Are Hospital Readmission Reduction Programs Truly Evidence Based?

When politicians attempt to make changes to health policy based on sentiments rather than on evidence-based conclusions, physicians often find themselves trying to meet unrealistic expectations.

Although there’s no denying that trying to keep patients out of the hospital is a good thing, hospital readmissions reduction programs have, over the last several years, proven to be a thorn in the sides of both hospital administrators and physicians alike. Even worse, recent data published in 2018 suggest that the assumption that lower readmission rates means better quality of care may have been overstated. In some cases, the effort to reduce hospital readmissions has resulted in worse outcomes for patients.

The hospital readmissions reduction program (HRRP) is a provision of the Affordable Care Act (ACA) that seeks to link hospital payments for inpatient admissions with quality of hospital care. In short, the HRRP requires the Secretary of the Department of Health and Human Services to reduce payments to hospitals when they are found to have excess readmissions.¹

The idea is that the program would provide incentives for hospitals to improve care coordination and postdischarge planning aimed at reducing hospital readmissions, particularly for acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass grafting, elective primary total hip arthroplasty, or total knee arthroplasty. Any unplanned readmission that happens within 30 days of discharge from the index admission counts as a readmission, regardless of the reason for the readmission.¹

Unfortunately, the policy ignores patient-related factors that may affect readmissions but are beyond the physician’s control. For example, despite my efforts to reduce hospital readmissions for congestive heart failure, I have found that readmission rates plateau because of a small number of patients who are readmitted repeatedly because they are either noncompliant with medical therapy and/or continue to abuse alcohol and illicit drugs.

Despite best efforts to set these patients up with home monitoring, frequent cardiology follow-ups, and pharmacy telephone and face-to-face visits for medication counseling, these patients continue to be readmitted 20 to 30 times per year. In resource-poor hospitals, the decreased reimbursement for caring for these patients may inadvertently deplete their already limited funds.

In fact, a recent randomized controlled trial published in JAMA that included 2494 patients hospitalized with heart failure across 10 hospitals in Canada suggests that even in patients who are presumably compliant with therapy (who, for example, are not taking illicit drugs), the implementation of a patient-centered transitional care model did not improve a composite end point of all-cause readmissions, emergency department visits, or death within 3 months.²

This article originally appeared on Medical Bag