Understanding Readmissions in Medicare Beneficiaries During the 90-Day Follow-Up Period of an Acute Myocardial Infarction Admission.

Background Medicare has a voluntary episodic payment model for Medicare beneficiaries that bundles payment for the index acute myocardial infarction (AMI) hospitalization and all post-discharge services for a 90-day follow-up period. The purpose of this study is to report on the types and frequency of readmissions and identify demographic and clinical factors associated with readmission of Medicare beneficiaries that survived their AMI hospitalization. Methods and Results This retrospective study used the Inpatient Standard Analytical File for 2014. There were 143 286 Medicare beneficiaries with AMI who were discharged alive from 3619 hospitals. All readmissions occurring in any hospital within 90 days of the index AMI discharge date were identified. Of 143 286 Medicare beneficiaries discharged alive from their index AMI hospitalization, 28% (40 145) experienced at least 1 readmission within 90 days and 8% (11 477) had >1 readmission. Readmission rates were higher among Medicare beneficiaries who did not undergo a percutaneous coronary intervention in their index AMI admission (34%) compared with those that underwent a percutaneous coronary intervention (20.2%). Using all Medicare beneficiary's index AMI, 27 comorbid conditions were significantly associated with the likelihood of a Medicare beneficiary having a readmission during the follow-up period. The strongest clinical characteristics associated with readmissions were dialysis dependence, type 1 diabetes mellitus, and heart failure. Conclusions This study provides benchmark information on the types of hospital readmissions Medicare beneficiaries experience during a 90-day AMI bundle. This paper also suggests that interventions are needed to alleviate the need for readmissions in high-risk populations, such as, those managed medically and those at risk of heart failure.

Impact of Complications on Resource Utilization During 90-Day Coronary Artery Bypass Graft Bundle for Medicare Beneficiaries.

BACKGROUND: The study reports the impact of adverse events during the index coronary artery bypass graft surgery (CABG) on Medicare reimbursement for the index hospitalization and a 90-day follow-up period. METHODS: This retrospective study used 2014 Medicare claims files for hospitals, skilled nursing services, rehabilitation facilities, long-term care facilities, home health services, and outpatient visits. The study sample is 37,106 Medicare beneficiaries that survived an index CABG in a US hospital during the first three quarters of 2014. Adverse events included acute renal failure, new onset hemodialysis, postoperative respiratory failure, any infection (postoperative infection, or sepsis), postoperative shock and hemorrhage, postoperative stroke, and reoperation during index hospitalization. RESULTS: Total average Medicare reimbursement for all services consumed during index CABG hospitalization and the 90-day postdischarge period was $42,063 ± $23,284. The index CABG hospitalization accounted for $32,544 ± $14,406, 77.4% of the bundle. Medicare beneficiaries having at least one adverse event had significantly higher total average Medicare reimbursement by $15,941 ($54,280 versus $38,339) for the bundle compared with Medicare beneficiaries not having an adverse event. The risk-adjusted incremental Medicare reimbursement for the entire 90-day bundle exceeded $20,000 for four adverse events: new-onset hemodialysis, $33,250; septicemia, $32,063; postoperative stroke, $24,117; and postoperative infection, $23,801. CONCLUSIONS: Medicare beneficiaries who have adverse events during their index CABG hospitalization will significantly affect that hospital's financial risk. The challenge under the voluntary CABG bundled payment program will be to monitor and reduce adverse events and manage the services consumed by Medicare beneficiaries having adverse events delivered at all the venues of care.

Trends in Aortic Valve Replacement Procedures Between 2009 and 2015: Has Transcatheter Aortic Valve Replacement Made a Difference?

