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

Abstract

BackgroundMedicare's Hospital Readmissions Reduction Program assesses financial penalties to hospitals based on risk‐standardized readmission rates after specific episodes of care, including acute myocardial infarction. Detailed information about the type of patients included in the penalty is unknown.Methods and ResultsStarting with administrative data from Medicare, we conducted physician‐adjudicated chart reviews of all patients considered 30‐day readmissions after acute myocardial infarction from July 2012 to June 2015. Of 197 readmissions, 68 (34.5%) received percutaneous coronary intervention and 18 (9.1%) underwent coronary artery bypass grafting on index hospitalization. The remaining 111 patients did not receive any intervention. Of the 197 patients, 56 patients (28.4%) were considered too high risk for invasive management, 23 (11.7%) had nonobstructive coronary artery disease on diagnostic catheterization and therefore no indication for revascularization, 19 patients had a type II myocardial infarction (9.6%) for which noninvasive, outpatient workup was recommended, and 13 (6.6%) declined further care. The most common readmission diagnoses were cardiac causes and noncardiac chest discomfort, infection, and gastrointestinal bleeding.ConclusionsOur results demonstrate that more than a quarter of the patients included in the penalty do not receive revascularization either because of provider assessment of risk or patient preference, and nearly one tenth have type II myocardial infarction. As such, administrative codes for prohibitive procedural risk, patient‐initiated “do not resuscitate” status, or type II myocardial infarction may improve the risk‐adjustment of the metric. Furthermore, provider organizations seeking to reduce readmission rates should focus resources on the needs of these patients, such as care coordination, hospice services when requested by patients, and treatment of noncardiac conditions.

Myocardial infarction classification and its implications on measures of cardiovascular outcomes, quality, and racial/ethnic disparities

“…Acute MI is one of six conditions included in the HRRP, with a combined total of $528 million being withheld from hospitals due to readmissions in 2017 8 . Of all readmitted patients with MI contributing to the HRRP penalty, about 10% may have actually had type 2 MI 8,11 . In conjunction with the Hospital Value‐Based Purchasing Program, and after strict adjudication with physician medical record reviewers using the most current universal definition of MI, 7 McCarthy et al found that approximately 41% of patients with nonischemic myocardial injury are frequently misdiagnosed and subsequently billed as having type 2 MI 10 .…”

Misclassification of Myocardial Injury as Myocardial Infarction

“…Thirty-day readmission rates for myocardial injury in this study are higher than the national 30-day readmission rates for acute MI (21% vs 14.8%), 5 and many patients with T2MI are included in Hospital Readmission Reduction Program penalties. 6 Because the methods for these programs effectively compare hospitals against one another, hospitals that include highrisk patients with myocardial injury as having T2MI may perform more poorly in value-based payment programs. Alternatively, because patients with myocardial injury may have more comorbidities than the general MI population, including patients with myocardial injury patients could conceivably reduce risk-standardized mortality and readmission rates.…”

Type 2 Myocardial Infarction and the Hospital Readmission Reduction Program

“…Approximately 40% of readmissions were due to infectious or bleeding complications, and non-cardiovascular causes of rehospitalization outnumbered those due to cardiovascular reasons (11). Similarly, examining 30-day readmissions after type 2 MI, Martin and colleagues found that greater than a quarter of readmissions were due to infection and another quarter due to non-cardiac chest pain (3).…”

“…Thus, it seems unreasonable to hold hospitals accountable for readmission of these patients, in the absence of strategies to prevent repeat hospitalization. Indeed, many patients with type 2 MI will be readmitted for non-cardiovascular reasons related to their comorbidities (3,11).…”

“…Despite differences between type 1 and type 2 MI (Table 1), both are included under the HRRP, and it is reasonable to suspect that readmission following type 2 MI contributes a substantial amount of penalty funds under the law. Few data are available to date, but at least 10% of all readmitted patients (cardiovascular and non-cardiovascular patients) that have actually contributed to the HRRP penalty may have type 2 MI (3). Until recently, it was not possible to differentiate patients with type 1 and type 2 MI using administrative data due to the absence of an International Statistical Classification of Diseases and Related Health Problems (ICD) code for each subtype of MI.…”