Risk Factors for 30-Day Readmissions after Acute Myocardial Infarction
Keywords:acute myocardial infarction, 30-day readmission, hospital readmission, predictive model
The hospital readmission rate has been thought to reflect the quality of patient care. Understanding the risk factors for these can guide strategies to reduce them.
Retrospective cohort design that included all the admissions for AMI from October 2011 to September 2014. Primary outcome was 30-day readmission rate. Secondary outcomes were 7-day readmission rate, reasons for readmission and cardiac-related readmission rate. Univariate and multivariate logistic regression were conducted with Hosmer-Lemeshow goodness-of-fit statistics for model calibration and ROC curve for model discrimination.
We identified 2958 cases of AMI and 334 readmissions (11.3%). The final sample for analysis included 310 readmitted and 652 non-readmitted patients. The principal causes of readmission were cardiac related (42%), followed by respiratory (15%) and gastrointestinal (11%). Separate analysis for the early readmissions showed the same pattern. 42% of the readmissions happened during the first week and 68% in the first 2 weeks after discharge. Median time for readmission was 10 days. Older age, days from admission to catheterization, complete medical therapy at discharge, diabetes, hypertension, stroke, major psychiatric disorders, insurance status, chronic kidney disease and congestive heart failure were independently associated with 30-day readmission. The final multivariate model discriminated well with a ROC of 0.753 (95% CI 0.72-0.79).
Reasons for readmission found in our study were consistent with previous studies. Absolute readmission rates reported in this study were lower than in some prior publications. We present novel and addressable patient risk factors derived from the index admission that can be used to predict readmission.
BerensonRA, PaulusRA,KalmanNS. Medicare’s readmissions-reduction program—a positive alternative. N Engl JMed. 2012;366:1364-1366. doi: 10.1056/NEJMp1201268
Moon MA. U.S. tops 16 nations in STEMI readmissions. CardiologyNews. February 2012:30.
Au AG, McAlister FA, Bakal JA, et al. Predicting the risk of unplanned readmission or death within 30 days of discharge after a heart failure hospitalization. Am Heart J. 2012;164:365-372. doi: 10.1016/j.ahj.2012.06.010
Bradley EH, Curry L, Horwitz LI, et al. Contemporary evidence about hospital strategies for reducing 30-day readmissions. J Am Coll Cardiol. 2012;60:607-614. doi: 10.1016/j.jacc.2012.03.067.
Bettger JP, Alexander KP, Dolor RJ, et al. Transitional care after hospitalization for acute stroke or myocardial infarction. Ann Intern Med. 2012;157:407-416. doi: 10.7326/0003-4819-157-6-201209180-00004.
Dunlay SM, Weston SA, Killian JM, Bell MR, Jaffe AS, Roger VL. Thirty-day rehospitalizations after acute myocardial infarction: a cohort study. Ann Intern Med. 2012 Jul 3;157(1):11-8. doi: 10.7326/0003-4819-157-1-201207030-00004.
Dharmarajan K, Hseih AF, Lin Z, et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA. 2013 Jan 23;309(4):355–63. DOI:http://dx.doi.org/10.1001/jama.2012.216476.
Mathews R, Chen AY, Thomas L, Wang TY, Chin CT, Thomas KL, Roe MT, Peterson ED, Differences in short-term versus long-term outcomes of older black versus white patients with myocardial infarction: findings from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of American College of Cardiology/American Heart Association Guidelines (CRUSADE). Circulation. 2014 Aug 19;130(8):659-67. doi: 10.1161/CIRCULATIONAHA.113.008370. Epub 2014 Jul 7.
Ranasinghe I, Wang Y, Dharmarajan K, Hsieh AF, Bernheim SM, Krumholz HM. Readmissions after Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia among Young and Middle-Aged Adults: A Retrospective Observational Cohort Study PLoS Med. 2014 Sep 30;11(9):e1001737. doi: 10.1371/journal.pmed.1001737.
Desai MM, Stauffer BD, Feringa HH, Schreiner GC. Statistical models and patient predictors of readmission for acute myocardial infarction: a systematic review. Circ Cardiovasc Qual Outcomes. 2009 Sep;2(5):500-7. doi: 10.1161/CIRCOUTCOMES.108.832949.
Southern DA, Ngo J, Martin BJ, Galbraith PD, Knudtson ML, Ghali WA, James MT, Wilton SB. Characterizing types of readmission after acute coronary syndrome hospitalization: implications for quality reporting. J Am Heart Assoc. 2014 Sep 18;3(5). pii: e001046. doi: 10.1161/JAHA.114.001046.
Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med2006;166:1822-8. doi:10.1001/archinte.166.17.1822.
Thygesen K, Alpert JS, White HD. Universal definition of myocardial infarction. Eur Heart J. 2007; 28:2525–2538. [PubMed: 17951287] doi: http://dx.doi.org/10.1093/eurheartj/ehm355
Faul, F, Erdfelder, E, Buchner, A, & Lang, AG Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods 2009; 41: 1149-1160.
Hospital Readmissions Reduction Program. Affordable Care Act., Subpart 1 of 42 CRT part 412. Sect. 1886(q) (2012).
Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013 Oct 15;128(16):e240-327. doi: 10.1161/CIR.0b013e31829e8776.
Levey AS, Coresh J, Greene T, Stevens LA, Zhang YL, Hendriksen S, et al. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med. 2006; 145:247–254. doi:10.7326/0003-4819-145-4-200608150-00004
Lemeshow S, Hosmer DW. The use of goodness-of-fit statistics in the development of logistic regression models. Am J Epidemiol. 1982;115:92–106.
Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology. 1982;143:29–36. doi: http://dx.doi.org/10.1148/radiology.143.1.7063747
Hebert C, Shivade C, Foraker R, Wasserman J, Roth C, Mekhjian H, Lemeshow S, Embi P. Diagnosis-specific readmission risk prediction using electronic health data: a retrospective cohort study. BMC Med Inform Decis Mak. 2014 Aug 4;14:65. doi: 10.1186/1472-6947-14-65.
Brown JR, Conley SM, Niles NW 2nd. Predicting readmission or death after acute ST-elevation myocardial infarction. Clin Cardiol. 2013 Oct;36(10):570-5. doi: 10.1002/clc.22156.
Curtis JP, Schreiner G, Wang Y, Chen J, Spertus JA, Rumsfeld JS, et al. All-cause readmission and repeat revascularization after percutaneous coronary intervention in a cohort of Medicare patients. J Am Coll Cardiol. 2009; 54:903–907. doi: 10.1016/j.jacc.2009.04.076.
Hannan EL, Zhong Y, Krumholz H, et al. 30-day readmission for patients undergoing percutaneous coronary interventions in New
York state. JACC Cardiovasc Interv. 2011;4:1335–1342. doi: 10.1016/j.jcin.2011.08.013.
Yeh RW, Rosenfield K, Zelevinsky K, et al. Sources of hospital variation in short-term readmission rates after percutaneous coronary intervention. Circ Cardiovasc Interv. 2012;5:227–236. doi: 10.1161/CIRCINTERVENTIONS.111.967638.
Lopes RD, Gharacholou SM, Holmes DN, Thomas L, Wang TY, Roe MT, Peterson ED, Alexander KP. Cumulative Incidence of Death and Rehospitalization Among the Elderly in the First Year after NSTEMI. Am J Med. 2015 Jun;128(6):582-90. doi: 10.1016/j.amjmed.2014.12.032.
Dunlay SM, Pack QR, Thomas RJ, Killian JM, Roger VL, Participation in cardiac rehabilitation, readmissions, and death after acute myocardial infarction. Am J Med. 2014 Jun;127(6):538-46. doi: 10.1016/j.amjmed.2014.02.008.
Chen J,Ross JS,Carlson MD,et al. Skilled nursing facility referral andhospital readmission rates after heart failure or myocardial infarction Am J Med. 2012 Jan;125(1):100.e1-9. doi: 10.1016/j.amjmed.2011.06.011.
Krumholz HM, Lin Z, Drye EE, Desai MM, Han LF, Rapp MT, Mattera JA, Normand SL. An administrative claims measure suitable for profiling hospital performance based on 30-day all-causereadmission rates among patients with acute myocardial infarction. Circ Cardiovasc Qual Outcomes. 2011 Mar;4(2):243-52. doi: 10.1161/CIRCOUTCOMES.110.957498.
Shewan LG, Coats AJS, Henein M. Requirements for ethical publishing in biomedical journals. International Cardiovascular Forum Journal 2015;2:2 DOI: 10.17987/icfj.v2i1.4
Authors who publish with this journal agree to the following terms:
a. The authors will retain copyright under a Creative Commons Attribution License (CC-BY 4.0) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
b. Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
c. Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).