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Ludmir J, Suero-Abreu GA, Gonzalez de la Nuez A, Robles M, Wood MJ, Del Carmen MG, Wasfy JH. Building a post-myocardial infarction discharge intervention program for Hispanic patients. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2024; 12:100730. [PMID: 38087744 DOI: 10.1016/j.hjdsi.2023.100730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/08/2023] [Accepted: 12/03/2023] [Indexed: 03/12/2024]
Abstract
Hispanic patients disproportionally suffer from disparities in care delivery in the setting of acute myocardial infarction (AMI). More specifically, Hispanic patients have higher 30-day readmission rates post-AMI and are less likely to be referred to cardiac rehab. Because of the challenges Hispanic patients face with post-AMI care, the Hispanic Acute Myocardial Infarction Discharge Intervention Study (HAMIDI) was launched to provide a culturally sensitive discharge framework to improve readmission and mortality rates in this population. Patients enrolled in this study participate in a comprehensive post-discharge program involving follow-up with a Spanish-speaking cardiologist, a two-part educational virtual group visit program, and access to support throughout the study. During the initial year of the study, 35 patients enrolled and successfully participated in the program. This case study reviews the implementation process, initial outcomes, challenges, and future plans of the program.
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Affiliation(s)
- Jonathan Ludmir
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, USA.
| | - Giselle A Suero-Abreu
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, USA
| | | | - Martin Robles
- Department of Internal Medicine, University of California, San Francisco, Fresno, USA
| | - Malissa J Wood
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, USA
| | - Marcela G Del Carmen
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, USA
| | - Jason H Wasfy
- Corrigan Minehan Heart Center, Massachusetts General Hospital, Harvard Medical School, USA
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Puro N, Cronin CE, Franz B, Singh S, Feyereisen S. Differential impact of hospital and community factors on breadth and depth of hospital population health partnerships. Health Serv Res 2024; 59 Suppl 1:e14238. [PMID: 37727122 PMCID: PMC10796292 DOI: 10.1111/1475-6773.14238] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023] Open
Abstract
OBJECTIVE The aim was to identify hospital and county characteristics associated with variation in breadth and depth of hospital partnerships with a broad range of organizations to improve population health. DATA SOURCES The American Hospital Association Annual Survey provided data on hospital partnerships to improve population health for the years 2017-2019. DESIGN The study adopts the dimensional publicness theory and social capital framework to examine hospital and county characteristics that facilitate hospital population health partnerships. The two dependent variables were number of local community organizations that hospitals partner with (breadth) and level of engagement with the partners (depth) to improve population health. The independent variables include three dimensions of publicness: Regulative, Normative and Cultural-cognitive measured by various hospital factors and presence of social capital present at county level. Covariates in the multivariate analysis included hospital factors such as bed-size and system membership. METHODS We used hierarchical linear regression models to assess various hospital and county factors associated with breadth and depth of hospital-community partnerships, adjusting for covariates. PRINCIPAL FINDINGS Nonprofit and public hospitals provided a greater breadth (coefficient, 1.61; SE, 0.11; p < 0.001 and coefficient, 0.95; SE, 0.14; p < 0.001) and depth (coefficient, 0.26, SE, 0.04; p < 0.001 & coefficient, 0.13; SE, 0.05; p < 0.05) of partnerships than their for-profit counterparts, partially supporting regulative dimension of publicness. At a county level, we found community social capital positively associated with breadth of partnerships (coefficient, 0.13; SE, 0.08; p < 0.001). CONCLUSIONS An environment that promotes collaboration between hospitals and organizations to improve population health may impact the health of the community by identifying health needs of the community, targeting social determinants of health, or by addressing patient social needs. However, findings suggest that publicness dimensions at an organizational level, which involves a culture of public value, maybe more important than county factors to achieve community building through partnerships.
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Affiliation(s)
- Neeraj Puro
- College of Business, Health Administration DepartmentFlorida Atlantic UniversityBoca RatonFloridaUSA
| | - Cory E. Cronin
- College of Health Sciences and ProfessionsOhio UniversityAthensOhioUSA
| | - Berkeley Franz
- Heritage College of Osteopathic MedicineOhio UniversityIrvineCaliforniaUSA
| | - Simone Singh
- Department of Health Management and PolicyUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
| | - Scott Feyereisen
- College of Business, Health Administration DepartmentFlorida Atlantic UniversityBoca RatonFloridaUSA
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Achanta A, Wasfy JH. More advanced statistical techniques are not yet sufficient to realize the promise of risk prediction to reduce readmission. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 56:25-26. [PMID: 37394318 DOI: 10.1016/j.carrev.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 07/04/2023]
Affiliation(s)
- Aditya Achanta
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Jason H Wasfy
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America; Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America.
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Kodeboina M, Piayda K, Jenniskens I, Vyas P, Chen S, Pesigan RJ, Ferko N, Patel BP, Dobrin A, Habib J, Franke J. Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:ijerph20095633. [PMID: 37174152 PMCID: PMC10177939 DOI: 10.3390/ijerph20095633] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/24/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Abstract
Clinical and economic burdens exist within the coronary artery disease (CAD) care pathway despite advances in diagnosis and treatment and the increasing utilization of percutaneous coronary intervention (PCI). However, research presenting a comprehensive assessment of the challenges across this pathway is scarce. This contemporary review identifies relevant studies related to inefficiencies in the diagnosis, treatment, and management of CAD, including clinician, patient, and economic burdens. Studies demonstrating the benefits of integration and automation within the catheterization laboratory and across the CAD care pathway were also included. Most studies were published in the last 5-10 years and focused on North America and Europe. The review demonstrated multiple potentially avoidable inefficiencies, with a focus on access, appropriate use, conduct, and follow-up related to PCI. Inefficiencies included misdiagnosis, delays in emergency care, suboptimal testing, longer procedure times, risk of recurrent cardiac events, incomplete treatment, and challenges accessing and adhering to post-acute care. Across the CAD pathway, this review revealed that high clinician burnout, complex technologies, radiation, and contrast media exposure, amongst others, negatively impact workflow and patient care. Potential solutions include greater integration and interoperability between technologies and systems, improved standardization, and increased automation to reduce burdens in CAD and improve patient outcomes.
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Affiliation(s)
- Monika Kodeboina
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80138 Naples, Italy
- Clinic for Internal Medicine and Cardiology, Marien Hospital, 52066 Aachen, Germany
| | - Kerstin Piayda
- Cardiovascular Center Frankfurt, 60389 Frankfurt, Germany
- Department of Cardiology and Vascular Medicine, Medical Faculty, Justus-Liebig-University Giessen, 35392 Giessen, Germany
| | | | | | | | | | | | | | | | | | - Jennifer Franke
- Cardiovascular Center Frankfurt, 60389 Frankfurt, Germany
- Philips Chief Medical Office, 22335 Hamburg, Germany
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Nguyen MT, Ali A, Ngo L, Ellis C, Psaltis PJ, Ranasinghe I. Thirty-Day Unplanned Readmissions Following Elective and Acute Percutaneous Coronary Intervention. Heart Lung Circ 2023; 32:619-628. [PMID: 37003938 DOI: 10.1016/j.hlc.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/04/2022] [Accepted: 02/28/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Prior studies have reported a high rate of unplanned readmissions following acute percutaneous coronary intervention (PCI). Data outside the USA comparing 30-day unplanned readmissions following elective PCI to those who undergo acute PCI remain limited. METHODS Patients who underwent a PCI procedure in Australia and New Zealand between 2010 and 2015 were included. We determined the rates, causes and predictors of 30-day unplanned readmissions, as well as rates of repeat revascularisation procedures, for patients who underwent an elective or acute PCI. Predictors of readmissions were identified using logistic regression. RESULTS A total of 199,686 PCI encounters were included, of which 74,890 (37.5%) were elective and 124,796 (62.5%) were acute procedures. Overall, 10.6% of patients had at least one unplanned readmission within 30 days of discharge with lower rates following elective PCI (7.0%) compared to acute PCI (12.7%) (p<0.01). Non-specific chest pain was the commonest cause of readmission after elective and acute PCI, accounting for 20.7% and 21.5% of readmission diagnoses, respectively. Readmissions for acute myocardial infarction (13.0% vs 4.6%, p<0.01) and heart failure (6.5% vs 3.3%, p<0.01) were higher following acute PCI compared to elective PCI. Among readmitted patients, 16.7% had a coronary catheterisation, 12.2% had a PCI and 0.7% had coronary artery bypass surgery. Multivariable predictors of 30-day unplanned readmission included female sex and comorbidities such as heart failure, metastatic disease, chronic lung disease and renal failure (p<0.0001 for all). CONCLUSIONS Unplanned readmissions following elective or acute PCI are high. Clinical and quality-control measures are required to prevent avoidable readmissions in both settings.
