Unplanned Readmission Within 6 Months Affects 25% of PCI Patients in the US

A study of contemporary practice suggests that more needs to be done to prevent readmissions, particularly among those with nonspecific chest pain.

Unplanned Readmission Within 6 Months Affects 25% of PCI Patients in the US

Unplanned readmissions beyond the first month after PCI are more common than previously thought, with approximately one in four patients being readmitted within 6 months of discharge, nationwide data from the United States show. The researchers say based on their findings, more investment in outreach services and earlier follow-up visits may be helpful preventive strategies.

“Whilst unplanned readmissions at 30 days have been taken empirically as a quality metric in the Affordable Care Act, we show that readmissions within this time point are merely the tip of the iceberg, and readmissions in the longer term is a much bigger problem,” senior author Mamas Mamas, BMBCh, DPhil (Royal Stoke Hospital, Stoke-on-Trent, England), said in an email. “Our analysis shows that the same sort of patients identified in our prior analysis as being at risk of readmissions within 30 days will also be at risk of readmission at the longer timepoints, namely older patients, females, and multimorbid patients.”

The earlier study found that one in 10 PCI patients in the United States have an unplanned readmission within 30 days.

In an editorial accompanying the new study, Michael Ragosta, MD (University of Virginia Health System, Charlottesville), notes that it is currently unclear how much effort should be expended to preventing unplanned readmissions until more is known about who and what to target and how best to accomplish that.

But Ragosta agrees that “understanding how often and why patients ‘bounce back’ after PCI should be added to our quality efforts.”

Causes and Timelines Vary

For the study, published online March 27, 2019, in JACC: Cardiovascular Interventions, Mamas and colleagues, including lead author Chun Shing Kwok, MD (Keele Cardiovascular Research Group, Stoke-on-Trent, England), looked at data on 2,412,000 patients from the Nationwide Readmissions Database who underwent PCI in the United States between 2010 and 2014.

When readmissions were examined by time period, the researchers found cumulative rates of 2.5% within 7 days, 9.9% between 8 and 30 days, 18% between 31 and 90 days, and 24.8% between 91 and 180 days. The median time to readmission was 35 days, with a peak admission time of 7 days. At all time periods, noncardiac causes were the primary reason for readmission. Of the noncardiac readmissions in the first 7 days, nearly one-quarter were for nonspecific chest pain. As nonspecific chest pain readmissions declined over subsequent months, readmissions for noncardiac causes such as GI bleeding and infections were found to increase.

CAD, including angina, was the most common cardiac cause for readmission during each time period studied, accounting for 37.4% to 39.3% of all cardiac readmissions. Acute MI was the second-most-common cardiac cause for readmission, followed by heart failure.

Among patients with acute MI, readmissions were highest in the first 7 days compared with other time periods, while those with heart failure were most likely to be readmitted between 8 and 30 days.

Importantly, patients who were readmitted in the first 7 days were found to have had the shortest length of stay during their index hospitalization for PCI (2.4 days) and also the least expensive index admission cost ($18,631) compared with patients readmitted during any other time point in the study.

“As we are moving towards day-case elective PCI, and a push towards shorter length of stay for acute coronary syndromes, there is less opportunity to involve other specialties in managing patients’ comorbid conditions, such as diabetes, respiratory diseases, [and] heart failure, and potentially the savings achieved through shorter length of stay may be offset by increasing rates of unplanned readmissions in the longer term,” Mamas said. “I believe that there is no such thing as a free lunch.”

Among the cardiac causes of readmission, 27% were due to MI in the first 7 days. “Whilst our data is not granular enough to determine whether this is due to acute stent thrombosis, it is likely that a significant proportion of these cases will be,” Mamas added. “It is important to optimize PCI procedures during the index event to reduce the risk of these events, such as using intravascular imaging (IVUS and OCT) to reduce this risk, but also [to emphasize] to patients the need to continue DAPT, as many will stop taking medications as they feel better.”

Since heart failure was another important cause of cardiac readmissions, he added, it is important to assess left ventricular function prior to PCI and use the admission as a means of optimizing therapy. “But as importantly, if identified to have impaired LV function, [clinicians should use] the index admission as an opportunity to refer to heart failure services,” he said. The finding that bleeding events accounted for 5% of all unplanned readmissions for noncardiac causes “emphasizes the importance of assessing bleeding risk of patients prior to the PCI procedure and considering using platforms that require shorter DAPT regimes in patients found to be at high risk of bleeding complications,” he continued.

More Questions Than Answers About Nonspecific Chest Pain

In his editorial, Ragosta said the study raises important questions about patients who are readmitted with nonspecific chest pain.

“Were some of these really ischemic syndromes? Alternatively, perhaps they never had ischemic chest pain in the first place and were readmitted with the same pain for which they underwent an unnecessary PCI,” he writes. Since the study did not include same-day discharge patients, Ragosta said information on that group will be needed along with the impact of radial access on readmissions.

To TCTMD, Mamas agreed that it will be crucial to learn more about how nonspecific chest pain leads to readmission, adding that many of those treated at the index PCI may have had evidence of ischemia or functionally significant CAD on noninvasive imaging or invasive pressure wire assessment, yet their symptomatology may not have been related to their underlying CAD or may have been due to microvascular disease.

“Treating their epicardial coronary stenoses in such situations won’t significantly impact on their symptoms, which may cause many patients to worry that their PCI hasn’t worked and to seek medical attention,” he observed. “I think it is important to be upfront with patients about their expectations, and be upfront that whilst the PCI may improve their symptoms, it doesn't always. Early follow-up post-PCI may help with reducing the impact of unplanned readmissions for this reason, as patients’ symptoms can be assessed early on. Our other unpublished work suggests that ‘nonspecific’ chest pain may not be as benign as believed, as around 3% of patients discharged with this diagnosis will be readmitted with a serious CV event such as an acute coronary syndrome, aortic dissection, or pulmonary embolism.”

Disclosures
  • The study was conducted as part of Kwok’s PhD research, which was supported by Biosensors International.
  • Mamas and Ragosta report no relevant conflicts of interest.

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