Coronary revascularization outcomes in relation to skilled nursing facility use following hospital discharge

Abstract

Background Observational analyses comparing coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) among elderly or frail patients are likely biased by treatment selection. PCI is typically chosen for frail patients, while CABG is more common for patients with good recovery potential. Hypothesis We hypothesized that skilled nursing facility (SNF) use after revascularization is a measure of relative frailty associated with outcomes following coronary revascularization. Methods We used a 20 percent sample of Medicare beneficiaries aged 65 years or older who received inpatient PCI or CABG between 2007–2014. Key explanatory variables were the revascularization strategy and SNF use after revascularization. We used Cox regression to evaluate death and repeat revascularization within one year and logistic regression to evaluate SNF use and 30‐day readmissions/death. Results CABG patients were 25.1 percentage points [95% confidence interval: 24.7, 25.5] more likely to use SNF following revascularization than inpatient PCI patients. SNF use was associated with a higher death rate (hazard ratio (HR): 3.19 [3.02, 3.37]) and a 16.2 percentage point (15.5, 16.9) increase in 30‐day readmissions/death. Among patients with SNF use, CABG was associated with a decrease in 30‐day readmissions/death compared to PCI. Conclusions While CABG was associated with higher rates of SNF use and 30‐day readmission/death overall, CABG was associated with significantly lower rates of 30‐day readmissions/death among patients with SNF use. The findings suggest that caution is needed in treatment selection for patients at high‐risk for SNF use and that selection of inpatient PCI over CABG may be associated with frailty and worse outcomes for some patients.

Perioperative Coronavirus Vaccination—Timing and Implications: A Guidance Document

“…39 length of stay at the facility of 10.6 days. 45,46 Although vaccines themselves do not cause active infection, uncertainty may arise between similarities in adverse effects versus postoperative infections or complications (fever, fatigue, myalgia) or even confusion with COVID-19 illness itself. Between 50% and 70% of patients receiving the mRNA vaccines developed some form of systemic reaction within 0 to 7 days of vaccination, with the second dose producing more systemic effects and the elderly population reporting more adverse effects.…”

The correlation between COVID‐19 vaccination and cardiac surgery: When is safe to vaccinate?

“…For instance, for patients undergoing coronary bypass surgery, the median length of stay at a nursing facility is 10.6 days, with discharge being highly correlated to age. 15 Deferring vaccination until full recovery is also useful in avoiding unwanted reactogenicity, adverse (and potentially confounding) effects of COVID‐19 vaccination when recuperating postoperatively. This is accentuated by the fact that most (up to 70%) patients who receive messenger RNA (mRNA) vaccines experience systemic adverse effects within 0–7 days of vaccination.…”

“…For example, the shared decision across cardiothoracic surgical teams in Hong Kong was to delay administrating the COVID‐19 vaccination to patients until 3–6 months after surgery by accounting for differences in convalescent times as well as any postsurgery complications. For instance, for patients undergoing coronary bypass surgery, the median length of stay at a nursing facility is 10.6 days, with discharge being highly correlated to age 15 . Deferring vaccination until full recovery is also useful in avoiding unwanted reactogenicity, adverse (and potentially confounding) effects of COVID‐19 vaccination when recuperating postoperatively.…”