Data Presented to AHA Shows Medicare’s HRRP Only Reduces Readmissions for the Wealthy

Posters presented at the American Heart Association (AHA) conference in Chicago, Illinois found that neighborhood income and socioeconomic status had an effect on heart failure and readmission rates all combined causes.

Medicare’s Hospital Readmissions Reduction Program (HRRP), the centerpiece of CMS’s protocol for assessing hospital quality, has primarily worked to reduce readmissions among the wealthiest patients, while readmissions continue to climb among the poor , according to data presented today at the American Heart Association (AHA) Scientific Sessions in Chicago.

The data, presented in a poster session, focused on the relationship between neighborhood household income and 30-day readmission rates in patients with HF.1 The researchers investigated whether the HRRP actually had an effect on readmissions to HF by comparing readmissions by income level in the years before and after the HRRP came into effect.

The study used the National Readmissions Database to find all admissions of adults over the period 2010 to 2019 with a primary diagnosis of HF who had an unplanned readmission within 30 days. . Household income was divided into 4 quartiles: low income, middle income, upper middle income and high income. All-cause 30-day readmission rates by annual trend were collected using household income quartile. The pre-HRRP period of 2010 to 2012 was compared to the post-HRRP period of 2013 to 2019 when comparing adjusted readmission rates.

Adjusted 30-day all-cause readmission rates increased for patients in the low-income (18.8% to 19.0%) and middle-income quartiles (17.6% to 17.9%) during evaluating 9,020,742 indexed hospitalizations from 2010 to 2019. Readmission rates remained similar in the upper middle income quartile (17.7% to 17.3%) and decreased in the high income quartile (16 .8% to 16.4%). The association between HRRP and all-cause readmission varied, with patients in the lower quartiles experiencing a greater increase in readmissions.

“A federal government-implemented hospital readmission reduction program in 2012 hasn’t really had its true effect,” said study author Stephen J Greene, MD. “Readmissions continue to increase, especially for people in the lower quartiles. This may inform us or the federal government in its decision making as it tries to propose either an amendment to this policy or a different policy.

Researchers in this poster concluded that adjusted 30-day all-cause readmission rates were affected by neighborhood household income among patients hospitalized with HF in the United States from 2010 to 2019. Readmission rates also increased for patients in the bottom 2 quartiles, with the greatest overall increases in patients in the bottom quartile.

A second poster assessed whether neighborhood socioeconomic status (NSES) predicted higher rates of HF readmission to a safety net system.2 A retrospective cohort study based on electronic health records was conducted that evaluated adults with HF from 2001 to 2019. All patients were from a municipal safety net hospital in San Francisco and Fine-Gray survival models were used to conduct the study. Residential addresses have been geocoded.

The NSES was composed of a patient’s income, education, employment, and housing and tailored to the San Francisco Bay Area in quintiles, with 1 being the lowest socioeconomic status and 5 the highest socioeconomic status.

There were 2507 participants, of whom 179 (7.1%) were readmitted within 30 days for HF and 374 (14.9%) were readmitted for any cause. There were 639 participants who were readmitted for CI and 1185 (47.3%) readmitted for any cause within one year.

Unadjusted analyzes revealed that NSES was associated with HF readmission and all-cause readmission at 30 days and 1 year. Quintile 1 had a 58% higher risk of readmission for CI (RR, 1.58; 95% CI, 1.07-2.33) and a 56% higher risk of all-cause readmission (RR, 1 .56; 95% CI, 1.19-2.05) at 1 year relative to quintile 5 after adjusting for demographics, substance use, and comorbidities. All quintiles had a higher risk of all-cause readmission at 1 year compared to quintile 5, including quintile 2 (RR, 1.53; 95% CI, 1.16-2.03) and quintile 4 (RR, 1.50; 95% CI, 1.10-2.03).

The researchers concluded that NSES was associated with a higher risk of HF and all-cause readmissions within 1 year in a hospital with a safety net.

Both posters establish evidence that neighborhood socioeconomic status and household income determine health outcomes for patients diagnosed with HF.

For years, IC specialists have cried foul of the HRRP, saying it is acting against safety net hospitals that treat poor patients who arrive with accumulated comorbidities and higher smoking rates, which are more likely to explain higher readmission rates than poor care.

Yet the penalties can cost institutions up to 3% of Medicare payments a year, despite criticism that hospitals caring for the poor need more resources, not less. This week alone, Medicare fined 2,300 institutions. To research in JAMA and elsewhere found that the HRRP induces hospitals to refuse readmission to patients for fear of being penalized, resulting in higher HF mortality for certain groups.

References

  1. Greene SJ, Aliyev N, Almani MU, Ullah MQ, Fonarow GC, Khan MS. Household income and trends in 30-day readmission of heart failure patients. Presented at: AHA 2022; November 5-7, 2022; Chicago, IL. Summary SA2124.
  2. Jeon D, Ma Y, Thakkar A, Durstenfeld MS, Hsue P. Neighborhood socioeconomic status and heart failure or all-cause readmission to a safety net system. Presented at: AHA 2022; November 5-7, 2022; Chicago, IL. Summary SA2127.

Ryan H. Bowman