Heavy US Burden of 30-Day Readmissions After PCI

Patrice Wendling

April 13, 2018

Nearly 1 in 10 patients undergoing contemporary percutaneous coronary intervention (PCI) will return for an unplanned readmission within 30 days, a national analysis suggests.  

Moreover, in-hospital mortality was 2.4% for the index PCI but rose to 2.8% for cardiac readmissions and 3.1% for noncardiac readmissions, which made up the lion's share of bouncebacks.

Senior study author, Mamas Mamas, BMBCh, DPhil, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom, told theheart.org | Medscape Cardiology that part of the problem is interventional cardiologists in both the United States and the United Kingdom face increasing pressure to reduce hospital length of stay or to perform PCI as an outpatient procedure.

"That might be reasonable because the rates of cardiac complications have declined, partly because of better technique, better drugs, better platforms, better imaging," he said. "But on the other hand, that really takes away our ability to manage the patient holistically. We often think of patients as angiograms with legs rather than thinking of the patient as a holistic entity; and whilst we manage their coronary disease, they have a number of other conditions, comorbidities."

Indeed, patients who were readmitted were older than those who did not return to hospital (67.3 years vs 64.5 years), were more likely to be female (39.4% vs 31.3%), and were more likely to have more comorbidities (mean, 5.7 vs 4.9) and a higher Charlson Comorbidity Index score (1.9 vs 1.3; P < .001).

In multiple regression, Charlson score (odds ratio [OR], 1.28; 95% CI, 1.27 - 1.29) and number of comorbidities (OR, 1.18; 95% CI, 1.17 - 1.18) were independent predictors of readmission.

Some of the largest ORs were observed for the comorbidities of chronic kidney disease (OR, 1.50), liver disease (OR, 1.42), atrial fibrillation (OR, 1.41), and chronic lung disease (OR, 1.36; P value for all < .001), according to the study, appearing in the April 9 issue of JACC Cardiovascular Interventions.

"I was really shocked that 1 in 10 patients are readmitted," Mamas said. "It's not the sort of number we encounter in clinical practice, and I think the reason for that is that patients get admitted under different teams, so as the interventional cardiologist, we don't know that they've been readmitted."

"If readmissions are going to be used as a quality metric — and I think it is a quality metric maybe not just of the PCI procedure but perhaps of the overall quality of care that a patient receives in the hospital — then this is where, in my view, we have to think about closer working between different specialties," he added.

Though unplanned readmissions within 30 days are used to deny UK hospitals payment for index procedures and an individual physician's PCI mortality and major adverse coronary event rate can be found online, there is no national readmissions database.

As a result, the investigators, led by Chun Shing Kwok, MBBS, Keele University, Stoke-on-Trent, examined data from 833,344 patients in the US Nationwide Readmissions Database who underwent PCI from 2013 to 2014. Of these, 9.3% had an unplanned readmission within 30 days.

Overall, 56.1% of unplanned readmission were due to noncardiac causes. Most commonly these were for nonspecific chest pain (14.8%), infection (12.3%), gastrointestinal disease (10.4%), respiratory disease (8.6%), and major bleeding complications (5.9%). The most common causes of cardiac readmissions were coronary artery disease, including angina (31.6%), heart failure (25.1%), acute myocardial infarction (21.6%), arrhythmias (15.8%), and pericarditis (1.5%).

Mehdi Shishehbor, DO, MPH, Cleveland Medical Center, Ohio, who coauthored a related editorial, told theheart.org | Medscape Cardiology the study is more comprehensive than prior reports restricted to Medicare patients and thus was able to show, for example, that patients with private insurance (OR, 0.67) and the uninsured (OR, 0.69) had lower readmission rates.

"Is that bad or good, it's hard to know," he said. "Does it mean that they had a higher mortality because they weren't readmitted or that folks who are uninsured are less likely to go to the emergency room because they know they don't have insurance?"

"It's a really sophisticated healthcare system that we have yet it's rudimentary in the sense that patients go to another location and you don't have their records, you don't even know how to get a hold of the person that did the intervention," Shishehbor said.

Notably, the risk for an unplanned 30-day readmission was higher for patients discharged to a short-term hospital (OR, 1.62), care facility (OR, 1.57), or transferred to another institution (OR, 1.41) vs home.

For patients who left against medical advice, the risk was nearly double (OR, 1.91; 95% CI, 1.65 - 2.22), the highest in the study.

"We have another paper coming out looking specifically at discharge against medical advice and they have a really huge risk of unplanned readmission," Mamas said. "And if someone discharges against medical advice in the US, they're pretty much on their own."

"In the UK, every patient has a primary care physician, so in these sorts of cases it would be our responsibility to contact the primary care physician" who then can prepare a drug script to make sure the patient at least gets their antiplatelet therapies, he said.

The editorialists, led by Ankur Kalra, MD, also from Cleveland Medical Center, write that better risk models are needed to identify patients at high risk for readmission and that streamlining discharge disposition based on pre-PCI risk-adjusted readmission screening may guide clinical decision making and resource allocation at discharge.

They also caution that "reducing appropriate readmissions may come at a cost" and highlight a recent study in which reductions in heart failure hospitalizations after implementation of the Hospital Readmission Reduction Program were accompanied by increased 30-day mortality.

"We need to be a little bit more sophisticated in regard to when we say 'readmission,' what type of readmission that is," Shishehbor said. "Should a physician be punished if the patient got a PCI and was then readmitted for a UTI or sinusitis?"

"We are just focused on the endgame, the end result, which is readmission, but we are not really rewarding the institutions that are taking initiatives to be personalized, to identify high-risk patients, and to implement programs that will reduce readmissions," he said. "That would help us understand which readmissions are bad and which readmissions are good. If you're doing all the right things and the patient gets readmitted appropriately, then you should actually be rewarded, not punished."

The study was conducted as part of Kwok's PhD research, which was supported by Biosensors International. Kalra is a consultant to Medtronic. Shishehbor is a consultant and advisory to Abbott, Medtronic, Philips, and Boston Scientific. Simon has received honoraria for educational activities from Medtronic.

JACC Cardiovasc Interv. 2018;11:665-674, 675-676. Abstract, Editorial

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