Incidence and predictors of readmissions to non-index hospitals after transcatheter aortic valve replacement and the impact on in-hospital outcomes: From the nationwide readmission database

Incidence and Predictors of Readmissions to Non-Index Hospitals After Transcatheter Aortic Valve Implantation in the Contemporary Era in New South Wales, Australia

BACKGROUND

In Australia, transcatheter aortic valve implantation (TAVI) is only performed in a limited number of specialised metropolitan centres, many of which are private hospitals, making it likely that TAVI patients who require readmission will present to another (non-index) hospital. It is important to understand the impact of non-index readmission on patient outcomes and healthcare resource utilisation.

METHOD

We analysed linked hospital and death records for residents of New South Wales, Australia, aged ≥18 years, who had an emergency readmission within 90 days following a TAVI procedure in 2013-2022. Mixed-effect, multi-level logistic regression models were used to evaluate predictors of non-index readmission, and associations between non-index readmission and readmission length of stay, 90-day mortality, and 1-year mortality.

RESULTS

Of 4,198 patients (mean age, 82.7 years; 40.6% female) discharged alive following TAVI, 933 (22.2%) were readmitted within 90 days of discharge. Over three-quarters (76.0%) of those readmitted returned to a non-index hospital, with no significant difference in readmission principal diagnosis between index hospital and non-index hospital readmissions. Among readmitted patients, independent predictors of non-index readmission included: residence in regional or remote areas, lower socio-economic status, having a pre-procedure transfer, and a private index hospital. Readmission length of stay (median, 4 days), 90-day mortality (adjusted odds ratio [OR] 1.04, 95% confidence interval [CI] 0.56-1.96) and 1-year mortality (adjusted OR 1.01, 95% CI 0.64-1.58) were similar between index and non-index readmissions.

CONCLUSIONS

Non-index readmission following TAVI was highly prevalent but not associated with increased mortality or healthcare utilisation. Our results are reassuring for TAVI patients in regional and remote areas with limited access to return to index TAVI hospitals.

Characteristics and Outcomes of Pediatric Nonindex Readmission: Evidence From Florida Hospitals

OBJECTIVES

Increasing pediatric care regionalization may inadvertently fragment care if children are readmitted to a different (nonindex) hospital rather than the discharge (index) hospital. Therefore, this study aimed to assess trends in pediatric nonindex readmission rates, examine the risk factors, and determine if this destination difference affects readmission outcomes.

METHODS

In this retrospective cohort study, we use the Healthcare Cost and Utilization Project State Inpatient Database to include pediatric (0 to 18 years) admissions from 2010 to 2017 across Florida hospitals. Risk factors of nonindex readmissions were identified by using logistic regression analyses. The differences in outcomes between index versus nonindex readmissions were compared for in-hospital mortality, morbidity, hospital cost, length of stay, against medical advice discharges, and subsequent hospital visits by using generalized linear regression models.

RESULTS

Among 41 107 total identified readmissions, 5585 (13.6%) were readmitted to nonindex hospitals. Adjusted nonindex readmission rate increased from 13.3% in 2010% to 15.4% in 2017. Patients in the nonindex readmissions group were more likely to be adolescents, live in poor neighborhoods, have higher comorbidity scores, travel longer distances, and be discharged at the postacute facility. After risk adjusting, no difference in in-hospital mortality was found, but morbidity was 13% higher, and following unplanned emergency department visits were 28% higher among patients with nonindex readmissions. Length of stay, hospital costs, and against medical advice discharges were also significantly higher for nonindex readmissions.

CONCLUSIONS

A substantial proportion of children experienced nonindex readmissions and relatively poorer health outcomes compared with index readmission. Targeted strategies for improving continuity of care are necessary to improve readmission outcomes.

Ninety-Day Readmission After Open Surgical Repair of Stanford Type A Aortic Dissection

BACKGROUND

Investigations into readmissions after surgical repair of acute Stanford Type A aortic dissection (TAAD) remain scarce. We analyzed potential risk factors for readmission after TAAD.

METHODS

The 2013-2014 United States Nationwide Readmissions Database was queried for TAAD index hospitalizations and 90-day readmissions indicated by diagnostic and procedural codes. Multivariable analysis was completed to identify risk factors and the most common reasons for readmission.