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Affiliation(s)
- Mau T Nguyen
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia; Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.
| | - Anna Ali
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia; Royal Australasian College of Surgeons, Adelaide, SA, Australia
| | - Linh Ngo
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia; School of Clinical Medicine, The University of Queensland, Brisbane, Qld, Australia
| | - Chris Ellis
- Cardiology Department, Auckland City Hospital, Auckland, New Zealand
| | - Peter J Psaltis
- Vascular Research Centre, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia; Department of Cardiology, Central Adelaide Local Health Network, Adelaide, SA, Australia; Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Isuru Ranasinghe
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia; School of Clinical Medicine, The University of Queensland, Brisbane, Qld, Australia
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Eccleston D, Duong MN, Chowdhury E, Schwarz N, Reid C, Liew D, Conradie A, Worthley SG. Early vs. Late Readmission following Percutaneous Coronary Intervention: Predictors and Impact on Long-Term Outcomes. J Clin Med 2023; 12:jcm12041684. [PMID: 36836219 PMCID: PMC9958941 DOI: 10.3390/jcm12041684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/19/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Readmissions within 1 year after percutaneous coronary intervention (PCI) are common (18.6-50.4% in international series) and a burden to patients and health services, however their long-term implications are not well characterised. We compared predictors of 30-day (early) and 31-day to 1-year (late) unplanned readmission and the impact of unplanned readmission on long-term clinical outcomes post-PCI. METHODS Patients enrolled in the GenesisCare Cardiovascular Outcomes Registry (GCOR-PCI) from 2008 to 2020 were included in the study. Multivariate logistic regression analysis was performed to identify predictors of early and late unplanned readmission. A Cox proportion hazards regression model was used to explore the impact of any unplanned readmission during the first year post-PCI on the clinical outcomes at 3 years. Finally, patients with early and late unplanned readmission were compared to determine which group was at the highest risk of adverse long-term outcomes. RESULTS The study comprised 16,911 consecutively enrolled patients who underwent PCI between 2009-2020. Of these, 1422 patients (8.5%) experienced unplanned readmission within 1-year post-PCI. Overall, the mean age was 68.9 ± 10.5 years, 76.4% were male and 45.9% presented with acute coronary syndromes. Predictors of unplanned readmission included increasing age, female gender, previous CABG, renal impairment and PCI for acute coronary syndromes. Unplanned readmission within 1 year of PCI was associated with an increased risk of MACE (adjusted HR 1.84 (1.42-2.37), p < 0.001) and death over a 3-year follow-up (adjusted HR 1.864 (1.34-2.59), p < 0.001) compared with those without readmission within 1-year post-PCI. Late compared with early unplanned readmission within the first year of PCI was more frequently associated with subsequent unplanned readmission, MACE and death between 1 and 3 years post-PCI. CONCLUSIONS Unplanned readmissions in the first year following PCI, particularly those occurring more than 30 days after discharge, were associated with a significantly higher risk of adverse outcomes, such as MACE and death at 3 years. Strategies to identify patients at high risk of readmission and interventions to reduce their greater risk of adverse events should be implemented post-PCI.
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Affiliation(s)
- David Eccleston
- Department of Medicine, University of Melbourne, Parkville, VIC 3050, Australia
- Correspondence:
| | | | | | | | - Christopher Reid
- School of Public Health, Curtin University, Perth, WA 6845, Australia
| | - Danny Liew
- Adelaide Med School, Adelaide, SA 5000, Australia
| | - Andre Conradie
- Cardiology Department, Friendly Society Private Hospital, Bundaberg, QLD 4670, Australia
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Amritphale A, Fonarow GC, Amritphale N, Omar B, Crook ED. All-cause unplanned readmissions in the United States: insights from the Nationwide Readmission Database. Intern Med J 2023; 53:262-270. [PMID: 34633136 DOI: 10.1111/imj.15581] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 10/02/2021] [Accepted: 10/06/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are few studies looking into adult, all-cause and age-group-specific unplanned readmissions. The predictors of such unplanned readmissions for all inpatient encounters remain obscure. AIMS To describe the incidence and factors associated with unplanned readmissions in all inpatient encounters in the United States. METHODS The US Nationwide Readmission Database (NRD) is a representative sample of hospitalisations in the United States (from approximately 28 states) accounting for approximately 60% of the US population. All inpatient encounters during January-November 2017 in the NRD were evaluated for the rates, predictors and costs of unplanned 30 days readmissions for age groups 18-44 years, 45-64 years, 65-75 years and ≥75 years. Elective readmissions and those patients who died on their index hospitalisations were excluded. Weighted analysis was performed to obtain nationally representative data. RESULTS We identified 28 942 224 inpatient encounters with a total of 3 051 189 (10.5%) unplanned readmissions within 30 days. The age groups 18-44 years, 45-64 years, 65-74 years and ≥75 years had 7.0%, 12.0%, 11.7% and 12.3% readmissions respectively. Female gender, private insurance and elective admissions were negative predictors for readmissions. For the group aged 18-44 years, schizophrenia and diabetes mellitus complications were the most frequent primary diagnosis for readmissions, while in all older age groups septicaemia and heart failure were the most frequent primary diagnosis for readmissions. CONCLUSIONS Thirty-day unplanned readmissions are common in patients over age 45 years, leading to significant morbidity. Effective strategies for reducing unplanned readmission may help to improve quality of care, outcomes and higher value care.
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Affiliation(s)
- Amod Amritphale
- Department of Internal Medicine, University Hospital, University of South Alabama, Mobile, Alabama, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, David Geffen School of Medicine at UCLA, University of California, Los Angeles, California, USA
| | - Nupur Amritphale
- Children and Women's Hospital, University of South Alabama, Mobile, Alabama, USA
| | - Bassam Omar
- Department of Internal Medicine, University Hospital, University of South Alabama, Mobile, Alabama, USA
| | - Errol D Crook
- Department of Internal Medicine, University Hospital, University of South Alabama, Mobile, Alabama, USA
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Jin J. Analysis of risk factors and nursing intervention of heart failure after emergency PCI in patients with acute coronary syndrome. Minerva Pediatr (Torino) 2022; 74:813-815. [PMID: 36178340 DOI: 10.23736/s2724-5276.22.07054-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Jinhua Jin
- Department of Cardiovascular Medicine, Run Run Shaw Hospital, Medical College of Zhejiang University, Hangzhou, China -
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David F, Philipp J, Henrike AB, Nikolaos PP, Christine PH, Martin C, Oliver PR, Benjamin S. Impact of the Educational Level on Non-Fatal Health Outcomes following Myocardial Infarction. Curr Probl Cardiol 2022; 47:101340. [DOI: 10.1016/j.cpcardiol.2022.101340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/29/2022] [Indexed: 11/03/2022]
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Xu W, Tu H, Xiong X, Peng Y, Cheng T. Predicting the Risk of Unplanned Readmission at 30 Days After PCI: Development and Validation of a New Predictive Nomogram. Clin Interv Aging 2022; 17:1013-1023. [PMID: 35818480 PMCID: PMC9270887 DOI: 10.2147/cia.s369885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/21/2022] [Indexed: 11/23/2022] Open
Abstract
Objective This study aimed to develop and validate a risk prediction model that can be used to identify percutaneous coronary intervention (PCI) patients at high risk for 30-day unplanned readmission. Patients and Methods We developed a prediction model based on a training dataset of 1348 patients after PCI. The data were collected from January 2020 to December 2020. Clinical characteristics, laboratory data and risk factors were collected using the hospital database. The LASSO regression method was applied to filter variables and select predictors, and feature selection for a 30-day readmission risk model was optimized using least absolute shrinkage. Multivariate logistic regression was used to construct a nomogram. The performance and clinical utility of the nomogram were evaluated with a receiver operating characteristic (ROC) curve, a calibration curve, and decision curve analysis (DCA). Internal validation of the predictive accuracy was performed using bootstrapping validation. Results The predictors included in the prediction nomogram were medical insurance, length of stay, left ventricular ejection fraction on admission, history of hypertension, the presence of chronic lung disease, the presence of anemia, and serum creatinine level on admission. The area under the receiver operating characteristic curve for the predictive model was 0.735 (95% CI: 0.711–0.759). The P value of the Hosmer–Lemeshow goodness of fit test was 0.326, indicating good calibration, and the calibration curves showed good agreement between the classifications and actual observations. DCA also demonstrated that the nomogram was clinically useful. A high c-index value of 0.723 was obtained during the internal validation. Conclusion We developed an easy-to-use nomogram model to predict the risk of readmission 30 days after discharge for PCI patients. This risk prediction model may serve as a guide for screening high-risk patients and allocating resources for PCI patients at the time of hospital discharge and may provide a reference for preventive care interventions.
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Affiliation(s)
- Wenjun Xu
- Department of Nursing, the Second Affiliated Hospital of Nanchang University, NanChang, Jiangxi, 330000, People’s Republic of China
- School of Nursing, Nanchang University, NanChang, Jiangxi, 330000, People’s Republic of China
| | - Hui Tu
- Department of Nursing, the Second Affiliated Hospital of Nanchang University, NanChang, Jiangxi, 330000, People’s Republic of China
- Correspondence: Hui Tu, Department of Nursing, the Second Affiliated Hospital of Nanchang University, 1 Minde Road, NanChang, Jiangxi, 330000, People’s Republic of China, Tel +86 135-76095925, Email
| | - Xiaoyun Xiong
- Department of Nursing, the Second Affiliated Hospital of Nanchang University, NanChang, Jiangxi, 330000, People’s Republic of China
| | - Ying Peng
- Department of Nursing, the Second Affiliated Hospital of Nanchang University, NanChang, Jiangxi, 330000, People’s Republic of China
- School of Nursing, Nanchang University, NanChang, Jiangxi, 330000, People’s Republic of China
| | - Ting Cheng
- Department of Nursing, the Second Affiliated Hospital of Nanchang University, NanChang, Jiangxi, 330000, People’s Republic of China
- School of Nursing, Nanchang University, NanChang, Jiangxi, 330000, People’s Republic of China
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Sheldon M, Blankenship JC. STEMI in nonagenarians: Never too old. Catheter Cardiovasc Interv 2022; 100:17-18. [PMID: 35819148 DOI: 10.1002/ccd.30306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 06/11/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Mark Sheldon
- Division of Cardiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - James C Blankenship
- Division of Cardiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
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Abstract
PURPOSE OF REVIEW The past decade has brought increased efforts to better understand causes for ACS readmissions and strategies to minimize them. This review seeks to provide a critical appraisal of this rapidly growing body of literature. RECENT FINDINGS Prior to 2010, readmission rates for patients suffering from ACS remained relatively constant. More recently, several strategies have been implemented to mitigate this including improved risk assessment models, transition care bundles, and development of targeted programs by federal organizations and professional societies. These strategies have been associated with a significant reduction in ACS readmission rates in more recent years. With this, improvements in 30-day post-discharge mortality rates are also being appreciated. As we continue to expand our knowledge on independent risk factors for ACS readmissions, further strategies targeting at-risk populations may further decrease the rate of readmissions. Efforts to understand and reduce 30-day ACS readmission rates have resulted in overall improved quality of care for patients.
