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Original Investigation
March 2018

Association of the Hospital Readmissions Reduction Program With Surgical Readmissions

Author Affiliations
  • 1Dow Health Services Research Division, Department of Urology, University of Michigan, Ann Arbor
  • 2Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
  • 3Department of Health Management and Policy, University of Michigan, Ann Arbor
  • 4Department of Economics, University of Michigan, Ann Arbor
  • 5National Bureau of Economic Research, Cambridge, Massachusetts
  • 6Center for Healthcare Outcomes and Policy, Department of Surgery, University of Michigan, Ann Arbor
  • 7Surgical Innovation Editor, JAMA Surgery
  • 8Kidney Epidemiology Cost Center, University of Michigan, Ann Arbor
JAMA Surg. 2018;153(3):243-250. doi:10.1001/jamasurg.2017.4585
Key Points

Question  What is the association of the Hospital Readmissions Reduction Program with readmissions after surgical procedures targeted by the policy and other major procedures with historically high readmission rates not under its purview?

Findings  In this cohort study of 672 135 Medicare beneficiaries treated at 2773 hospitals, we found that readmissions decreased significantly for all procedures during the study period. Corresponding with the performance period of the policy, readmissions after targeted procedures decreased significantly faster compared with 2 earlier periods, while readmission rates for nontargeted procedures stabilized.

Meaning  The Hospital Readmissions Reduction Program may decrease readmissions for targeted procedures; however, there were no associated spillover effects for common nontargeted procedures.

Abstract

Importance  Readmissions after surgery lead to poor patient outcomes and increased costs. The Hospital Readmissions Reduction Program (HRRP) penalizes hospitals with excess readmissions after specified medical and surgical discharges.

Objective  To evaluate the association of the HRRP with readmissions after major joint surgery (targeted) and procedures with historically high rates not under its purview (nontargeted).

Design, Setting, and Participants  In this population-based analysis using a 20% Medicare sample, a retrospective cohort study was performed of patients undergoing one of 5 major surgical procedures between January 1, 2006, and November 30, 2014. The study included 507 663 patients with targeted (total knee arthroplasty and total hip arthroplasty) and 164 472 patients with nontargeted (abdominal aortic aneurysm repair, colectomy, and lung resection) procedures performed at 2773 hospitals.

Exposure  Implementation of the HRRP policy.

Main Outcomes and Measures  Hospital-level 30-day risk-adjusted rates of readmission and observation stays were calculated using multivariable logistic regression models. Changes in these rates were analyzed for 3 distinct periods (prepolicy [January 1, 2006, to June 30, 2010], performance [July 1, 2010, to June 30, 2013], and penalty [July 1, 2013, to November 30, 2014]) corresponding to the HRRP implementation timeline for major joint surgery using interrupted time series.

Results  Among 672 135 Medicare beneficiaries 66 years or older treated at 2773 hospitals, readmissions for all procedures decreased significantly over the study period. Readmission rates after targeted procedures decreased faster during the performance period (slope, −0.060; 95% CI, −0.079 to −0.041) compared with the prepolicy period (slope, −0.012; 95% CI, −0.027 to 0.034) (P < .002). For the nontargeted procedures, readmission rates were decreasing during the prepolicy period (slope, −0.200; 95% CI, −0.240 to −0.160) but stabilized during the performance period (slope, 0.008; 95% CI, −0.049 to 0.066 (P < .001). The use of observation stays increased slightly, accounting for 11% of the decrease in readmissions.

Conclusions and Relevance  The HRRP effectively decreased readmissions for targeted procedures. There were no associated spillover effects for common nontargeted procedures. A better understanding of differences in the association of the policy with medical and surgical discharges will be necessary to further enhance its generalizability.

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