Reducing readmissions: At what cost?

Abstract

We read with great enthusiasm the article by Thurston et al on the utilization of a multidisciplinary team to reduce heart failure readmission rates with special attention focused on the pharmacist role. While we applaud the authors highlighting the positive impact that a pharmacist can have on reducing readmissions in this select patient cohort, we do wish to highlight some of our concerns. In recent years, there has been an increasing concern that the Hospital Readmissions Reduction Program (HRRP), while reducing readmissions, may be associated with increased mortality. While rooted in a fundamentally altruistic idea, pay for performance (P4P), which gives financial incentives to those who meet metrics determined by the HRRP, has been warped and manipulated into a process in which the patients suffer. Tying financial compensation to readmission rates can apply pressure to clinicians on delaying readmissions, increase utilization of observation days instead of admission, and implementing faulty triage systems to delay admissions until post 30 days discharge. In December 2018, Wadhera et al published a paper examining HRRP data and examining potential unintended consequences of its implementation. They found that after the announcement of HRRP and once implemented there was an increase in 30 days post discharge mortality in HF patients. While this was a retrospective study and causation cannot be attributed to HRRP, it does add to the growing body of literature on the unintended consequences of HRRP. The study presented by Hale et al adds to the paucity of literature on the impact that pharmacists can have on readmissions for patients with heart failure, with only one study to date showing a trend toward mortality reduction with a pharmacist impact. In the P4P era, higher quality evidence is needed on the impact a pharmacist can have on not only readmissions but mortality, as well. ORCID