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Unplanned hospital readmissions after acute myocardial infarction: a nationwide analysis of rates, trends, predictors and causes in the United States between 2010 and 2014. Coron Artery Dis 2021; 31:354-364. [PMID: 31972608 DOI: 10.1097/mca.0000000000000844] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Unplanned hospital readmissions are an important quality metric for benchmarking, but there are limited data following an acute myocardial infarction (AMI). This study aims to examine the 30-day unplanned readmission rate, predictors, causes and outcomes after hospitalization for AMI. METHODS The USA Nationwide Readmission Database was utilized to analyze patients with a primary diagnosis of AMI between 2010 and 2014. Rates of readmissions, causes and costs were determined and multiple logistic regressions were used to identify predictors of readmissions. RESULTS Of 2 204 104 patients with AMI, the 30-day unplanned readmission rate was 12.3% (n = 270 510), which changed from 13.0 to 11.5% between 2010 and 2014. The estimated impact of readmissions in AMI was ~718 million USD and ~281000 additional bed days per year. Comorbidities such as diabetes [odds ratio (OR) 1.27, 95% confidence interval (CI) 1.25-1.29], chronic lung disease (OR 1.29, 95% CI 1.26-1.31), renal failure (OR 1.38, 95% CI 1.35-1.40) and cancer (OR 1.35, 95% CI 1.30-1.41) were independently associated with unplanned readmission. Discharge against medical advice was the variable most strongly associated with unplanned readmission (OR 2.40, 95% CI 2.27-2.54). Noncardiac causes for readmissions accounted for 52.9% of all readmissions. The most common cause of cardiac readmission was heart failure (14.3%) and for noncardiac readmissions was infections (8.8%). CONCLUSION Readmissions during the first month after AMI occur in more than one in 10 patients resulting in a healthcare cost of ~718 million USD per year and ~281000 additional bed days per year. These findings have important public health implications. Strategies to identify and reduce readmissions in AMI will dramatically reduce healthcare costs for society.
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Wilson NA, Reich AJ, Graham J, Bhatt DL, Nguyen LL, Weissman JS. Patient perspectives on the need for implanted device information: Implications for a post-procedural communication framework. Health Expect 2021; 24:1391-1402. [PMID: 33974346 PMCID: PMC8369078 DOI: 10.1111/hex.13273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/05/2021] [Accepted: 04/15/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Shared decision making and patient-centred communication have become part of pre-procedural decisions and perioperative care across medical specialties. However, gaps exist in patient communication about the implanted device received and the benefits in sharing information about their procedure and device. OBJECTIVE To understand the patients' knowledge of identifying information for their implanted devices and perspectives on sharing their implanted device information. METHODS Four focus groups were conducted with patients who had received a cardiac or vascular implanted device from one of the study sites within the previous 6 months. Data were transcribed and thematically analysed. RESULTS Five themes emerged: lack of awareness of identifying information on implanted devices; value of information on implanted devices; varying trust with sharing device information; perceived risk with sharing device information; and lack of consensus on a systematic process for tracking implanted devices. DISCUSSION Patients desire post-procedural information on their implanted device and a designated plan for longitudinal follow-up, but lack trust and perceive risk with broadly sharing their implanted device information. CONCLUSION After receiving an implanted device, post-procedural patient communication needs to be expanded to include identifying information on the device including the unique device identifier, how long-term tracking will be supported and the process for notification in case of a problem with the device. This communication should also include education on how sharing device information supports patients' long-term health care, post-market safety surveillance and research. PATIENT OR PUBLIC CONTRIBUTION The research team included members who were also patients with implanted devices.
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Affiliation(s)
- Natalia A Wilson
- College of Health Solutions, Arizona State University, Phoenix, AZ, USA
| | - Amanda J Reich
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Deepak L Bhatt
- Heart and Vascular Center, Brigham and Women's Hospital, Boston, MA, USA
| | - Louis L Nguyen
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Joel S Weissman
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
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Sykes R, Mohamed MO, Kwok CS, Mamas MA, Berry C. Percutaneous coronary intervention and 30-day unplanned readmission with chest pain in the United States (Nationwide Readmissions Database). Clin Cardiol 2021; 44:291-306. [PMID: 33590937 PMCID: PMC7943906 DOI: 10.1002/clc.23543] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/28/2020] [Accepted: 12/30/2020] [Indexed: 11/08/2022] Open
Abstract
Percutaneous coronary intervention (PCI) improves anginal chest pain in most, but not all, treated patients. PCI is associated with unplanned readmission for angina and non-specific chest pain within 30-days of index PCI. Patients with an index hospitalization for PCI between January-November in each of the years 2010-2014 were included from the United States Nationwide Readmissions Database. Of 2 723 455 included patients, the 30-day unplanned readmission rate was 7.2% (n = 196 581, 42.3% female). This included 9.8% (n = 19 183) with angina and 11.1% (n = 21 714) with non-specific chest pain. The unplanned readmission group were younger (62.2 vs 65.1 years; P < 0.001), more likely to be females (41.0% vs 34.2%; P < 0.001), from the lowest quartile of household income (32.9% vs 31.2%; P < 0.001), have higher prevalence of cardiovascular risk factors or have index PCI performed for non-acute coronary syndromes (ACS) (OR:3.46, 95%CI 3.39-3.54). Factors associated with angina readmissions included female sex (OR:1.28, 95%CI 1.25-1.32), history of ischemic heart disease (IHD) (OR:3.28, 95%CI 2.95-3.66), coronary artery bypass grafts (OR:1.79, 95%CI 1.72-2.86), anaemia (OR:1.16, 95%CI 1.11-1.21), hypertension (OR:1.13, 95%CI 1.09, 1.17), and dyslipidemia (OR:1.10, 95%CI 1.06-1.14). Non-specific chest pain compared with angina readmissions were younger (mean difference 1.25 years, 95% CI 0.99, 1.50), more likely to be females (RR:1.13, 95%CI 1.10, 1.15) and have undergone PCI for non-ACS (RR:2.17, 95%CI 2.13, 2.21). Indications for PCI other than ACS have a greater likelihood of readmission with angina or non-specific chest pain at 30-days. Readmissions are more common in patients with modifiable risk factors, previous history of IHD and anaemia.
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Affiliation(s)
- RobertA Sykes
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,Golden Jubilee National Hospital, UK
| | | | | | | | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,Golden Jubilee National Hospital, UK.,Royal Stoke University Hospital, UK
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16
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Kwok CS, Chatterjee S, Bagur R, Sharma K, Alraies MC, Fischman D, Savage M, Mohamed M, Shoaib A, Patel T, Mamas MA. Multiple unplanned readmissions after discharge for an admission with percutaneous coronary intervention. Catheter Cardiovasc Interv 2021; 97:395-408. [PMID: 32108416 DOI: 10.1002/ccd.28797] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 01/15/2020] [Accepted: 02/10/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE This study aims to describe temporal trends, characteristics, and clinical outcomes of patients with more than one unplanned readmission within 30 and 180 days after admission with percutaneous coronary intervention (PCI). BACKGROUND There is limited understanding of multiple readmissions after PCI. METHODS Patients undergoing PCI between 2010 and 2014 in the U.S. Nationwide Readmission Database were evaluated for unplanned readmissions at 30 and 180 days after discharge. Trends in multiple readmissions, characteristics of patients, and causes of first readmissions are described. RESULTS A total of 2,324,194 patients were included in the analysis of 30-day unplanned readmissions and 1,327,799 patients in the analysis of 180-day unplanned readmission. The proportions of patients with a single readmission and multiple readmissions within 30 days were 8.5 and 1.0% and at 180 days were 15.4 and 9.1%, respectively. Common reasons for first readmission among patients with multiple readmissions were coronary artery disease, including angina, heart failure, and acute myocardial infarction. Factors associated with multiple readmissions were discharge against medical advice, discharge to care home, renal failure, and liver failure. The total cost of multiple readmissions is significant, with an increase from ~$20,000 for no readmission to over $60,000 at 30-day follow up and $86,000 at 180-day follow up. CONCLUSIONS Multiple readmissions are rare within 30 days after PCI but increase to nearly 1 in 10 patients at 180 days, and 20-25% of patients who have multiple readmissions are readmitted for the same cause as for the first and second readmissions.
