April 30, 2019
By Will Boggs MD
NEW YORK (Reuters Health) - Impaired functional mobility is the strongest predictor of 30-day hospital readmission for older adults hospitalized with acute myocardial infarction (AMI), researchers report.
About one in five older adults hospitalized for AMI are readmitted within 30 days of discharge. Most of these readmissions are unrelated to the sequelae of the index AMI, researchers say, and the few available risk models may not be broadly representative of older adults.
Dr. John A. Dodson from New York University School of Medicine, in New York City, and colleagues used data from the SILVER-AMI prospective study of more than 3,000 patients 75 and older to develop and validate a readmission risk model suitable for predischarge use in older patients hospitalized for AMI.
From 72 candidate variables, the authors identified eight variables significantly associated with readmission: reduced ejection fraction, impaired functional mobility, poor patient-reported health status, prior arrhythmia, acute kidney injury, low initial diastolic blood pressure, chronic obstructive pulmonary disease (COPD) and lack of early P2Y12 inhibitor use.
The strongest predictor of readmission was functional mobility, based on the Timed Up and Go (TUG), with a TUG between 15 and 25 seconds tied with a 46% increase in the odds of readmission and a TUG of 25 seconds or longer tied to an 86% increased odds of readmission. Only the latter result was statistically significant.
Discrimination of the model was moderate (C statistic, 0.65 for the derivation cohort and 0.63 for the validation cohort), indicating that much of the variability in readmission risk among these older patients remains unexplained by patient-level characteristics, the researcher report in Circulation: Cardiovascular Quality and Outcomes, online April 23.
They developed a web-based risk calculator for 30-day readmission, which is available at www.silverscore.org.
"Future studies that incorporate factors beyond patient-level characteristics (such as hospital stressors or health system performance) may lead to improved discrimination," the authors conclude.
Dr. Michael W. Rich of Washington University School of Medicine in St. Louis, Missouri, who wrote a linked editorial, told Reuters Health by email, "The most interesting finding is that the prolonged TUG time was the strongest predictor of 30-day readmission, being associated with a nearly 2-fold increase in risk even after taking other factors into consideration, such as health status, left ventricular function, and common comorbidities."
"This implies that in patients 75 or older with myocardial infarction, we need to be paying more attention to physical function and frailty at the time of hospital discharge, and consider early implementation of interventions designed to improve function and (hopefully) reduce the risk for early readmission and other adverse outcomes," he said.
"To me the most important caveat is the recognition of the key factors that connote increased risk for poor outcomes (not just 30-day readmissions, but patient-centered outcomes, such as quality of life and maintenance of independence) in older adults, including function (e.g., TUG test) and health status, and incorporating these factors into each patient's care plan," Dr. Rich said.
This "applies to all hospitalized older adults, not just those admitted with AMI," he said.
Dr. Shannon M. Dunlay from Mayo Clinic, in Rochester, Minnesota, who has researched risk factors for readmission in heart-failure patients, said the new findings "could be used in clinical practice to identify older patients hospitalized with MI who are at high risk for readmission and may benefit from closer follow-up in the outpatient setting. The inclusion of a web-based risk calculator makes this very user friendly." Dr. Dunlay was not involved in the study.
She told Reuters Health by email that it was "surprising that diastolic blood pressure was predictive; usually, systolic blood pressure has been associated with worse outcomes in heart failure."
Dr. Dodson did not respond to a request for comments.
SOURCE: https://bit.ly/2GSyukL and https://bit.ly/2GSywsT
Circ Cardiovasc Qual Outcomes 2019.
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