Clinical Model to Predict 90-Day Risk of Readmission After Acute Myocardial Infarction

The effect of diabetes mellitus on perioperative outcomes after colorectal resection: a national cohort study

BACKGROUND

Diabetes mellitus is a significant modulator of postoperative outcomes and is an important risk factor in the patient selection process. We aimed to investigate the effect of diabetes mellitus and use of insulin on outcomes after colorectal resection using a national cohort.

METHODS

Adults with a recorded colorectal resection in England between 2010 and 2020 were identified from Hospital Episode Statistics data linked to the Clinical Practice Research Database. The primary outcome was 90-day mortality. Secondary outcomes included hospital length of stay (LOS) and readmission within 90 days.

RESULTS

Of the 106 139 (52 875, 49.8% male) patients included, diabetes mellitus was prevalent in 10 931 (10.3%), 2145 (19.6%) of whom had a record of use of insulin. Unadjusted 90-day mortality risk was 5.7%, with an increased adjusted hazard ratio (aHR) for people with diabetes mellitus (aHR 1.28, 95% confidence interval [CI] 1.19-1.37, P<0.001). This risk was higher in both people with diabetes using insulin (aHR 1.51, 95% CI 1.31-1.74, P<0.001) and not using insulin (aHR 1.22, 95% CI 1.13-1.33, P<0.001), compared with those without diabetes. Ninety-day readmission occurred in 20 542 (19.4%) patients and this was more likely in those with diabetes mellitus (aHR 1.23, 95% CI 1.18-1.29, P<0.001). Median (inter-quartile range) LOS was 8 (5-15) days and was higher in people with diabetes mellitus (adjusted time ratio 1.10, 95% CI 1.08-1.11, P<0.001).

CONCLUSIONS

People with diabetes mellitus undergoing colorectal resection are at a higher risk of 90-day mortality, prolonged LOS, and 90-day readmission, with use of insulin associated with additional risk.

Characteristics of High-Performing Hospitals in Cardiogenic Shock Following Acute Myocardial Infarction

Cardiogenic shock after acute myocardial infarction (AMI-CS) carries significant mortality despite advances in revascularization and mechanical circulatory support. We sought to identify the process-based and structural characteristics of centers with lower mortality in AMI-CS. We analyzed 16,337 AMI-CS cases across 440 centers enrolled in the National Cardiovascular Data Registry's Chest Pain-MI Registry, a retrospective cohort database, between January 1, 2015, and December 31, 2018. Centers were stratified across tertiles of risk-adjusted in-hospital mortality rate (RAMR) for comparison. Risk-adjusted multivariable logistic regression was also performed to identify hospital-level characteristics associated with decreased mortality. The median participant age was 66 (interquartile range 57 to 75) years, and 33.0% (n = 5,390) were women. The median RAMR was 33.4% (interquartile range 26.0% to 40.0%) and ranged from 26.9% to 50.2% across tertiles. Even after risk adjustment, lower-RAMR centers saw patients with fewer co-morbidities. Lower-RAMR centers performed more revascularization (92.8% vs 90.6% vs 85.9%, p <0.001) and demonstrated better adherence to associated process measures. Left ventricular assist device capability (odds ratio [OR] 0.78 [0.67 to 0.92], p = 0.002), more frequent revascularization (OR 0.93 [0.88 to 0.98], p = 0.006), and higher AMI-CS volume (OR 0.95 [0.91 to 0.99], p = 0.009) were associated with lower in-hospital mortality. However, several such characteristics were not more frequently observed at low-RAMR centers, despite potentially reflecting greater institutional experience or resources. This may reflect the heterogeneity of AMI-CS even after risk adjustment. In conclusion, low-RAMR centers do not necessarily exhibit factors associated with decreased mortality in AMI-CS, which may reflect the challenges in performing outcomes research in this complex population.

Association of Sociodemographic Characteristics With 1-Year Hospital Readmission Among Adults Aged 18 to 55 Years With Acute Myocardial Infarction

Importance

Among younger adults, the association between Black race and postdischarge readmission after hospitalization for acute myocardial infarction (AMI) is insufficiently described.