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Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK.,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Saurav Chatterjee
- Division of Cardiovascular Medicine, Hoffman Heart Institute, Saint Francis Hospital, Teaching Affiliate of the University of Connecticut School of Medicine, Hartford, Connecticut
| | - Rodrigo Bagur
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
| | - Kamal Sharma
- Department of Cardiology, U.N. Mehta Institute of Cardiology and Research Centre (UNMICRC), Asarwa, India
| | - M Chadi Alraies
- Department of Cardiology, Detroit Medical Center, Detroit Heart Hospital, Wayne State University, Detroit, Michigan
| | - David Fischman
- Department of Medicine (Cardiology), Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Michael Savage
- Department of Medicine (Cardiology), Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Mohamed Mohamed
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK.,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Ahmad Shoaib
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
| | - Tejas Patel
- Department of Cardiology, Apex Heart Institute, Ahmedabad, India
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK.,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
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Trends, Predictors, and Outcomes Associated With 30-Day Hospital Readmissions After Percutaneous Coronary Intervention in a High-Volume Center Predominantly Using Radial Vascular Access. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1525-1531. [DOI: 10.1016/j.carrev.2020.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/18/2020] [Indexed: 11/22/2022]
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18
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Biswas S, Dinh D, Lucas M, Duffy SJ, Brennan AL, Liew D, Cox N, Nadurata V, Reid CM, Lefkovits J, Stub D. Incidence and Predictors of Unplanned Hospital Readmission after Percutaneous Coronary Intervention. J Clin Med 2020; 9:jcm9103242. [PMID: 33050476 PMCID: PMC7600497 DOI: 10.3390/jcm9103242] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/25/2020] [Accepted: 10/03/2020] [Indexed: 11/24/2022] Open
Abstract
Unplanned readmissions to hospital after percutaneous coronary intervention (PCI) pose a significant burden to the healthcare system and are potentially preventable. In this study, we sought to determine the incidence of, and risk factors for, unplanned hospital readmissions within 30 days following PCI. We prospectively collected data on 28,488 patients undergoing PCI between 2013 and 2019, who were enrolled in the state-wide multi-centre Victorian Cardiac Outcomes Registry. Patients’ data were then linked to data from the Victorian Department of Health administrative database that records statewide hospital admissions. Disease diagnosis codes were used to identify cause of readmission. Patients who had an unplanned readmission were further divided into those who had a cardiac vs. non-cardiac cause for readmission. Overall, 3059 patients (10.7%) had an unplanned hospital readmission within 30 days of PCI, of which 1848 patients (60.4%) were readmitted for primarily cardiac diagnoses. Independent predictors of both 30-day unplanned cardiac and non-cardiac readmissions post-PCI were female sex, having ≥1 admission in the 12 months prior to PCI, acute coronary syndrome presentation, having any in-hospital complication and being discharged on an oral anticoagulant (all p < 0.05). A stepwise increase in readmission risk was observed with increasing number of admissions from 1 to ≥4 admissions in the 12 months prior to PCI. In conclusion, a substantial proportion of patients undergoing PCI have unexpected readmissions to hospital in the 30 days following PCI. Targeted strategies for patients with risk factors for readmission may be useful to reduce this significant burden to the healthcare system.
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Affiliation(s)
- Sinjini Biswas
- School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia; (S.B.); (D.D.); (M.L.); (S.J.D.); (A.L.B.); (D.L); (C.M.R.); (J.L.)
- Department of Cardiology, The Alfred Hospital, Melbourne 3004, Australia
| | - Diem Dinh
- School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia; (S.B.); (D.D.); (M.L.); (S.J.D.); (A.L.B.); (D.L); (C.M.R.); (J.L.)
| | - Mark Lucas
- School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia; (S.B.); (D.D.); (M.L.); (S.J.D.); (A.L.B.); (D.L); (C.M.R.); (J.L.)
| | - Stephen J. Duffy
- School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia; (S.B.); (D.D.); (M.L.); (S.J.D.); (A.L.B.); (D.L); (C.M.R.); (J.L.)
- Department of Cardiology, The Alfred Hospital, Melbourne 3004, Australia
| | - Angela L. Brennan
- School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia; (S.B.); (D.D.); (M.L.); (S.J.D.); (A.L.B.); (D.L); (C.M.R.); (J.L.)
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia; (S.B.); (D.D.); (M.L.); (S.J.D.); (A.L.B.); (D.L); (C.M.R.); (J.L.)
- Department of General Medicine, The Alfred Hospital, Melbourne 3004, Australia
| | - Nicholas Cox
- Department of Cardiology, Western Health, Melbourne 3021, Australia;
- Department of Medicine—Western Health, The University of Melbourne, Melbourne 3021, Australia
| | | | - Christopher M. Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia; (S.B.); (D.D.); (M.L.); (S.J.D.); (A.L.B.); (D.L); (C.M.R.); (J.L.)
- School of Public Health, Curtin University, Perth 6102, Australia
| | - Jeffrey Lefkovits
- School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia; (S.B.); (D.D.); (M.L.); (S.J.D.); (A.L.B.); (D.L); (C.M.R.); (J.L.)
- Department of Cardiology, Royal Melbourne Hospital, Melbourne 3050, Australia
| | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne 3004, Australia; (S.B.); (D.D.); (M.L.); (S.J.D.); (A.L.B.); (D.L); (C.M.R.); (J.L.)
- Department of Cardiology, The Alfred Hospital, Melbourne 3004, Australia
- Department of Cardiology, Western Health, Melbourne 3021, Australia;
- Baker IDI Heart and Diabetes Institute, Melbourne 3004, Australia
- Correspondence: ; Tel.: +61-3-9076-3263
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19
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Wasfy JH, Hidrue MK, Ngo J, Tanguturi VK, Cafiero-Fonseca ET, Thompson RW, Johnson N, McDermott ST, Singh JP, Del Carmen MG, Ferris TG. Association of an Acute Myocardial Infarction Readmission-Reduction Program With Mortality and Readmission. Circ Cardiovasc Qual Outcomes 2020; 13:e006043. [PMID: 32393130 DOI: 10.1161/circoutcomes.119.006043] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Reducing hospital readmission after acute myocardial infarction (AMI) has the potential to both improve quality and reduce costs. As such, readmission after AMI has been a target of financial penalties through Medicare. However, substantial concern exists about potential adverse effects and efficacious readmission-reduction strategies are not well validated. METHODS AND RESULTS We started an AMI readmissions reduction program in November 2017. Between July 2016 and February 2019, hospital billing data were queried to detect all inpatient hospitalizations at the Massachusetts General Hospital for AMI. Thirty-day readmission was identified through hospital billing data, and mortality was extracted from our electronic health record. The data set was merged with claims data for patients in accountable care organizations to detect readmission at other hospitals. We performed segmented linear regression, adjusting for secular trend and case mix, to assess the independent association of our program on both outcome variables. After inclusion and exclusion criteria were applied, the study population included 2020 patients. The overall 30-day readmission rate was higher before the intervention than after the intervention (15.5% versus 10.7%, P=0.002). The overall 30-day mortality rate was similar in both time periods (1.8% versus 1.4%, P=0.457). The program was associated with initial reduction in 30-day readmission (-9.8%, P=0.0002) and 30-day mortality (-2.6%, P=0.041). The program did not change trend in 30-day readmission (+0.19% readmissions/mo, P=0.554) and trend in 30-day mortality (-0.21% deaths/mo, P=0.119). CONCLUSIONS An AMI readmissions reduction program that increases outpatient and emergency department (ED) access to cardiology care is associated with reduced 30-day readmission and 30-day mortality. Similar statistical techniques can be used to conduct a rigorous, mechanistic program evaluation of other quality improvement initiatives.
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Affiliation(s)
- Jason H Wasfy
- Cardiology Division, Department of Medicine (J.H.W., V.K.T., S.T.M., J.P.S.), Massachusetts General Hospital, Harvard Medical School, Boston.,Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., J.N., M.G.d.C., T.G.F.)
| | - Michael K Hidrue
- Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., J.N., M.G.d.C., T.G.F.)
| | - Jacqueline Ngo
- Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., J.N., M.G.d.C., T.G.F.).,Performance Analysis and Improvement Unit, Massachusetts General Hospital, Boston (J.N., E.T.C.-F., N.J.)
| | - Varsha K Tanguturi
- Cardiology Division, Department of Medicine (J.H.W., V.K.T., S.T.M., J.P.S.), Massachusetts General Hospital, Harvard Medical School, Boston
| | | | - Ryan W Thompson
- Department of Medicine (T.G.F., R.W.T.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Natalie Johnson
- Performance Analysis and Improvement Unit, Massachusetts General Hospital, Boston (J.N., E.T.C.-F., N.J.)
| | - Susan T McDermott
- Cardiology Division, Department of Medicine (J.H.W., V.K.T., S.T.M., J.P.S.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jagmeet P Singh
- Cardiology Division, Department of Medicine (J.H.W., V.K.T., S.T.M., J.P.S.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology (M.G.d.C.), Massachusetts General Hospital, Harvard Medical School, Boston.,Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., J.N., M.G.d.C., T.G.F.)
| | - Timothy G Ferris
- Department of Medicine (T.G.F., R.W.T.), Massachusetts General Hospital, Harvard Medical School, Boston.,Massachusetts General Physicians Organization, Boston (J.H.W., M.K.H., J.N., M.G.d.C., T.G.F.)
