VA Achieves Reduction in Heart Failure Readmissions – Without Change in Mortality – Despite Non-Financial Incentives
Heart failure (HF) is a highly prevalent and costly disease with 6.5 million Americans affected (2011-2014) and an annual cost of $30.7 billion, 80% of which relates to hospitalizations. In October 2012, the Centers for Medicare and Medicaid Services initiated the Hospital Readmissions Reduction Program (HRRP), which targets HF readmission reduction through financial penalties on hospitals with high readmission rates. Readmission for HF decreased following implementation of HRRP; however, studies have raised concern for an associated mortality increase. This retrospective cohort study sought to evaluate trends in HF readmissions and mortality over the past decade in the VA healthcare system, which prioritized reducing readmissions without introducing financial penalties. Using data from all VA-paid HF admissions (VA and non-VA facilities) from 2007-2017, investigators identified 304,374 HF admissions from 164,566 patients over the 10-year study period. They then assessed all-cause 30-day and one-year readmission and mortality following discharge [Readmissions were excluded if not paid for by VA (about 10-15%)]. Left ventricular ejection fraction (LVEF) also was examined, as well as patient demographics, vital signs, weight, and recent comorbidities.
- Over a 10-year period in which VA worked to reduce hospital readmissions for Veterans with heart failure (e.g., through public reporting and QI programs), a steady decline in readmissions was seen with no increase in mortality. Between January 2007 and September 2017—
- There was a 2% decline in 30-day readmissions (from 11,792 of 52,748 patients to 15,578 of 76,662 patients) and a 1% decline in 1-year readmissions (from 32,341 of 52,748 patients to 31,659 of 52,544 patients).
- Mortality rates at 30 days decreased by 0.5% (from 3,060 of 52,748 patients to 4,159 of 78,058 patients), while mortality rates at 1-year increased by 1.3% (from 12,775 of 52,748 patients to 19,910 of 78,058 patients).
- Stratification by LVEF showed similar readmission reduction trends and no significant change in mortality regardless of strata.
- There were significant readmission reductions in all geographic regions of the United States, except the Western region.
- More needs to be done to identify drivers of readmission and to create better interventions that keep patients out of the hospital. The authors suggest prospective studies and randomized studies that look at the effects of those interventions across different hospitals and/or hospital systems.
- This study did not account for secular trends in HF severity that might differ between VA and non-VA populations, or additional policy changes unique to these systems.
Dr. Heidenreich leads MedSafe QUERI: Optimizing Appropriate Use of Medications for Veterans, and is part of HSR&D’s Center for Innovation to Implementation (Ci2i), both in Palo Alto, CA.
Parizo J, Kohsaka S, Sandhu A, Patel J, and Heidenreich P. Trends in Readmission and Mortality Rates Following Heart Failure Hospitalization in the Veterans Affairs Health Care System from 2007 to 2017. JAMA Cardiology. Brief Report. Epub ahead of print: June 17, 2020.