Decline Seen in Readmissions After PCI in the Medicare Population

From 2000 to 2012, the rate of readmission in the first 30 days after PCI declined modestly from 16.1% to 15.4% in the Medicare population, suggesting that efforts from the government and healthcare systems on preventing return trips to the hospital have paid dividends.

Even after accounting for upward trends in rates of various comorbidities in patients undergoing PCI, those treated in 2012 were a relative 33% less likely to be readmitted compared with those treated at the beginning of the study period, lead author Christian McNeely, MD (Washington University School of Medicine, St. Louis, MO), and colleagues report in a study published online ahead of print in the American Heart Journal last week.

“We’re on the right track as a healthcare system and as a cardiovascular community with improving certain outcomes after percutaneous coronary intervention,” McNeely told TCTMD.

Over the past decade or so, readmission rates in general have come under greater scrutiny and have become the focus of research and quality improvement programs. In the United States, the federal government indicated in 2008 that financial penalties might be implemented as a way to reduce readmissions. Such a system came in the form of the Hospital Readmissions Reduction Program (HRRP), which was established when President Barack Obama signed the Affordable Care Act into law in March 2010 and requires the Centers for Medicare and Medicaid Services (CMS) to reduce payments to hospitals with excess readmissions.

Commenting for TCTMD, Edward Hannan, PhD (University at Albany, NY), agreed that some progress has been made, but added that some questions remain about how two factors—an increasing trend toward outpatient PCI and uncertainty about trends in out-of-hospital mortality rates—are influencing changes in readmission rates. Both issues, he said, could potentially make it look like readmissions are declining even in the absence of improvements in quality of care and should be explored further.

“There are some hidden pockets there where quality of care could be getting worse even though readmissions are decreasing because patients are dying earlier or because they’re getting outpatient PCI,” he said.

Nonetheless, he added, the HRRP “seems to be helping” in reducing readmission rates after PCI. Although PCI itself is not one of the conditions targeted by the program, acute MI is, he pointed out. Moreover, general efforts made by hospitals to cut readmissions—better follow-up of patients and better coordination with outpatient care, for example—are going to affect areas not specifically targeted by CMS, he said.

Higher Mortality in Readmitted Patients

McNeely and colleagues set out to determine whether reductions in readmissions seen across a variety of conditions in recent years could also be observed for PCI. They looked at administrative CMS data on 3.25 million Medicare beneficiaries ages 65 years and older who were admitted for PCI between January 2000 and November 2012.

Over the study period, there were increases in the proportion of patients presenting with acute MI and rates of various comorbidities, including hypertension, diabetes, peripheral vascular disease, history of stroke or transient ischemic attack, heart failure, chronic obstructive pulmonary disease, renal failure, and A-fib.

Nevertheless, readmissions declined. The reduction translates to about 1,400 fewer readmissions at the end of the study period compared with the beginning, assuming roughly 200,000 PCIs performed each year in Medicare beneficiaries, according to the authors.

Most readmissions (more than 60%) were for cardiovascular-related conditions, although only 7.9% were for acute MI, unstable angina, or cardiac arrest/ventricular fibrillation.

That indicates that many patients were readmitted for more chronic problems that potentially did not require readmission, McNeely said. Better care coordination or education for those types of patients might help keep them out of the hospital, he added.

The investigators also examined management and outcomes of readmitted patients. Overall, 2.9% underwent balloon angioplasty and 2% underwent CABG, with both approaches becoming less frequently used over time. The rate of PCI with stenting varied, rising from 14.2% in 2000 to 23.7% in 2006 before falling to 12.1% in 2012.

In-hospital mortality during a readmission also fluctuated, declining from 2.8% in 2000 to 2.2% in 2006 before increasing to 3.1% in 2012.

Among those who survived the index PCI, patients who were readmitted in the subsequent 30 days were more likely to die (2.8% vs 0.6%; P = 0.0001). Mortality rates rose over time regardless of readmission status, a trend “likely most influenced by an increasingly higher-risk patient population being admitted for their initial PCI,” McNeely et al write.

Why Has Progress Been Made?

McNeely said that the study was not designed to delve into the reasons for the reduction in readmissions but added that multiple factors are likely responsible.

“A variety of changes have occurred in PCI, as well as the healthcare system in general, within the last decade,” he and his colleagues write in their paper. “Healthcare systems changes which may be contributing include public reporting of readmission data, the HRRP, the CMS’s Partnership for Patients Program, among others. Consequently, many healthcare organizations have implemented programs to try and reduce readmissions.”

They also point to a prior study that showed that about half of readmissions might be prevented “through better decision making, such as reducing vascular access complications by use of transradial access when feasible, avoiding unnecessary staged procedures, and better medical management of heart failure medications at discharge. Whether increasing adoption of these practices has contributed to the reduction in readmissions we observed is unclear based on our data.”

In an accompanying editorial, Varsha Tanguturi, MD, and Jason Wasfy, MD (Massachusetts General Hospital, Boston, MA), note that the declines in readmissions hastened after passage of the HRRP, which followed a 10-year period that saw substantial improvements in PCI quality.

“Taken together, the acceleration of decline in 2010 and the high proportion of low-acuity readmissions suggest that more efficient triage for low-risk patients may have driven this national decrease in PCI readmissions,” they write. “Evaluating this hypothesis will be critical, because it offers a pathway to improve both quality and value in care for PCI patients.”

Some Concerning Signs

Despite some heartening findings, however, the study also indicates that caution is needed, Tanguturi and Wasfy say.

Of concern are increases in the proportion of patients readmitted with procedural complications and in the mortality rate of patients who required a return visit to the hospital, they say.

“These trends are likely related to some extent to the increasing medical complexity of Medicare patients treated with PCI over time,” they write. “A deeper understanding of the costs and benefits of PCI as the PCI population becomes sicker is important. Furthermore, disentangling patient complexity from any changes in quality of care as a cause of readmissions due to procedural factors will be important.”

There was also a doubling in the proportion of patients with a history of A-fib, from 10.9% in 2000 to 19.3% in 2012.

“This may mean increasing frequency of clinicians considering the clinical decision of prescribing ‘triple therapy’—dual antiplatelet therapy plus oral anticoagulation,” the editorialists write. “Indeed, the proportion of hospital readmissions after PCI due to gastrointestinal hemorrhage also more than doubled from 2000 to 2012.”

That finding, they continue, “should hasten the urgency of understanding how antiplatelet and anticoagulation strategies apply to a PCI population in the United States that is increasingly complex medically.”

And finally, they write, “as we continue to explore the hypothesis that many patients with chest discomfort after PCI can be managed safely as outpatients, we need to monitor for any potential adverse consequences.”

In spite of those concerns, the study findings “should bolster our confidence that even more PCI readmissions are preventable” and that avoiding them “still represents substantial opportunity for improving quality, satisfaction, and value in the care of patients with coronary artery disease,” Tanguturi and Wasfy say.

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• The Case for Reviving PCI Readmission Metrics: A Holistic Approach Could Improve Both Quality, Value
• CMS Penalties Spur Efforts to Reduce 30-Day Hospital Readmissions
• Most Hospital Readmissions Within 30 Days of PCI Unrelated to Index Procedure