Community Factors Drive Hospital Readmissions in the Delta, Study in The American Journal of Managed Care&reg Finds

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The Hospital Readmissions Reduction Program (HRRP) has been controversial since it began in 2013, with critics saying it unfairly penalizes facilities that serve patients with chronic health issues. A study in the current issue of The American Journal of Managed Care® finds that community factors also matter a lot in a very poor region: the Mississippi Delta.

How much do community factors drive 30-day readmission rates, the yardstick that Medicare has used since 2013 to gauge whether patients with heart failure or a heart attack get adequate follow-up care?

In the Mississippi Delta, one of the country’s poorest areas, community factors matter a lot—so much so that once they are accounted for, readmissions here were not much different from those in the rest of the country for heart failure and were about the same for pneumonia and heart attacks (acute myocardial infarction), according to a new study.

Authors from the College of Public Health at the University of Arkansas for Medical Sciences, led by Hsueh-Fen Chen, PhD, write that their results have important policy implications—rather than rate hospitals entirely based on their performance compared with national averages, hospitals should be judged in part against prior performance.

To conduct the study, they examined data from 2013-2016 for counties that fall under the Mississippi Delta Regional Authority, in parts of eight states: Alabama, Arkansas, Illinois, Kentucky, Louisiana, Mississippi, Missouri, and Tennessee. The researchers compared 30-day readmission ratios for hospitals in the Delta region, the remaining counties of the eight Delta states, and the rest of the nation.

They found that when they did not control for hospital and community factors, Delta region and state hospitals had higher readmission ratios for pneumonia, heart failure, and heart attacks. But when they controlled for hospital and community factors, the significant difference in readmission ratios for pneumonia and heart attack disappeared, and the difference for heart failure was much less pronounced.


Factors linked to higher readmission ratios for pneumonia and heart failure were whether a patient was treated in a major teaching hospital, which tend to take the sickest patients, and the percentage of the community that is African American. Curiously, high poverty was associated with lower readmissions for heart attacks, but the researchers noted that mortality rates for this condition are very high if patients cannot access treatment in a timely manner.

In recent months, researchers from Harvard have found that HRRP has disproportionately penalized hospitals that serve minorities, and a group of cardiologists published a blockbuster finding that although 30-day readmissions are dropping, deaths from heart failure appear to be rising.

The authors of the Mississippi Delta study called for revisions to the HRRP, such as including improvement from past performance in penalty calculations and adding community characteristics in risk adjustment models. “This would likely reduce the unintended consequences of HRRP that may, with reductions in Medicare reimbursement, threaten the healthcare delivery system in the Mississippi Delta region and other similarly underserved areas,” they wrote.

In fact, CMS has recently updated the program in response to such criticism. In 2018, CMS has updated performance criteria to base a hospital’s penalties relative to other hospitals that are treating a similar share of Medicare patients who are also eligible for Medicaid, starting with fiscal year 2019.

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Surabhi Verma