Science in Social Media

Abstract

The Hospital Readmissions Reduction Program (HRRP), which levies financial penalties for excess readmissions after select medical and surgical admissions, has been as widely critiqued as it has been celebrated. On one hand, there have been clinically and statistically significant declines in readmission rates since the announcement of the HRRP in 2012, with the largest improvements occurring in hospitals receiving the largest penalties.1,2 On the other hand, penalties in the program have been disproportionately allocated to academic medical centers and hospitals serving vulnerable populations, leading to concerns about widening disparities in care.3 There has also been mixed evidence that the HRRP has increased the use of emergency departments and observation stays.1,4 But of the myriad effects from the HRRP, none have been as controversial as the effect on patient mortality. There has long been concern that penalties for readmissions might create a perverse incentive whereby patients would be denied appropriate and necessary hospital care, which would increase a patient’s risk of death. Initial evidence exploring this relationship exhibited a weak but statistically significant inverse association between hospital 30-day mortality and readmission rates for patients with congestive heart failure.5 Detecting a meaningful association between reduced readmissions and increased mortality would represent the worst-case scenario for the HRRP. Two recent studies exemplify this controversial topic. In July 2017, a study led by Dr Kumar Dharmarajan and Dr Harlan Krumholz demonstrated that although 30-day mortality rates for congestive heart failure increased overall between 2008 and 2014, the trends in mortality between 2010 and 2012—when readmission declines were the greatest—were comparable with other periods.6 Moreover, the authors found a direct but weak correlation between a hospital’s change in 30-day readmission rate from 2008 to 2014 to its change in 30-day mortality rate. Through traditional publication channels, …