Date Published: October 31, 2018
Publisher: Public Library of Science
Author(s): Mahesh K. Vidula, Cian P. McCarthy, Neel M. Butala, Kevin F. Kennedy, Jason H. Wasfy, Robert W. Yeh, Eric A. Secemsky, Islam Y. Elgendy.
Patients discharged on oral anticoagulant (OAC) therapy after percutaneous coronary intervention (PCI) represent a complex population and are at higher risk of early readmission. The reasons and predictors of early readmission in this group have not been well characterized. We identified patients in an integrated health care system who underwent PCI between 2009 and 2014 and were readmitted within 30 days within this health care system. Of the 9,357 patients surviving to discharge after the index PCI, 692 were readmitted within 30 days (7.4%). At the time of readmission, 143 had been discharged from the index PCI hospitalization on OACs (96.5% on warfarin) and 549 had not been discharged on OACs, with readmission rates of 12.9% and 6.7%, respectively (p<0.01). The most common reason for readmission among all patients was chest pain syndromes (21.7% on OACs, 34.4% not on OACs). However, bleeding represented the next most frequent cause of readmission among patients on OACs (14.0% on OACs vs 6.0% not on OACs, p<0.01). Among patients on OAC therapy, peripheral arterial disease (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.07–2.57, p = 0.02) and nonelective PCI (OR 1.91, 95% CI 1.17–3.12, p<0.01) were found to be independent predictors of 30-day readmission. During rehospitalization, compared to patients not on OACs, patients on OACs suffered a higher unadjusted rate of mortality (6.3% vs 1.8%, p<0.01) and a longer length of stay (6.4 ± 7.1 days vs 4.9 ± 6.8 days, p = 0.02). In conclusion, patients discharged on OAC therapy after PCI are commonly readmitted, with bleeding representing a major reason. These readmissions are associated with high mortality and longer lengths of stay. Interventions targeted towards optimizing discharge planning for these complex patients are needed to potentially reduce readmissions.
Readmissions following percutaneous coronary intervention (PCI) are expensive and burdensome for patients. A recent review found that rates of 30-day readmission after PCI range from 4.7–15.6%, and readmitted patients may be at increased risk of death at 1 year . The 30-day readmission rate is also used as a quality metric for hospitals, since readmissions may reflect the quality of care the patient received at the time of index hospitalization or after discharge . The Centers for Medicare & Medicaid Services (CMS) Hospital Readmissions Reduction Program now penalizes hospitals for higher than expected 30-day readmission rates for certain medical conditions, including acute myocardial infarction (MI) and heart failure . Since many of these patients undergo PCI during their hospitalization, reducing readmissions after PCI has become a priority for hospital systems, and interventions targeted towards reducing readmissions post-PCI have been implemented [2,4]. In addition, the CMS recently announced a new voluntary bundled payment model, the Bundled Payments for Care Improvement Advanced, which ties reimbursement for PCI to several quality measures including readmission .
In this study of over 1,100 patients on OAC therapy after PCI, we assessed the reasons and predictors for early readmissions. We found that patients discharged on OACs following PCI are more commonly readmitted within 30 days than patients not discharged on OACs, with chest pain (21.7%) and bleeding (14.0%) representing the major causes. Bleeding-related readmissions were significantly greater among OAC patients, of which the majority were due to gastrointestinal bleeding. Readmissions were associated with prolonged lengths of stay and a high unadjusted mortality rate in the OAC population. OAC use after discharge from index PCI was found to be a strong independent predictor of readmission among all readmitted patients, whereas among patients on OACs, peripheral arterial disease and nonelective index PCI were independently associated with 30-day readmission.
In conclusion, we found that patients on OACs are commonly readmitted within 30 days following PCI, with bleeding representing a major cause. These readmissions were associated with a high risk of mortality. Peripheral arterial disease and nonelective index PCI were important predictors of readmission in the OAC group. Therefore, patients on OACs merit close monitoring following discharge after PCI, and further research is required to determine how to prevent readmissions and bleeding-related events among this complex cohort of patients.