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20
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Relative Effects of the Hospital Readmissions Reduction Program on Hospitals That Serve Poorer Patients. Med Care 2020; 57:968-976. [PMID: 31567860 DOI: 10.1097/mlr.0000000000001207] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
IMPORTANCE Hospitals that serve poorer populations have higher readmission rates. It is unknown whether these hospitals effectively lowered readmission rates in response to the Hospital Readmissions Reduction Program (HRRP). OBJECTIVE To compare pre-post differences in readmission rates among hospitals with different proportion of dual-eligible patients both generally and among the most highly penalized (ie, low performing) hospitals. DESIGN Retrospective cohort study using piecewise linear model with estimated hospital-level risk-standardized readmission rates (RSRRs) as the dependent variable and a change point at HRRP passage (2010). Economic burden was assessed by proportion of dual-eligibles served. SETTING Acute care hospitals within the United States. PARTICIPANTS Medicare fee-for-service beneficiaries aged 65 years or older discharged alive from January 1, 2003 to November 30, 2014 with a principal discharge diagnosis of acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. MAIN OUTCOME AND MEASURE Decrease in hospital-level RSRRs in the post-law period, after controlling for the pre-law trend. RESULTS For AMI, the pre-post difference between hospitals that service high and low proportion of dual-eligibles was not significant (-65 vs. -64 risk-standardized readmissions per 10000 discharges per year, P=0.0678). For CHF, RSRRs declined more at high than low dual-eligible hospitals (-79 vs. -75 risk-standardized readmissions per 10000 discharges per year, P=0.0006). For pneumonia, RSRRs declined less at high than low dual-eligible hospitals (-44 vs. -47 risk-standardized readmissions per 10000 discharges per year, P=0.0003). Among the 742 highest penalized hospitals and all conditions, the pre-post decline in rate of change of RSRRs was less for high dual-eligible hospitals than low dual-eligible hospitals (-68 vs. -74 risk-standardized readmissions per 10000 discharges per year for AMI, -88 vs. -97 for CHF, and -47 vs. -56 for pneumonia, P<0.0001 for all). CONCLUSIONS AND RELEVANCE For all hospitals, differences in pre-post trends in RSRRs varied with disease conditions. However, for the highest-penalized hospitals, the pre-post decline in RSRRs was greater for low than high dual-eligible hospitals for all penalized conditions. These results suggest that high penalty, high dual-eligible hospitals may be less able to improve performance on readmission metrics.
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21
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Sukul D, Seth M, Dupree JM, Syrjamaki JD, Ryan AM, Nallamothu BK, Gurm HS. Drivers of Variation in 90-Day Episode Payments After Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2020; 12:e006928. [PMID: 30608883 DOI: 10.1161/circinterventions.118.006928] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is a common and expensive procedure that has become a target for bundled payment initiatives. We described the magnitude and determinants of variation in 90-day PCI episode payments across a diverse array of patients and hospitals. METHODS AND RESULTS We linked clinical registry data from PCIs performed at 33 Michigan hospitals to 90-day episodes of care constructed using Medicare fee-for-service and commercial insurance claims from January 2012 to October 2016. Payments were price standardized and risk adjusted using clinical and administrative variables in an observed-over-expected framework. Hospitals were stratified into quartiles based on average episode payments. Payment components between the highest and the lowest quartiles were compared with identified drivers of variation (ie, index hospitalization/procedure, readmissions, postacute care, and professional fees). Among 40 925 90-day PCI episodes, the average risk-adjusted 90-day episode payment by hospital ranged between $22 154 and $27 205 with a median of $24 696 (interquartile range, $24 190-$25 643). Hospitals in the lowest and the highest quartiles had average episode payments of $23 744 and $26 504, respectively (difference, $2760). Readmission payments were the primary driver of this variation (46.2%), followed by postacute care (22.6%). Readmissions remained the primary driver of variation in key subgroups, including inpatient and outpatient PCI, as well as PCI for acute myocardial infarction and nonacute myocardial infarction indications. CONCLUSIONS Substantial hospital-level variation exists in 90-day PCI episode payments. Over half the variation between high- and low-payment hospitals was related to care after the index procedure, primarily because of readmissions and postacute care. Hospitals and policymakers should consider targeting these components when developing initiatives to reduce PCI-related spending.
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Affiliation(s)
- Devraj Sukul
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (D.S., M.S., B.K.N., H.S.G.).,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., J.M.D., A.M.R., B.K.N.)
| | - Milan Seth
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (D.S., M.S., B.K.N., H.S.G.)
| | - James M Dupree
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., J.M.D., A.M.R., B.K.N.).,Michigan Value Collaborative, University of Michigan, Ann Arbor (J.M.D., J.D.S.).,Dow Division of Health Services Research, Department of Urology, University of Michigan, Ann Arbor (J.M.D.)
| | - John D Syrjamaki
- Michigan Value Collaborative, University of Michigan, Ann Arbor (J.M.D., J.D.S.)
| | - Andrew M Ryan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., J.M.D., A.M.R., B.K.N.).,Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor (A.M.R.).,University of Michigan Center for Evaluating Health Reform, Ann Arbor (A.M.R.)
| | - Brahmajee K Nallamothu
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (D.S., M.S., B.K.N., H.S.G.).,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor (D.S., J.M.D., A.M.R., B.K.N.).,Michigan Integrated Center for Health Analytics and Medical Prediction, Ann Arbor (B.K.N.).,Division of Cardiovascular Medicine, Department of Internal Medicine, VA Ann Arbor Healthcare System, Ann Arbor (B.K.N., H.S.G.)
| | - Hitinder S Gurm
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (D.S., M.S., B.K.N., H.S.G.).,Division of Cardiovascular Medicine, Department of Internal Medicine, VA Ann Arbor Healthcare System, Ann Arbor (B.K.N., H.S.G.)
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22
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Kwok CS, Amin AP, Shah B, Kinnaird T, Alkutshan R, Balghith M, Ratib K, Nolan J, Bagur R, Mamas MA. Cost of coronary syndrome treated with percutaneous coronary intervention and 30‐day unplanned readmission in the United States. Catheter Cardiovasc Interv 2019; 97:80-93. [DOI: 10.1002/ccd.28660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/07/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group Keele University Stoke‐on‐Trent UK
- Royal Stoke University Hospital Stoke‐on‐Trent UK
| | - Amit P. Amin
- Washington School of Medicine St. Louis Missouri
| | - Binita Shah
- VA New York Harbor Healthcare System (Manhattan Campus) and New York University School of Medicine New York New York
| | | | - Raed Alkutshan
- Royal Commission Health Services Program Jubail Saudi Arabia
| | - Muhammad Balghith
- King Saud bin Abdulaziz University for Health Sciences Riyadh Saudi Arabia
| | - Karim Ratib
- Royal Stoke University Hospital Stoke‐on‐Trent UK
| | - James Nolan
- Keele Cardiovascular Research Group Keele University Stoke‐on‐Trent UK
- Royal Stoke University Hospital Stoke‐on‐Trent UK
| | - Rodrigo Bagur
- Keele Cardiovascular Research Group Keele University Stoke‐on‐Trent UK
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group Keele University Stoke‐on‐Trent UK
- Royal Stoke University Hospital Stoke‐on‐Trent UK
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23
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Clegg SD, Blankenship JC. In STEMI, more stenting = less readmissions? Catheter Cardiovasc Interv 2019; 94:915-916. [PMID: 31793179 DOI: 10.1002/ccd.28604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 11/13/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Stacey D Clegg
- Division of Cardiology, University of New Mexico, Albuquerque, New Mexico
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Abstract
American health care is shifting from a fixed-cost, fee-for-service payment model to value-based payment, in which providers including physicians and hospitals increasingly face incentives to reduce the total cost of care and meet specific quality benchmarks. Leaders of organizations that pay for health care and employers have encouraged this shift in response to substantial increases in health care costs and generally mediocre health outcomes compared with other countries. Here, we make the case that although the pace and details of such payment reforms are uncertain, these underlying structural economic challenges make a transition to some sort of value-based care inevitable.
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Affiliation(s)
- Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Massachusetts General Physicians Organization, Harvard Medical School, Boston, MA, USA.
| | - Timothy G Ferris
- Massachusetts General Physicians Organization, Harvard Medical School, Boston, MA, USA; Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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25
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Kwok CS, Narain A, Pacha HM, Lo TS, Holroyd EW, Alraies MC, Nolan J, Mamas MA. Readmissions to Hospital After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Factors Associated with Readmissions. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 21:375-391. [PMID: 31196797 DOI: 10.1016/j.carrev.2019.05.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 05/05/2019] [Accepted: 05/17/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Readmissions after PCI are a burden to patients and health services that are not well understood. METHODS A systematic review was performed to identify studies of readmission after PCI. Readmission rates and causes of readmission were examined and factors associated with 30-day readmissions were combined using meta-analyses. RESULTS A total of 39 studies evaluated readmissions after PCI (6,569,690 patients, 31 studies). The 30-day readmission rate varied from 3.3%-15.8%. Beyond 30-days, the readmission rate was 6% at 2 months, 31.5% at 6 months, 18.6-50.4% at 12 months and 26.3-71% beyond 48 months. The pooled proportion of patients with cardiac cause for readmissions ranged from 4.6%-75.3%. The range of rates of 30-day readmissions for reinfarction/stent thrombosis, heart failure, chest pain and bleeding were 2.5%-9.5%, 5.9%-12%, 6.7-38.1% and 0.7-7.5%, respectively. Meta-analysis suggests that female gender (RR 1.25(1.20-1.30), I2 = 65.2%), diabetes (RR 1.22(1.20-1.25), I2 = 0%), heart failure (RR 1.43(CI 1.28-1.60), I2 = 92.8%), renal failure (RR 1.50(1.45-1.55), I2 = 0%), chronic lung disease (RR 1.34(1.26-1.44), I2 = 87.5%), peripheral artery disease (RR 1.20(1.15-1.25), I2 = 46.5%) and cancer (RR 1.35(1.15-1.58), I2 = 72.8%) were associated with 30-day readmissions. The average cost of unplanned and all 30-day readmissions has been reported to be $12,636 and $17,576, respectively. CONCLUSIONS We estimate that 1 in 7 patients who undergo PCI are readmitted within 30-days and the rate can rise to up to 3 in 4 patients beyond 3 years. Interventions should be considered to reduce readmissions such as discharge checklists, evaluation of medication compliance at follow-up and prompt management when patients re-present to emergency department.
