Unplanned 30-Day Readmission Risk Among Patients with Acute Myocardial Infarction:
a Report from TRANSLATE-ACS
Connie N. Hess, MD1; Tracy Y. Wang, MD, MHS1; Lisa McCoy1; Emily Honeycutt1;
John C. Messenger, MD2; William T. Smith IV, MD3; Marjorie E. Zettler, PhD, MPH4, Mark B. Effron, MD4;
Timothy D. Henry, MD5; Eric D. Peterson, MD, MPH1; Gregg C. Fonarow, MD6
1Duke
Clinical Research Institute; 2Denver VA Medical Center; 3New Hanover Regional Medical Center; 4Lilly USA, LLC; 5Minneaopolis Heart Institute Foundation at Abbott Northwestern Hospital; 6UCLA Medical Center
Results
Background
•
•
Hospital readmissions after acute myocardial infarction
(AMI) are a Medicare hospital performance measure.
Current readmission models have relied on
administrative data, have included planned
readmissions, and/or have examined limited patient
populations and risk factors.
• Overall 30-day readmission: 12.4% (n=1027)
• Unplanned readmission: 8.8% (n=730) vs. planned
readmission: 3.9% (n=324)
Baseline and in-hospital characteristics
Median age (years)
Male (%)
Non-white race (%)
Married (%)
Employed full/part time (%)
College degree or beyond (%)
Insurance:
Private
Medicare/Medicaid
Other
None
Hypertension
Diabetes (%)
Prior myocardial infarction (%)
Heart failure w/in 2 weeks (%)
STEMI (%)
DES implanted (%)
Mean ACTION mortality risk score*
Mean ACTION bleeding risk score*
Median EQ-5D health status score**
PHQ-2 depression score ≥3† (%)
Mean length of stay (days)
Transition of care planning
Discharged on all eligible 2° prevention medications (%)
Follow-up scheduled before discharge (%)
Post-discharge characteristics
Cardiac rehabilitation participation (%)
Primary care/cardiologist follow-up w/in 4 wks (%)
Perceived medication financial hardship§ (%)
Figure 1. Causes of unplanned 30-day readmission
Objectives
•
•
To examine the incidence and causes of unplanned
readmission within 30 days of discharge among AMI
patients treated with percutaneous coronary intervention
(PCI).
Cardiovascular
37%
Other
62%
To identify factors associated with unplanned 30-day
readmissions.
Bleeding
1%
Methods
% overall readmissions
• TRANSLATE-ACS (TReatment with ADP receptor
iNhibitorS: Longitudinal Assessment of Treatment
Patterns and Events after Acute Coronary Syndrome)
observational registry
Patient population
• 8265 AMI patients treated with PCI and ADP inhibitor and
discharged home alive from 216 hospitals between
4/2010 and 8/2012 with complete baseline, 6 week
follow-up, and hospital billing data
30
20
10
1
Hospital site by site
rank
Hospital
50
40
Planned readmissions (%)
• Multivariable logistic regression to identify factors
significantly associated with unplanned 30-day
readmission
Median 11.5% (IQR 5.6%, 16.7%)
40
Median 8.0% (IQR 2.3%, 12.3%)
% planned readmissions
• Cardiovascular and bleeding readmissions identified
using primary ICD-9 billing codes
50
0
Unplanned readmissions (%)
• Death within 30 days of discharge censored
% unplanned readmissions
Statistics
Overall readmissions (%)
Figure 2. Variation in readmissions among hospitals
Data Source
30
20
10
216
50
40
1
Hospital site by site
rank
Hospital
216
Unplanned
readmission
(n=730)
No unplanned
readmission