RESULTS

We identified 6,975 patients (65% male; age, 60.0±0.4 years) who underwent surgical repair for TAAD. Overall, 2,062 patients (29.6%) were readmitted within 90 days: 634 (30.7%) during the first 30 days, and 1,428 (69.3%) during days 31-90. Readmitted patients had a higher prevalence of chronic kidney disease at index admission (18.0% vs 11.6%, P=.002), greater overall index length of stay (17.8±0.6 vs 15.5±0.4 days; P=.0003), and greater index hospitalization cost ($90,637±$2,691 vs $80,082±$2,091; P=.0003). Mortality during readmission was 3.6% (n=74). Indications for readmission were most commonly cardiac (26.2%), infectious (17.8%), and pulmonary (11.7%). Multivariable analysis identified 2 independent risk factors for readmission: acute kidney injury (OR 1.49; 95% CI 1.24-1.78, P<.0001) and an Elixhauser Comorbidity Index >4 (OR 1.26; 95% CI 1.06-1.49, P=.009).

CONCLUSIONS

After surgical repair of TAAD, approximately 30% of patients were readmitted within 90 days, two thirds of them during the 31- to 90-day period. Targeted improvements in perioperative care and post-discharge follow-up of patients with multiple comorbidities could mitigate readmission rates. Efforts to reduce readmissions should be continued throughout the 90-day period.

Quantifying the Impact of Care Fragmentation on Outcomes After Transcatheter Aortic Valve Implantation

The Center for Medicare & Medicaid Services has identified readmission as an important quality metric in assessing hospital performance and value of care. The aim of this study was to quantify the impact of "care fragmentation" on transcatheter aortic valve implantation (TAVI) outcomes. Readmission to nonindex hospitals was defined as any hospital other than the hospital where the TAVI was performed. In this multicenter, population-based, nationally representative study, a nationally weighted cohort of US adult patients who underwent TAVI in the National Readmission Database between 01/01/2010 and 9/31/2015 were analyzed. Patient characteristics, trends, and outcomes after 90-day nonindex readmission were evaluated. Thirty-day metric was used as a reference group for comparison. A weighted total of 51,092 patients met inclusion criteria. Overall, the 90-day readmission rate after TAVI was 27.6% (30-day reference group: 17.4%), and 42% of these readmissions were to nonindex hospitals. Noncardiac causes accounted for most nonindex readmissions, but major cardiac procedures were more likely performed at index hospitals during readmission within 90 days. Despite the high co-morbidity burden of patients readmitted to nonindex hospitals, unadjusted and risk-adjusted all-cause mortality, readmission length of stay and total hospital costs following nonindex readmission were lower compared with index readmission at 90 days. In conclusion, in this real world, nationally representative cohort of TAVI patients in the United States, care fragmentation remains prevalent and represent an enduring, residual target for future health policies. Although the impactful readmissions may be directed toward index hospitals, concerted efforts are needed to address mechanisms that increase care fragmentation.

Identifying patients likely to be readmitted after transcatheter aortic valve replacement

Hospital readmission following transcatheter aortic valve replacement (TAVR) contributes considerably to the costs of care. Readmission rates following TAVR have been reported to be as high as 17.4% at 30 days and 53.2% at 1 year. Patient and procedural factors predict an increased likelihood of readmission including non-transfemoral access, acute and chronic kidney impairment, chronic lung disease, left ventricular systolic dysfunction, atrial fibrillation, major bleeding and prolonged index hospitalisation. Recent studies have also found the requirement for new pacemaker implantation and the severity of paravalvular aortic regurgitation and tricuspid regurgitation to be novel predictors of readmission. Post-TAVR readmission within 30 days of discharge is more likely to occur for non-cardiac than cardiac pathology, although readmission for cardiac causes, especially heart failure, predicts higher mortality than readmission for non-cardiac causes. To combat the risk of readmission and associated mortality, the routine practice of calculating and considering readmission risk should be adopted by the heart team. Furthermore, because most readmissions following TAVR occur for non-cardiac reasons, more holistic approaches to readmission prevention are necessary. Familiarity with the most common predictors and causes of readmission should guide the development of initiatives to address these conditions proactively.