BACKGROUND: This study reports trends in volume and adverse events associated with isolated aortic valve procedures performed in Medicare beneficiaries between 2009 and 2015. METHODS: This retrospective study used the annual fiscal year Medicare Provider Analysis and Review file to identify all Medicare beneficiaries undergoing an isolated aortic valve procedure. Outcome measures included three mortality rates and nine in-hospital adverse events. The final study population consisted of 233,660 hospitalizations. RESULTS: During the study period, Medicare beneficiaries undergoing an aortic valve procedure increased from 22,076 to 49,362, for an average annual growth rate of 14.45%. Transcatheter aortic valve replacement (TAVR) procedures per 100,000 Medicare beneficiaries grew from 10.7 in 2012 to 41.1 in 2015. Overall, in-hospital mortality rates, cumulative 30-day mortality rates, and 90-day postdischarge mortality rates declined annually during the study period. However, the 90-day mortality rate for TAVR was nearly double the rate for the tissue surgical aortic valve replacement group. Nearly 68% of Medicare beneficiaries experienced at least one in-hospital adverse event during their index hospitalization. Medicare beneficiaries undergoing TAVR had the lowest observed adverse events rates among the aortic valve procedures in 2015. CONCLUSIONS: The total number of Medicare beneficiaries undergoing isolated aortic valve procedures increased from 47.5 to 88.9 per 100,000 Medicare beneficiaries during the study period. Aortic valve procedures increased significantly during this study period primarily due to the increase in TAVR, with clinical outcomes improving as well. Although long-term outcomes of TAVR are still under investigation, these results are promising.

Implementation of an Early Discharge Protocol and Chest Pain Clinic for Low-Risk Chest Pain in the Emergency Department.

BACKGROUND: Most of the patients presenting to emergency department with chest pain are at low risk of adverse events. Identifying high-risk patients can be challenging and resource intensive. METHODS: We created a protocol to assist early discharge of low-risk adults with chest pain from emergency department. Also a chest pain clinic (CPC) was started for cardiology follow-up within 72 hours. In a retrospective cohort study, primary outcome of major adverse cardiac events (MACEs) of death, myocardial infarction, or revascularization was compared between CPC patients and those hospitalized for observation. In addition, rate of observation admissions and MACE were compared in the pre- and postintervention periods using piecewise regression and multiple logistic regression, respectively. RESULTS: A total of 1422 patients were admitted for observation, and 290 were seen in CPC in the 1-year postintervention period. Thirty-day MACE was very low (0.7% in observation and 0.3% in CPC) postintervention. A total of 3637 patients were admitted for observation over the 2-year preintervention period. Thirty-day-adjusted MACE rate was not significantly different between pre- and postintervention periods (0.4% vs. 0.6%, P = 0.3), also monthly observation admissions did not change significantly; however, utilization of stress testing (57.2% vs. 41.0%, P < 0.001) and cardiac catheterization (2.3% vs. 1.6%, P = 0.036) was reduced. CONCLUSION: Chest pain patients admitted for observation and risk stratification are at very low risk of 30-day MACE. An intervention based on a chest pain protocol and availability of early cardiology follow-up did not change the admission rate of these patients. This intervention was not associated with increased risk of adverse outcomes.

Clinical Outcomes of Transferred Versus Onsite Primary Percutaneous Coronary Intervention for Patients With STEMI: Time to Look Beyond Door to Balloon Time.

BACKGROUND: It is currently unknown if the delay due to practical aspects associated with transfer of patients from a non-percutaneous coronary intervention (PCI) facility to a primary PCI facility is associated with adverse outcomes. METHODS: We conducted a retrospective cohort study of all patients who presented with ST-segment elevation myocardial infarction (STEMI) and underwent primary PCI in 2 large regional STEMI centers in Massachusetts between January 2005 and June 2009. The cohort was divided into onsite patients who presented directly to the primary PCI center and transferred patients referred from another facility. The primary outcome was a composite of in-hospital major cardiovascular events (death, myocardial infarction, and stroke). Secondary outcomes were the individual components of the composite endpoint and bleeding complications. RESULTS: The cohort included a total of 1236 patients. Among them, 426 (34%) patients were transferred patients and 810 (66%) were onsite patients. The median door to balloon time was significantly higher at for transferred patients (124 vs. 71 minutes). There was no significant difference in primary composite endpoint between the 2 groups (onsite 3.8% vs. transfer 5.3%, odds ratio 1.50, 95% confidence interval 0.79-2.84; P = 0.21). Adjusted risk estimates did not show a statistical difference in all-cause bleeding rates between the groups (onsite 10.1% vs. transfer 7.3%, odds ratio 0.68, 95% confidence interval 0.41-1.14; P = 0.14). CONCLUSIONS: This study confirms that well-established and integrated regional STEMI programs provide equivalent care to transferred patients and onsite patients. Parameters beyond door to balloon times should be investigated for their contributions to improve patient outcomes.

