Study Shines Spotlight on US Readmissions After STEMI

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Thirty-day readmissions after ST-segment elevation myocardial infarction (STEMI) occur in greater than 1 in 10 treated patients, but the rate is higher in United States than in other countries, according to a study published in the January 4, 2012, issue of the Journal of the American Medical Association. The finding raises the questions of why the United States should be so different and what can be done to reduce repeat hospitalizations, researchers say.

For the retrospective analysis, Manesh R. Patel, MD, of Duke University Medical Center (Durham, NC), and colleagues studied data from 5,745 STEMI patients enrolled in the APEX AMI (Assessment of Pexelizumab in Acute Myocardial Infarction) trial from July 2004 to May 2006 who were slated for primary PCI. The study population included patients treated in the United States, Canada, Australia, New Zealand, and 13 European countries.

Of the 5,571 patients who survived to hospital discharge, 631 (11.3%) were readmitted within 30 days. The readmission rate of the US patients was 14.5% (95% CI 12.9%-16.2%), while that of patients outside the United States was 9.9% (95% CI 9.0%-10.9%).

Once readmissions for elective revascularization were excluded, 8.6% of patients from the overall cohort were readmitted, accounting for 10.5% (95% CI 9.0%-11.9%) of patients in the United States and 7.7% (6.9%-8.6%) of those outside the country.

Readmitted patients were more likely to have multivessel disease (57.1% vs. 38.2%; P < 0.001) and noninferior MI (63.9% vs. 58.1%; P = 0.005). Moreover, a larger proportion of the readmitted subgroup hailed from the United States compared with the subgroup that did not require repeat hospitalization (39.1% vs. 29.4%; P < 0.001).

Length of Stay Key

Lengths of stay were longer for patients outside the United States, amounting to 3 days or fewer for 60.0% of US patients vs. 15.9% outside the country (P < 0.001). In addition, hospital stays lasted 6 days or longer for 16.6% of US patients vs. 54.0% of those outside the United States (P < 0.001). On average, the duration ranged from 3 days in the United States to 8 days in Germany.

After adjustment for baseline characteristics, patient length of stay was no longer a significant predictor of 30-day readmission. The strongest predictors were:

  • Multivessel disease: OR 1.97; 95% CI 1.65-2.35
  • US enrollment: OR 1.68; 95% CI 1.37-2.07
  • Baseline heart rate: OR 1.09; 95% CI 1.05-1.15

However, when the researchers adjusted for length of stay, US enrollment was no longer associated with readmission (OR 1.18; 95% CI 0.87-0.96).

Adjusted readmission rates varied from 4.4% in Italy to 14.4% in Denmark, which corresponded with odds ratios ranging from 0.26 (95% CI 0.15-0.43) to 1.44 (95% CI 0.93-2.23) compared with the United States. The adjusted remission rate for all countries except the United States was 9.3% (OR 0.59; 95% CI 0.48-0.73).

With multivessel disease and US enrollment as the strongest predictors of readmission, Dr. Patel told TCTMD that the former is understandable, but the latter “points us to try and understand what the drivers are for readmission in the United States.” Importantly, the results indicate “a need to learn from other countries what we can do to prevent readmission,” he said in a telephone interview.

However, “we’re not saying that patients have to stay in the hospital longer after a heart attack. In fact, I think they can safely still be discharged at 3 to 4 days,” Dr. Patel said, adding that the time during which the patient is initially hospitalized should be used in an efficient manner and that discharge should only happen with a proper follow-up plan.

“We have to be very careful to make sure things are in place so the patient doesn’t get readmitted,” he said.

The Economics of Readmissions

In contrast, Jeffrey W. Moses, MD, of Columbia University Medical Center/Weill Cornell Medical Center (New York, NY), questions whether readmissions are necessarily bad or cost-ineffective. With the United States’ average initial hospitalization time at 3 days, he points out that the US system is actually cheaper than for example, Germany’s, where patients spend on average 8 days in the hospital.

“The authors don’t do this analysis,” he said in a telephone interview with TCTMD. “They just think that readmissions are bad, but they are not necessarily bad if you are cutting costs in other areas, like initial hospitalization.”

Dr. Moses also noted that because there is no mortality difference related to readmission, such hospitalizations are only considered bad because they are considered more expensive.

“[Other countries] are keeping people in too long,” he said. “No one is looking at those economics and this whole focus on readmissions is missing the fact that we don’t even know why these people are going back in. All they talk about is that the United States has opportunities to reduce readmission rates. They say that maybe we’re sending people out too quickly, but that’s absurd. We’re saving a fortune with the earlier discharge, and yes there will be a tradeoff. There will be people coming back after discharges, but economically that makes sense as long as people aren’t having irreversible damage from it.”

‘Elephant in the Room’

Joseph G. Cacchione, MD, of the Cleveland Clinic Foundation (Cleveland, OH), agreed, observing that “the effort to demonize the US health care system seems to dominate the medical literature.”

In a telephone interview with TCTMD, he noted that, “readmissions are ‘so bad’ because our system of reimbursement has decided that if you get admitted to the hospital for something, it’s going to cost a lot more money. Really, payment is the elephant in the room here. The payment system cannot be divorced from this readmission problem.”

Dr. Cacchione disagreed with the notion that readmissions should be a mark of health care quality. There are some situations where readmissions are necessary, he asserted, and further research needs to be completed on the cost/benefit ratio of readmitting patients.

“We have to understand longitudinal care over a long period of time,” he said. “Maybe patients who get readmitted are better off. We have to understand readmissions better within the context of the whole episode of care, not just the readmission.”

Ultimately, Dr. Moses sees these results as positive news for the US health care system, because the additional readmissions show that at least initially, US hospitals are more efficient and do not keep patients longer than necessary.

“No one has proven that [readmission is a quality issue] yet, but people are just jumping on this bandwagon without really understanding what these things mean, and whether these rates are too high or too low,” he concluded. “These readmission penalties are not based on sound data and no one seems to be picking up on this. Ironically, I think this is a great data set to prove that.”

Study Details

The median age for all patients was 61 years. Patients who were readmitted within 30 days had higher rates of comorbidities, including previous coronary artery disease, hypertension, and diabetes. Overall, patients who were readmitted had higher rates of in-hospital complications, including congestive heart failure and atrial fibrillation.

 


Source:
Kociol RD, Lopes RD, Clare R, et al. International variation in and factors associated with hospital readmission after myocardial infarction. JAMA. 2012;307:66-74.

 

 

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Disclosures
  • Drs. Cacchione, Moses, and Patel report no relevant conflicts of interest.

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