Readmissions as quality indicator for PCI: Think twice

PCI is on Medicare’s docket as a candidate for penalties for preventable 30-day readmissions. Based on a study in the March issue of the Journal of the College of Cardiology: Cardiovascular Interventions that found 39.5 percent of readmissions post-PCI were unrelated to the index admission, readmissions may be a questionable quality indicator.

Gregory W. Yost, DO, of the Geisinger Medical Center in Danville, Pa., and colleagues went one step beyond previous studies that evaluated PCI readmission. Rather than rely on ICD-9 codes, they reviewed individual charts to identify the causes of readmission and categorized readmissions as either related or unrelated to the index admission.

For their study, they collected data on all patients who underwent PCI at their center between Jan. 1, 2007, and April 12, 2007. They used data entered prospectively in the American College of Cardiology’s National Cardiovascular Data Registry at the time of the procedure; medical record review of readmissions through the system’s EHR; and the Social Security Death Index and phone calls for one-year follow-up.

Researchers determined if the readmission was related or unrelated to the index admission by reviewing documented histories, physical exam results, progress notes, the discharge summary, medication administration reconciliation and outpatient encounters. They classified readmissions as one of four types:  

  • PCI complications related to the PCI procedure;
  • Cardiac causes related to the index admission;
  • Noncardiac causes related to the index admission; and
  • Any cause not related to the PCI or index admission.

They recorded 3,255 PCI procedures on 2,807 patients, of whom 8 percent were readmitted within 30 days. The majority of the readmissions—39.5 percent—were not related to the PCI or index admission. Instead, the most common causes included noncardiac chest pain, new gastrointestinal issues, new infections, previously known anxiety and depression, new onset of atrial fibrillation or atrial flutter and end-stage renal disease-related complications. Cardiac causes unrelated to the PCI accounted for 35.6 percent of readmissions.

Thirteen percent of readmissions were noncardiac but related to the index admission. Complications during or after PCI led to 11.9 percent of readmissions, with in-stent thrombosis and vascular access problems as the most common complications.

“The relative rarity of these events may be because stent thrombosis has decreased substantially with newer generation stents, and vascular complications decreased after the adoption of radial access techniques at our medical center,” Yost et al wrote. “Although PCI complications have not been eliminated, even their complete eradication would minimally decrease the overall PCI readmission rate.”

They observed that the 8 percent readmission rate was lower than some other large studies found. They attributed their difference to their use of a single high-volume center with experienced operators, newer stent technologies, an integrated multispecialty practice with an EHR and a pharmacist-led program to optimize adherence to dual antiplatelet therapy.  

Yost and colleagues speculated that closer follow-up might have trimmed the number of readmissions that were unrelated to the index admission, but “in the vast majority there were no obvious lapses in care or clear-cut opportunities for improvement.”

In 2015, the Centers for Medicare & Medicaid Services is expected to expand a program that financially penalizes hospitals that have higher-than-expected 30-day readmission rates for acute MI, heart failure and pneumonia to include PCI, CABG, pulmonary obstructive disease and other vascular conditions. The authors wrote that their analysis may help to identify strategies to prevent PCI readmissions.

But they also noted that many factors correlated to PCI readmissions may not be modifiable. Given that almost 40 percent of readmissions in their study were not related to the index hospitalization, “Our data do not support use of readmission after PCI as an indicator of the quality of care during the index admission.”

They added that theirs was a single-center retrospective study and that while their individual review of readmissions improved accuracy, it was a labor-intensive approach.