Comparative Trends in Payment Adjustments Between Safety-Net and Other Hospitals Since the Introduction of the Hospital Readmission Reduction Program and Value-Based Purchasing

In the Research Letter titled “Comparative Trends in Payment Adjustments Between Safety-Net and Other Hospitals Since the Introduction of the Hospital Readmission Reduction Program and Value-Based Purchasing” published in the April 18, 2017, issue of JAMA, we reported incorrect trends in excess readmission ratios.¹ This study was a retrospective analysis of public data on hospital payment adjustments levied under the Hospital Readmission Reduction Program (HRRP) and Value-Based Purchasing differentiated by safety-net vs non–safety-net hospital status. The original article also analyzed the underlying excess readmission ratios used to calculate the HRRP payment penalties.

Readers noticed that the excess readmission ratios were lower than would be expected. In reviewing our data, we found that we had made a coding error while conducting initial sensitivity analyses. We assigned hospitals that had an insufficient volume of patients for the given HRRP conditions as having an excess readmission ratio value of 0, rather than a value of 1. Assigning a value of 1 implies that the low-volume hospitals’ readmissions were no different than expected, which is what we intended. In contrast, assigning them a 0 implied perfect performance (no readmissions), which we did not intend and which overstates performance. In addition, in reviewing our analytic files, we discovered we had applied exclusion criteria to our sample of hospitals that were salient to earlier published work but not to this study, resulting in 163 hospitals being excluded from the analysis.

Including the 163 additional hospitals had little effect on our main results. However, correcting the coding error and assigning hospitals with low volumes of patients in a particular condition category substantially changed the potential implications of this result. As such, we have requested the retraction and replacement of our original article. We have also gone back through our analysis in detail to ensure there are no other errors.

The effect of including the 163 hospitals is seen in minor changes to Table 1. The correction of the miscoding of the excess readmission ratios for low-volume hospitals with a 1 instead of 0 has resulted in changes to Table 2 of substantial magnitude. In sum, the mean excess readmission ratios for safety-net hospitals were above 1 throughout the period for all conditions tracked under the HRRP (not just pneumonia and heart failure as originally reported) and did not change in a meaningful way over time (in contrast to the decrease in fiscal year [FY] 2016 originally reported). Among non–safety-net hospitals, the mean excess readmission ratio was below 1 throughout the period for acute myocardial infarction, pneumonia, heart failure, and chronic obstructive pulmonary disease, as originally reported, but changed for knee and hip arthroplasty, for which it was just above 1 in both years these procedures were included in the HRRP. Our original conclusion that the performance of safety-net hospitals on the HRRP improved between FY 2013 and FY 2016 is unchanged. However, that the improvements may have been associated with improvements in readmission rates for pneumonia and heart failure is no longer correct. Rather, as we now point out in the replacement article, “The performance of safety-net hospitals on the HRRP has improved between FY 2013 and FY 2016 as reflected in the penalties. This does not appear to be driven by meaningful reductions in the excess readmission rates at safety-net hospitals but rather may have been driven by the design of the program and addition of arthroplasty readmission to the program in FY 2015, with mean excess readmission ratios above 1 for both types of hospitals in 2015 and 2016.”

We regret these errors and the confusion it may have caused JAMA, readers, and policy makers. We are thankful for the readers who pointed out the error in a timely fashion and in sufficient detail to allow us to quickly track down the issue and avoid extended public discourse based on incorrect analyses. The original article has been corrected, and an online supplement with the original version of the article with the incorrect information highlighted and a version of the replacement article with the corrections highlighted is available.