Association of the Hospital Readmissions Reduction Program With Surgical Readmissions

Abstract

Importance Readmissions after surgery lead to poor patient outcomes and increased costs. The Hospital Readmission Reduction Program (HRRP) penalizes hospitals with excess readmissions after specified medical and surgical discharges. Objective To evaluate the effect of this policy on readmissions after major joint surgery (targeted) and procedures with historically high rates not under its purview (non-targeted). Design Using a 20% Medicare sample we performed a retrospective cohort study of patients undergoing one of five major surgeries between January 1, 2006 and November 30, 2014. Setting Population based analysis. Participants Our study included 507,663 patients with targeted (total hip arthroplasty, total knee arthroplasty) and 164,472 patients with non-targeted (abdominal aortic aneurysm repair, colectomy, lung resection) procedures performed at 2,773 hospitals. Exposure Implementation of the HRRP policy. Main Outcomes and Measures We calculated hospital level 30-day risk-adjusted rates of readmission and observation stays using multivariable logistic regression models. Changes in these rates were analyzed for three distinct time periods (Pre-policy (1/1/2006 to 6/30/2010), Performance (7/1/2010 to 6/30/2013), Penalty (7/1/13 to 11/30/14)) corresponding to the HRRP implementation timeline for major joint surgery, using interrupted time series. Results 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 to the Pre-policy period (slope: −0.012, 95% CI: −0.027 to 0.034, p <0.002). For non-targeted procedures, readmission rates were decreasing during the Pre-policy period (slope: −0.20, 95% CI: −0.24 to −0.16) but stabilized during the Performance period (slope: 0.0084, 95% CI: −0.049 to 0.066, p <0.001). Use of observation stays increased slightly, accounting for 11% of the decrease in readmissions. Conclusions The HRRP effectively decreased readmissions for targeted procedures. There were no associated spillover effects for common non-targeted procedures. A better understanding of differences in impact of the policy across medical and surgical discharges will be necessary to further enhance its effects and generalizability.

Comparison of Hospital Readmission After Total Hip and Total Knee Arthroplasty vs Spinal Surgery After Implementation of the Hospital Readmissions Reduction Program

“…Previous studies examining surgical readmissions approximated secular trends by defining the nontargeted group to include 3 to 5 surgical procedures, including colectomy, abdominal aortic aneurysm repair, and others. 8 , 9 , 10 These procedures were likely chosen because they are common among elderly populations, have a high risk of readmission, and are high cost. We argue that the use of lumbar spine fusion and laminectomy as control procedures provides a better understanding of how the HRRP was associated with THA and TKA readmission trends than do a random selection of common surgical procedures.…”

“…7 To our knowledge, this study is the first to evaluate the association of the HRRP with surgical readmissions after penalty onset and with a newly available data set designed to study readmissions. 8 , 9 , 10 Our hypothesis is that 30-day readmissions after targeted procedures would experience a more pronounced decline during the HRRP implementation and penalty periods when compared with readmissions after similar nontargeted procedures. If true, this finding would argue that the HRRP is associated with a greater decrease in readmissions after targeted surgical discharges.…”

Health Care Policy and Outcomes after Colon and Rectal Surgery: What Is the Bigger Picture?—Cost Containment, Incentivizing Value, Transparency, and Centers of Excellence

“…Results of recent studies have been variable regarding the effectiveness of HVBP, with a preponderance of evidence demonstrating that the HVBP may reduce readmissions, but it is not associated with improvement in measures of clinical process or patient experience and may actually increase mortality and reward some low-quality hospitals. 12, [14][15][16] Raw data regarding readmission should be interpreted carefully, especially in this "carrot and stick" model of reimbursement and penalties. There is significant variation among hospitals in readmission rates for colorectal cancer surgery, ranging from 0 to 41%, but after adjusting for patient characteristics, comorbidities, and operation types, this variability was reduced.…”

Readmission after pancreatic resection: causes, costs and cost-effectiveness analysis of high versus low quality hospitals using the Nationwide Readmission Database

“…In addition, outcome and readmission data have been made publically available to guide decision-making and improvements in care. [8][9][10] After the initial success of the program for medical conditions (e.g. myocardial infarction, pneumonia, heart failure), HRRP has continued to expand with the recent inclusion of major surgical procedures.…”