A federal program designed to reduce heart failure (HF) readmission rates may achieve that goal, but possibly at the expense of increasing HF death rates, according to a new study published in JAMA Cardiology. The study compares 30-day and one-year readmission and mortality rates in 115,245 fee-for-service Medicare beneficiaries ages 65 years and older who were treated for HF at 416 U.S. hospitals before and after implementation of the Hospital Readmissions Reduction Program (HRRP). The HRRP was established by the Affordable Care Act to reduce readmission rates for HF (the most common reason for readmission among Medicare beneficiaries), acute myocardial infarction, and pneumonia.

Between January 1, 2006, and March 31, 2010-before HRRP implementation-the 30-day all-cause risk-adjusted HF readmission rate was 20%, dropping to 18.4%, from October 1, 2012, through December 31, 2014-the period of time hospitals began to be penalized for excessive HF readmissions. This reduction was significant. But 30-day risk-adjusted mortality rates between these two time periods increased significantly as well, from 7.2% to 8.6%, respectively. A similar pattern was noted at one year, with a drop in the risk-adjusted readmission rate and an increase in the risk-adjusted mortality rate, both statistically significant.

The findings "raise concerns that the HRRP, while achieving desired reductions in readmissions, may have incentivized hospitals in a way that has compromised the survival of patients with HF," the authors conclude, noting possible hospital strategies to "game" the system, such as delaying readmissions past 30 days, monitoring patients in observation units, or treating them in EDs instead of inpatient units.

For nurses and other health care professionals, the study's results serve as a reminder that "like drugs and devices, public health policies should be tested in a rigorous fashion-most preferably in randomized trials-before their widespread adoption," the authors write. They add that if confirmed by additional studies, the findings "may require reconsideration of [implementing] the HRRP in HF."-Elizabeth Mechcatie, BSN, MA

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