The Comparison of Physician to Computer Interpreted Electrocardiograms on ST-elevation Myocardial Infarction Door-to-balloon Times.

OBJECTIVE: The purpose of the project was to study the impact that immediate physician electrocardiogram (ECG) interpretation would have on door-to-balloon times in ST-elevation myocardial infarction (STEMI) as compared with computer-interpreted ECGs. METHODS: This was a retrospective cohort study of 340 consecutive patients from September 2003 to December 2009 with STEMI who underwent emergent cardiac catheterization and percutaneous coronary intervention. Patients were stratified into 2 groups based on the computer-interpreted ECG interpretation: those with acute myocardial infarction identified by the computer interpretation and those not identified as acute myocardial infarction. Patients (n = 173) from September 2003 to June 2006 had their initial ECG reviewed by the triage nurse, while patients from July 2006 to December 2009 (n = 167) had their ECG reviewed by the emergency department physician within 10 minutes. Times for catheterization laboratory activation and percutaneous coronary intervention were recorded in all patients. RESULTS: Of the 340 patients with confirmed STEMI, 102 (30%) patients were not identified by computer interpretation. Comparing the prior protocol of computer ECG to physician interpretation, the latter resulted in significant improvements in median catheterization laboratory activation time {19 minutes [interquartile range (IQR): 10-37] vs. 16 minutes [IQR: 8-29]; P < 0.029} and in median door-to-balloon time [113 minutes (IQR: 86-143) vs. 85 minutes (IQR: 62-106); P < 0.001]. CONCLUSION: The computer-interpreted ECG failed to identify a significant number of patients with STEMI. The immediate review of ECGs by an emergency physician led to faster activation of the catheterization laboratory, and door-to-balloon times in patients with STEMI.

Improving the process of informed consent for percutaneous coronary intervention: patient outcomes from the Patient Risk Information Services Manager (ePRISM) study.

BACKGROUND: While the process of informed consent is designed to transfer knowledge of the risks and benefits of treatment and to engage patients in shared medical decision-making, this is poorly done in routine clinical care. We assessed the impact of a novel informed consent form for percutaneous coronary intervention (PCI) that is more simply written, includes images of the procedure, and embeds individualized estimates of outcomes on multiple domains of successful informed consent and shared decision-making. METHODS: We interviewed 590 PCI patients receiving traditional consent documents and 527 patients receiving novel ePRISM consents at 9 US centers and compared patients' perceptions, knowledge transfer, and engagement in medical decision-making. Heterogeneity across sites was assessed and adjusted for using hierarchical models. RESULTS: Site-adjusted analyses revealed more frequent review (72% for ePRISM vs 45% for original consents) and better understanding of the ePRISM consents (ORs=1.8-3.0, depending upon the outcome) with marked heterogeneity across sites (median relative difference [MRD] in the ORs of ePRISM's effect =2-3.2). Patients receiving ePRISM consents better understood the purposes and risks of the procedure (ORs=1.9-3.9, MRDs=1.1-6.2), engaged more in shared decision-making (proportional OR=2.1 [95% CI=1.02-4.4], MRD=2.2) and discussed stent options with their physicians (58% vs. 31%; site-adjusted odds ratio=2.7 [95% CI=1.2, 6.3], MRD=2.6) more often. CONCLUSIONS: A personalized consent document improved the process of informed consent and shared decision-making. Marked heterogeneity across hospitals highlights that consent documents are but one aspect of engaging patients in understanding and participating in treatment.

Trends in coronary revascularization procedures among Medicare beneficiaries between 2008 and 2012.

