Risk-Standardized Readmission Metric and Care Quality in MI

Study Questions:

What is the association between excess readmission ratio (ERR) for myocardial infarction (MI) with in-hospital process of care measures and 1-year clinical outcomes?

Methods:

This was an observational analysis of hospitalized patients with MI from the National Cardiovascular Data Registry/Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines. Centers subject to the first cycle of the Hospital Readmissions Reduction Program between July 1, 2008 and June 30, 2011 were analyzed for the ERR for MI (MI-ERR) in 2011. The main outcome measure was adherence to process of care measures during index hospitalization in the overall study population, and risk of the composite outcome of mortality or all-cause readmission within 1 year of discharge and its individual components among participants with available Centers for Medicare and Medicaid Services–linked data.

Results:

The median ages of patients in the MI-ERR >1 and tertiles 1, 2, and 3 of the MI-ERR >1 groups were 64, 63, 64, and 63 years, respectively. Among 380 hospitals that treated a total of 176,644 patients with MI during the study period, 43% had MI-ERR >1. The proportions of patients of black race, those with heart failure signs at admission, and bleeding complications increased with higher MI-ERR. There was no significant association between adherence to MI performance measures and MI-ERR (adjusted odds ratio, 0.94; 95% confidence interval, 0.81-1.08, per 0.1-unit increase in MI-ERR for overall defect-free care). Among the 51,453 patients with 1-year outcome data available, higher MI-ERR was associated with higher adjusted risk of the composite outcome and all-cause readmission within 1 year of discharge. This association was largely driven by readmissions early after discharge and was not significant in landmark analyses beginning 30 days after discharge. The MI-ERR was not associated with risk for mortality within 1 year of discharge in the overall and 30-day landmark analyses.

Conclusions:

The authors concluded that participating hospitals’ risk-adjusted 30-day readmission rates following MI were not associated with in-hospital quality of MI care or early clinical outcomes.

Perspective:

This study reports no significant association between MI-ERR and measures of care quality for MI during the index hospitalization. Furthermore, MI-ERR was not significantly associated with mortality risk at 1-year follow-up after adjustment for potential confounders, and higher MI-ERR was significantly associated with greater risk for 1-year all-cause readmission. This was driven by readmissions that occurred soon after hospitalization and was not significant for readmissions beyond the first 30 days. Additional studies are indicated to determine whether 30-day readmission rates are associated with other meaningful quality measures and to understand the impact of penalties associated with readmission rates on hospital performance and patient outcomes over time.

Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure

Keywords: ACTION Registry, Acute Coronary Syndrome, Heart Failure, Medicare, Myocardial Infarction, National Cardiovascular Data Registries, Outcome Assessment (Health Care), Patient Discharge, Patient Readmission, Primary Prevention, Quality of Health Care, Risk Management


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