Objectives

To examine whether racial differences exist in all-cause 1-year hospital readmission among younger adults hospitalized for AMI and whether that difference retains significance after adjustment for cardiac factors and social determinants of health (SDOHs).

Design, Setting, and Participants

The VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) study was an observational cohort study of younger adults (aged 18-55 years) hospitalized for AMI with a 2:1 female-to-male ratio across 103 US hospitals from January 1, 2008, to December 31, 2012. Data analysis was performed from August 1 to December 31, 2021.

Main Outcomes and Measures

The primary outcome was all-cause readmission, defined as any hospital or observation stay greater than 24 hours within 1 year of discharge, identified through medical record abstraction and clinician adjudication. Logistic regression with sequential adjustment evaluated racial differences and potential moderation by sex and SDOHs. The Blinder-Oaxaca decomposition quantified how much of any racial difference was explained and not explained by covariates.

Results

This study included 2822 participants (median [IQR] age, 48 [44-52] years; 1910 [67.7%] female; 2289 [81.1%] White and 533 [18.9%] Black; 868 [30.8%] readmitted). Black individuals had a higher rate of readmission than White individuals (210 [39.4%] vs 658 [28.8%], P < .001), particularly Black women (179 of 425 [42.1%]). After adjustment for sociodemographic characteristics, cardiac factors, and SDOHs, the odds of readmission were 34% higher among Black individuals (odds ratio [OR], 1.34; 95% CI, 1.06-1.68). The association between Black race and 1-year readmission was positively moderated by unemployment (OR, 1.68; 95% CI, 1.09- 2.59; P for interaction = .02) and fewer number of working hours per week (OR, 1.01; 95% CI, 1.00-1.02; P for interaction = .01) but not by sex. Decomposition indicates that 79% of the racial difference in risk of readmission went unexplained by the included covariates.

Conclusions and Relevance

In this multicenter study of younger adults hospitalized for AMI, Black individuals were more often readmitted in the year following discharge than White individuals. Although interventions to address SDOHs and employment may help decrease racial differences in 1-year readmission, more study is needed on the 79% of the racial difference not explained by the included covariates.

In-hospital outcomes and readmission in older adults treated with percutaneous coronary intervention for stable ischemic heart disease

Background

Percutaneous coronary intervention (PCI) for stable ischemic heart disease (SIHD) in older adults requires a meticulous assessment of procedural risks and benefits, but contemporary data on outcomes in this population is lacking. Therefore, we examined the risk of near-term readmission, bleeding, and mortality in high-risk cohort of older adults undergoing inpatient PCI for SIHD.

METHODS

We analyzed the National Readmissions Database from 2017 to 2018 to identify index hospitalizations in which PCI was performed for SIHD. Patients were stratified into those ≥ 75 years old (older adults) and those < 75 years old. The primary outcome was 90-day readmission. Secondary outcomes included in-hospital mortality, hospital length of stay (LOS), and total hospital charge.

RESULTS

A total of 74,516 patients underwent inpatient PCI for SIHD, of whom 24,075 were older adults. Older adult patients had higher odds of in-hospital mortality (OR = 2.00, 95% CI: 1.68-2.38), intracranial hemorrhage (OR = 2.03, 95% CI: 1.24-3.34), and gastrointestinal hemorrhage (OR = 1.72, 95% CI: 1.43-2.07) during index hospitalization, with longer LOS and in-hospital charge. Older adults also experienced a higher hazard of 90-day readmission for any cause (HR = 1.61, 95% CI: 1.57-1.66) and cardiovascular causes (HR = 1.84, 95% CI: 1.77-1.91).

CONCLUSION

Older adults undergoing inpatient PCI for SIHD were at increased risk for in-hospital mortality, periprocedural morbidities, higher cost, and readmissions compared with younger adults. Understanding these differences may improve shared decision-making for patients with SIHD being considered for PCI.

Readmission After ACS: Burden, Epidemiology, and Mitigation

PURPOSE OF REVIEW

The past decade has brought increased efforts to better understand causes for ACS readmissions and strategies to minimize them. This review seeks to provide a critical appraisal of this rapidly growing body of literature.

