Causes of Short-Term Readmission After Percutaneous Coronary Intervention

Abstract

R eadmission after inpatient hospitalization is common and costly. According to an analysis of Medicare claims data, 19.6% of Medicare patients discharged after a hospital admission during which percutaneous coronary intervention (PCI) is performed are readmitted within 30 days, and the Medicare Payment Advisory Commission has estimated that preventable readmissions cost Medicare as much as $12 billion per year. 1 The Affordable Care Act has created financial penalties for hospitals that have risk-adjusted readmission rates for specific conditions exceeding specific benchmarks. 2 Some have criticized this strategy, arguing that few readmissions are preventable and variation in readmission rates reflects differences in patient populations rather than hospital quality. 3 Despite these concerns, and driven by a need to improve care and lower costs, Medicare has begun implementing its value-based purchasing program to provide incentives for hospitals to reduce readmissions after acute myocardial infarction, pneumonia, and congestive heart failure. The Affordable Care Act empowers the Secretary of Health and Human Services to expand the applicable conditions beyond these 3 diagnoses in fiscal year 2015 to readmissions that represent conditions or procedures that are high volume or costly, 2 including chronic obstructive lung disease, coronary artery bypass grafting, vascular surgery, and PCI. 4 In 2011, the National Quality Forum endorsed 30-day readmission after PCI as an important quality measure, and hospitals that had chosen to participate in voluntary reporting had risk-adjusted readmission rates published publicly in the summer of 2013. 5 Editorial see p 9Background-Rehospitalization within 30 days after an admission for percutaneous coronary intervention (PCI) is common, costly, and a future target for Medicare penalties. Causes of readmission after PCI are largely unknown. Methods and Results-To illuminate the causes of PCI readmissions, patients with PCI readmitted within 30 days of discharge between 2007 and 2011 at 2 hospitals were identified, and their medical records were reviewed. Of 9288 PCIs, 9081 (97.8%) were alive at the end of the index hospitalization. Of these, 893 patients (9.8%) were readmitted within 30 days of discharge and included in the analysis. Among readmitted patients, 341 patients (38.1%) were readmitted for evaluation of recurrent chest pain or other symptoms concerning for angina, whereas 59 patients (6.6%) were readmitted for staged PCI without new symptoms. Complications of PCI accounted for 60 readmissions (6.7%). For cases in which chest pain or other symptoms concerning for angina prompted the readmission, 21 patients (6.2%) met criteria for myocardial infarction, and repeat PCI was performed in 54 patients (15.8%). The majority of chest pain patients (288; 84.4%) underwent ≥1 diagnostic imaging test, most commonly coronary angiography, and only 9 (2.6%) underwent target lesion revascularization. Conclusions-After PCI, readmissions within 30 days were seldom related to PCI comp...

Clinical Interventions to Reduce Preventable Hospital Readmission After Percutaneous Coronary Intervention

“…Our checklist, in contrast, was designed to be implemented at the time of discharge and addresses previous research on the causes and preventability of PCI readmissions. 11 The checklist for post-PCI patients includes a sublingual nitroglycerin prescription and confirmation of insurance coverage of prescribed antiplatelet agents. The checklist also recommends timely follow-up, especially for patients at high risk for readmission either by the readmission risk score or by the subjective assessment of the clinician.…”

Clinical Profile of Acute Myocardial Infarction Patients Included in the Hospital Readmissions Reduction Program

“…First are tactics that are likely to appropriately triage and evaluate patients with chest discomfort after PCI. We previously have shown that improved access to cardiology care in the emergency department can reduce unnecessary readmissions for low‐risk chest discomfort after PCI 6. Other strategies include reducing risk of infection and gastrointestinal bleeding.…”

“…After the passage of HRRP as part of health reform in 2010, large analyses of administrative data have shown that readmission rates after AMI decreased faster than they had been decreasing before the law 4, 5, 6. Because distinguishing these types of different patients with AMI is difficult from administrative data, it is not known what specific tactics have reduced readmissions or could further improve performance in the future.…”

Future of the PCI Readmission Metric

“…A similar analysis within the Partners Healthcare system in Boston, Massachusetts, demonstrated compatible results with only 6.7% of readmissions related to procedural complications and 38.1% of readmissions for chest discomfort or other symptoms concerning for angina without immediately obvious stent thrombosis. 13 Detailed adjudication of those cases revealed that only 2.6% of those patients with chest discomfort underwent target lesion revascularization (TLR) despite 84.4% of patients undergoing at least one diagnostic procedure during the readmission. 13 …”

“…13 Detailed adjudication of those cases revealed that only 2.6% of those patients with chest discomfort underwent target lesion revascularization (TLR) despite 84.4% of patients undergoing at least one diagnostic procedure during the readmission. 13 …”