BACKGROUND: This study reports on the trends in the volume and outcomes of coronary revascularization procedures performed on Medicare beneficiaries between 2008 and 2012. METHODS AND RESULTS: This retrospective study identifies all Medicare beneficiaries undergoing a coronary revascularization procedure: coronary artery bypass graft surgery or percutaneous coronary intervention (PCI) performed in either the nonadmission or inpatient setting. International Classification of Diseases, 9th Revision, Clinical Modification procedure codes (inpatient setting) and Current Procedural Terminology and Ambulatory Payment Classification codes (nonadmission) were used to identify revascularizations. The study population consists of 2,768,007 records. This study finds that the rapid growth in nonadmission PCIs performed on Medicare beneficiaries (60,405-106,495) has been more than offset by the decrease in PCI admissions (363,384-295,434) during the study period. There also were >18,000 fewer coronary artery bypass graft admissions in 2012 than in 2008. This study finds lower observed mortality rates (3.7%-3.2%) among Medicare beneficiaries undergoing any coronary artery bypass graft surgery and higher observed mortality rates (1.7%-1.9%) for Medicare beneficiaries undergoing any PCI encounter. This study also finds a growth in the number of facilities performing revascularization procedures during the study period: 268 (20.2%) more sites were performing nonadmission PCIs; 136 (8.2%) more sites were performing inpatient PCIs; and 19 (1.6%) more sites were performing coronary artery bypass graft surgery. CONCLUSIONS: The total number of revascularization procedures performed on Medicare beneficiaries peaked in 2010 and declined by >4% per year in 2011 and 2012. Observed mortality rates among all Medicare beneficiaries undergoing any coronary revascularization remained between 2.1% and 2.2% annually during the study period.

Predicting the restenosis benefit of drug-eluting versus bare metal stents in percutaneous coronary intervention.

BACKGROUND: Drug-eluting stents (DES) for percutaneous coronary intervention decrease the risk of restenosis compared with bare metal stents. However, they are costlier, require prolonged dual antiplatelet therapy, and provide the most benefit in patients at highest risk for restenosis. To assist physicians in targeting DES use in patients at the highest risk for target vessel revascularization (TVR), we developed and validated a model to predict TVR. METHODS AND RESULTS: Preprocedural clinical and angiographic data from 27 107 percutaneous coronary intervention hospitalizations between October 1, 2004, and September 30, 2007, in Massachusetts were used to develop prediction models for TVR at 1 year. Models were developed from a two-thirds random sample and validated in the remaining third. The overall rate of TVR was 7.6% (6.7% with DES, 11% with bare metal stents). Significant predictors of TVR included prior percutaneous coronary intervention, emergency or salvage percutaneous coronary intervention, prior coronary bypass surgery, peripheral vascular disease, diabetes mellitus, and angiographic characteristics. The model was superior to a 3-variable model of diabetes mellitus, stent diameter, and stent length (c statistic, 0.66 versus 0.60; P<0.001) and was well calibrated. The predicted number needed to treat with DES to prevent 1 TVR compared with bare metal stents ranged from 6 (95% confidence interval, 5.4-7.6) to 80 (95% confidence interval, 62.7-116.3), depending on patients' clinical and angiographic factors. CONCLUSIONS: A predictive model using commonly collected variables can identify patients who may derive the greatest benefit in TVR reduction from DES. Whether use of the model improves the safety and cost-effectiveness of DES use should be tested prospectively.

The recognition of acute coronary ischemia in the outpatient setting.

BACKGROUND: The missed diagnosis of acute myocardial infarction has been studied in the Emergency Department, but few studies have investigated how often coronary ischemia is correctly identified in the outpatient setting. METHODS: This was a single center retrospective observational study of patients with Health Alliance Plan medical insurance hospitalized at a US tertiary center with acute myocardial infarction in 2004. Outpatient encounters in the 30 days preceding acute myocardial infarction were reviewed by two independent cardiologists for presenting symptoms and diagnostic decision-making in order to classify patient presentations as acute coronary ischemia, stable angina or neither. RESULTS: There were 331 patients with acute myocardial infarction, including 190 (57%) with a primary diagnosis of AMI and evaluated by a physician in the preceding 30 days. This group included 68 patients with 95 documented outpatient encounters by a primary care physician, cardiologist, or other internal medicine specialist which formed the final study population. Mean interval between these encounters and AMI was 17 +/- 11 days. Of these patients, 7 (10%) had symptoms of acute coronary ischemia, 5 (7%) had stable angina symptoms, and 56 (83%) had no symptoms of coronary ischemia at their outpatient encounters. Of the 7 patients with acute coronary ischemic symptoms, 5 were correctly identified and 2 were misidentified. CONCLUSION: A majority of patients with subsequent AMI visit an outpatient provider in the month preceding AMI. However, few present with symptoms of coronary ischemia in the outpatient setting (10%) and these symptoms are not always identified as such.

