Thirty-Day Postdischarge Mortality Among Black and White Patients 65 Years and Older in the Medicare Hospital Readmissions Reduction Program

Importance: The Medicare Hospital Readmissions Reduction Program (HRRP) has disproportionately penalized hospitals that treat many black patients, which could worsen health outcomes in this population. Objective: To determine whether short-term mortality rates increased among black and white adults 65 years and older after initiation of the HRRP and whether trends differed by race. Design, Setting, and Participants: In a cohort study using an interrupted time-series analysis conducted from March 15, 2018, to January 23, 2019, in 3263 eligible acute care hospitals nationally, risk-adjusted mortality rates observed after Medicare started to impose penalties (October 1, 2012, to November 30, 2014) were compared with projections based on pre-HRRP trends (January 1, 2007, to March 31, 2010) among adults 65 years and older with acute myocardial infarction (AMI), heart failure (HF), or pneumonia. Observed-to-projected differences were then compared between racial groups. Exposures: Hospital discharge during pre-HRRP and HRRP penalty periods. Main Outcomes and Measures: Thirty-day postdischarge all-cause mortality. Results: In the 3263 acute care hospitals included in the analysis, black patients (627 373 index discharges) were more likely than white patients (5 845 130 index discharges) to be younger (mean SD age, 77.8 8.3 vs 80.5 8.2 years; P < .001), women (60.5% vs 53.7%; P < .001), dually covered by Medicare and Medicaid (45.7% vs 17.2%; P < .001), and treated at a penalized hospital (AMI, 82.8%; HF, 83.8%; and pneumonia, 82.6% vs 69.6%; 73.3%; and 71.7%; all P < .001). Pre-HRRP mortality rates for black vs white patients were 7.04% (95% CI, 6.75% to 7.33%) vs 7.47% (95% CI, 7.37% to 7.57%) for AMI, 6.69% (95% CI, 6.56% to 6.82%) vs 8.56% (95% CI, 8.48% to 8.64%) for HF, and 8.08% (95% CI, 7.88% to 8.27%) vs 8.27% (95% CI, 8.19% to 8.35%) for pneumonia. By the HRRP penalty period, observed mortality for AMI decreased more, relative to projections, among black than white patients (difference-in-differences, -1.65 percentage points; 95% CI, -3.19 to -0.10; P = .04). For HF, mortality increased relative to projections among white patients but not among black patients; however; mortality trends did not differ by race (difference-in-differences, -0.37 percentage points; 95% CI, -1.08 to 0.34; P = .31). For pneumonia, observed mortality was similar to projections in both racial groups, and trends did not differ by race (difference-in-differences, -0.54 percentage points; 95% CI, -1.66 to 0.59; P = .35). At both penalized and nonpenalized hospitals, mortality trends were similar or decreased more among black patients than white patients. Conclusions and Relevance: In this study of patients 65 years and older, short-term postdischarge mortality did not appear to increase for black patients under the HRRP, suggesting that certain value-based payment policies can be implemented without harming black populations. However, mortality seemed to increase for white patients with HF and this situation warrants investigation.