Division of Cardiovascular Medicine, Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts.
Division of Cardiology, University of Colorado School of Medicine, Aurora.
JAMA Cardiol. 2018 Jan 1;3(1):44-53. doi: 10.1001/jamacardio.2017.4265.
Public reporting of hospitals' 30-day risk-standardized readmission rates following heart failure hospitalization and the financial penalization of hospitals with higher rates have been associated with a reduction in 30-day readmissions but have raised concerns regarding the potential for unintended consequences.
To examine the association of the Hospital Readmissions Reduction Program (HRRP) with readmission and mortality outcomes among patients hospitalized with heart failure within a prospective clinical registry that allows for detailed risk adjustment.
DESIGN, SETTING, AND PARTICIPANTS: Interrupted time-series and survival analyses of index heart failure hospitalizations were conducted from January 1, 2006, to December 31, 2014. This study included 115 245 fee-for-service Medicare beneficiaries across 416 US hospital sites participating in the American Heart Association Get With The Guidelines-Heart Failure registry. Data analysis took place from January 1, 2017, to June 8, 2017.
Time intervals related to the HRRP were before the HRRP implementation (January 1, 2006, to March 31, 2010), during the HRRP implementation (April 1, 2010, to September 30, 2012), and after the HRRP penalties went into effect (October 1, 2012, to December 31, 2014).
Risk-adjusted 30-day and 1-year all-cause readmission and mortality rates.
The mean (SD) age of the study population (n = 115 245) was 80.5 (8.4) years, 62 927 (54.6%) were women, and 91 996 (81.3%) were white and 11 037 (9.7%) were black. The 30-day risk-adjusted readmission rate declined from 20.0% before the HRRP implementation to 18.4% in the HRRP penalties phase (hazard ratio (HR) after vs before the HRRP implementation, 0.91; 95% CI, 0.87-0.95; P < .001). In contrast, the 30-day risk-adjusted mortality rate increased from 7.2% before the HRRP implementation to 8.6% in the HRRP penalties phase (HR after vs before the HRRP implementation, 1.18; 95% CI, 1.10-1.27; P < .001). The 1-year risk-adjusted readmission and mortality rates followed a similar pattern as the 30-day outcomes. The 1-year risk-adjusted readmission rate declined from 57.2% to 56.3% (HR, 0.92; 95% CI, 0.89-0.96; P < .001), and the 1-year risk-adjusted mortality rate increased from 31.3% to 36.3% (HR, 1.10; 95% CI, 1.06-1.14; P < .001) after vs before the HRRP implementation.
Among fee-for-service Medicare beneficiaries discharged after heart failure hospitalizations, implementation of the HRRP was temporally associated with a reduction in 30-day and 1-year readmissions but an increase in 30-day and 1-year mortality. If confirmed, this finding may require reconsideration of the HRRP in heart failure.
重要提示：医院心力衰竭住院患者 30 天风险标准化再入院率的公开报告以及对再入院率较高的医院进行经济处罚与 30 天再入院率的降低有关，但这也引起了人们对潜在不良后果的关注。
目的：通过允许进行详细风险调整的前瞻性临床注册中心，调查心力衰竭患者住院的医院再入院率降低计划（HRRP）与再入院和死亡率之间的关联。
设计、地点和参与者：2006 年 1 月 1 日至 2014 年 12 月 31 日，对美国心脏协会 Get With The Guidelines-Heart Failure 注册中心 416 家美国医院的 115245 名全付费医疗保险受益人进行了指数心力衰竭住院的中断时间序列和生存分析。数据分析于 2017 年 1 月 1 日至 2017 年 6 月 8 日进行。
暴露情况：与 HRRP 相关的时间间隔包括 HRRP 实施前（2006 年 1 月 1 日至 2010 年 3 月 31 日）、HRRP 实施期间（2010 年 4 月 1 日至 2012 年 9 月 30 日）和 HRRP 处罚生效后（2012 年 10 月 1 日至 2014 年 12 月 31 日）。
主要结果和测量：风险调整后 30 天和 1 年全因再入院率和死亡率。
结果：研究人群（n=115245）的平均（SD）年龄为 80.5（8.4）岁，62927 人（54.6%）为女性，91996 人（81.3%）为白人，11037 人（9.7%）为黑人。30 天风险调整后再入院率从 HRRP 实施前的 20.0%下降到 HRRP 处罚阶段的 18.4%（HRRP 实施后与实施前相比，0.91；95%CI，0.87-0.95；P<0.001）。相比之下，30 天风险调整后死亡率从 HRRP 实施前的 7.2%上升到 HRRP 处罚阶段的 8.6%（HRRP 实施后与实施前相比，1.18；95%CI，1.10-1.27；P<0.001）。1 年风险调整后再入院率和死亡率也呈现出类似的模式。1 年风险调整后再入院率从 57.2%下降到 56.3%（HR，0.92；95%CI，0.89-0.96；P<0.001），1 年风险调整后死亡率从 31.3%上升到 36.3%（HR，1.10；95%CI，1.06-1.14；P<0.001）。
结论和相关性：在心力衰竭住院后出院的全付费医疗保险受益人中，HRRP 的实施与 30 天和 1 年再入院率的降低有关，但与 30 天和 1 年死亡率的增加有关。如果这一发现得到证实，可能需要重新考虑心力衰竭患者的 HRRP。