Sex differences in hospital risk-adjusted mortality rates for Medicare beneficiaries undergoing CABG surgery.

BACKGROUND: The primary purpose of this study was to rank US hospitals performing coronary artery bypass graft (CABG) surgery on Medicare beneficiaries into 4 performance tiers and determine if there were overall and sex-specific differences in the risk-adjusted mortality rates across performance tiers. METHODS: A retrospective analysis was done using a Medicare Provider Analysis and Review (MEDPAR) file of all Medicare beneficiaries who underwent CABG surgery without valve repair or replacement during fiscal years 2003 and 2004. Logistic regression models controlling for demographic characteristics, comorbidities, and cardiac risk factors were used to predict the probability of in-hospital mortality. Hospitals performing at least 52 CABG surgeries during a fiscal year (at least 17 female patients) were ranked into 4 tiers. Rankings were based on the number of lives saved, calculated as the expected number of risk-adjusted deaths minus the actual number of deaths in the hospital during each fiscal year. RESULTS: Average risk-adjusted mortality rate was stable and declining over the 2 years: 3.68% in 2003 and 3.61% in 2004. In 2004, the average risk-adjusted mortality rate ranged from 1.39% in tier 1 hospitals to 6.40% in tier 4 hospitals. The sex-specific mortality rate was consistently higher for women in all tiers, with the differential smallest (0.68%) in tier 1 hospitals and greatest (2.67%) in tier 4 hospitals. CONCLUSION: The sex differential increases from top- to bottom-tier hospitals, suggesting female beneficiaries could benefit from having CABG performed at tier 1 hospitals.

The frequency and cost of complications associated with coronary artery bypass grafting surgery: results from the United States Medicare program.

BACKGROUND: We estimate the incremental hospital resource consumption associated with treating selected complications experienced by Medicare beneficiaries undergoing coronary artery bypass grafting (CABG). METHODS: This retrospective study, using the Medicare Provider Analysis and Review file, identified 114,233 Medicare beneficiaries who survived CABG without concomitant valve repair during a hospitalization for fiscal year 2005. The frequencies of seven complications were determined: hemorrhage or postoperative shock, reoperation, postoperative adult respiratory distress syndrome, new-onset hemodialysis, postoperative stroke, postoperative infection and septicemia. The observed and adjusted incremental hospital resources consumed (cost and length-of-stay) in treating beneficiaries experiencing each of the selected complications were estimated. RESULTS: The mean cost of a hospitalization associated with a CABG procedure among Medicare beneficiaries was $32,201 +/- $23,059, and the mean length of stay was 9.9 +/- 7.8 days. After adjusting for patient demographics and comorbid conditions, the 13.64% of Medicare beneficiaries experiencing any of the study complications consumed significantly more hospital resources (incremental cost, $15,468) and had a longer length of stay (incremental stay, 5.3 days). CONCLUSIONS: Despite ongoing improvements in outcomes, major complications remain common after bypass grafting and add substantially to hospital costs for these procedures. These findings suggest that the potential cost savings of redirecting resources currently spent on treating complications will help make the "business case" for investing in patient safety initiatives and best practices guidelines shown to reduce selected complications.

Cardiovascular centers of excellence program: a system approach for improving the care and outcomes of cardiovascular patients at HCA hospitals.

