Medicare has imposed payments cut to hospitals with high re-admission rates by the implementation of the Hospital Readmission Reduction Program (HRRP). Then, we have seen a drop in the re-admission rate in the USA. The same phenomenon was observed in Canada where no equivalent of HRRP was found.
A cohort study of more than 3 million adults admitted for heart failure treating patients from 2005 through 2015 has shown a 30-day re-admission rate in both country US (21.2% to 18.5%) compared to Canada (19.7% to 17.6%) was almost similar. This observation was made by Finlay McAllister MD and colleagues of the University of Alberta in Edmonton.
Years before the HHRP changes (2012), there were no difference in the re-admission rate in both country as reported in the JAMA Cardiology. The length of stay went down marginally in Canada 7.5 to 7.3 days) while it remains stable in the United States at 4.9 days. Benefits with the HRRP program on the re-admission rate were modest. More, a false impression that the financial penalties may have overshadowed the implementation of the program.
Money was withheld from hospitals showing a higher than expected re-admission rate in the goals to achieve better outcomes especially on heart failure patients or patients admitted with a diagnosis of pneumonia or myocardial infarcts. A drop in the re-admission rate for these conditions was recorded in many studies linking the HHRP to a higher mortality rate.
Medicare patients in the USA and patients from the Canadian Health Institute were used for this study but unfortunately, the out-of-hospital deaths were not recorded, bringing restrictions on the outcomes of the study. Others concluded that this study may have not bought any benefit at all to the management of such patients in the United States and Canada but on the contrary, changes in clinical practice may have been responsible.
There may be some pharmacological and non-pharmacological factors as well, which have contributed to the improvements notably a greater use of the electronic health records, better approaches to caring for patient with heart failure etc. in both countries while physicians may have enhanced their ability to care for such patients. All have also contributed to the drop in the re-admission rate. We believe that all physicians practicing should understand the rationale in admission vs re-admission rate and compare such in their practice. The importance of the Primary Care Physician or the Family Practice Physician is in this process is primordial.
McAllister study was supported by the National Heart, Lung and Blood Institute grant as well as the Alberta Health Services Chair in Cardiovascular Outcomes.
Maxime Coles MD
1- Samsky MD et al “Trends in re-admissions and length of stay for patients hospitalized with heart failure in Canada and the United States” JAMA Cardiology2019.
2- JHA AK: “What re-admissions rate in Canada tell us about the Hospital Re-Admission Reduction Program. JAMA Cardiology (2019)