Author + information
- Received December 27, 2018
- Revision received March 28, 2019
- Accepted April 16, 2019
- Published online July 8, 2019.
- Rohan Khera, MDa,∗ (, )@rohan_khera,
- Yongfei Wang, MSb,c,
- Khurram Nasir, MD, MPH, MScb,c,
- Zhenqiu Lin, PhDb and
- Harlan M. Krumholz, MD SMb,c,d@hmkyale
- aDivision of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
- bCenter for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- cSection of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- dDepartment of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- ↵∗Address for correspondence:
Dr. Rohan Khera, Division of Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, E5.730, Dallas, Texas 75390.
Background The Hospital Readmissions Reduction Program (HRRP) has been associated with reduced 30-day readmissions for acute myocardial infarction (AMI) and heart failure (HF).
Objectives The purpose of this study was to test whether this 30-day readmission reduction is a manifestation of practices that defer or avoid hospitalizations beyond the 30-day period.
Methods At all U.S. hospitals under HRRP, the authors calculated daily readmission rates for elderly Medicare fee-for-service beneficiaries through day-60 post-discharge following a hospitalization for AMI and HF—the 2 target cardiovascular conditions—as well as pneumonia in July 2008 to June 2016. The authors applied a robust bias-corrected nonparametric regression approach to evaluate for discontinuities in rates around day 30.
Results The authors identified 3,256 eligible hospitals, with median readmission rates in the days 1 to 30 and 31 to 60 post-discharge of 19.6% (interquartile range [IQR]: 16.7% to 22.9%) and 7.8% (IQR: 6.5% to 9.4%) for AMI, 23.0% (IQR: 20.6% to 25.3%) and 11.4% (IQR: 10.2% to 12.6%) for HF, and 17.5% (IQR: 15.4% to 19.8%) and 8.3% (IQR: 7.3% to 9.3%) for pneumonia, respectively. Daily readmission rates decreased across most of the 60 post-discharge days, with no discontinuities in the local polynomial regression for readmission at the 30-day mark, with a >95% power to detect 0.1% difference for each outcome across post-discharge day 30. Similarly, there was no discontinuity in mortality at 30 days post-discharge, or for either outcome at hospitals that incurred readmission penalties.
Conclusions There was no evidence that clinicians adopted strategies that specifically deferred admissions or affected mortality in the 30-day period after discharge. The findings are consistent with the institution of strategies that generally affected readmission risk after discharge.
Dr. Khera is supported by the National Center for Advancing Translational Sciences (UL1TR001105) of the National Institutes of Health. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Mr. Wang and Drs. Lin and Krumholz work under contract with the Centers for Medicare & Medicaid Services to develop and maintain performance measures that are publicly reported. Dr. Krumholz is a recipient of research grants, through Yale, from Medtronic and Johnson & Johnson (Janssen) to develop methods of clinical trial data sharing, and from Medtronic and the U.S. Food and Drug Administration to develop methods for post-market surveillance of medical devices; has served as chair of a Cardiac Scientific Advisory Board for UnitedHealth; has been a participant/participant representative of the IBM Watson Health Life Sciences Board; has served on the Advisory Boards for Element Science and for Facebook, and the Physician Advisory Board for Aetna; was a recipient of a research agreement, through Yale, from the Shenzhen Center for Health Information for work to advance intelligent disease prevention and health promotion; collaborates with the National Center for Cardiovascular Diseases in Beijing; has received payment from the Arnold & Porter Law Firm for work related to the Sanofi clopidogrel litigation and from the Ben C. Martin Law Firm for work related to the Cook IVC filter litigation; and is the founder of Hugo, a personal health information platform. Dr. Nasir has reported that he has no relationships relevant to the contents of this paper to disclose.
Listen to this manuscript's audio summary by Editor-in-Chief Dr. Valentin Fuster on JACC.org.
- Received December 27, 2018.
- Revision received March 28, 2019.
- Accepted April 16, 2019.
- 2019 American College of Cardiology Foundation
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