Debate Continues on PCI Readmissions, Focus Shifts to Hospital Variation

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In the continued debate over whether hospital readmissions after percutaneous coronary intervention (PCI) should be a marker of quality of care, a new study published online, March 20, 2012, ahead of print in Circulation: Cardiovascular Interventions, shows marked variation in 30-day readmission rates. The study is the first to examine variation among hospitals, and suggests that only a small amount of readmissions are due to actual measures of hospital quality.

Robert W. Yeh, MD, MSc, of Massachusetts General Hospital (Boston, MA), and colleagues collected data from 36,060 patients undergoing PCI who survived to discharge at 24 hospitals in Massachusetts from September 2005 to August 2008.

Wide Variation in Readmission Predictors

The 30-day readmission rate was 12.4% (n = 4,469), with a median discharge time of 11 days. The 10 most common principal discharge diagnoses comprised 65% of all readmissions. Among these were:

• Ischemic heart disease (24.5%)
• Chest and respiratory symptoms (12.3%)
• Heart failure (8.5%)
• Acute MI (4.8%)
• Procedural complications (4.3%)
• Cardiac dysrhythmias (3.8%)

Among readmitted patients, 17.8% (n = 796) underwent repeat PCI and 1.9% (n = 83) had CABG during the readmission hospitalization. Revascularization of the target vessel of the index PCI occurred in 8.1% of readmitted patients.

After multivariate analysis of hospital quality variables, several predictors of readmission were found (table 1).

Table 1. Adjusted Predictors of Readmission (Hospital Quality Model)

Explanatory factors not normally included in hospital quality analyses also were associated with readmission at 30 days (table 2).

Table 2. Adjusted Predictors of Readmission (Explanatory Model)

 
Unadjusted 30-day readmission rates varied among hospitals from 0 to 20.7% (median 12.4%). Researchers identified 709 staged readmissions that were not associated with an acute cardiovascular diagnosis. When these readmissions were excluded, there was still substantial variation in risk-standardized readmission (7.1%-15.2%). Complete revascularization was the only predictor of readmission no longer associated with readmission risk after exclusion of staged PCIs (OR 0.94; 95% CI 0.82-1.09).

‘Jury’s Still Out’ on Quality Marker

In a telephone interview with TCTMD, Dr. Yeh said the motivation for this study was to point out the distinct variability in PCI readmission rates and causes among hospitals.

“In the existing literature, we knew there was variability in the crude rates of PCI readmission, . . . but none of them had looked at how the quality measure would affect hospitals and whether or not differences between hospitals would be explained by other quality-related factors,” he said.

Asked if readmissions after PCI should be a marker of quality of care, Dr. Yeh said, “I think the jury’s still out. Our data showed that certainly there is wide heterogeneity in risk standardized readmission rates between hospitals. What that means is that it’s not just measurable differences in patients that explain why readmission rates are so different between hospitals.”

Because they showed that known steps to reduce complications could not fully explain the variation, Dr. Yeh said the focus should be on figuring out what is responsible for readmissions in the first place.

“If you believe the unexplained variation is probably due to differences in quality between hospitals, then you have to say that PCI readmissions are probably a good measure of hospital quality,” he said. “But if you believe, like I do, that there are probably a whole host of things . . . that are responsible for the variation in PCI readmission rates, then it probably wouldn’t be an appropriate measure of hospital quality, although it’s probably a good measure of health care quality.”

‘Global Approach’ Needed

In a telephone interview with TCTMD, Edward Hannan, PhD, of the University of Albany (Albany, NY), commented that that although there is large variation among hospitals, “it’s not any larger than I would have expected it to be.”

Dr. Hannan coauthored a study on PCI readmissions in New York State in December 2011 that implied that readmissions should serve as a marker of quality of care. Nevertheless, with regard to the current study, he observed that such a conclusion may be premature, “based on the amount of variation there is and based on some unknown reasons for why there is that variation.”

Stephen G. Ellis, MD, of the Cleveland Clinic (Cleveland, OH), told TCTMD in a telephone interview that going forward, “since the models aren’t very good at predicting who’s likely to be readmitted, it’s going to be challenging for hospitals to identify high-risk patients. . . . So if it’s going to be done, you have to have a global approach.”

Dr. Ellis said his institution is currently piloting a program that requires 1-week follow-up for all PCI patients with a physician assistant. Although the program is too new to have any results, he said that he expects it will help identify preventable complications and hopefully reduce readmission rates.

It’s All About Reimbursement

Regardless, Dr. Hannan said the ultimate focus will be on the Centers for Medicare and Medicaid Services (CMS).

“If they are going to reimburse based on readmissions, then what we do going forward is drill down and try to figure out all these other reasons for readmissions,” he said. “Certainly, the stuff about the continuity of care and the linking with outpatient and primary care is a huge factor.”

Even so, Dr. Hannan said the study “make[s] a good point that of course there can be some adverse consequences as a result of not paying for readmissions, including not readmitting patients when they need to be readmitted and perhaps keeping patients a little longer in the hospital to be sure they won’t be readmitted. Those are things that need to be monitored and kept track of as we go forward.”

To hone in on this issue even more, Dr. Yeh suggested detailed medical record review of all readmitted patients.

“We need to see what are the true causes of being readmitted . . . and really try to find out the etiology,” he said. “Physicians who really understand cardiovascular care and PCI need to do medical record chart review and say this looks like a readmission because of x, and whether or not x is modifiable by some measure of quality is really the main question.”

Study Details

Readmitted patients were older, more often female, nonwhite, and Medicare-insured, and had a higher prevalence of comorbidities and procedural complications after the index PCI. Readmitted patients also were more often transferred to other hospitals after PCI or discharged to extended-care facilities or nursing homes, and were less often discharged on antiplatelet medications, beta blockers, or statins.

 

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Source:
Yeh RW, Rosenfield K, Zelevinsky K, et al. Sources of hospital variation in short-term readmission rates after percutaneous coronary intervention. Circ Cardiovasc Interv. 2012;Epub ahead of print.

 

 

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• Hospital Readmission Post-PCI Linked to Increased Mortality

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