• Roshun Sankaran, Devraj Sukul, Ushapoorna Nuliyalu, Baris Gulseren, Tedi A Engler, Emily Arntson, Hanna Zlotnick, Justin B Dimick, and Andrew M Ryan.
• University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109, USA.
• BMJ. 2019 Jul 3; 366: l4109.

ObjectiveTo evaluate the association between hospital penalization in the US Hospital Acquired Condition Reduction Program (HACRP) and subsequent changes in clinical outcomes.DesignRegression discontinuity design applied to a retrospective cohort from inpatient Medicare claims.Setting3238 acute care hospitals in the United States.ParticipantsMedicare fee-for-service beneficiaries discharged from acute care hospitals between 23 July 2014 and 30 November 2016 and eligible for at least one targeted hospital acquired condition (n=15 470 334).InterventionHospital receipt of a penalty in the first year of the HACRP.Main Outcome MeasuresEpisode level count of targeted hospital acquired conditions per 1000 episodes, 30 day readmissions, and 30 day mortality.ResultsOf 724 hospitals penalized under the HACRP in fiscal year 2015, 708 were represented in the study. Mean counts of hospital acquired conditions were 2.72 per 1000 episodes for penalized hospitals and 2.06 per 1000 episodes for non-penalized hospitals; 30 day readmissions were 14.4% and 14.0%, respectively, and 30 day mortality was 9.0% for both hospital groups. Penalized hospitals were more likely to be large, teaching institutions, and have a greater share of patients with low socioeconomic status than non-penalized hospitals. HACRP penalties were associated with a non-significant change of -0.16 hospital acquired conditions per 1000 episodes (95% confidence interval -0.53 to 0.20), -0.36 percentage points in 30 day readmission (-1.06 to 0.33), and -0.04 percentage points in 30 day mortality (-0.59 to 0.52). No clear patterns of clinical improvement were observed across hospital characteristics.ConclusionsPenalization was not associated with significant changes in rates of hospital acquired conditions, 30 day readmission, or 30 day mortality, and does not appear to drive meaningful clinical improvements. By disproportionately penalizing hospitals caring for more disadvantaged patients, the HACRP could exacerbate inequities in care.Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

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