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Vol. 71. Núm. 9.
Páginas 757-758 (Septiembre 2018)
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Vol. 71. Núm. 9.
Páginas 757-758 (Septiembre 2018)
Scientific letter
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Patterns of Inpatient Care and Readmission Rates (30-day, 3-month and 1-year) in Myocardial Infarction in Spain. Differences Between STEMI and NSTEMI
Patrones de atención hospitalaria y tasas de reingreso (a 30 días, a 3 meses y a 1 año) en infarto de miocardio en España. Diferencias entre IAMCEST e IAMSEST
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Luis Rodríguez-Padiala,
Autor para correspondencia
lrpadial@gmail.com

Corresponding author:
, Francisco J. Elolab, Cristina Fernández-Pérezb, José L. Bernalb,c, Vicente Bertomeub,d, Andrés Iñigueze
a Servicio de Cardiología, Complejo Hospitalario Universitario de Toledo, Toledo, Spain
b Fundación Instituto para la Mejora de la Asistencia Sanitaria, Madrid, Spain
c Servicio de Gestión, Hospital 12 de Octubre, Madrid, Spain
d Servicio de Cardiología, Hospital San Juan, Universidad Miguel Hernández, San Juan de Alicante, Alicante, Spain
e Servicio de Cardiología, Complejo Hospitalario de Vigo, Vigo, Pontevedra, Spain
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Tablas (2)
Table 1. Baseline Characteristics of STEMI and NSTEMI Patients and Differences Between Them
Table 2. Readmission Rates by Type of Treatment Received in STEMI
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To the Editor,

A significant number of patients with acute myocardial infarction (AMI) are readmitted after hospital discharge, which produces a major impact on health care costs.1 Because some of these readmissions can be a sign of deficient inpatient care2 and many could potentially be preventable, a better understanding of them is worthwhile.3 In fact, readmission rates are a significant component of current quality improvement strategies.

In a previous study, we analyzed cardiac disease readmission rates after AMI based on the discharge data set of the Spanish national health system.4 In this letter, we present a subanalysis focused on differences in readmission rates between ST-segment elevation myocardial infarction (STEMI) and non–ST-elevation acute myocardial infarction (NSTEMI).

The methodology has been described in our previous publication.4 In brief, through the minimum basic data set of hospital discharges of the Spanish national health system, a total of 33 538 patients with at least 1-year of follow-up were identified: 18 189 patients (54.2%) with STEMI (codes 410.*1, except 410.71) and 15 349 patients (48.5%) with NSTEMI (code 410.71 for NSTEMI). Hospital risk standardized readmission rates were calculated using a multilevel model.

The patients’ characteristics are displayed in Table 1. Readmission rates were 4.7% at 30 days, 8.1% at 3 months and 18.1% at 1 year for STEMI and 6.3% at 30 days, 10.8% at 3 months and 22.7% at 1 year for NSTEMI (P<.001 for all comparisons). The risk standardized readmission rates at 30 days, 3 months, and 1 year were slightly lower in patients with STEMI than in those with NSTEMI (17.3%±4.7% vs 18.5%±4.7% at 1 year; P<.001). At 1 year, mortality from cardiac disease (1.5% vs 2.7%; P<.001) and the risk of developing heart failure (24.8% vs 28.8%; P<.001) were also lower in STEMI than in NSTEMI patients.

Table 1.

Baseline Characteristics of STEMI and NSTEMI Patients and Differences Between Them

  OverallSTEMINSTEMIP 
Factor  N
(33 538) 
n
(18 189) 
%
(54.2) 
n
(15 349) 
%
(45.8) 
 
