Readmissions After TAVR Common, With Most Due to Noncardiac Reasons

Patients undergoing TAVR frequently require readmission within 30 days of the procedure, at a level consistent with the all-cause rate seen in the Medicare population, a new study shows. Comorbidities, access site, and a requirement for skilled nursing care all predict the need for a return trip to the hospital.

In a look at a national US database, 17.9% of patients were readmitted within 30 days, lead author Dhaval Kolte, MD, PhD (Brown University, Providence, RI), and colleagues report in a study published online December 29, 2016, ahead of print in Circulation: Cardiovascular Interventions. Most rehospitalizations (61.8%) were due to noncardiac causes, with the remaining cardiac cases most frequently related to heart failure (22.5%) and arrhythmias (6.6%).

Because the TAVR field is rapidly evolving and the treatment is increasingly being used in lower-risk patients, it remains important to focus on reducing readmissions, Kolte told TCTMD. This effort, he said, in turn will cut healthcare costs.

Thirty-day readmissions are tracked as a performance metric for several conditions, including heart failure and MI, and Kolte et al suggest that doing the same for patients undergoing TAVR “may help incentivize hospitals to develop and implement institution-specific strategies to reduce readmissions.”

But, Kolte said, it may be too soon to implement that approach for TAVR, noting that more research into whether there is a relationship between procedure volume and readmissions and whether there are any specific interventions that can affect the outcome would be important.

Commenting on the study for TCTMD, Edward Hannan, PhD (University at Albany, NY), said it is a “tough call” as to whether 30-day readmissions should be used as a performance metric for TAVR but added that “it may be wise to wait a while before doing this.”

He took issue with one of the conclusions of the study authors, who write that “public reporting of such measures for TAVR should be avoided as this may lead to inadvertent risk-averse behavior among operators and institutions as seen with PCI.”

Hannan said he found that recommendation odd and suggested that instead efforts should be made in “working to prevent risk-averse behavior in a public reporting environment.”

Wide Variation in Readmission Rates

Prior studies have identified 30-day readmission rates following TAVR of 14.6% to 20.9%, but information on predictors of that outcome using nationally representative data have been lacking.

To that end, Kolte et al examined information from the Nationwide Readmissions Database on 12,221 patients who underwent TAVR at 210 US centers between January and November 2013. The median readmission rate was very close to the all-cause readmission rate seen in a 2015 study of Medicare beneficiaries (17.8%). In the current study, however, the rate ranged widely across centers from 0% to 50%.

Several factors were independently associated with an increased likelihood of requiring readmission, with hazard ratios ranging from 1.16 to 1.47:

• Initial length of stay > 5 days
• Acute kidney injury
• Presence of more than four Elixhauser comorbidities
• Transapical access
• Chronic kidney disease
• Chronic lung disease
• Discharge to a skilled nursing facility

“Awareness of these predictors can help identify and target high-risk patients for interventions to reduce readmissions and costs,” the authors say.

The median cost of a readmission was $8,302, and on average, that cost accounted for 16.4% of the total cost for the episode of care, including the index hospitalization and readmission. “Although reductions in the cost of index TAVR admissions can improve overall cost-effectiveness of TAVR when compared with [surgery], efforts to reduce unplanned rehospitalizations can help lower costs even further,” the authors say.

How Can TAVR Readmissions Be Lowered?

Kolte said it remains unclear whether any specific interventions can reduce readmissions following TAVR, but he suggested some possible approaches. Pre-existing comorbidities are difficult to change considering patients undergoing TAVR are typically at high risk, “but certainly having a multidisciplinary team—we already have the heart team approach but also involving nephrologists or pulmonologists on the team—to optimize patients with CKD and chronic lung disease would be something to look at.”

Access site is another aspect to evaluate, he said. “For those patients who don’t qualify for transfemoral access, the default approach should not be transapical TAVR,” Kolte advised, adding that they should instead be evaluated for one of the alternate access approaches.

The relationship between readmissions and prolonged length of stay and discharge to a skilled nursing facility probably reflect frailty, Kolte said, and thus “improving the support system or having frequent follow-up postdischarge would probably help to reduce readmissions.”

Hannan said that improving follow-up and continuity of care after discharge is probably the most important way to lower the risk of rehospitalization.

In an accompanying editorial, Rajesh Swaminathan, MD, and Sunil Rao, MD (Duke University Medical Center, Durham, NC), say that the study “provides invaluable information for patients, practitioners, and hospitals seeking to improve long-term outcomes from TAVR.”

They agree with Kolte and Hannan that the time is not right for using 30-day readmissions as a performance metric for TAVR. But, they add, “given the rate at which TAVR indications are rapidly expanding, and the concomitant costs that this may impose on the healthcare system, the day when hospitals are held responsible for TAVR readmissions is likely not far off. The study by Kolte et al is a big step in preparing the field for that day.”