Unplanned Readmissions Within 30 Days Post-PCI Affect Nearly One in 10 US Patients
An increase in comorbid patients undergoing procedures and a desire to discharge quickly may help explain high readmission rates, experts say.
Approximately 1 in 10 PCI patients in the United States have an unplanned readmission within 30 days, a new study shows, even in the context of contemporary PCI, which includes safer procedures and better techniques than decades past.
Of note, new data indicate that most readmissions are related to chronic medical conditions and other noncardiac causes.
The findings may be eye-opening for some interventional cardiologists, said the study’s senior author Mamas Mamas, BMBCh, DPhil (Royal Stoke Hospital, Stoke-on-Trent, England), partly because readmissions are often only brought to their attention when they involve complications related to the procedure.
“The fact that noncardiac readmissions are so common after a cardiac procedure is quite surprising,” Mamas told TCTMD. Some potential explanations include more comorbid patients receiving PCI than ever before, and pressure to discharge patients as soon as possible after their procedure, he added.
“As a way of driving down costs, a lot of hospitals in the UK and the US are pushing for early discharge [because it’s beneficial] from a financial perspective, but for cardiologists it means we have less time to manage our patients’ comorbidities and less time to get other specialties involved in the care of our patients,” Mamas explained. Instead, those patients are often referred to outpatient care for ongoing management or optimization of comorbid conditions, but that may not happen for a variety of reasons, resulting in the need for a readmission to manage the problem.
The study was published online April 3, 2018, in JACC: Cardiovascular Interventions.
Discharge Location Important
Mamas and colleagues, including lead author Chun Shing Kwok, MD (Keele Cardiovascular Research Group, Stoke-on-Trent, England), examined 2013-2014 data from the Nationwide Readmissions Database on 833,344 men and women who underwent PCI in the United States. Overall, 9.3% of patients had an unplanned readmission within 30 days of discharge. Readmitted patients were more likely to be older, female, and to present on the weekend. They also were less likely to have private health insurance and had lower median household incomes compared with non-readmitted patients.
The average number of comorbidities was also higher for readmitted patients when compared with those not readmitted (5.7 vs 4.9). Furthermore, the index admission length of stay was greater in patients who were readmitted (4.7 days vs 3.9 days). Independent predictors of 30-day readmission were leaving the hospital against medical advice, being discharged to a short-term hospital or care home rather than directly home, and being transferred to another institution rather than home. Conversely, factors associated with decreased risk of unplanned readmission included having private insurance or no insurance, elective index admission, and receiving a DES. The most common comorbidities associated with readmission were chronic kidney disease, liver disease, A-fib, and chronic lung disease.
Noncardiac causes accounted for 56.1% of all return trips to the hospital. Among the most frequent were nonspecific chest pain (14.8%), infection (12.3%), gastrointestinal disease (10.4%), respiratory disease (8.6%), and major bleeding complications (5.9%).
“Readmission should be considered a high-risk event because if you look at the mortality associated with it, it’s higher than that of the index PCI, and that’s quite unfortunate,” Mamas noted. Following index PCI 2.4% of patients died versus 3.1% of those with an unplanned noncardiac readmission and 2.8% with an unplanned cardiac readmission.
“Often people think about readmission in terms of the costs associated with it, but I would say we should think about it in terms of patient outcomes as well,” said, adding that readmissions might be a good addition to current measures of PCI quality.
Tackling Appropriate Versus Inappropriate Readmissions
In an editorial accompanying the study, Ankur Kalra, MD (Cleveland Medical Center, Cleveland, Ohio), and colleagues point out that a major limitation is the inability to define appropriate versus inappropriate readmissions in the cohort. They say better ways to identify patients at high risk for readmission are needed and should take into account all comorbid conditions and base discharge timing on pre-PCI risk-adjusted readmission screening.
Kalra and colleagues also point to an interesting finding of the current analysis, which was lower readmission among those with no insurance.
“Although the exact mechanism for this is unknown, it is possible that patients who are uninsured have a higher threshold for seeking emergent medical care,” they write. “Beyond addressing patient-related anxiety, educating allied healthcare professionals and post-care facilities may also reduce readmissions.”
A comprehensive approach to post-PCI management “that extends patient care from the hospital facilities to patients’ homes in a continuum will be indispensable to curb inappropriate readmission,” they conclude.
Kwok CS, Rao SV, Potts JE, et al. Burden of 30-day readmissions after percutaneous coronary intervention in 833,344 patients in the United States: predictors, causes, and cost insights from the Nationwide Readmission Database. J Am Coll Cardiol Intv. 2018;Epub ahead of print.
Kalra A, Shishehbor MH, Simon DI. Percutaneous coronary intervention readmissions: where are the solutions? J Am Coll Cardiol Intv. 2018;Epub ahead of print.
- The study was conducted as part of Kwok’s PhD research, which was supported by Biosensors International.
- Kalra reports consulting for Medtronic.