Men  23 885  71.2  13 409  73.7  10 476  68.3  <.0001 
Age, mean±standard deviation  67.4±13.665.5±13.869.5±13.2<.001 
Angina pectoris/old myocardial infarction  1900  5.7  740  4.1  1160  7.6  <.0001 
Congestive heart failure  7582  22.6  3890  21.4  3692  24.1  <.0001 
Coronary atherosclerosis/other chronic ischemic heart disease  25 242  75.3  14 076  77.4  11 166  72.7  <.0001 
Acute coronary syndrome  1897  5.7  1339  7.4  558  3.6  <.0001 
Specified arrhythmias  8609  25.7  4604  25.3  4005  26.1  <.0001 
Valvular or rheumatic heart disease  4606  13.7  2224  12.2  2382  15.5  <.0001 
Cerebrovascular disease  795  2.4  356  2.0  439  2.9  <.0001 
Stroke  179  0.5  109  0.6  70  0.5  .01 
Vascular or circulatory disease  3383  10.1  1633  9.0  1750  11.4  <.0001 
Hemiplegia, paraplegia, paralysis, functional disability  788  2.3  366  2.0  422  2.7  <.0001 
Diabetes mellitus or diabetes mellitus complications  10 441  31.1  4952  27.2  5489  35.8  <.0001 
Renal failure  4063  12.1  1723  9.5  2340  15.2  <.0001 
End-stage renal disease or dialysis  154  0.5  47  0.3  107  0.7  <.0001 
Other urinary tract disorders  593  1.8  294  1.6  299  1.9  .02 
Chronic obstructive pulmonary disease  2721  8.1  1311  7.2  1410  9.2  <.0001 
Pneumonia  545  1.6  284  1.6  261  1.7  .3 
Asthma  577  1.7  297  1.6  280  1.8  .2 
Fluid, electrolyte, and acid-base disorders  866  2.6  393  2.2  473  3.1  <.0001 
History of infection  1220  3.6  640  3.5  580  3.8  .2 
Metastatic cancer or acute leukemia  163  0.5  85  0.5  78  0.5  .6 
Cancer  979  2.9  445  2.4  534  3.5  <.0001 
Iron deficiency or other anemias and blood disease  2451  7.3  1047  5.8  1404  9.1  <.0001 
Decubitus ulcer or chronic skin ulcer  177  0.5  79  0.4  98  0.6  .01 
Dementia or other specified brain disorders  1029  3.1  514  2.8  515  3.4  .005 
Protein-calorie malnutrition  75  0.2  27  0.1  48  0.3  .002 
Anterior myocardial infarction  788  2.3  651  3.6  137  0.9  <.0001 
Other location myocardial infarction  534  1.6  487  2.7  47  0.3  <.0001 

NSTEMI, non–ST-elevation acute myocardial infarction; STEMI, ST-segment elevation myocardial infarction.

Significant differences in readmission rates among the different types of hospitals were observed both in STEMI and NSTEMI patients, with lower rates in hospitals treating more patients (> 204 AMI discharges) (25% vs 19% for STEMI; 31,5% vs 29% for NSTEMI, at 1 year; P<.001) and with a cardiac catheterization laboratory (only for STEMI).

Lower readmission rates were noted in STEMI patients treated with percutaneous coronary intervention (PCI) in their index episode (Table 2), as well as in NSTEMI patients (7.2% at 30 days, 13.4% at 3 months, and 27.5% at 1 year with PCI, and 7.4% at 30 days, 14.2% at 3 months, and 28.7% at 1 year without revascularization treatment (P<.001, for all comparisons). A significant difference was observed between the risk standardized readmission rates depending on the medical unit responsible for attending the AMI, with cardiac units (5.4% at 30 days, 9.1% at 3 months, and 20.1% at 1 year for STEMI and 7.2% at 30 days, 13.5% at 3 months, and 27.8% at 1 year for NSTEMI) having fewer readmissions than other medical services (6.1% at 30 days, 10.2% at 3 months, and 23.2% at 1 year for STEMI and 7.7% at 30 days, 14.9% at 3 months, and 29.3% at 1 year for NSTEMI; P<.001, for all comparisons).

Table 2.

