Targeting PCI Readmissions at the Facility Level May Not Lessen Mortality: VA Study

Patients who are readmitted within 30 days of PCI are more likely to die within the first year, but at the hospital level, readmission rates do not correlate well with mortality risk, a study of centers within the US Department of Veterans Affairs (VA) system shows.

“Based on our analysis, it is unlikely that incentivizing hospitals to avoid post-PCI readmissions will impact the increased mortality of this high-risk group,” Timothy Hegeman, DO (Vanderbilt University Medical Center, Nashville, TN), and colleagues write in a study published online September 14, 2016, ahead of print in the Journal of the American Heart Association.

“Still, readmission is costly and generally undesirable to patients and the health system,” they continue. “Efforts directed at reducing readmissions may improve patient satisfaction and cost, while separate efforts directed at understanding the underlying association between readmission and mortality may someday lead to improved survival in this high-risk group.”

Commenting on the study for TCTMD, Joseph Cacchione, MD (Cleveland Clinic, OH), said that the lack of an association between facility-level readmissions and mortality does not mean that reducing repeat visits should not be a focus for hospitals, primarily because of the high costs associated with them. 

“That’s why this is important,” he said, noting that readmitted patients are typically in the top 10% to 20% of all patients in terms of longitudinal costs.

Keeping patients out of the hospital will become even more imperative for health systems with the move toward bundled or episode-based payments that would hold hospitals accountable for care both during the initial inpatient stay and for 90 days after discharge, Cacchione said. “I think health systems will invest in that when they’re financially at risk for these things.”

The first step toward cutting readmissions might include the development of predictive models to identify patients who are most at risk, so they can be targeted with interventions, he said. Strategies might include enhanced care coordination, measures aimed at ensuring compliance with medications, increased education of patients to get them engaged in their own care, and early and more frequent follow-up after discharge, he suggested.

But initially, the ability to track patients as they move throughout the healthcare system and different settings needs to be improved, Cacchione said. “Providers are going to need more longitudinal data on their patients to understand what are the drivers of readmission.”

Readmitted Patients Have Elevated Mortality Risk

The Centers for Medicare & Medicaid Services reduces payments to hospitals with excess readmissions among various types of patients. PCI is not included in the program, although there has been discussion about adding it, according to the authors.

“Readmission rate may reflect ‘systems’ issues or care processes and may be a marker of fragmented care, a deficit that goes hand in hand with poor-quality longitudinal care,” they say, noting that if readmission and mortality were associated at the hospital level, it would indicate that focusing on repeat visits as a quality metric could potentially boost patient outcomes.

To explore the issue, they looked at data from the VA Clinical Assessment, Reporting, and Tracking (CART) program. The study included 41,069 patients who underwent PCI at 62 sites between October 2007 and August 2012.

Overall, 12.2% of patients needed to be rehospitalized within 30 days of their procedure, although that rate ranged from 6.6% to 19.4% across centers. Readmitted patients had an elevated risk of 1-year mortality after accounting for potential confounders (HR 1.53; 95% CI 1.44-1.63).

An Opportunity to Improve Care

That relationship represents an opportunity to improve the care of readmitted patients, according to Hegeman et al.

“Either the readmission itself causes patient harm or the current models lack clinically significant confounding factors,” they write. “Every measured risk factor of chronic disease and disability was more prevalent in the readmitted group, and it is likely that unmeasured risk factors varied similarly, with worse health status in those who were readmitted. Social situation, overall frailty, living situation, and medical literacy likely impact both post-PCI readmission and mortality, but were not captured in the hazards model. Improving outcomes in this high-risk population will likely involve careful exploration of these less well-documented risk factors.”

The lack of an association between adjusted facility-level readmission rates and 1-year mortality (P = 0.613), on the other hand, suggests “that the relationship is not causal, but instead mediated by unmeasured confounding,” they say. “This is not to say that quality improvement efforts in this arena are futile, only that those targeted at the facility level may not accurately single out the highest-risk population and modify mortality.”

The authors acknowledge that the findings may not be applicable to the general population because they are derived from data from the VA system, where more than 98% of patients are male.

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