Jason Wasfy (Cardiology Division, Massachusetts General Hospital, Boston, USA) and others report in Circulation: Cardiovascular Interventions that recurrent chest discomfort is the most common cause for readmission after percutaneous coronary intervention (PCI). They add that patients readmitted for chest discomfort are associated with high rates of diagnostic imaging but frequently do not meet the criteria for myocardial infarction.
Wasfy et al write that as hospitals [In the USA at least] are under pressure to lower readmission rates to lower costs, understanding the reasons for readmission is “critically important” for identifying strategies for improvement. They conducted the current study because limited data are available for why—according to Medicare figures—nearly 20% of patients are readmitted to hospital within 30 days of undergoing PCI. “We sought to characterise the reasons for 30-day readmission after PCI through detailed exploration of the medical records at two hospitals within a large integrated healthcare system. We further examined the use of diagnostic testing and therapeutic procedures for the most common causes of readmission”, Wasfy et al comment.
The authors identified 852 patients (of a possible 9,081 who survived to discharge) who were readmitted within 30 days of undergoing PCI during the study period. They note: “The largest category of reasons for readmission was chest discomfort, accounting for 341 readmissions (38.1%).”Of these patients, 84.5% underwent at least one diagnostic imaging study (eg. coronary angiography). The authors add: “However, less than one in eight patients readmitted with chest discomfort required a repeat revascularisation procedure, with only 2.6% requiring repeat revascularisation of the vessel treated on initial presentation. Less than one in 14 met criteria for myocardial infarction during the procedure.”
According to Wasfy et al, their results indicate that many patients with low-risk chest discomfort may be effectively evaluated in the outpatient or observational setting. They recommend that hospitals could potentially reduce the rate of readmissions after PCI by introducing an algorithm to prevent unnecessary admissions, stating it could be used to assess outpatients and those in the emergency room. “Such an algorithm could entail, first, the rapid clinical assessment of any patient with angina for signs and symptoms consistent with stent thrombosis or myocardial infarction… Outpatients considered to be at higher risk based on typical symptoms or ECG changes would be referred to an emergency department thereafter,” Wasfy et al comment. Once patients were at the emergency department, the authors explain, a cardiologist could then evaluate them to see if they could be discharged (because they had low-risk features on assessment) or admitted for further evaluation (because they had high-risk features on assessment). They note: “This type of algorithm should be assessed prospectively for future research” and conclude: “Reducing readmissions for low-risk chest discomfort after PCI has the potential to save substantial healthcare costs. The effect of those changes on safety and patient satisfaction deserve further investigation.”
Wasfy told Cardiovascular News: “Reducing costs and improving value in American medicine remains a crucial challenge. We just have to do this right for the sake of our patients. Our study demonstrates that many readmissions are inevitable. The best prospects for reducing readmissions are developing alternative clinical pathways to evaluate patients with low-risk chest discomfort. Other possible prospects include deferring certain staged PCI procedures unless patients have new or ongoing symptoms, consistent with appropriate use guidelines. Improving outpatient access to primary care doctors also may improve our ability to diagnose and treat conditions unrelated to the PCI procedure, such as pneumonia, bronchitis, or urinary tract infections.”
