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The rate at which patients undergoing percutaneous coronary intervention (PCI) are readmitted to the hospital within 30 days is greater than 15%, according to a retrospective study focusing on New York State published in the December 2011 issue of JACC: Cardiovascular Interventions. Whether this percentage should be a cause for concern, however, is a matter of debate.

Using data from the New York Percutaneous Coronary Interventions Reporting System (PCIRS), investigators led by Edward L. Hannan, PhD, of the University at Albany, State University of New York (Albany, NY), identified 37,234 patients who underwent 40,093 PCI procedures in New York State from January through November 2007. They looked at the proportion of these patients who were readmitted to the hospital within 30 days and evaluated whether demographic variables, preprocedural risk factors, PCI complications, or length of stay predicted readmission as well as the impact of planned readmissions.

One-Fifth of Readmissions Involve Staging

Overall, 15.6% of PCI patients were readmitted to the hospital within 30 days. Of these readmissions, 20.6% were due to staged PCI. Staged readmission was more common among patients who experienced an acute MI within 24 hours before the index PCI (17.3% vs. 15.4%; P = 0.0005). In addition, patients who were age 65 years or older were more likely to be readmitted than younger patients (17.2% vs. 13.9%; P < 0.0001).

Among the 12.4% of readmitted patients who were not staged, 5.0% underwent target vessel PCI. Apart from this indication, the most common cardiac-related reasons for readmission were:

• Chronic ischemic heart disease (22.9%)
• Chest pain (11.1%)
• Heart failure (7.6%)
• Arrythmias (4.4%)
• AMI (2.9%)

Among patients readmitted for noncardiac reasons, the most common principal diagnoses focused on:

• Complications from a previous procedure/medical care (6.7%)
• Digestive system (6.0%)
• Noncardiac circulatory system (5.7%)
• Respiratory system (4.9%)

Of all readmitted patients, 32.2% underwent repeat PCI, while 1.3% received CABG surgery. Nearly two-thirds (63.8%) of the repeat PCIs were staged.

Four deaths occurred among staged PCI patients, for a mortality rate of 0.3%. For unstaged readmissions, the mortality rate was 1.8%, with a 0.7% incidence among PCI patients and 2.0% among non-PCI patients (P < 0.0001).

Analysis revealed a host of predictors of unstaged readmission within 30 days including:

• Age over 65 years (OR 1.02; P < 0.0001)
• Female sex (OR 1.32; P < 0.0001)
• Low ejection fraction (< 20%; OR 2.08; P < 0.0001)
• Peripheral vascular disease (OR 1.43; P < 0.0001)
• Chronic obstructive pulmonary disease (OR 1.60; P < 0.0001)
• Diabetes (OR 1.21; P < 0.0001)
• Two-day or longer hospital stay (2-day OR 1.34, 3-day OR 1.67, 4-day or longer OR 2.25; P < 0.0001 for all)

High Readmissions a Red Flag?

“Readmissions are costly to our health care system and are a potential quality-of-care issue,” said Dr. Hannan in an e-mail correspondence with TCTMD. “Furthermore, the [Centers for Medicare and Medicaid Services] is preparing to deny payment for certain types of readmissions. Therefore, it is important to understand the causes and reasons for readmissions.”

Dr. Hannan suggested that readmission rates are high because “there is poor coordination of care after discharge, [and] patients at high risk for readmission don't appear to be flagged and followed effectively. There definitely needs to be better coordination with ambulatory and outpatient care whereby there is follow-up after patients are discharged. This is particularly important for patients at high risk of short-term mortality and readmission.”

Also, more needs to be done to better identify causes of readmission and to examine the reasons for and cost-effectiveness of staging, he added.

An Unavoidable Circumstance?

But Jeffrey W. Moses, MD, of Columbia University Medical Center/Weill Cornell Medical Center (New York, NY), questions whether a 15.6% readmission rate is inappropriately high. “These people are sick,” he told TCTMD in a telephone interview. “They have other diseases. There are other things driving these patients back into the hospital. These [readmissions] are not necessarily related to anything other than comorbidities and age. I don’t know that that’s avoidable.

“Very few [readmissions] were driven by identifiable complications of the procedure,” Dr. Moses noted. “Among more than 40,000 patients who initially underwent PCI, all the reasons for readmissions that could conceivably be due to complications of the initial PCI, including identified complications, MI, TVR, and kidney injury, amount to less than 1,000 cases. That is a very low complication rate. You have to look at the initial admission and aftercare to see if there was something there that made them come back because it clearly wasn’t complications.”

Dr. Moses also pointed to the pressures to shorten length of stay for the initial hospitalization. “The trade-off is that there is going to be a certain number of patients who are going to be readmitted,” he said, adding, “The solution isn’t to lengthen the initial hospitalization—that will just drive costs up.

“The staging rate is 3%,” Dr. Moses noted, yet “[the authors imply] that staging is somehow not a good a thing. [But] when you’re doing complicated patients, sometimes staging is in the best interest of the patient both in terms of safety and the precision of the job.”

‘Not Necessarily Evil’

In an accompanying editorial, Joseph G. Cacchione, MD, of the Cleveland Clinic Foundation (Cleveland, OH), agrees that the reasons for ‘high’ readmission rates need to be rigorously dissected.

“[To determine] whether ‘avoidable’ readmissions are a failure of care, a complication, or are appropriate is a matter that requires further study,” he writes. “The current system, which uses readmission rates as a surrogate for quality, will continue to be challenged due to the absence of rigorous objective data to measure avoidability. The reimbursement system may play a role in changing the paradigm in which additional care serves as a financial incentive for providers.

“Readmissions are not necessarily evil,” Dr. Cacchione concludes. “Studies such as this . . . should provide the foundation for prospective predictable models of readmission to promote better clinical care in a more cost-effective environment.”

2. Cacchione JG. Not all readmissions are created equal. J Am Coll Cardiol Intv. 2011;4:1343-44.

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