Cardiac Complications Are a Common Cause of Readmission Following Endovascular AAA Interventions

Given the variety of reasons a patient may be rehospitalized, the study author argues that this metric should not be used to penalize hospitals.

Cardiac Complications Are a Common Cause of Readmission Following Endovascular AAA Interventions

About one in 10 patients are readmitted to the hospital within 30 days following endovascular aneurysm intervention (EVAI) for abdominal aortic aneurysm (AAA), primarily for reasons related to cardiac complications and infection, according to new data.

“Endovascular aneurysm treatment is becoming more and more popular, understandably. The data look quite strong and while vascular surgeons are the ones that most commonly perform these, there are a number of interventional cardiologists that perform them as well,” senior study author Deepak L. Bhatt, MD, MPH (Brigham and Women’s Hospital, Boston, MA), told TCTMD. “But it is an area that hasn't been incredibly well studied in terms of readmission, and much like in cardiology where we're looking at things like heart failure readmission and readmission after PCI, we thought it would be useful and informative to the medical community to take that same approach and look at readmissions after endovascular aneurysm treatment.”

For the study, published online December 19, 2018, ahead of print in the American Journal of Cardiology, lead author Varunsiri Atti, MD (Michigan State University, East Lansing), Bhatt, and colleagues looked at 138,014 AAA patients from the Nationwide Readmission Database who were treated with EVAI between 2010 and 2014.

Overall, 10.24% were readmitted within 30 days (median 11 days), with the main causes being cardiac conditions (16.34%), infection (15.40%), vascular complications (12.86%), and renal complications (10.91%). The most common cardiac conditions were heart failure (6.41%), ischemic heart disease (3.80%), and arrhythmia (2.76%). Among those who were readmitted, 0.23% had a repeat intervention and 4.45% died in the hospital.

The researchers found a progressive decline in readmissions over the study period from 11.3% in 2010 to 9.6% in 2014 (P for trend < 0.0001).

On multivariate analysis, older age, female sex, heart failure, A-fib, peripheral vascular disease, anemia, chronic obstructive pulmonary disease, and chronic kidney disease were linked with an increased 30-day readmission risk.

Benchmark Attained

The readmission rate found here “is not a trivial number” and will serve as a benchmark going forward, according to Bhatt.

Moreover, Bhatt said, the fact that cardiac complications commonly led to readmissions means that physicians should be rethinking how they approach many of these patients preoperatively. “We of course think about vascular surgery procedures like open surgery for AAA as something that requires preoperative cardiology assessment in many cases,” he said. “But perhaps we should also be using that approach for patients that are getting [EVAI]—that is, not just assuming because it's an endovascular AAA that that patient isn't at risk for cardiac complications. In fact, they are.”

In that vein, Bhatt suggested that postprocedural care might need to be changed in some patients to reduce their risk of cardiac issues following an EVAI. “We know from a lot of older studies that patients that have AAAs have a higher risk of things like coronary artery disease and myocardial infarction, so those are patients at a minimum we want to keep a close eye on from a cardiac perspective. We want to make sure that their cardiovascular risk factors are well controlled, and that might help keep them out of the hospital and potentially make them live longer.”

He said he was not surprised to see a gradual decrease in readmissions over time given improvements in technique and technology. However, “I certainly wouldn't want these data somehow used to justify using readmissions as a way of penalizing either doctors or hospitals or health care systems,” Bhatt argued.

“I'm a big believer in not using readmissions to penalize hospitals or physicians in any way. I think that's extremely counterproductive because it potentially creates a perverse incentive where patients who should get hospitalized maybe aren't getting hospitalized,” he explained. “If anything, I think the data help support not doing that because some of these different causes of readmission have nothing to do with the procedure at all.”

Future research should focus on reducing readmissions, but not at the expense of patients who truly need to be back in the hospital, Bhatt said. “We always have to be careful, we don't want to do what might have happened with heart failure where readmissions are going down, mortality is going up. It creates an uncomfortable situation where you're not sure if one thing is causing the other. So here I think we want to look for interventions to keep these patients out of the hospital but in a way that doesn't hurt them otherwise and hopefully helps them,” he concluded.

Disclosures
  • Atti reports no relevant conflicts of interest.
  • Bhatt reports receiving grants from Amarin, AstraZeneca, Bristol-Myers Squibb, Roche, Eisai, Ethicon, Medtronic, Sanofi Aventis, Pfizer, Forest Laboratories/AstraZeneca, Ischemix, Amgen, Lilly, Chiesi, Ironwood, Abbott, Regeneron, PhaseBio, Idorsia, Synaptic, and The Medicines Company; receiving unfunded research support from FlowCo, PLx Pharma, Novo Nordisk, Takeda, and Merck; serving on the advisory boards of Medscape Cardiology, Regado Biosciences, and Cardax; serving on the board of directors of the Boston VA Research Institute; being the deputy editor of Clinical Cardiology; being a site coinvestigator for Biotronik, Boston Scientific, Svelte, and St. Jude Medical (now Abbott); receiving honoraria from the American College of Cardiology (ACC); serving on clinical trial committees funded by Bayer and Boehringer Ingelheim; receiving personal fees from the Duke Clinical Research Institute, Mayo Clinic, Population Health Research Institute, Belvoir Publications, Slack Publications, WebMD, Elsevier, the Society of Cardiovascular Patient Care, HMP Global, the Harvard Clinical Research Institute (now Baim Institute for Clinical Research), the Journal of the American College of Cardiology, Cleveland Clinic, Mount Sinai School of Medicine, and TobeSoft; and receiving nonfinancial support from the ACC, the American Heart Association, and the Society of Cardiovascular Patient Care.

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