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Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Primary Care & Health Sciences, Keele University, Stoke-on-Trent, UK; Royal Stoke University Hospital, Stoke-on-Trent, UK.
| | - Aditya Narain
- Keele Cardiovascular Research Group, Primary Care & Health Sciences, Keele University, Stoke-on-Trent, UK; Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | - Ted S Lo
- Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | - M Chadi Alraies
- Wayne State University, Detroit Medical Center, Detroit, MI, USA
| | - Jim Nolan
- Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Primary Care & Health Sciences, Keele University, Stoke-on-Trent, UK; Royal Stoke University Hospital, Stoke-on-Trent, UK
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Kwok CS, Balacumaraswami L, Mamas MA. Should we implement interventions to reduce readmissions in open heart valve surgery? Int J Cardiol 2019; 289:50-51. [PMID: 31056412 DOI: 10.1016/j.ijcard.2019.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 04/05/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK; Royal Stoke University Hospital, Stoke-on-Trent, UK.
| | | | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK; Royal Stoke University Hospital, Stoke-on-Trent, UK
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27
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Kwok CS, Shah B, Al-Suwaidi J, Fischman DL, Holmvang L, Alraies C, Bagur R, Nagaraja V, Rashid M, Mohamed M, Martin GP, Kontopantelis E, Kinnaird T, Mamas M. Timing and Causes of Unplanned Readmissions After Percutaneous Coronary Intervention: Insights From the Nationwide Readmission Database. JACC Cardiovasc Interv 2019; 12:734-748. [PMID: 30928446 DOI: 10.1016/j.jcin.2019.02.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 01/23/2019] [Accepted: 02/05/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The aim of this study was to describe the rates and causes of unplanned readmissions at different time periods following percutaneous coronary intervention (PCI). BACKGROUND The rates and causes of readmission at different time periods after PCI remain incompletely elucidated. METHODS Patients undergoing PCI between 2010 and 2014 in the U.S. Nationwide Readmission Database were evaluated for the rates, causes, predictors, and costs of unplanned readmission between 0 and 7 days, 8 and 30 days, 31 and 90 days, and 91 and 180 days after index discharge. RESULTS This analysis included 2,412,000 patients; 2.5% were readmitted between 0 and 7 days, 7.6% between 8 and 30 days, 8.9% between 31 and 90 days, and 8.0% between 91 and 180 days (cumulative rates 2.5%, 9.9%, 18.0%, and 24.8%, respectively). The majority of readmissions during each time period were due to noncardiac causes (53.1% to 59.6%). Nonspecific chest pain was the most common identifiable noncardiac cause for readmission during each time period (14.2% to 22.7% of noncardiac readmissions). Coronary artery disease including angina was the most common cardiac cause for readmission during each time period (37.4% to 39.3% of cardiac readmissions). The second most common cardiac cause for readmission was acute myocardial infarction between 0 and 7 days (27.6% of cardiac readmissions) and heart failure during all subsequent time periods (22.2% to 23.7% of cardiac readmissions). CONCLUSIONS Approximately 25% of patients following PCI have unplanned readmissions within 6 months. Causes of readmission depend on the timing at which they are assessed, with noncardiovascular causes becoming more important at longer time points.
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Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Binita Shah
- VA New York Harbor Healthcare System, New York University School of Medicine, New York, New York
| | - Jassim Al-Suwaidi
- Heart Hospital, Hamad Medical Corporation and Weill Cornell Medical College, Doha, Qatar
| | - David L Fischman
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Lene Holmvang
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Chadi Alraies
- Wayne State University School of Medicine, Detroit Heart Hospital, Detroit, Michigan
| | - Rodrigo Bagur
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
| | - Vinayak Nagaraja
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
| | - Mohamed Mohamed
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Glen P Martin
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Evan Kontopantelis
- Division of Informatics, Imaging and Data Science, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Tim Kinnaird
- Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom.
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Vidula MK, McCarthy CP, Butala NM, Kennedy KF, Wasfy JH, Yeh RW, Secemsky EA. Causes and predictors of early readmission after percutaneous coronary intervention among patients discharged on oral anticoagulant therapy. PLoS One 2018; 13:e0205457. [PMID: 30379868 PMCID: PMC6209191 DOI: 10.1371/journal.pone.0205457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 09/25/2018] [Indexed: 11/19/2022] Open
Abstract
Patients discharged on oral anticoagulant (OAC) therapy after percutaneous coronary intervention (PCI) represent a complex population and are at higher risk of early readmission. The reasons and predictors of early readmission in this group have not been well characterized. We identified patients in an integrated health care system who underwent PCI between 2009 and 2014 and were readmitted within 30 days within this health care system. Of the 9,357 patients surviving to discharge after the index PCI, 692 were readmitted within 30 days (7.4%). At the time of readmission, 143 had been discharged from the index PCI hospitalization on OACs (96.5% on warfarin) and 549 had not been discharged on OACs, with readmission rates of 12.9% and 6.7%, respectively (p<0.01). The most common reason for readmission among all patients was chest pain syndromes (21.7% on OACs, 34.4% not on OACs). However, bleeding represented the next most frequent cause of readmission among patients on OACs (14.0% on OACs vs 6.0% not on OACs, p<0.01). Among patients on OAC therapy, peripheral arterial disease (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.07-2.57, p = 0.02) and nonelective PCI (OR 1.91, 95% CI 1.17-3.12, p<0.01) were found to be independent predictors of 30-day readmission. During rehospitalization, compared to patients not on OACs, patients on OACs suffered a higher unadjusted rate of mortality (6.3% vs 1.8%, p<0.01) and a longer length of stay (6.4 ± 7.1 days vs 4.9 ± 6.8 days, p = 0.02). In conclusion, patients discharged on OAC therapy after PCI are commonly readmitted, with bleeding representing a major reason. These readmissions are associated with high mortality and longer lengths of stay. Interventions targeted towards optimizing discharge planning for these complex patients are needed to potentially reduce readmissions.
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Affiliation(s)
- Mahesh K. Vidula
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Cian P. McCarthy
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Neel M. Butala
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Kevin F. Kennedy
- Saint Luke's Mid America Heart Institute/University of Missouri–Kansas City, Kansas City, Missouri, United States of America
| | - Jason H. Wasfy
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Robert W. Yeh
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Eric A. Secemsky
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- * E-mail:
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Kwok CS, Martinez SC, Pancholy S, Ahmed W, Al-Shaibi K, Potts J, Mohamed M, Kontopantelis E, Curzen N, Mamas MA. Effect of Comorbidity On Unplanned Readmissions After Percutaneous Coronary Intervention (From The Nationwide Readmission Database). Sci Rep 2018; 8:11156. [PMID: 30042466 PMCID: PMC6057975 DOI: 10.1038/s41598-018-29303-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/02/2018] [Indexed: 12/18/2022] Open
Abstract
It is unclear how comorbidity influences rates and causes of unplanned readmissions following percutaneous coronary intervention (PCI). We analyzed patients in the Nationwide Readmission Database who were admitted to hospital between 2010 and 2014. The comorbidity burden as defined by the Charlson Comorbidity Index (CCI). Primary outcomes were 30-day readmission rates and causes of readmission according to comorbidity burden. A total of 2,294,346 PCI procedures were included the analysis. The patients in CCI = 0, 1, 2 and ≥3 were 842,272(36.7%), 701,476(30.6%), 347,537(15.1%) and 403,061(17.6%), respectively. 219,227(9.6%) had an unplanned readmission within 30 days and rates by CCI group were 6.6%, 8.6%, 11.4% and 15.9% for CCI groups 0, 1, 2 and ≥3, respectively. The CCI score was also associated with greater cost (cost of index PCI for not readmitted vs readmitted was CCI = 0 $21,257 vs $19,764 and CCI ≥ 3 $26,736 vs $27,723). Compared to patients with CCI = 0, greater CCI score was associated with greater independent odds of readmission (CCI = 1 OR 1.25(1.22–1.28), p < 0.001, CCI ≥ 3 OR 2.08(2.03–2.14), p < 0.001). Rates of non-cardiac causes for readmissions increased with increasing CCI group from 49.4% in CCI = 0 to 57.1% in CCI ≥ 3. Rates of early unplanned readmission increase with greater comorbidity burden and non-cardiac readmissions are higher among more comorbid patients.