BACKGROUND: A voluntary continuous quality improvement (CQI) effort, the cardiovascular Centers of Excellence (COE) program was implemented by HCA, Inc., to improve cardiovascular care in its hospital system. METHODS: The cardiovascular COE program targeted 165 hospitals that provide cardiovascular services in at least one major service area. Awards (unrestricted grants) provided hospitals with an incentive to participate. RESULTS: One hundred fifty-eight hospitals (95.8%) completed the entire 2005 cardiovascular COE program; five were identified as cardiovascular COE. The program developed three key CQI activities: (1) an ongoing Web-based survey to inventory, track, and verify evidence-based practices across all aspects of patient care, including clinical practices, leadership, communications, patient safety, and patient education; (2) quarterly benchmark reports tracking risk-adjusted outcomes and evidence-based practices; and (3) regularly scheduled educational programs presented by an interdisciplinary team in which lessons learned from an institution's successful, evidence-based, best-practice implementation were discussed. DISCUSSION: The COE program successfully encouraged facilities to proacrively investigate their evidence-based clinical standards and outcomes.

Active Lipid Management In Coronary Artery Disease (ALMICAD) study.

PURPOSE: Many providers have implemented specialized lipid clinics to more effectively identify, monitor, and treat hyperlipidemia in patients with coronary artery disease. The effectiveness of such a strategy is not known. We sought to investigate whether a specialized clinic achieves better lipid results and clinical outcomes than standard care. SUBJECTS AND METHODS: A total of 1233 patients who had coronary disease documented by coronary angiography were randomized to lipid clinic or standard care groups by their providers and followed for 2 years. The primary end point was a composite of death, myocardial infarction, repeat revascularization, and stroke. RESULTS: Lipid clinic (n=617) and standard care (n=616) groups had no significant baseline differences. After 2 years, the lipid clinic group had similar total cholesterol (166+/-42 mg/dL vs 166+/-41 mg/dL, P=.83), low-density lipoprotein cholesterol levels (84+/-32 vs 85+/-32, P=.28), and percentage of patients with low-density lipoprotein cholesterol less than 100 mg/dL (77.5% vs 77.6%, P=.97). There were no significant differences in the primary end point (12.3% vs 11.4%, P=.60) and mortality (7.6% vs 7.3%, P=.80) between the lipid clinic and standard care groups. CONCLUSIONS: In patients identified by diagnostic coronary angiography and managed within a single health care system, implementation of a specialized lipid clinic did not achieve greater attainment of hyperlipidemia treatment goals or improved cardiac outcomes.

The frequency and incremental cost of major complications among medicare beneficiaries receiving implantable cardioverter-defibrillators.

OBJECTIVES: We aimed to quantify the frequency and nature of early complications after implantable cardioverter-defibrillator (ICD) implantation in general practice, and estimate the incremental costs of those complications to the health care system. BACKGROUND: Cardioverter-defibrillator implantation rates are rising quickly. Little has been published regarding the outcomes and costs of these procedures in unselected populations. METHODS: Using Medicare Provider Analysis and Review (MedPAR) files, we identified 30,984 admissions containing procedure codes for new ICD or cardiac resynchronization therapy defibrillator implantation in fiscal year 2003. The frequencies of eight complicating diagnoses during these admissions were determined. Length of stay (LOS) and total hospital costs, derived using whole-hospital cost to charge ratios, were calculated for each admission. The incremental effects of any and each complication on LOS and hospital cost were estimated in multivariable models, adjusting for demographic factors and comorbid conditions. RESULTS: The mean cost for all admissions was 42,184 dollars (median 37,902 dollars) with mean LOS of 4.7 days (median 2.0 days). One or more complications were coded in 10.8% of admissions, most commonly "mechanical complication of the ICD" and hemorrhage/hematoma. The occurrence of any complication increased adjusted LOS by 3.4 days and costs by 7,251 dollars. Each of the individual complications was associated with highly significant increases in both LOS (1 to 10 days) and hospital cost (5,000 dollars to 20,000 dollars). CONCLUSIONS: In fiscal 2003, 10.8% of Medicare patients undergoing cardioverter-defibrillator implantation experienced one or more early complications, associated with significant increases in LOS and costs. Efforts to reduce these complications could have significant clinical and financial benefits.

