Association of the Hospital Readmissions Reduction Program With Mortality During and After Hospitalization for Acute Myocardial Infarction, Heart Failure, and Pneumonia
Association of the Hospital Readmissions Reduction Program With Mortality During and After Hospitalization for Acute Myocardial Infarction, Heart Failure, and Pneumonia
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DOI：
10.1001/jamanetworkopen.2018.2777
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发表时间：
2018-09-01
影响因子：
13.8
通讯作者：
Krumholz, Harlan M.
中科院分区：
文献类型：
--
作者：
Khera, Rohan;Dharmarajan, Kumar;Krumholz, Harlan M.
美国医院再入院减少计划（HRRP）与因急性心肌梗死（AMI）、心力衰竭（HF）和肺炎住院的医疗保险受益人的再入院减少有关。评估是否存在伴随死亡率增加的伤害信号是很重要的。目的评估HRRP的宣布或实施是否与AMI、HF或肺炎住院后住院或出院后30天死亡率的增加相关。设计、设置和参与者在这项队列研究中，使用医疗保险数据，所有AMI、HF、肺炎住院患者，和肺炎是在2006年1月1日至2014年12月31日期间，在65岁及以上的医疗保险受益人中发现的。在宣布和实施HRRP后，使用中断的时间序列框架评估了住院和出院后30天死亡率的风险调整率趋势变化。分析时间为2017年11月和2017年12月。结果2010年3月HRRP公布，2012年10月实施其处罚。主要结果和指标住院和出院后30天死亡率的每月风险调整率。结果样本包括170万AMI，400万HF和350万肺炎住院。从2006年到2014年。3种疾病的住院死亡率降低（AMI从10.4%降至9.7%，HF从4.3%降至3.5%，肺炎，从5.3%降至4.0%），而AMI的30天出院后死亡率从7.4%降至7.0（趋势P < .001），但HF从7.4%增加到9.2%（趋势P < .001），肺炎从7.6%增加到8.6%（趋势P < .001）。在HRRP公布之前，AMI的每月出院后死亡率是稳定的（每月变化的斜率，0.002%; 95%CI。每月-0.001%至0.006%）。HF每月增加0.004%（95% CI，0.000%至0.007%），肺炎每月增加0.005%（95% CI，0.002%至0.008%）。在HRRP宣布或实施前后，斜率没有变化（P > 0.05）。相比之下，在HRRP宣布时，所有情况下的再入院率的斜率均出现显着负偏差。结论和相关性在医疗保险受益人中，没有证据表明与HRRP宣布或实施相关的住院或出院后死亡率增加--在此期间，再入院率大幅减少。因此，再入院率的改善与住院或出院后30天死亡率的增加无关。
IMPORTANCE The US Hospital Readmissions Reduction Program (HRRP) was associated with reduced readmissions among Medicare beneficiaries hospitalized for acute myocardial infarction (AMI), heart failure (HF), and pneumonia. It is important to assess whether there has been a signal for concomitant harm with an increase in mortality.OBJECTIVE To evaluate whether the announcement or the implementation of HRRP was associated with an increase in either in-hospital or 30-day postdischarge mortality following hospitalization for AMI, HF, or pneumonia.DESIGN, SETTING, AND PARTICIPANTS In this cohort study, using Medicare data, all hospitalizations for AMI, HF, and pneumonia were identified among fee-for-service Medicare beneficiaries aged 65 years and older from January 1, 2006, to December 31, 2014. These were assessed for changes in trends for risk-adjusted rates of in-hospital and 30-day postdischarge mortality after announcement and implementation of the HRRP using an interrupted time series framework. Analyses were done in November 2017 and December 2017.EXPOSURES Announcement of the HRRP in March 2010, and implementation of its penalties in October 2012.MAIN OUTCOMES AND MEASURES Monthly risk-adjusted rates of in-hospital and 30-day postdischarge mortality.RESULTS The sample included 1.7 million AMI, 4 million HF, and 3.5 million pneumonia hospitalizations. Between 2006 and 2014. in-hospital mortality decreased for the 3 conditions (AMI, from 10.4% to 9.7%; HF, from 4.3% to 3.5%; pneumonia, from 5.3% to 4.0%) while 30-day postdischarge mortality decreased from 7.4% to 7.0% for AMI (P for trend < .001), but increased from 7.4% to 9.2% for HF (P for trend < .001) and from 7.6% to 8.6% for pneumonia (P for trend < .001). Before the HRRP announcement, monthly postdischarge mortality was stable for AMI (slope for monthly change, 0.002%; 95% CI. -0.001% to 0.006% per month). and increased by 0.004% (95% CI, 0.000% to 0.007%) per month for HF and by 0.005% (95% CI, 0.002% to 0.008%) per month for pneumonia. There were no inflections in slope around HRRP announcement or implementation (P > .05 for all). In contrast, there were significant negative deflections in slopes for readmission rates at HRRP announcement for all conditions.CONCLUSIONS AND RELEVANCE Among Medicare beneficiaries, there was no evidence for an increase in in-hospital or postdischarge mortality associated with HRRP announcement or implementation-a period with substantial reductions in readmissions. The improvement in readmission was therefore not associated with any increase in in-hospital or 30-day postdischarge mortality.