Impact of Hospital Readmissions Reduction Program Penalties on Hip and Knee Replacement Readmissions

Abstract

Background: Little is known about the impact of the U.S. Centers for Medicare & Medicaid Services' Hospital Readmissions Reduction Program (HRRP) expansion to include readmissions following elective primary total hip and knee replacements; the expansion was finalized in 2013 and was implemented in 2014. We examined whether hospitals at risk of relatively large penalties from this expansion experienced greater declines in joint replacement readmissions compared with hospitals at risk of smaller penalties. Methods: We used Medicare's 2009 to 2016 Hospital Compare data sets to examine the impact of the HRRP's expansion in the July 2013 to June 2016 period (post-expansion) compared with the July 2009 to June 2012 period (preexpansion). The primary outcome was the hospital-level, 30-day, risk-standardized readmission rate (hereafter called the readmission rate) following joint replacement surgical procedures. We used the percentage of a hospital's total inpatient revenue attributed to Medicare (categorized into quartiles) to represent the risk of penalties. We used hierarchical linear regression models to examine the adjusted impact of the HRRP's expansion. Results: Our study cohort included 2,326 acute care hospitals. In the pre-HRRP expansion phase, the mean readmission rate was 5.36% among hospitals with the highest proportion of Medicare revenues (quartile 4) and 5.46% among hospitals with the lowest proportion of Medicare revenues (quartile 1). With the HRRP expansion, the readmission rate declined by 18.92% (1.01 percentage points) among quartile-4 hospitals and by 17.97% (0.98 percentage point) among quartile-1 hospitals (p = 0.45). This nonsignificant difference in readmission rate declines between quartiles persisted in multivariable analysis (a decline of 18.41% [0.98 percentage point] in quartile 4 and a decline of 17.35% [0.94 percentage point] in quartile 1; p = 0.35). Conclusions: The HRRP's expansion to include joint replacements did not lead to greater reductions in postoperative readmissions among hospitals at risk of larger penalties in comparison with hospitals at risk of smaller penalties. Readmission rates were declining at similar rates among all hospitals, before and after the HRRP's expansion. Clinical Relevance: Readmissions and complications following joint replacements are measures of the quality of surgical care. These events have important clinical and economic implications for patients and providers. This study is clinically relevant because it examines whether policy interventions, such as the HRRP, have the potential to reduce these unintended consequences of surgical care. I n 2012, the U.S. Centers for Medicare & Medicaid Systems implemented the Hospital Readmissions Reduction Program (HRRP) to encourage hospitals to reduce read-missions for medical conditions. Under this initiative, hospitals with higher-than-expected readmission rates for Medicare feefor-service patients receive penalties as high as 3% of their base Disclosure: The efforts of Drs. Thirukumaran, Glance, Cai, and Li a...

International comparison of variation in performance between hospitals for THA and TKA: Is it even possible? A systematic review including 33 studies and 8 arthroplasty register reports

“…The studies included numbers of patients ranging from 122 to 524,892 for THA, from 84 to 952,593 for TKA, and from 1596 to 878,098 for THA and TKA combined. Four studies did not report the number of patients included (15,27,28,29). A wide range was found for the number of hospitals included for THA, TKA, and THA and TKA combined (i.e.…”

“…From the 13 studies reporting readmission rates, the between-hospital variation was reported in 5 studies (3 MQ, 2 LQ) for THA (9,21,30,35,36), 4 studies (3 MQ, 1 LQ) for TKA (21,33,35,37), and 6 studies (3 MQ, 3 LQ) for THA and TKA combined (15,16,28,38,39,40). Ten studies reported the variation for readmission more than once with different indicator definitions in all domains except for the type of patients selected (Table 4).…”

“…From the 20 studies reporting complication rates, the between-hospital variation was reported in 11 studies (5 MQ, 6 LQ) for THA (9,10,21,27,41,42,43,44,45,46,47), 8 studies (4 MQ, 4 LQ) for TKA (10,21,33,44,45,46,47,48) and 8 studies (1 HQ, 3 MQ, 4 LQ) for THA and TKA combined (14,15,16,32,38,47,49,50). Eight studies reported the variation more than once with different outcome definition, follow-up, and type of hospitals selected (Table 5).…”

“…In addition, scientific articles are published for quality improvement purposes; for example, hospitals are benchmarked, ranked, or (statistical) methods are compared to monitor the quality of care delivered (9,10,11,12,13). The most commonly used quality indicators in this context are implant revision, readmission, and complications, as these indicators are considered reliable, actionable, and fit for purpose (14,15,16,17,18,19). However, the reliability of hospital rankings has been shown to be affected by for example, minor registration incompleteness in the outcome and low event rates, with particularly low volume providers being less likely to become an outlier in funnel plots (11,13).…”

Which Factors Predict 30-Day Readmission After Total Hip and Knee Replacement Surgery?

“…In 2014, this list of diagnoses was expanded to include orthopedic surgeries, such as total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, the expansion of the Hospital Readmissions Reduction Program has not led to great declines in readmissions [1][2][3][4].…”