International Variation in and Factors Associated With Hospital Readmission After Myocardial Infarction

Study Questions:

What is the international variation in readmission rates among patients treated with primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI)?

Methods:

The authors retrospectively evaluated the country level variation in readmission among 5,745 patients with STEMI who were enrolled in the Assessment of Pexelizumab in Acute Myocardial Infarction trial. This trial enrolled 5,745 patients with STEMI at 296 sites in the United States, Canada, Australia, New Zealand, and 13 European countries. Multivariable logistic regression analysis was used to identify independent predictors of all-cause and nonelective 30-day post-discharge readmission.

Results:

Of the 5,571 patients discharged alive, 631 (11.3%) were readmitted within 30 days. Patients recruited in the US had higher 30-day readmission rates (14.5% vs. 9.9%; p < 0.001). Median length of stay was shortest for US patients (median 3 days) and longest in patients from Germany (median 8 days). The predictors of all-cause 30-day readmission included multivessel disease (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.65-2.35) and US location (OR, 1.68; 95% CI, 1.37-2.07), but multivessel disease was not a significant predictor when admission for elective revascularization was excluded. Enrollment in the US was, however, an independent predictor of readmission (OR, 1.53; 95% CI, 1.20-1.96) after excluding elective readmissions for revascularization. After adjustment for country-level median length of stay, US location was no longer an independent predictor of 30-day all-cause or nonelective readmission. There was an inverse relation between country-level median length of stay and readmission, with a 14% reduction in the odds of readmission for each additional in-hospital day (OR, 0.86; 95% CI, 0.78-0.96). There was no impact of US enrollment on in-hospital death (OR, 0.88; 95% CI, 0.60-1.30) or 30-day post-admission death (OR, 1.0; 95% CI, 0.72-1.39).

Conclusions:

The authors concluded that there was significant variation in the rate of readmission among patients with STEMI, with the US having the highest rates of readmission.

Perspective:

There is increasing interest in readmission after hospitalization after STEMI as a quality and an economic measure. This study demonstrates a marked variation in readmission rates across the participating countries without differences in mortality. The higher rate of readmission in the US is counterbalanced by short length of stay, and efforts to reduce readmission may come at the cost of prolonging duration of hospitalization. Further studies are warranted to define patient-level predictors of readmission so that focused interventions can be targeted to reduce readmission rates.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Novel Agents

Keywords: New Zealand, Antibodies, Monoclonal, Humanized, Myocardial Infarction, Canada, Germany, Europe, Patient Discharge, Angioplasty, Balloon, Coronary, Percutaneous Coronary Intervention, Length of Stay, Surgical Procedures, Elective, Patient Readmission, Australia, Cardiovascular Diseases, Confidence Intervals, Hospitalization, United States, Single-Chain Antibodies


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