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. Whether readmission reductions have had the unintended consequence of increasing mortality after hospitalization is unknown.

Objective  To examine the correlation of paired trends in hospital 30-day readmission rates and hospital 30-day mortality rates after discharge.

Design, Setting, and Participants  Retrospective study of Medicare fee-for-service beneficiaries aged 65 years or older hospitalized with HF, AMI, or pneumonia from January 1, 2008, through December 31, 2014.

Exposure  Thirty-day risk-adjusted readmission rate (RARR).

Main Outcomes and Measures  Thirty-day RARRs and 30-day risk-adjusted mortality rates (RAMRs) after discharge were calculated for each condition in each month at each hospital in 2008 through 2014. Monthly trends in each hospital’s 30-day RARRs and 30-day RAMRs after discharge were examined for each condition. The weighted Pearson correlation coefficient was calculated for hospitals’ paired monthly trends in 30-day RARRs and 30-day RAMRs after discharge for each condition.

Results  In 2008 through 2014, 2 962 554 hospitalizations for HF, 1 229 939 for AMI, and 2 544 530 for pneumonia were identified at 5016, 4772, and 5057 hospitals, respectively. In January 2008, mean hospital 30-day RARRs and 30-day RAMRs after discharge were 24.6% and 8.4% for HF, 19.3% and 7.6% for AMI, and 18.3% and 8.5% for pneumonia. Hospital 30-day RARRs declined in the aggregate across hospitals from 2008 through 2014; monthly changes in RARRs were −0.053% (95% CI, −0.055% to −0.051%) for HF, −0.044% (95% CI, −0.047% to −0.041%) for AMI, and −0.033% (95% CI, −0.035% to −0.031%) for pneumonia. In contrast, monthly aggregate changes across hospitals in hospital 30-day RAMRs after discharge varied by condition: HF, 0.008% (95% CI, 0.007% to 0.010%); AMI, −0.003% (95% CI, −0.005% to −0.001%); and pneumonia, 0.001% (95% CI, −0.001% to 0.003%). However, correlation coefficients in hospitals’ paired monthly changes in 30-day RARRs and 30-day RAMRs after discharge were weakly positive: HF, 0.066 (95% CI, 0.036 to 0.096); AMI, 0.067 (95% CI, 0.027 to 0.106); and pneumonia, 0.108 (95% CI, 0.079 to 0.137). Findings were similar in secondary analyses, including with alternate definitions of hospital mortality.

Conclusions and Relevance  Among Medicare fee-for-service beneficiaries hospitalized for heart failure, acute myocardial infarction, or pneumonia, reductions in hospital 30-day readmission rates were weakly but significantly correlated with reductions in hospital 30-day mortality rates after discharge. These findings do not support increasing postdischarge mortality related to reducing hospital readmissions.

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