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Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK. .,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK.
| | - Sara C Martinez
- Division of Cardiology, Providence St. Peter Hospital, Olympia, Washington, USA
| | - Samir Pancholy
- The Wright Center for Graduate Medical Education, The Commonwealth Medical College, Scranton, PA, USA
| | - Waqar Ahmed
- Department of Cardiology, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Khaled Al-Shaibi
- Department of Cardiology, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Jessica Potts
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK
| | - Mohamed Mohamed
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK.,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | | | - Nick Curzen
- University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine, University of Southampton, Southampton, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK.,Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, UK
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30
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Kwok CS, Rao SV, Gilchrist I, Martinez SC, Al Ayoubi F, Potts J, Rashid M, Kontopantelis E, Myint PK, Mamas MA. Relation Between Age and Unplanned Readmissions After Percutaneous Coronary Intervention (Findings from the Nationwide Readmission Database). Am J Cardiol 2018; 122:220-228. [PMID: 29861049 DOI: 10.1016/j.amjcard.2018.03.367] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/21/2018] [Accepted: 03/27/2018] [Indexed: 11/17/2022]
Abstract
It is unclear how age affects rates and causes of unplanned early readmissions after percutaneous coronary intervention (PCI). We analyzed patients in the Nationwide Readmission Database in the United States from 2010 to 2014 and examined the impact of age on readmissions after PCI. The primary outcomes were age-specific 30-day rates and causes of unplanned readmissions. A total of 2,294,345 procedures were analyzed with a 9.6% unplanned readmission rate within 30 days. Unplanned readmissions were 8.1%, 8.1%, 9.5%, and 12.6% for age groups <55, 55.0 to 64.9, 65.0-74.9, and ≥75 years, respectively. With increasing age, there was an increase in the rate of noncardiac causes for readmissions (for ages <55, 55.0 to 64.9, and ≥75 years, the rates were 54.1%, 54.8%, 56.6%, and 57.1%, respectively; p <0.001). Older age was associated with an increased prevalence of infections (13.9% ≥75 years vs 7.7% <55 years), gastrointestinal disease (11.5% ≥75 years vs 9.5% <55 years), and bleeding (7.4% ≥75 years vs 2.9% <55 years) as causes for noncardiac readmissions and a reduced prevalence of nonspecific chest pain (9.9% ≥75 years vs 31.4% <55 years). For cardiac causes, older age was associated with increased prevalence for readmissions due to heart failure (34.6% ≥75 years vs 11.9% <55 years) but a reduced prevalence of coronary artery disease, including angina (25.7% ≥75 years vs 51.3% <55 years). In conclusion, older patients have the highest rates of unplanned 30-day readmissions after PCI, with different causes for readmission compared with younger patients. Interventions designed to reduce readmissions after PCI should be age specific.
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Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom.
| | - Sunil V Rao
- Department of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
| | - Ian Gilchrist
- Division of Interventional Cardiology, Penn State Heart and Vascular Institute, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Sara C Martinez
- Division of Cardiology, Providence St. Peter Hospital, Olympia, Washington
| | - Fakhr Al Ayoubi
- Department of Cardiac Sciences KFCC, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Jessica Potts
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
| | - Evangelos Kontopantelis
- Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Phyo K Myint
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
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Litovchik I, Pereg D, Shlomo N, Vorobeichik D, Beigel R, Iakobishvili Z, Vered Z, Goldenberg I, Minha S. Characteristics and outcomes associated with 30-day readmissions following acute coronary syndrome 2000-2013: the Acute Coronary Syndrome Israeli Survey. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 8:738-744. [PMID: 29617148 DOI: 10.1177/2048872618767997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Readmissions following acute myocardial infarction are associated with poor outcomes and a heavy economic burden. There are few evidence-based data on the characteristics and outcomes of patients readmitted following acute coronary syndrome. We explored the incidence and outcomes of patients readmitted after an acute coronary syndrome in the past decade. METHODS The study population comprised all acute coronary syndrome patients who were enrolled and prospectively followed up in the biennial Acute Coronary Syndrome Israeli Survey from 2000 to 2013. Multivariate analysis identified factors independently associated with readmission and long-term mortality. RESULTS There were 13,010 study patients, of whom 556 (4.2%) had an unplanned readmission within 30 days of the index event. Stent thrombosis during the index hospitalisation (odds ratio (OR) 8.43; 95% confidence interval (CI) 4.11-16.07; P<0.001), female sex (OR 1.34; 95% CI 1.1-1.63; P=0.003), older age (>65 years; OR 1.28; 95% CI 1.06-1.55; P=0.011), and lack of dual-antiplatelet therapy (OR 1.52; 95% CI 1.25-1.86; P<0.001) were independently associated with readmission. Readmitted patients were less likely to have been treated with guideline-directed medical therapy during hospitalisation and at discharge, and were less likely to have undergone coronary angiography. A strong trend towards decline in readmission rates following acute coronary syndrome was observed between 2000 and 2013 (P<0.001). However, the association between readmission and poor long-term outcome was more pronounced among patients readmitted during more recent years (2008-2013). CONCLUSIONS Patients readmitted to hospital following acute coronary syndrome comprise an undertreated, high-risk cohort. Our findings indicate that despite a significant decline in readmission rates following acute coronary syndrome over the past decade, readmission within 30 days following acute coronary syndrome still portends a grave outcome.
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Affiliation(s)
- Ilia Litovchik
- Department of Cardiology, Assaf-Harofeh Medical Center, Israel.,Sackler School of Medicine, Tel-Aviv University, Israel
| | - David Pereg
- Sackler School of Medicine, Tel-Aviv University, Israel.,Department of Cardiology, Meir Medical Center, Israel
| | - Nir Shlomo
- Sackler School of Medicine, Tel-Aviv University, Israel.,Leviev Heart Center, Sheba Medical Center, Israel
| | - Dina Vorobeichik
- Sackler School of Medicine, Tel-Aviv University, Israel.,Leviev Heart Center, Sheba Medical Center, Israel
| | - Roy Beigel
- Sackler School of Medicine, Tel-Aviv University, Israel.,Leviev Heart Center, Sheba Medical Center, Israel
| | | | - Zvi Vered
- Department of Cardiology, Assaf-Harofeh Medical Center, Israel.,Sackler School of Medicine, Tel-Aviv University, Israel
| | - Ilan Goldenberg
- Sackler School of Medicine, Tel-Aviv University, Israel.,Leviev Heart Center, Sheba Medical Center, Israel
| | - Sa'ar Minha
- Department of Cardiology, Assaf-Harofeh Medical Center, Israel.,Sackler School of Medicine, Tel-Aviv University, Israel
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32
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Kwok CS, Potts J, Gulati M, Alasnag M, Rashid M, Shoaib A, Ul Haq MA, Bagur R, Mamas MA. Effect of Gender on Unplanned Readmissions After Percutaneous Coronary Intervention (from the Nationwide Readmissions Database). Am J Cardiol 2018; 121:810-817. [PMID: 29448978 DOI: 10.1016/j.amjcard.2017.12.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/13/2017] [Accepted: 12/27/2017] [Indexed: 11/28/2022]
Abstract
Women who undergo percutaneous coronary intervention (PCI) are at higher risk of adverse outcomes compared with men, but it is unknown whether gender affects early unplanned rehospitalization. We analyzed 832,753 patients who underwent PCI from 2013 to 2014 in the Nationwide Readmissions Database. We compared gender differences in incidences, predictors, causes, and cost of unplanned 30-day readmissions and examined the effect of co-morbidity. A total of 832,753 men and women who survived the index PCI and were not admitted for a planned readmission were included in the analysis. Overall, 9.4% of patients had an unplanned readmission within 30 days. Thirty-day readmission rates were higher in women compared with men (11.5% vs 8.4%, p <0.001) even after multivariate adjustment (odds ratio 1.19, 95% confidence interval 1.16 to 1.22, p <0.001), although women had significantly lower costs associated with the readmission ($11,927 vs $12,758, p <0.001). The cause of readmission for women and men were similar and the majority of the readmissions were due to noncardiac causes (58% vs 55%), the most common of which were nonspecific chest pain, gastrointestinal disease, and infections. In contrast, for cardiac readmissions, women are more likely to be readmitted for heart failure (29.64% vs 22.34%), whereas men are more likely to be readmitted for coronary artery disease, including angina (33.47% vs 28.54%). In conclusion, gender disparities exist in rates of unplanned rehospitalization after PCI, where more than 1 in 10 women who undergo PCI are readmitted within 30 days. Gender differences were not observed for causes of noncardiac readmissions, whereas important differences were observed for cardiovascular causes.
