1. Unplanned 30-Day Readmission Risk Among Patients with Acute Myocardial Infarction: a Report from TRANSLATE-ACS Connie N. Hess, MD 1 ; Tracy Y. Wang, MD, MHS 1 ; Lisa McCoy 1 ; Emily Honeycutt 1 ; John C. Messenger, MD 2 ; William T. Smith IV, MD 3 ; Marjorie E. Zettler, PhD, MPH 4, Mark B. Effron, MD 4 ; Timothy D. Henry, MD 5 ; Eric D. Peterson, MD, MPH 1 ; Gregg C. Fonarow, MD 6 Hospital readmissions after acute myocardial infarction (AMI) are a Medicare hospital performance measure. Current readmission models have relied on administrative data, have included planned readmissions, and/or have examined limited patient populations and risk factors. Background Results Conclusions Unplanned 30-day readmissions occur after AMI in 1 in 11 patients. The majority of unplanned readmissions are non-cardiovascular. Rates of readmission vary among hospitals. Clinical, socio-demographic, and functional variables may identify patients at higher risk for unplanned readmissions and allow for targeted strategies to reduce rehospitalizations. Methods Data Source TRANSLATE-ACS (TReatment with ADP receptor iNhibitorS: Longitudinal Assessment of Treatment Patterns and Events after Acute Coronary Syndrome) observational registry Patient population 8265 AMI patients treated with PCI and ADP inhibitor and discharged home alive from 216 hospitals between 4/2010 and 8/2012 with complete baseline, 6 week follow-up, and hospital billing data Statistics Death within 30 days of discharge censored Cardiovascular and bleeding readmissions identified using primary ICD-9 billing codes Multivariable logistic regression to identify factors significantly associated with unplanned 30-day readmission Table 2. Timing of ADP receptor inhibitor switch Figure 2. Variation in readmissions among hospitals Limitations Hospitals participating in TRANSLATE perhaps not representative Case report form may not capture all factors related to unplanned readmission Residual measured or unmeasured confounding may account for some of these findings Table 2. Factors associated with 30-day unplanned readmission Objectives To examine the incidence and causes of unplanned readmission within 30 days of discharge among AMI patients treated with percutaneous coronary intervention (PCI). To identify factors associated with unplanned 30-day readmissions. Overall 30-day readmission: 12.4% (n=1027) Unplanned readmission: 8.8% (n=730) vs. planned readmission: 3.9% (n=324) Table 1. Patient characteristics 1 Duke Clinical Research Institute; 2 Denver VA Medical Center; 3 New Hanover Regional Medical Center; 4 Lilly USA, LLC; 5 Minneaopolis Heart Institute Foundation at Abbott Northwestern Hospital; 6 UCLA Medical Center Hospital site Planned readmissions (%) Median 2.0% (IQR 0.0%, 5.9%) Figure 1. Causes of unplanned 30-day readmission Unplanned readmission (n=730) No unplanned readmission (n=7535) p Baseline and in-hospital characteristics Median age (years) Male (%) Non-white race (%) Married (%) Employed full/part time (%) College degree or beyond (%) Insurance: Private Medicare/Medicaid Other None Hypertension Diabetes (%) Prior myocardial infarction (%) Heart failure w/in 2 weeks (%) STEMI (%) DES implanted (%) Mean ACTION mortality risk score* Mean ACTION bleeding risk score* Median EQ-5D health status score** PHQ-2 depression score ≥3 † (%) Mean length of stay (days) Transition of care planning Discharged on all eligible 2° prevention medications (%) Follow-up scheduled before discharge (%) Post-discharge characteristics Cardiac rehabilitation participation (%) Primary care/cardiologist follow-up w/in 4 wks (%) Perceived medication financial hardship § (%) 61.0 63.6 15.2 59.3 43.4 49.3 59.9 21.4 2.5 14.2 72.6 34.0 21.9 10.4 53.9 64.9 31.5 27.8 70.0 12.6 3.7 70.7 77.0 27.4 79.6 41.5 60.0 73.4 12.8 64.8 51.5 53.1 65.3 17.0 2.8 13.5 66.8 25.3 18.8 6.0 51.8 70.8 29.8 25.3 75.0 7.1 3.1 67.7 74.3 29.7 83.3 38.2 0.129 <0.0001 0.056 0.002 <0.0001 0.058 0.014 0.001 <0.001 0.036 <0.0001 0.268 0.001 <0.0001 <0.001 <0.0001 0.102 0.023 0.515 0.682 0.002 *ACTION score is a validated risk score predicting in-hospital mortality and bleeding **EQ-5D = EuroQol EQ-5D health status measure †PHQ2 = Patient Health Questionnaire-2 §Medication financial hardship = moderate/much/extreme vs. no/minimal hardship Parameter Wald Chi- Square Adj OR Lower 95% CI Upper 95% CI P-value Female vs. Male 12.571.401.161.680.000 PHQ2>310.941.531.191.970.001 In-hosp Event: Bleeding8.171.751.192.560.004 Length of Stay 8.131.051.021.080.004 Prior Heart Failure7.281.541.132.110.007 Diabetes6.851.281.061.540.009 Atrial fib/flutter5.701.481.072.050.017 CVD 5.451.501.072.110.020 Smoker5.300.810.670.970.021 Any DES5.190.820.690.970.023 Chronic Lung Disease4.581.311.021.670.032 STEMI vs. NSTEMI3.501.180.991.390.061 Procedure Success3.460.770.581.010.063 Defect free discharge therapy 3.121.170.981.390.077 Author disclosures: C.N. Hess, None; T.Y. Wang, Bristol-Myers Squibb/Sanofi Aventis Partnership, Significant, Research Grant; Schering Plough/Merck & Co., Significant, Research Grant; The Medicines Co., Significant, Research Grant; Heartscape Technologies, Inc., Significant, Research Grant; Canyon Pharmaceuticals, Significant, Research Grant; Eli Lilly/Daiichi Sankyo Alliance, Significant, Research Grant; Medco Health Solutions, Inc., Modest, Honoraria; Astrazeneca, Modest, Honoraria; American College of Cardiology Foundation, Modest,Honoraria; L. Kaltenbach, None; E. Honeycutt, None; J.C. Messenger, None; W.T. Smith, None; M.E. Zettler, Eli Lilly, Significant, Employment; M.B. Effron, Eli Lilly, Significant, Employment; Eli Lilly, Significant, Ownership Interest; T.D. Henry, Eli Lilly, Significant, Research Grant; Daiichi, Significant, Research Grant; Eli Lilly, Modest, Consultant/Advisory Board; Daiichi, Modest, Consultant/Advisory Board; E.D. Peterson, Eli Lilly, Significant, Research Grant; Janssen Pharmaceuticals, Significant, Research Grant; G.C. Fonarow, None. Hospital site Overall readmissions (%) Median 11.5% (IQR 5.6%, 16.7%) Hospital site Unplanned readmissions (%) Median 8.0% (IQR 2.3%, 12.3%)