Majority of Short-term PCI Readmissions for Angina Concerns, not Complications

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Readmissions within 30 days after percutaneous coronary intervention (PCI) are seldom related to complications of the procedure. Rather, they more often stem from recurrent chest pain and other potential angina-related concerns, according to a medical record analysis published online January 14, 2014, ahead of print in Circulation: Cardiovascular Interventions.

Researchers led by Robert W. Yeh, MD, MSc, of Massachusetts General Hospital (Boston, MA), reviewed the medical records of all PCI patients readmitted within 30 days of discharge between 2007 and 2011 at Mass General and Brigham and Women’s Hospital (Boston, MA).

Over One-Third Readmitted for Angina

There were 9,288 PCI procedures over the study period, with the majority of treated patients (97.8%, n = 9,081) surviving to discharge. Of this cohort, 9.8% (n = 893) were readmitted within 30 days of discharge for reasons including:

• Chest pain or other angina-related concerns (38.1%)
• Staged PCI without new symptoms (6.6%)
• Congestive heart failure (5.9%)
• Vascular/bleeding complications of PCI (4.4%)
• Nonaccess site bleeding (3.7%)
• GI hemorrhage (3.1%)
• Stent thrombosis (2.5%)
• Elective peripheral procedure or surgery not related to PCI (2.2%)
• Elective CABG (2.1%)

Patients readmitted for chest pain or angina-related concerns were younger (63.7 years vs 66.8 years; P < 0.001) than other readmitted patients and more likely to have commercial insurance (34.3% vs 24.2%; P <0.001). In all, 6.2% (n = 21) of them presented with a new or repeat MI.

Of the 341 patients with chest pain or other potential angina-related symptoms, the majority (84.5%; n = 288) had 1or more diagnostic imaging studies during readmission, including:

• Echocardiogram (18.5%)
• SPECT (29%)
• Diagnostic coronary angiography (56.6%)

Diagnostic angiography resulted in repeat PCI in 54 cases (15.8%), encompassing both target vessel (15.8%) and non-target vessel (10.3%). The overall TLR rate was 2.6%.

Readmission Rates So Low That Quality Improvements May Not Help

“We found that the incidence of 30-day readmission because of complications of PCI is relatively low,” the authors state. “…If these results are generalizable to other health systems, genuine improvements in quality that reduce PCI complications will not likely reduce hospital readmission rates significantly. . .”

Nevertheless, Dr. Yeh and colleagues did offer their own algorithm for curbing potentially unnecessary readmissions after PCI:

1. Rapid clinical assessment of any patient with angina for signs and symptoms of stent thrombosis or MI; Outpatients considered to be at higher risk would be referred to an ED thereafter
2. Patients with reassuring initial ECG and troponin could be evaluated by a cardiologist in the ED before admission; Patients considered at low risk could be discharged directly, whereas those with high-risk features could be admitted for further evaluation

Patients with reassuring initial ECG and troponin could be evaluated by a cardiologist in the ED before admission; Patients considered at low risk could be discharged directly, whereas those with high-risk features could be admitted for further evaluation

In addition, the authors note, “It is possible that deferring a repeat procedure beyond 30 days, or even longer, may permit optimal medical therapy alone to alleviate patients’ symptoms and obviate the need for a repeat revascularization procedure at all.”

In a telephone interview with TCTMD, Gregory J. Dehmer, MD, of Texas A&M University Health Science Center College of Medicine (Temple, TX), indicated that he did not find the results of the study surprising. In fact, “It really rings true with our own experience at my own institution,” he said.

Dr. Dehmer noted that it is unrealistic, as the authors suggest, for non-high-risk patients to simply go to their doctor’s office in the event of chest pain. “When you’re in the back of an ambulance with the lights going, that’s not going to happen, you’re going to the ED,” he predicted. “So here comes the patient into a very overcrowded ER with chest pain. [They’ll be] going into the hospital to rule out MI.”

Good for the Patient, Bad for the System

Nevertheless, although a significant number of patients in the study presented with angina, “very few wound up having anything,” Dr. Dehmer said. “Testing was done, a lot of them got re-cathed—but most of these were false alarms. It’s good for the patient that they’re not having anything wrong, but it’s not good for the overall system.”

Dr. Dehmer acknowledged that “[o]bviously readmissions are a big problem incurring enormous expenses and we’re trying to pare this down.”

Currently, more than 300 of the nearly 1,200 hospitals participating in the ACC’s National Cardiovascular Data Registry (NCDR) CathPCI Registry have elected to release their 30-day readmission rates for Medicare Fee-for-Service patients treated from January 2010 to November 2011. Hospitals are assigned to categories by how they fare—better, similar, or worse—compared with the nationwide registry’s overall readmission rate of 11.9%. Importantly, rates are adjusted for baseline patient risk factors such as sex and age.

Individual hospital data are available on a special section of the Hospital Compare website run by the Centers for Medicare and Medicaid Services.

A Wake-up Call for Administrators

While lauding the approach, Dr. Dehmer asserted, “There’s no way the government can review all of these cases to determine if these should’ve really happened and whether to penalize. But their approach has been successful, because now they have everybody really paying attention because there’s money in the game. Too many readmissions and you’re not going to get paid. For any hospital administrator, that’s a wake-up call. So that’s really brought a focus to this, and people are questioning what we can do to reduce this.”

The problem, he cautioned, is that not all readmissions can be prevented.

Some readmissions are for staged PCI or elective CABG. Because those procedures are planned, they should not be counted, Dr. Dehmer insisted. “There has to be a way of better defining this process to separate events that are truly ‘shame on you’ events that should not have happened.” He used the example of a patient with heart failure who undergoes PCI and then released but without instruction to restart his diuretic. “So they come back in a week, and they’re all swelled up with HF,” he said. “Stuff like that should not happen, and that’s what we really need to work to prevent.”

He acknowledged that readmissions will never be completely eliminated. “But if we can get it down to 15% [or even] 10%, it’s still going to save a bunch of money, and that’ll be a good thing,” Dr. Dehmer said.

 

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Source:
Wasfy JH, Strom JB, O’Brien C, et al. Causes of short-term readmission after percutaneous coronary intervention. Circ Cardiovasc Interv. 2014;Epub ahead of print.

 

Disclosures:

• The study was supported in part by the Massachusetts Department of Public Health and a grant from the American Heart Association.
• Drs. Yeh and Dehmer report no relevant conflicts of interest.

 

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