Nov. 29, 2011 In an analysis of the outcomes for more than 15,000 patients who underwent a percutaneous coronary intervention (PCI; procedures such as balloon angioplasty or stent placement used to open narrowed coronary arteries), nearly one in 10 were readmitted to the hospital within 30 days, and these patients had a higher risk of death within one year, according to a study published Online First by the Archives of Internal Medicine, one of the JAMA/Archives journals. Various factors were associated with hospital readmission, including female sex, Medicare insurance, unstable angina and others.
"Thirty-day readmission rates have become a quality performance measure, and the Center for Medicare and Medicaid Services (CMS) publicly reports hospital-level, 30-day, risk-standardized readmission rates for patients hospitalized with congestive heart failure (CHF), acute myocardial infarction [AMI; heart attack], and for patients undergoing PCI," according to background information in the article. "However, little is known regarding the factors associated with 30-day readmission after PCI."
Farhan J. Khawaja, M.D., of the Mayo Clinic and Mayo Foundation, Rochester, Minn., and colleagues conducted a study to identify factors associated with 30-day readmission rates, the reason for the readmission, and the association of 30-day readmission with one-year mortality for patients after PCI. For the study, the researchers identified 15,498 PCI hospitalizations (elective or for acute coronary syndromes) from January 1998 through June 2008. Various models were used to estimate the adjusted association between demographic, clinical, and procedural variables and 30-day readmission and 1-year mortality.
The researchers found that overall, 1,459 patients who had PCI procedures (9.4 percent) were readmitted within 30 days. There were 106 deaths within 30 days (0.68 percent), including 33 deaths that occurred during or after a readmission and 73 deaths that were not associated with a readmission. "After multivariate analysis, demographic factors associated with an increased risk of 30-day readmission after PCI included female sex, Medicare insurance, and less than a high school education. The clinical and procedural factors associated with an increased risk of readmission included CHF at presentation, cerebrovascular accident or transient ischemic attack, moderate to severe renal disease, chronic obstructive pulmonary disease, peptic ulcer disease, metastatic cancer, and a length of stay of more than three days," the authors write. Of the 1,459 PCIs readmitted within 30 days, 1,003 (69 percent) were readmitted for cardiac-related reasons.
After adjustment for various factors, patients who were readmitted within 30 days had a higher rate of death at one year compared with patients who were not readmitted.
"Thirty-day risk-standardized readmission rates after PCI have become a publicly reported performance measure, and there is high interest from hospitals and clinicians to understand and improve modifiable factors associated with 30-day readmission rates," the researchers write.
"Lack of early follow-up has been associated with increased risk of readmission among patients with heart failure and may also be playing a role in patients undergoing PCI. Early follow-up allows patients and clinicians to ensure understanding and compliance, and to gauge the effectiveness of therapies. The educational component of follow-up cannot be underestimated because in one study, less than half of patients were able to list their diagnoses and the names, purpose, and adverse effects of their medications at the time of discharge. Education at the time of discharge and early follow-up also needs to be tailored to patient education level, which has previously been shown to be associated with the risk of readmission among Medicare beneficiaries."
Commentary: Prediction Is Very Hard, Especially About the Future
In an invited commentary accompanying the article, Adrian F. Hernandez, M.D., M.H.S., and Christopher B. Granger, M.D., of Duke University Medical Center, Durham, N.C., write that "in the end, reducing hospital readmission rates by preventing progression of disease and occurrence of events should be a goal of care."
"To reduce readmissions, we need better evidence on effective approaches that address our health systems shortcomings, ideally identifying and intervening in the most vulnerable patients. Early outpatient follow-up may be a strategy to reduce readmissions but other interventions will be necessary for this complex, multifaceted problem. Understanding the common issues between PCI readmissions vs. other medical or surgical conditions will be necessary to have broad-based solutions. The challenge is determining what, if any, of these solutions will reduce readmissions and improve overall quality of care during this period of patient vulnerability and fragmented care."
Hospital Readmission Occurs Frequently For Patients With Certain Type of Heart Attack Who Receive PCI
Patients with a ST-segment elevation myocardial infarction (STEMI; a certain pattern on an electrocardiogram following a heart attack) who received a primary percutaneous coronary intervention (PCI) had a hospital readmission rate of 7 to 20 percent after 3 years for new coronary revascularization procedures, heart failure, heart attack, and serious bleeding events, which were negatively associated with long-term survival for these patients, according to results of a research letter published in the Nov. 28 issue of the Archives of Internal Medicine, one of the JAMA/Archives journals.
"The implementation of primary percutaneous coronary intervention has significantly improved the clinical outcome of patients admitted for STEMI. However, some patients still develop recurrent adverse events, with a negative impact on survival," according to background information in the article.
Gianluca Campo, M.D., of the Azienda Ospedaliera Universitaria Sant'Anna and Laboratorio di Terapie e Tecnologie Avanzate, Ferrara, Italy, and colleagues analyzed data from the REAL (Regisiro Angioplastiche dell'Emilia-Romagna) registry in order to evaluate the 3-year readmission rate for cardiovascular causes and their influence on death. The study population included 11,118 patients with STEMI (from January 2003 to June 2009) undergoing primary PCI enrolled in the REAL registry. After the index hospitalization, the researchers observed 7,867 readmissions.
"The most frequent diseases or conditions associated with hospital readmissions were coronary revascularization (CR; 28 percent), acute or congestive heart failure (HF; 26 percent), supraventricular arrhythmias (SA; 13 percent), MI (11 percent), and serious bleeding events (SBE; 10 percent). Interestingly, the patients with one hospital admission for HF, SA, or SBE frequently showed a second (or more) readmission for the same cause (36 percent, 34 percent, and 22 percent, respectively). All these events tended to be more frequent during the first year. This was particularly evident for CR. Approximately 60 percent of these procedures was target vessel revascularization, whereas approximately 17 percent was staged intervention," the authors write.
Overall, there were 1,779 deaths. The cumulative incidence of death was 12.1 percent at one year and 17.5 percent at three years. Mortality was associated with the occurrence of adverse events requiring a new hospitalization.
"Several registries suggest that there is an underuse of effective cardiac therapies. Our findings reinforce the need for the application of timely and effective preventive and treatment strategies," the researchers write.
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- Farhan J. Khawaja; Nilay D. Shah; Ryan J. Lennon; Joshua P. Slusser; Aziz A. Alkatib; Charanjit S. Rihal; Bernard J. Gersh; Victor M. Montori; David R. Holmes; Malcolm R. Bell; Jeptha P. Curtis; Harlan M. Krumholz; Henry H. Ting. Factors Associated With 30-Day Readmission Rates After. Archives of Internal Medicine, 2011; DOI: 10.1001/archinternmed.2011.569
- Adrian F. Hernandez; Christopher B. Granger. Prediction Is Very Hard, Especially About the Future: Can We Prevent Events That Lead to Readmission Following Percutaneous Coronary Intervention?: Comment on 'Factors Associated With 30-Day Readmission Rates After Percutaneous Coronary Intervention'. Archives of Internal Medicine, 2011; DOI: 10.1001/archinternmed.2011.568
- G. Campo, F. Saia, P. Guastaroba, J. Marchesini, E. Varani, A. Manari, F. Ottani, S. Tondi, R. De Palma, A. Marzocchi. Prognostic Impact of Hospital Readmissions After Primary Percutaneous Coronary Intervention. Archives of Internal Medicine, 2011; 171 (21): 1948 DOI: 10.1001/archinternmed.2011.536
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