Impact of Hospital Readmissions Reduction Program Penalties on Hip and Knee Replacement Readmissions: Comparison of Hospitals at Risk of Varying Penalty Amounts.

backgroundLittle is known about the impact of the U.S. Centers for Medicare & Medicaid Services' Hospital Readmissions Reduction Program (HRRP) expansion to include readmissions following elective primary total hip and knee replacements; the expansion was finalized in 2013 and was implemented in 2014. We examined whether hospitals at risk of relatively large penalties from this expansion experienced greater declines in joint replacement readmissions compared with hospitals at risk of smaller penalties.

methodsWe used Medicare's 2009 to 2016 Hospital Compare data sets to examine the impact of the HRRP's expansion in the July 2013 to June 2016 period (post-expansion) compared with the July 2009 to June 2012 period (pre-expansion). The primary outcome was the hospital-level, 30-day, risk-standardized readmission rate (hereafter called the readmission rate) following joint replacement surgical procedures. We used the percentage of a hospital's total inpatient revenue attributed to Medicare (categorized into quartiles) to represent the risk of penalties. We used hierarchical linear regression models to examine the adjusted impact of the HRRP's expansion.

resultsOur study cohort included 2,326 acute care hospitals. In the pre-HRRP expansion phase, the mean readmission rate was 5.36% among hospitals with the highest proportion of Medicare revenues (quartile 4) and 5.46% among hospitals with the lowest proportion of Medicare revenues (quartile 1). With the HRRP expansion, the readmission rate declined by 18.92% (1.01 percentage points) among quartile-4 hospitals and by 17.97% (0.98 percentage point) among quartile-1 hospitals (p = 0.45). This nonsignificant difference in readmission rate declines between quartiles persisted in multivariable analysis (a decline of 18.41% [0.98 percentage point] in quartile 4 and a decline of 17.35% [0.94 percentage point] in quartile 1; p = 0.35).

conclusionsThe HRRP's expansion to include joint replacements did not lead to greater reductions in postoperative readmissions among hospitals at risk of larger penalties in comparison with hospitals at risk of smaller penalties. Readmission rates were declining at similar rates among all hospitals, before and after the HRRP's expansion. CLINICAL RELEVANCE: Readmissions and complications following joint replacements are measures of the quality of surgical care. These events have important clinical and economic implications for patients and providers. This study is clinically relevant because it examines whether policy interventions, such as the HRRP, have the potential to reduce these unintended consequences of surgical care.