RECENT FINDINGS

Prior to 2010, readmission rates for patients suffering from ACS remained relatively constant. More recently, several strategies have been implemented to mitigate this including improved risk assessment models, transition care bundles, and development of targeted programs by federal organizations and professional societies. These strategies have been associated with a significant reduction in ACS readmission rates in more recent years. With this, improvements in 30-day post-discharge mortality rates are also being appreciated. As we continue to expand our knowledge on independent risk factors for ACS readmissions, further strategies targeting at-risk populations may further decrease the rate of readmissions. Efforts to understand and reduce 30-day ACS readmission rates have resulted in overall improved quality of care for patients.

Home health care after discharge is associated with lower readmission rates for patients with acute myocardial infarction

OBJECTIVE

We studied the utilization of home health care (HHC) among acute myocardial infarction (AMI) patients, impact of HHC on and predictors of 30-day readmission.

METHODS

We queried the National Readmission Database (NRD) from 2012 to 2014identify patients with AMI discharged home with (HHC+) and without HHC (HHC-). Linkage provided in the data identified patients who had 30-day readmission, our primary end-point. The probability for each patient to receive HHC was calculated by a multivariable logistic regression. Average treatment of treated weights were derived from propensity scores. Weight-adjusted logistic regression was used to determine impact of HHC on readmission.

RESULTS

A total of 406 237 patients with AMI were discharged home. Patients in the HHC+ cohort (38 215 patients, 9.4%) were older (mean age 77 vs. 60 years P < 0.001), more likely women (53 vs. 26%, P < 0.001), have heart failure (5 vs. 0.5%, P < 0.001), chronic kidney disease (26 vs. 6%, P < 0.001) and diabetes (35 vs. 26%, P < 0.001). Patients readmitted within 30-days were older with higher rates of diabetes (RR = 1.4, 95% CI: 1.37-1.48) and heart failure (RR = 5.8, 95% CI: 5.5-6.2). Unadjusted 30-day readmission rates were 21 and 8% for HHC+ and HHC- patients, respectively. After adjustment, readmission was lower with HHC (21 vs. 24%, RR = 0.89, 95% CI: 0.82-0.96; P < 0.001).

CONCLUSION

In the United States, AMI patients receiving HHC are older and have more comorbidities; however, HHC was associated with a lower 30-day readmission rate.

Prediction models for hospital readmissions in patients with heart disease: a systematic review and meta-analysis

OBJECTIVE

To describe the discrimination and calibration of clinical prediction models, identify characteristics that contribute to better predictions and investigate predictors that are associated with unplanned hospital readmissions.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

Medline, EMBASE, ICTPR (for study protocols) and Web of Science (for conference proceedings) were searched up to 25 August 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were eligible if they reported on (1) hospitalised adult patients with acute heart disease; (2) a clinical presentation of prediction models with c-statistic; (3) unplanned hospital readmission within 6 months.

PRIMARY AND SECONDARY OUTCOME MEASURES

Model discrimination for unplanned hospital readmission within 6 months measured using concordance (c) statistics and model calibration. Meta-regression and subgroup analyses were performed to investigate predefined sources of heterogeneity. Outcome measures from models reported in multiple independent cohorts and similarly defined risk predictors were pooled.

RESULTS

Sixty studies describing 81 models were included: 43 models were newly developed, and 38 were externally validated. Included populations were mainly patients with heart failure (HF) (n=29). The average age ranged between 56.5 and 84 years. The incidence of readmission ranged from 3% to 43%. Risk of bias (RoB) was high in almost all studies. The c-statistic was <0.7 in 72 models, between 0.7 and 0.8 in 16 models and >0.8 in 5 models. The study population, data source and number of predictors were significant moderators for the discrimination. Calibration was reported for 27 models. Only the GRACE (Global Registration of Acute Coronary Events) score had adequate discrimination in independent cohorts (0.78, 95% CI 0.63 to 0.86). Eighteen predictors were pooled.

CONCLUSION

Some promising models require updating and validation before use in clinical practice. The lack of independent validation studies, high RoB and low consistency in measured predictors limit their applicability.

PROSPERO REGISTRATION NUMBER

CRD42020159839.