(n=7535)
61.0
63.6
15.2
59.3
43.4
49.3
60.0
73.4
12.8
64.8
51.5
53.1
59.9
21.4
2.5
14.2
72.6
34.0
21.9
10.4
53.9
64.9
31.5
27.8
70.0
12.6
3.7
65.3
17.0
2.8
13.5
66.8
25.3
18.8
6.0
51.8
70.8
29.8
25.3
75.0
7.1
3.1
0.001
<0.001
0.036
<0.0001
0.268
0.001
<0.0001
<0.0001
<0.0001
<0.001
<0.0001
70.7
77.0
67.7
74.3
0.102
0.023
27.4
79.6
41.5
29.7
83.3
38.2
0.515
0.682
0.002
Median 2.0% (IQR 0.0%, 5.9%)
*ACTION score is a validated risk score predicting in-hospital mortality and bleeding
**EQ-5D = EuroQol EQ-5D health status measure
†PHQ2 = Patient Health Questionnaire-2
§Medication financial hardship = moderate/much/extreme vs. no/minimal hardship
30
20
10
0
0
Table 2. Factors associated with 30-day unplanned readmission
Table 1. Patient characteristics
1
Hospital site bysite
rank
Hospital
216
Wald
Lower Upper
Chi- Adj OR
P-value
95% CI 95% CI
Square
12.57
1.40
1.16
1.68
0.000
Parameter
p
Female vs. Male
PHQ2>3
0.129
<0.0001
0.056
0.002
<0.0001
0.058
0.014
10.94
1.53
1.19
1.97
0.001
In-hosp Event: Bleeding
Length of Stay
Prior Heart Failure
Diabetes
8.17
8.13
7.28
6.85
1.75
1.05
1.54
1.28
1.19
1.02
1.13
1.06
2.56
1.08
2.11
1.54
0.004
0.004
0.007
0.009
Atrial fib/flutter
CVD
Smoker
5.70
5.45
5.30
1.48
1.50
0.81
1.07
1.07
0.67
2.05
2.11
0.97
0.017
0.020
0.021
Any DES
5.19
0.82
0.69
0.97
0.023
Chronic Lung Disease
STEMI vs. NSTEMI
Procedure Success
Defect free discharge
therapy
4.58
3.50
3.46
1.31
1.18
0.77
1.02
0.99
0.58
1.67
1.39
1.01
0.032
0.061
0.063
3.12
1.17
0.98
1.39
0.077
Limitations
• Hospitals participating in TRANSLATE perhaps not representative
• Case report form may not capture all factors related to unplanned
readmission
• Residual measured or unmeasured confounding may account for
some of these findings
Conclusions
•
•
•
•
Unplanned 30-day readmissions occur after AMI in 1 in 11 patients.
The majority of unplanned readmissions are non-cardiovascular.
Rates of readmission vary among hospitals.
Clinical, socio-demographic, and functional variables may identify
patients at higher risk for unplanned readmissions and allow for
targeted strategies to reduce rehospitalizations.
Author disclosures: C.N. Hess, None; T.Y. Wang, Bristol-Myers Squibb/Sanofi Aventis Partnership, Significant, Research Grant; Schering Plough/Merck & Co., Significant, Research Grant; The Medicines Co., Significant, Research Grant; Heartscape Technologies, Inc., Significant,
Research Grant; Canyon Pharmaceuticals, Significant, Research Grant; Eli Lilly/Daiichi Sankyo Alliance, Significant, Research Grant; Medco Health Solutions, Inc., Modest, Honoraria; Astrazeneca, Modest, Honoraria; American College of Cardiology Foundation, Modest,Honoraria; L.
Kaltenbach, None; E. Honeycutt, None; J.C. Messenger, None; W.T. Smith, None; M.E. Zettler, Eli Lilly, Significant, Employment; M.B. Effron, Eli Lilly, Significant, Employment; Eli Lilly, Significant, Ownership Interest; T.D. Henry, Eli Lilly, Significant, Research Grant; Daiichi,
Significant, Research Grant; Eli Lilly, Modest, Consultant/Advisory Board; Daiichi, Modest, Consultant/Advisory Board; E.D. Peterson, Eli Lilly, Significant, Research Grant; Janssen Pharmaceuticals, Significant, Research Grant; G.C. Fonarow, None.