‘Shotgunning’ Approach Appears to Knock Down Readmissions After PCI

Implementation of a series of wide-ranging initiatives aimed at reducing readmissions after PCI appears to have paid off at one large, tertiary care center, with the 30-day rate falling from 9.6% to 5.3% over a 5-year period, a new analysis shows.

Key components of the effort included the development of educational videos addressing common reasons for readmission, creation of a postdischarge clinic staffed by cardiology fellows, and introduction of electronic alerts to notify cardiologists when their patients present to the emergency department after PCI, lead author Varsha Tanguturi, MD (Massachusetts General Hospital, Boston), and colleagues report in a study published online August 23, 2016, ahead of print in Circulation: Cardiovascular Quality and Outcomes.

“It was very difficult. It took several years,” senior author Jason Wasfy, MD (Massachusetts General Hospital), told TCTMD about getting the program up and running, noting that it required cultural changes in terms of what members of the team had traditionally been doing.

“It really does take a team,” he said. “It takes a team that involves physicians, nurses, pharmacists, educational specialists, and most of all our patients. It was critically important throughout the entire set of interventions that we engaged patients in understanding what they want in terms of us delivering care to them, what sorts of things they get nervous about. . . . And we wanted to be responsive to those concerns.”

Commenting on the study for TCTMD, James Blankenship, MD (Geisinger Medical Center, Danville, PA), said that an important aspect of the Mass General group’s effort is the use of initiatives aimed at multiple factors associated with preventable readmissions instead of just one.

“They did a good job of shotgunning the problem,” said Blankenship, who is the immediate past president of the Society for Cardiovascular Angiography and Interventions. “It’s not like shooting a deer, it’s like shooting a flock of geese.”

Although it’s unclear exactly how much of the drop in readmissions could be attributed to the initiatives and how much to other reasons, Blankenship said that “the almost 50% drop that they observed is much more dramatic than would have just gone on in the background.”

Targeting the Index Hospitalization and Postdischarge Setting

To reduce readmissions, the researchers took action in multiple settings, starting with the index hospitalization.

During that first admission, clinicians used a validated risk-assessment program to estimate the risk of readmission, as well as risks of MACE, in-hospital mortality, in-hospital bleeding, acute kidney insufficiency with or without need for dialysis, and maximum recommended contrast dose. And before letting the patients go home, physicians went through a discharge checklist addressing access to medications and timely follow-up and they provided educational videos addressing chest discomfort, heart failure, the role of anxiety, how to use nitroglycerin to treat angina, and how to contact cardiologists in the outpatient setting.

The team also created the urgent access clinic to provide patients with timely appointments with outpatient providers.

If patients returned to the emergency department for any reason, a system automatically notified their cardiologists to facilitate early interactions and potentially obviate the need for hospital admission. A risk-stratification algorithm was created to help triage patients presenting with chest discomfort.

Wasfy noted that there was very little cost to getting these initiatives off the ground because much of the work was done voluntarily by clinicians and some of the technological aspects piggybacked on existing systems.

“We are really committed to improving the quality of care but also improving value in cardiology care delivery, so we’re very proud of the fact that we’ve been able to do this with a very low budget,” he said.

Wave of the Future

Wasfy acknowledged that there have been overall declines in readmissions in recent years, but he said that much of the drop observed at Mass General is likely due to the specific interventions because the magnitude of the reduction is greater than the secular trend. Nonetheless, his team is planning on teasing out the impact of the initiatives by looking at statewide data on readmissions.

There is some uncertainty about the potential impact of these initiatives, but “clearly this kind of an effort is what we’re all going to have to be doing in a few years,” Blankenship commented, citing the recently announced plan to bundle payments for acute MI care and CABG.

“Integrated payment programs like bundling that force you to pay attention to costs after discharge are going to promote this kind of cooperative project, and systems that have already figured this out and already put an emphasis on postdischarge care are going to be way ahead,” he said.

If the positive impact of the effort described in the current study can be definitively proven in the future, he said, “the message would be to the rest of us that we should go out and develop similar programs like this.”

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