January 13, 2017
By Marilynn Larkin
NEW YORK (Reuters Health) - Readmissions 30 days after transcatheter aortic valve replacement (TAVR) generally are related to patient comorbidities, TAVR approach, hospital length-of-stay and post-procedure complications, researchers say.
Given the paucity of information on the incidence, causes, predictors and costs of readmissions in the first month after TAVR, Dr. J. Dawn Abbott of Brown University in Providence, Rhode Island and colleagues analyzed data from 12,221 TAVR patients who underwent the procedure in 2013 and survived the initial hospitalization.
As reported December 29 online in Circulation: Cardiovascular Interventions, 2,188 patients (17.9%) were readmitted to the hospital within a month after TAVR. Independent predictors of 30-day readmission included hospital stay of more than five days before discharge post-TAVR (hazard ratio, 1.47); acute kidney injury (HR, 1.23); more than four comorbidities, as specified in Elixhauser Comorbidity Index (HR, 1.22); a transapical approach to TAVR (HR, 1.21); chronic kidney disease (HR, 1.20); chronic lung disease (HR, 1.16); and discharge to skilled nursing facility (HR, 1.16).
Overall, noncardiac causes - notably, respiratory problems (14.7%), infections (12.8%), bleeding (7.6%), and peripheral vascular disease (4.3%) - were responsible for 61.8% of readmissions. Cardiac causes - most commonly, heart failure (22.5%) and arrhythmias (6.6%) - were responsible for 38.2% of readmissions.
The median length of stay and cost of readmissions were four days and $8,302, respectively.
Dr. Abbott told Reuters Health, "Despite the advanced age of the population (mean, 81.5 years) and high prevalence of comorbidities, the overall readmission rate of 17.9% compares favorably with readmission rates for other cardiac and noncardiac conditions, such as heart failure, myocardial infarction and pneumonia."
The main cardiac-related cause, heart failure, "can be targeted with care transition programs to reduce the incidence," she said by email.
"As valve technology and operator experience improve, the noncardiac causes of readmission such as infection, respiratory disease and peripheral vascular disease should decrease due to lower rates of general anesthesia, vascular cutdowns, and the transapical approach," Dr. Abbott added. "Variability in readmission rates across centers may be used to identify best practices for reducing readmission."
Dr. Sunil V. Rao of Duke University Medical Center in Durham, North Carolina, coauthor of a related editorial, told Reuters by email that from his perspective, the key take-home points are:
1) Readmissions have become a performance measure for hospitals. Readmissions are measured for patients admitted for heart failure and other cardiac conditions, and hospitals are being penalized for higher-than-expected readmission rates;
2) There are no proven methods to reduce hospital readmissions, although research is ongoing;
3) Importantly, powerful risk-adjustment models to account for patient factors are lacking; and
4) The relationship between readmissions and longer-term outcomes, such as survival, is unclear.
Dr. Rao concluded, "Given the above, using readmission after TAVR as a performance measure (and financially penalizing hospitals for readmissions) may be premature."
SOURCE: http://bit.ly/2jNq57Q and http://bit.ly/2iR9jjW
Circ Cardiovasc Interv 2016.
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