Readmission Rates by Type of Treatment Received in STEMI

  Treatment  STEMI
    Mean  SD  P 
30-day RSRRNone  5044  5.87  1.77  <.001a
PCIb  11 392  5.38  1.58 
Fibrinolysis  520  6.31  1.73 
Bothb  1233  5.52  1.46 
3-month RSRRNone  5044  9.77  2.63  <.001a
PCIb  11 392  8.97  2.36 
Fibrinolysis  520  10.63  3.06 
Bothb  1233  9.09  2.27 
1-year RSRRNone  5044  22.72  7.41  <.001a
PCIb  11 392  19.57  5.52 
Fibrinolysis  520  25.56  8.52 
Bothb  1233  20.47  6.64 

PCI, percutaneous coronary intervention; RSRR, risk standardized readmission rates; SD, standard deviation; STEMI, ST-segment elevation myocardial infarction.

a

Chi-square.

b

Bonferroni: in multiple comparisons all differences<.05 except comparisons between PCI and both (nonsignificant).

We analyzed only those readmissions related to cardiac disease instead of all-cause readmissions in order to focus more on those most related to the index admission, as suggested by Southern et al.5

This study has several limitations. Despite being a retrospective analysis, the use of administrative records to estimate outcomes in health services has been validated, and it is currently applied by other authors. The model developed by Medicare & Medicaid Services was used in this study. With respect to the adjustment models, there are confounding factors that are impossible to identify, but which may have a significant impact. Nevertheless, the models used in this study compare favorably against models published elsewhere in terms of their predictive capacity.

This study demonstrates that, within the Spanish national health system, the probability of readmission in the short- and mid-term and the presence of death and heart failure at 1 year are higher after NSTEMI than after STEMI. Furthermore, readmission rates in both types of AMI were associated with some characteristics of the hospital, as well as with discharge from the cardiology unit and the performance of PCI during the index hospitalization. Significant interregional and interhospital differences in managing AMI have been observed in Spain.6 Whereas patients with STEMI usually undergo emergent revascularization, the therapeutic strategy in NSTEMI is extremely variable and, in most cases, patients do not undergo coronary angiography at the times recommended in the guidelines. Our findings may suggest that NSTEMI patients can also benefit from the use of care networks that favor PCI and the participation of cardiology services with sufficiently large caseloads.

FUNDING

The work for this paper was funded by unconditional grants from Fundación Interhospitalaria para Investigación Cardiovascular and Laboratorios Menarini S.L. (RECALCAR Project).

.

Acknowledgments

The authors thank the Spanish Ministry of Health, Social Services, and Equality for the help provided to the Spanish Society of Cardiology to develop the RECALCAR study, with special gratitude to the General Directorate of Public Health, Quality, and Innovation.

References
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H.M. Krumholz, A.R. Merrill, E.M. Schone, et al.
Patterns of hospital performance in acute myocardial infarction and heart failure 30-day mortality and readmission.
Circ Cardiovasc Qual Outcomes., 2 (2009), pp. 407-413
[2]
C.M. Ashton, D.J. Del Junco, J. Souchek, N.P. Wray, C.L. Mansyur.
The association between the quality of inpatient care and early readmission: a meta-analysis of the evidence.
Med Care., 35 (1997), pp. 1044-1059
[3]
K. Dharmarajan, A.F. Hsieh, Z. Lin, et al.
Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia.
JAMA., 309 (2013), pp. 355-363
[4]
L. Rodríguez-Padial, F.J. Elola, C. Fernández-Perez, et al.
Patterns of inpatient care in acute myocardial infarction and 30-day, 3-month and 1-year cardiac diseases readmission rates in Spain.
Int J Cardiol., 230 (2017), pp. 14-20
[5]
D.A. Southern, J. Ngo, B.J. Martin, et al.
Characterizing types of readmission after acute coronary syndrome hospitalization: implications for quality reporting.
J Am Heart Assoc., 3 (2014), pp. e001046
[6]
V. Bertomeu, A. Cequier, J. Bernal, In-hospital Mortality Due to Acute Myocardial Infarction, et al.
Relevance of Type of Hospital and Care Provided. RECALCAR Study.
Rev Esp Cardiol., 66 (2013), pp. 935-942
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