Characteristics and Outcomes of Early Recurrent Myocardial Infarction After Acute Myocardial Infarction

Background We aimed to understand the characteristics and outcomes of patients readmitted with a recurrent myocardial infarction (RMI) within 90 days of discharge after an acute myocardial infarction (early RMI). Methods and Results We analyzed the timing of reinfarction, etiology, and outcome for all patients admitted with an early RMI within 90 days of discharge after an acute myocardial infarction between January 1, 2010 and January 1, 2017. We identified 6626 admissions for acute myocardial infarction (index myocardial infarction) which led to 168 cases of RMI within 90 days of discharge. The mean patient age was 65.1±13.1 years, and 37% were women. The 90-day probability of readmission with an early RMI was 2.5%. Black race, medical management, higher troponin T, and shorter length of stay were independent predictors of early RMI. Medically managed group had a higher risk for early RMI compared with percutaneous coronary intervention (P=0.04) or coronary artery bypass grafting (P=0.2). Predominant mechanisms for reinfarction were stent thrombosis (17%), disease progression (12%), and unchanged coronary artery disease (11%). At 5 years, the all-cause mortality rate for patients with an early RMI was 49% (95% CI, 40%-57%) compared with 22% (95% CI, 21%-23%) for patients without an early RMI (P<0.0001). Conclusions Early RMI is a life-threatening condition with nearly 50% mortality within 5 years. Stent-related events and progression in coronary artery disease account for most early RMI. Medication compliance, aggressive risk factor management, and care transitions should be the cornerstone in preventing early RMI.

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.

Perceived Versus Actual Risks of 30-Day Readmission in Patients With Cardiovascular Disease

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of hospitalization in the United States, and patients with CVD are at a high risk of readmission after discharge. We examined whether patients' perceived risk of readmission at discharge was associated with actual 30-day readmissions in patients hospitalized with CVD.

METHODS

We recruited 730 patients from the Duke Heart Center who were admitted for treatment of CVD between January 1, 2015, and August 31, 2017. A standardized survey was linked with electronic health records to ascertain patients' perceived risk of readmission, and other sociodemographic, psychosocial, behavioral, and clinical data before discharge. All-cause readmission within 30 days after discharge was examined.

RESULTS

Nearly 1-in-3 patients perceived a high risk of readmission at index admission and those who perceived a high risk had significantly more readmissions within 30 days than patients who perceived low risks of readmission (23.6% versus 15.8%, P=0.016). Among those who perceived a high risk of readmission, non-White patients (odds ratio [OR], 2.07 [95% CI, 1.28-3.36]), those with poor self-rated health (OR, 2.30 [95% CI, 1.38-3.85]), difficulty accessing care (OR, 2.72 [95% CI, 1.24-6.00]), and prior hospitalizations in the past year (OR, 2.13 [95% CI, 1.21-3.74]) were more likely to be readmitted. Among those who perceived a low risk of readmission, patients who were widowed (OR, 2.69 [95% CI, 1.60-4.51]) and reported difficulty accessing care (OR, 1.89 [95% CI, 1.07-3.33]) were more likely to be readmitted.

CONCLUSIONS

Patients who perceived a high risk of readmission had a higher rate of 30-day readmission than patients who perceived a low risk. These findings have important implications for identifying CVD patients at a high risk of 30-day readmission and targeting the factors associated with perceived and actual risks of readmission.

Prognostic Implications of Early and Midrange Readmissions After Acute Heart Failure Hospitalizations: A Report From a Japanese Multicenter Registry

Background

Although 30‐day readmission is thought to be an important quality indicator in patients with hospitalized heart failure, its prognostic impact and comparison of patients who were readmitted beyond 30 days has not been investigated. We assessed early (0–30 days) versus midrange (31–90 days) readmission in terms of incidence and distribution, and elucidated whether the timing of readmission could have a different prognostic significance.

Methods and Results

We examined patients with hospitalized heart failure registered in the WET‐HF (West Tokyo Heart Failure) registry. The primary outcomes analyzed were all‐cause death and HF readmission. Data of 3592 consecutive patients with hospitalized heart failure (median follow‐up, 2.0 years [interquartile range, 0.8–3.1 years]; 39.6% women, mean age 73.9±13.3 years) were analyzed. Within 90 days after discharge, HF readmissions occurred in 11.1% patients. Of them, patients readmitted within 30 and 31 to 90 days after discharge accounted for 43.1% and 56.9%, respectively. Independent predictors of 30‐ and 90‐day readmission were almost identical, and after adjustment, readmission for HF within 90 days (including both early and midrange readmission) was an independent predictor of subsequent all‐cause death (hazard ratio, 2.36; P<0.001). Among 90‐day readmitted patients, the time interval from discharge to readmission was not significantly associated with subsequent all‐cause death.

