Nearly 10% of Patients Having Balloon Angioplasty, Stent Placed Go Back to Hospital in Days
Readmitted patients after PCI also had higher risk of death within one year; most readmitted for cardiac-related problems
Nov. 28, 2011 - In an analysis of the outcomes for more than 15,000 patients who underwent a percutaneous coronary
intervention (PCI; procedures such as balloon angioplasty or stent placement used to open narrowed coronary arteries), nearly one in 10 were
readmitted to the hospital within 30 days, and these patients had a higher risk of death within one year, according to a study published
Online First by the Archives of Internal Medicine, one of the JAMA/Archives journals.
Most of the readmissions were for cardiac-related reasons. Various factors were associated with hospital readmission, including female sex, Medicare insurance, unstable angina and
"Thirty-day readmission rates have become a quality performance measure, and the Center for Medicare and Medicaid
Services (CMS) publicly reports hospital-level, 30-day, risk-standardized readmission rates for patients hospitalized with congestive heart
failure (CHF), acute myocardial infarction [AMI; heart attack], and for patients undergoing PCI," the researchers write in explaining their
study. "However, little is known regarding the factors associated with 30-day readmission after PCI."
The study by Farhan J. Khawaja, M.D., of the Mayo Clinic and Mayo Foundation, Rochester, Minn., and colleagues, was to
identify factors associated with 30-day readmission rates, the reason for the readmission, and the association of 30-day readmission with
one-year mortality for patients after PCI.
For the study, the researchers identified 15,498 PCI hospitalizations (elective or for acute coronary syndromes) from
January 1998 through June 2008. Various models were used to estimate the adjusted association between demographic, clinical, and procedural
variables and 30-day readmission and 1-year mortality.
The researchers found that overall, 1,459 patients who had PCI procedures (9.4 percent) were readmitted within 30 days.
There were 106 deaths within 30 days (0.68 percent), including 33 deaths that occurred during or after a readmission and
73 deaths that were not associated with a readmission.
"After multivariate analysis, demographic factors associated with an increased risk of 30-day readmission after PCI
included female sex, Medicare insurance, and less than a high school education.
The clinical and procedural factors associated with an increased risk of readmission included CHF at presentation,
cerebrovascular accident or transient ischemic attack, moderate to severe renal disease, chronic obstructive pulmonary disease, peptic ulcer
disease, metastatic cancer, and a length of stay of more than three days," the authors write.
Of the 1,459 PCIs readmitted within 30 days, 1,003 (69 percent) were readmitted for cardiac-related reasons.
After adjustment for various factors, patients who were readmitted within 30 days had a higher rate of death at one year
compared with patients who were not readmitted.
"Thirty-day risk-standardized readmission rates after PCI have become a publicly reported performance measure, and there
is high interest from hospitals and clinicians to understand and improve modifiable factors associated with 30-day readmission rates," the
"Lack of early follow-up has been associated with increased risk of readmission among patients with heart failure and may
also be playing a role in patients undergoing PCI. Early follow-up allows patients and clinicians to ensure understanding and compliance, and
to gauge the effectiveness of therapies.
The educational component of follow-up cannot be underestimated because in one study, less than half of patients were
able to list their diagnoses and the names, purpose, and adverse effects of their medications at the time of discharge. Education at the time
of discharge and early follow-up also needs to be tailored to patient education level, which has previously been shown to be associated with
the risk of readmission among Medicare beneficiaries."
This study was funded by the Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn.
Commentary: Prediction Is Very Hard, Especially About the Future
In an invited commentary accompanying the article, Adrian F. Hernandez, M.D., M.H.S., and Christopher B. Granger, M.D.,
of Duke University Medical Center, Durham, N.C., write that "in the end, reducing hospital readmission rates by preventing progression of
disease and occurrence of events should be a goal of care."
"To reduce readmissions, we need better evidence on effective approaches that address our health systems shortcomings,
ideally identifying and intervening in the most vulnerable patients.
Early outpatient follow-up may be a strategy to reduce readmissions but other interventions will be necessary for this
complex, multifaceted problem. Understanding the common issues between PCI readmissions vs. other medical or surgical conditions will be
necessary to have broad-based solutions.
The challenge is determining what, if any, of these solutions will reduce readmissions and improve overall quality of
care during this period of patient vulnerability and fragmented care."
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