JAMA surgery 2017 11 22() doi 10.1001/jamasurg.2017.4585
Readmissions after surgery lead to poor patient outcomes and increased costs. The Hospital Readmissions Reduction Program (HRRP) penalizes hospitals with excess readmissions after specified medical and surgical discharges.
To evaluate the association of the HRRP with readmissions after major joint surgery (targeted) and procedures with historically high rates not under its purview (nontargeted).
Design, Setting, and Participants
In this population-based analysis using a 20% Medicare sample, a retrospective cohort study was performed of patients undergoing one of 5 major surgical procedures between January 1, 2006, and November 30, 2014. The study included 507 663 patients with targeted (total knee arthroplasty and total hip arthroplasty) and 164 472 patients with nontargeted (abdominal aortic aneurysm repair, colectomy, and lung resection) procedures performed at 2773 hospitals.
Implementation of the HRRP policy.
Main Outcomes and Measures
Hospital-level 30-day risk-adjusted rates of readmission and observation stays were calculated using multivariable logistic regression models. Changes in these rates were analyzed for 3 distinct periods (prepolicy [January 1, 2006, to June 30, 2010], performance [July 1, 2010, to June 30, 2013], and penalty [July 1, 2013, to November 30, 2014]) corresponding to the HRRP implementation timeline for major joint surgery using interrupted time series.
Among 672 135 Medicare beneficiaries 66 years or older treated at 2773 hospitals, readmissions for all procedures decreased significantly over the study period. Readmission rates after targeted procedures decreased faster during the performance period (slope, -0.060; 95% CI, -0.079 to -0.041) compared with the prepolicy period (slope, -0.012; 95% CI, -0.027 to 0.034) (P < .002). For the nontargeted procedures, readmission rates were decreasing during the prepolicy period (slope, -0.200; 95% CI, -0.240 to -0.160) but stabilized during the performance period (slope, 0.008; 95% CI, -0.049 to 0.066 (P < .001). The use of observation stays increased slightly, accounting for 11% of the decrease in readmissions. Conclusions and Relevance
The HRRP effectively decreased readmissions for targeted procedures. There were no associated spillover effects for common nontargeted procedures. A better understanding of differences in the association of the policy with medical and surgical discharges will be necessary to further enhance its generalizability.