Conclusions

Among patients readmitted within 90 days after index hospitalization discharge, ≈60% of readmission events occurred beyond 30 days. Patients readmitted within 90 days had a higher risk of long‐term mortality, regardless of the temporal proximity of readmission to the index hospitalization.

Understanding Readmissions in Medicare Beneficiaries During the 90-Day Follow-Up Period of an Acute Myocardial Infarction Admission

Background

Medicare has a voluntary episodic payment model for Medicare beneficiaries that bundles payment for the index acute myocardial infarction (AMI) hospitalization and all post‐discharge services for a 90‐day follow‐up period. The purpose of this study is to report on the types and frequency of readmissions and identify demographic and clinical factors associated with readmission of Medicare beneficiaries that survived their AMI hospitalization.

Methods and Results

This retrospective study used the Inpatient Standard Analytical File for 2014. There were 143 286 Medicare beneficiaries with AMI who were discharged alive from 3619 hospitals. All readmissions occurring in any hospital within 90 days of the index AMI discharge date were identified. Of 143 286 Medicare beneficiaries discharged alive from their index AMI hospitalization, 28% (40 145) experienced at least 1 readmission within 90 days and 8% (11 477) had >1 readmission. Readmission rates were higher among Medicare beneficiaries who did not undergo a percutaneous coronary intervention in their index AMI admission (34%) compared with those that underwent a percutaneous coronary intervention (20.2%). Using all Medicare beneficiary's index AMI, 27 comorbid conditions were significantly associated with the likelihood of a Medicare beneficiary having a readmission during the follow‐up period. The strongest clinical characteristics associated with readmissions were dialysis dependence, type 1 diabetes mellitus, and heart failure.

Conclusions

This study provides benchmark information on the types of hospital readmissions Medicare beneficiaries experience during a 90‐day AMI bundle. This paper also suggests that interventions are needed to alleviate the need for readmissions in high‐risk populations, such as, those managed medically and those at risk of heart failure.

Association between post-discharge secondary care and risk of repeated hospital presentation, entry into long-term care and mortality in older people after acute hospitalization

AIM

Hospitalizations are frequent among acutely ill older people, and might be reduced by post-discharge secondary care (PDSC). We aimed to determine the proportion of older patients planned to receive or attending PDSC after acute hospitalization and the association with undesirable outcomes.

METHODS

A retrospective observational study was carried out using an electronic health record system in two hospitals in New Zealand. Patients were aged ≥75 years, initially presented at an emergency department (ED) and were discharged from medical, surgical, geriatrics or orthopedics wards in three 2-week periods. Planned PDSC at discharge, attended PDSC, ED presentation, long-term care (LTC) admission and death in 90 days after discharge were obtained through the health record system. Proportional hazards regression assessed the associations of planned or attended PDSC with undesirable outcomes (ED presentation, LTC admission and death) within 90 days of discharge.

RESULTS

Clinical records for 1085 patients were extracted, 963 were eligible. Of these, 413 (42.9%) had planned PDSC in discharge summaries, and 573 (59.5%) actually attended in 90 days. Patients planned for PDSC had a similarly adjusted hazard of ED presentation (HR 0.99, P = 0.92), LTC admission (HR 0.73, P = 0.25) and death (HR 0.80, P = 0.34) within 90 days of discharge, compared with those not planned. Similar non-significant associations were observed between attended PDSC and undesirable outcomes.

CONCLUSIONS

In patients aged ≥75 years in New Zealand, we did not find "planned PDSC" at discharge or "attended PDSC" after an acute hospitalization to be associated with ED presentation, LTC admission and death within 90 days after discharge. Other potential benefits of planned or attended PDSC require further investigation. Geriatr Gerontol Int 2019; 19: 1048-1053.