According to a study published Online First by the Archives of Internal Medicine, one of the JAMA/Archives journals, an examination of the outcomes of over 15,000 individuals who underwent a percutaneous coronary intervention (PCI; balloon angioplasty or stent placement procedures to open narrow coronary arteries) revealed that almost 1 in 10 individuals were readmitted to hospital within 30 days. Furthermore, these patients also had an increased risk of death within one year. Several factors were connected with hospital readmission, including Medicare insurance, female sex, unstable angina and others.
The researchers explain:
“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. 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 carried out an investigation in order to detect factors connected with 30-day readmission rates as well as the reason for the readmission and the connection of 30-day readmission with one-year mortality rates for individuals after PCI. The team identified 15,498 PCI hospitalizations (elective or for acute coronary syndromes) between January 1998 and June 2008. A range of models were used in order to estimate the adjusted connection between clinical, demographic, and procedural variable as well as 30-day readmission and one-year mortality.
The team found that overall, 9.4% (1,459) patients who had undergone PCI procedures were readmitted to hospital within 30 days. Out of the 1,459 patients readmitted 1,003 (69%) were readmission due to cardiac-related reasons. Within 30 days there were 106 deaths (0.68%), including 73 deaths not linked to a readmission and 33 deaths that occurred during or after readmission.
The researchers state:
“After multivariate analysis, demographic factors associated with an increased risk of 30-day readmission for 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 include 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.”
After the researchers adjusted for various factors they discovered that individuals who were readmitted within 30 days had a higher death rate at one year compared to individuals who were not readmitted.
The researchers explain:
“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.
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.”
Adrian F. Hernandez, M.D., M.H.S., and Christopher B. Granger, M.D., of Duke University Medical Center, Durham, N.C., wrote in an invited commentary accompanying the report:
“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 readmission and improve overall quality of care during this period of patient vulnerability and fragmented care.”
Written by Grace Rattue