Spontaneous late thrombolysis of an occluded saphenous vein graft subsequent to acute myocardial infarction treated with percutaneous coronary intervention to the native culprit vessel.

A 67-year-old male with prior history of myocardial infarction and coronary artery bypass grafting (individual vein grafts to the left anterior descending artery [LAD] and right coronary artery) presented with an acute anterior ST elevation myocardial infarction and cardiogenic shock. The vein graft to the LAD was occluded with heavy thrombus burden and there was severe native CAD. Given the degree of thrombus burden and other anatomic considerations, percutaneous intervention with stenting was performed to the native proximal LAD. Three months later, after complaining of atypical chest pain, repeat angiogram revealed a spontaneous widely patent vein graft to the LAD and occluded proximal LAD.

Hospital resources consumed in treating complications associated with percutaneous coronary interventions.

Nearly 9.5% of all Medicare beneficiaries who undergo a percutaneous coronary intervention (PCI) procedure develop > or =1 of 7 acute complications. This study used 2 approaches (regression analysis and propensity-matched samples) to estimate the cost of selected complications, based on administrative data from 335,477 Medicare beneficiaries who underwent PCI during a hospitalization in fiscal year 2002. Selected complications included hospital mortality, emergency/urgent coronary artery bypass surgery, postoperative stroke, acute renal failure, vascular complications, septicemia, and adult respiratory distress syndrome. The observed average cost of a PCI hospitalization for patients who did not develop complications was 13,861 dollars +/- 9,635 dollars, with an average length of stay of 3.0 +/- 3.2 days, compared with 26,807 dollars +/- 27,596 dollars and 8.0 +/- 8.9 days for patients who did develop complications. Estimates of the adjusted incremental hospital cost of treating any acute complication except death varied from a high of 33,030 dollars for patients who developed septicemia to a low of 4,278 dollars for those who developed vascular complications, whereas estimates of the incremental length of stay ranged from a high of 12.3 days for patients who had septicemia to a low of 1.8 days for patients who had vascular complications. In conclusion, we found that the incremental hospital resources that are consumed to treat patients with acute PCI complications are large compared with the cost of an uncomplicated PCI hospitalization.

Early invasive strategy improves outcomes in patients with acute coronary syndrome with previous coronary artery bypass graft surgery: a report from TACTICS-TIMI 18.

BACKGROUND: Patients with previous coronary artery bypass graft surgery (CABG) have been classified as a high-risk subset of patients who experience non-ST elevation acute coronary syndrome (ACS). Recent studies suggest that an early invasive strategy is beneficial in moderate- and high-risk patients with non-ST elevation ACS. We hypothesized that an early invasive strategy is associated with improved outcomes in patients with non-ST elevation ACS with prior CABG. METHODS AND RESULTS: In the Treat Angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction 18 trial (TACTICS-TIMI 18), 2220 patients with non-ST segment elevation ACS were randomized to an early invasive or conservative (selectively invasive) strategy. All patients were treated with aspirin, heparin, and tirofiban. Four hundred eighty-four (22%) of these patients had undergone CABG before enrollment. We analyzed whether patients with previous CABG had different 6-month outcomes and whether an early invasive strategy was associated with an improvement in long-term outcomes. Prior CABG was associated with a higher risk of adverse outcomes by 6 months, including a higher rate of readmission for ACS (17.4% vs 11.0%, P < 0.001) and a higher incidence of the composite end point of death, myocardial infarction, or rehospitalization for ACS (22.3% vs 16.4%, P = 0.002). There was a trend toward a higher incidence of myocardial infarction (7.1% vs 5.3%, P = 0.051). An early invasive strategy was associated with a reduction in the composite of death or myocardial infarction (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.31-1.0; P = 0.089) and a significant reduction in the incidence of myocardial infarction at 6 months (OR, 0.44; 95% CI, 0.21-0.93; P=0.032). CONCLUSIONS: Patients with non-ST segment elevation ACS who have had previous CABG are a high-risk subset. An early invasive strategy reduces risk of myocardial infarction in this high-risk group.