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Affiliation(s)
- Chun Shing Kwok
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom.
| | - Jessica Potts
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom
| | - Martha Gulati
- Division of Cardiology, University of Arizona, Phoenix, Arizona
| | - Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Muhammad Rashid
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom
| | - Ahmad Shoaib
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom
| | - Muhammad Ayyaz Ul Haq
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom
| | - Rodrigo Bagur
- Division of Cardiology, London Health Sciences Centre, Department of Medicine, and Epidemiology & Biostatistics, Western University, London, Ontario, Canada
| | - Mamas Andreas Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
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Kwok CS, Rao SV, Potts JE, Kontopantelis E, Rashid M, Kinnaird T, Curzen N, Nolan J, Bagur R, Mamas MA. Burden of 30-Day Readmissions After Percutaneous Coronary Intervention in 833,344 Patients in the United States: Predictors, Causes, and Cost. JACC Cardiovasc Interv 2018; 11:665-674. [DOI: 10.1016/j.jcin.2018.01.248] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/18/2017] [Accepted: 01/09/2018] [Indexed: 10/17/2022]
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Venkatason P, Zaharan NL, Ismail MD, Wan Ahmad WA, Mahmood Zuhdi AS. Trends and variations in the prescribing of secondary preventative cardiovascular therapies for non-ST elevation myocardial infarction (NSTEMI) in Malaysia. Eur J Clin Pharmacol 2018; 74:953-960. [PMID: 29582106 PMCID: PMC5999133 DOI: 10.1007/s00228-018-2451-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 03/19/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE Information is lacking on prescribing of preventative cardiovascular pharmacotherapies for patients with non-ST elevation myocardial infarction (NSTEMI) in the Asian region. This study examined the prescribing rate of these pharmacotherapies, comparing NSTEMI to STEMI, and variations across demographics and clinical factors within the NSTEMI group in the multi-ethnic Malaysian population. METHODS This is a retrospective analysis of the Malaysian National Cardiovascular Disease Database-Acute Coronary Syndrome registry from year 2006 to 2013 (n = 30,873). On-discharge pharmacotherapies examined were aspirin, ADP-antagonists, statins, ACE-inhibitors, angiotensin-II-receptor blockers, and beta-blockers. Multivariate logistic regression was used to calculate adjusted odds ratio of receiving individual pharmacotherapies according to patients' characteristics in NSTEMI patients (n = 11,390). RESULTS Prescribing rates for cardiovascular pharmacotherapies had significantly increased especially for ADP-antagonists (76%) in NSTEMI patients. More than 85% were prescribed statins and antiplatelets but rates remained significantly lower compared to STEMI. Women and those over 65 years old were less likely to be prescribed these pharmacotherapies compared to men and younger NSTEMI patients. Chinese and Indians were more likely to receive selected pharmacotherapies compared to Malays (main ethnicity). Geographical variations were observed; East Malaysian (Malaysian Borneo) patients were less likely to receive these compared to Western region of Malaysian Peninsular. Underprescribing in patients with risk factors such as diabetes were observed with other co-morbidities influencing prescribing selectively. CONCLUSION This study uncovers demographic and clinical variations in cardiovascular pharmacotherapies prescribing for NSTEMI. Concerted efforts by policy makers, specialty societies, and physicians are required focusing on elderly, women, Malays, East Malaysians, and high-risk patients.
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Affiliation(s)
- Padmaa Venkatason
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Nur Lisa Zaharan
- Department of Pharmacology, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Muhammad Dzafir Ismail
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - Wan Azman Wan Ahmad
- Department of Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
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Cohort Description for MADDEC – Mass Data in Detection and Prevention of Serious Adverse Events in Cardiovascular Disease. IFMBE PROCEEDINGS 2018. [DOI: 10.1007/978-981-10-5122-7_278] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Affiliation(s)
- Jordan B Strom
- From the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Robert W Yeh
- From the Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
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Iniciativas para conseguir una atención excelente en el síndrome coronario agudo. Rev Esp Cardiol (Engl Ed) 2017. [DOI: 10.1016/j.recesp.2017.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Ganguli I, Sikora C, Nestor B, Sisodia RC, Licurse A, Ferris TG, Rao S. A Scalable Program for Customized Patient Education Videos. Jt Comm J Qual Patient Saf 2017; 43:606-610. [DOI: 10.1016/j.jcjq.2017.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 05/23/2017] [Accepted: 05/30/2017] [Indexed: 10/19/2022]
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Lozano Í, Rondán J, Vegas JM, Segovia E. Initiatives to Achieve Excellence in the Care of Acute Coronary Syndrome. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2017; 70:1026-1027. [PMID: 28774631 DOI: 10.1016/j.rec.2017.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 05/30/2017] [Indexed: 06/07/2023]
Affiliation(s)
- Íñigo Lozano
- Servicio de Cardiología, Hospital de Cabueñes, Gijón, Asturias, Spain.
| | - Juan Rondán
- Servicio de Cardiología, Hospital de Cabueñes, Gijón, Asturias, Spain
| | - José M Vegas
- Servicio de Cardiología, Hospital de Cabueñes, Gijón, Asturias, Spain
| | - Eduardo Segovia
- Servicio de Cardiología, Hospital de Cabueñes, Gijón, Asturias, Spain
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O'Brien C, Valsdottir L, Wasfy JH, Strom JB, Secemsky EA, Wang Y, Yeh RW. Comparison of 30-Day Readmission Rates After Hospitalization for Acute Myocardial Infarction in Men Versus Women. Am J Cardiol 2017; 120:1070-1076. [PMID: 28781023 DOI: 10.1016/j.amjcard.2017.06.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/15/2017] [Accepted: 06/30/2017] [Indexed: 10/19/2022]
Abstract
Readmission after hospitalization for acute myocardial infarction (AMI) significantly contributes to preventable morbidity and health-care costs. Outcomes after AMI vary by sex but the relationship of sex to readmissions warrants further exploration. Using the 2013 Nationwide Readmissions Database, we identified patients with a principal discharge diagnosis of AMI and stratified all-cause 30-day readmissions by sex and age. Of 214,824 patients, 44% were 18 to 64 years of age, 56% were ≥65 years, and 28% and 45%, respectively, were female. For patients 18 to 64 years, the readmission rate was 14% for women and 10% for men (p <0.001). For patients ≥65 years, the readmission rate was 18% for women and 16% for men (p <0.001). After adjusting for co-morbidities, women had a significantly higher risk of 30-day readmission compared with men, an effect that was strongest in younger women (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.06 to 1.39, for ages 18 to 44; OR 1.13, 95% CI 1.07 to 1.18, for ages 45 to 64; OR 1.13, 95% CI 1.07 to 1.19, for ages 65 to 74, interaction p <0.001). The procedure rates during the index hospitalization were significantly lower for women. The most common readmission diagnoses were recurrent AMI, ischemic heart disease, and heart failure. Costs associated with readmissions after AMI totaled $447,506,740, of which $176,743,622 were attributed to readmissions of women. In conclusion, women are at higher risk of short-term readmission after an AMI hospitalization than men, particularly younger women. Sex-specific strategies to reduce these readmissions may be warranted.
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Gavin MC, Zimetbaum PJ, Tuttle M, Ullman EA, Grossman SA. Cardiac Direct Access Unit: A novel effort to leverage access to cardiologists to reduce hospitalization admissions. Am J Emerg Med 2017; 35:910-911. [DOI: 10.1016/j.ajem.2017.03.070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 03/26/2017] [Indexed: 01/16/2023] Open
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Belardi JA, Albertal M. Predicting Early Readmission Following PCI: A Work in Progress. Catheter Cardiovasc Interv 2017; 89:964-965. [PMID: 28488410 DOI: 10.1002/ccd.27070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 03/29/2017] [Indexed: 11/09/2022]
Abstract
Early hospital readmissions after percutaneous coronary interventions (PCI) are common and costly. From the NCDR CathPCI Registry and the Centers for Medicare and Medicaid Services, a risk prediction model was generated using 14 clinical variables, demonstrating modest discrimination. Future research is needed to identify interventions aim to reduce early readmissions. The use of this risk model may help guide these interventions.
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Affiliation(s)
- Jorge A Belardi
- Department of Interventional Cardiology and Endovascular Therapeutics, Instituto Cardiovascular de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Mariano Albertal
- Department of Interventional Cardiology and Endovascular Therapeutics, Instituto Cardiovascular de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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Oseran A, Wasfy JH. Cardiovascular Disease Prevention: The Role of Policy Interventions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:43. [PMID: 28466121 DOI: 10.1007/s11936-017-0545-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OPINION STATEMENT Health outcomes in cardiovascular disease in the USA have generally been improving over the past several decades. Those gains have been related to both developments in prevention and treatment of cardiovascular disease. To further enhance improvement in health outcomes, including cardiovascular outcomes, health policies have been implemented to incentivize prevention. These policies have strong conceptual appeal and have been associated with improvements in some health metrics. However, robust research methods, accounting for bias and statistical confounding, are critical to confirm that these policies are associated with prevention of cardiovascular events for patients over time.
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Affiliation(s)
- Andrew Oseran
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Cardiac Unit Associates, Yawkey 5B, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
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Wasfy JH. Integrating local data into readmission risk prediction. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2017; 18:77-78. [PMID: 28288749 DOI: 10.1016/j.carrev.2017.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 01/05/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Jason H Wasfy
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Siegel AJ, Bhatti NA, Wasfy JH. Reprising Ramadan-Related Angina Pectoris: A Potential Strategy for Risk Reduction. AMERICAN JOURNAL OF CASE REPORTS 2016; 17:841-844. [PMID: 27829657 PMCID: PMC5106208 DOI: 10.12659/ajcr.900133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Patient: Male, 69 Final Diagnosis: Coronary artery disease Symptoms: Angina pectoris Medication: Aspirin Clinical Procedure: Coronary artery bypass surgery Specialty: Cardiology
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Affiliation(s)
- Arthur J Siegel
- Divisions of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nasir A Bhatti
- Divisions of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jason H Wasfy
- Divisions of Cardiology, Massachusetts General Hospital, Boston, MA, USA
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