Thirty-Day Postdischarge Mortality Among Black and White Patients 65 Years and Older in the Medicare Hospital Readmissions Reduction Program
Authors: Peter Huckfeldt, José Escarce, Neeraj Sood, Zhiyou Yang, Ioana Popescu, Teryl Nuckols
Journal: JAMA Network Open (2019)

<h3>Importance</h3> The Medicare Hospital Readmissions Reduction Program (HRRP) has disproportionately penalized hospitals that treat many black patients, which could worsen health outcomes in this population. <h3>Objective</h3> To determine whether short-term mortality rates increased among black and white adults 65 years and older after initiation of the HRRP and whether trends differed by race. <h3>Design, Setting, and Participants</h3> In a cohort study using an interrupted time-series analysis conducted from March 15, 2018, to January 23, 2019, in 3263 eligible acute care hospitals nationally, risk-adjusted mortality rates observed after Medicare started to impose penalties (October 1, 2012, to November 30, 2014) were compared with projections based on pre-HRRP trends (January 1, 2007, to March 31, 2010) among adults 65 years and older with acute myocardial infarction (AMI), heart failure (HF), or pneumonia. Observed-to-projected differences were then compared between racial groups. <h3>Exposures</h3> Hospital discharge during pre-HRRP and HRRP penalty periods. <h3>Main Outcomes and Measures</h3> Thirty-day postdischarge all-cause mortality. <h3>Results</h3> In the 3263 acute care hospitals included in the analysis, black patients (627 373 index discharges) were more likely than white patients (5 845 130 index discharges) to be younger (mean [SD] age, 77.8 [8.3] vs 80.5 [8.2] years;<i>P</i> &lt; .001), women (60.5% vs 53.7%;<i>P</i> &lt; .001), dually covered by Medicare and Medicaid (45.7% vs 17.2%;<i>P</i> &lt; .001), and treated at a penalized hospital (AMI, 82.8%; HF, 83.8%; and pneumonia, 82.6% vs 69.6%; 73.3%; and 71.7%; all<i>P</i> &lt; .001). Pre-HRRP mortality rates for black vs white patients were 7.04% (95% CI, 6.75% to 7.33%) vs 7.47% (95% CI, 7.37% to 7.57%) for AMI, 6.69% (95% CI, 6.56% to 6.82%) vs 8.56% (95% CI, 8.48% to 8.64%) for HF, and 8.08% (95% CI, 7.88% to 8.27%) vs 8.27% (95% CI, 8.19% to 8.35%) for pneumonia. By the HRRP penalty period, observed mortality for AMI decreased more, relative to projections, among black than white patients (difference-in-differences, −1.65 percentage points; 95% CI, −3.19 to −0.10;<i>P</i> = .04). For HF, mortality increased relative to projections among white patients but not among black patients; however; mortality trends did not differ by race (difference-in-differences, −0.37 percentage points; 95% CI, −1.08 to 0.34;<i>P</i> = .31). For pneumonia, observed mortality was similar to projections in both racial groups, and trends did not differ by race (difference-in-differences, −0.54 percentage points; 95% CI, −1.66 to 0.59;<i>P</i> = .35). At both penalized and nonpenalized hospitals, mortality trends were similar or decreased more among black patients than white patients. <h3>Conclusions and Relevance</h3> In this study of patients 65 years and older, short-term postdischarge mortality did not appear to increase for black patients under the HRRP, suggesting that certain value-based payment policies can be implemented without harming black populations. However, mortality seemed to increase for white patients with HF and this situation warrants investigation.