Predictors of Early (0-7 Days) and Late (8-30 Days) Readmission in a Cohort of Acute Coronary Syndrome Patients.

Background: Readmissions following acute coronary syndrome are unevenly distributed across the 30-day post-discharge period. There is limited data on predictors of all-cause readmission in early (0-7 day) and late (8-30 day) post-discharge periods for this population; the purpose of this retrospective cohort study was to identify predictors of early and late readmission. Methods: Patients at Michigan Medicine (Ann Arbor, Michigan, United States) with a principal discharge diagnosis of unstable angina, ST-segment elevation myocardial infarction, or non-ST segment elevation myocardial infarction between April 2008 and November 2017 were identified. Predictors of early and late readmission were analyzed with multivariable logistic regression models. Results: Of 1120 patients hospitalized following acute coronary syndrome, 198 (17.68%) were readmitted within 30 days while 70 (6.25%) were readmitted within 7 days of discharge. Of 30-day readmissions, early readmissions were more likely in females [OR 2.26, 95% confidence interval (CI) 1.23, 4.16], non-white individuals (p=0.05), or patients requiring intensive care unit admission during hospitalization (OR 2.20, 95% CI 1.14, 4.24). Relative to patients not readmitted within 7 days, patients who were female, had history of atrial fibrillation, principal discharge diagnosis of non-ST segment elevation myocardial infarction, or required intensive care unit admission were more likely readmitted early. History of congestive heart failure was a predictor of late readmission when compared to patients not readmitted in 30 days. Conclusion: Following acute coronary syndrome, predictors of readmission varied between early and late readmission groups. Readmission predictors provides healthcare providers with information useful in minimizing readmissions and concomitant financial penalties.

Early (0-7 day) and late (8-30 day) readmission predictors in acute coronary syndrome, atrial fibrillation, and congestive heart failure patients.

OBJECTIVES: Thirty-day readmission following hospitalization for acute coronary syndrome (ACS), atrial fibrillation (AF), or congestive heart failure (CHF) is common, and many occur within one week of discharge. Using a cohort of patients hospitalized for ACS, AF, or CHF, we sought to identify predictors of 30-day, early (0-7 day), and late (8-30 day) all-cause readmission. METHODS: We identified 3531 hospitalizations for ACS, AF, or CHF at a large academic medical center between 2008 and 2018. Multivariable logistic regression models were created to identify predictors of 30-day, early, and late unplanned, all-cause readmission, adjusting for discharge diagnosis and other demographics and comorbidities. RESULTS: Of 3531 patients hospitalized for ACS, AF, or CHF, 700 (19.8%) were readmitted within 30 days, and 205 (29.3%) readmissions were early. Of all 30-day readmissions, 34.8% of ACS, 16.8% of AF, and 26.0% of the CHF cohorts' readmissions occurred early. Higher hemoglobin was associated with lower 30-day readmission [adjusted (adj) OR 0.92, 95% CI 0.88-0.97] while patients requiring intensive care unit (ICU) admission were more likely readmitted within 30 days (adj OR 1.31, 95% CI 1.03-1.67). Among patients with a 30-day readmission, females (adj OR 1.73, 95% CI 1.22, 2.47) and patients requiring ICU admission (adj OR 2.03, 95% CI 1.27, 3.26) were more likely readmitted early than late. Readmission predictors did not vary substantively by discharge diagnosis. CONCLUSION: Patients admitted to the ICU were more likely readmitted in the early and 30-day periods. Other predictors varied between readmission groups. Since outpatient follow-up often occurs beyond 1 week of discharge, early readmission predictors can help healthcare providers identify patients who may benefit from particular post-discharge services.

Trends in Calcium Channel Blocker Use in Patients with Heart Failure with Reduced Ejection Fraction and Comorbid Atrial Fibrillation.

BACKGROUND: Heart failure with reduced ejection fraction and atrial fibrillation commonly coexist. Most calcium channel blockers are not recommended in heart failure with reduced ejection fraction, but their use has been seldom evaluated. For patients with heart failure with reduced ejection fraction and comorbid atrial fibrillation, we sought to 1) determine the proportion discharged on contraindicated calcium channel blockers, 2) describe how clinicians' use of these medications at discharge have changed over time, and 3) identify predictors for contraindicated calcium channel blocker prescription at discharge. METHODS: We analyzed 395 patients discharged with heart failure with reduced ejection fraction and atrial fibrillation between 2008 and 2018. Discharge on a contraindicated calcium channel blocker (any calcium channel blocker except amlodipine) was the primary outcome. Changes in calcium channel blocker prescription over time were evaluated with a Cochran-Armitage trend test. Multivariable logistic regression was used to identify predictors of calcium channel blocker prescription at discharge. RESULTS: Twenty-nine (7.3%) patients were discharged on a contraindicated calcium channel blocker without change over time (Ptrend = .38). Of these, 26 (86.7%) were discharged on multiple atrioventricular nodal blocking medications. Hypertension (odds ratio [OR] 7.87; 95% confidence interval [CI], 1.04-59.40) and female sex (OR 3.01; 95% CI, 1.36-6.67) were both associated with contraindicated calcium channel blocker prescription at discharge while diabetes mellitus was negatively associated with this outcome (OR 0.34; 95% CI, 0.14-0.88). CONCLUSION: One in 14 patients with heart failure with reduced ejection fraction and comorbid atrial fibrillation were discharged on a contraindicated calcium channel blocker, without change over time. Most patients were discharged on multiple atrioventricular nodal blockers, highlighting potential need for greater coordination between discharging physicians, pharmacists, and electrophysiology.

Cardiac Transitional Care Effectiveness: Does Overall Comorbidity Burden Matter?

BACKGROUND: Cardiovascular disease is the most common cause of mortality and hospitalization in the United States. Transitional care initiatives can improve outcomes for cardiac patients, but it is unclear whether patients with different baseline comorbidity burden benefit equally. We evaluated the effectiveness of the Bridging the Discharge Gap Effectively (BRIDGE) program, a nurse-practitioner-led transitional care clinic, in mitigating adverse clinical outcomes in cardiac patients with varying Charlson comorbidity index (CCI). METHODS: We studied patients referred to BRIDGE between 2008 and 2017 postdischarge for a cardiac condition. Using proportional hazards regression models, we evaluated associations between attendance at BRIDGE and hospital readmission, emergency department (ED) visit, and a composite outcome consisting of readmission, ED visit, or mortality, and assessed interaction between BRIDGE attendance and CCI. RESULTS: Of 4559 patients, 3256 (71.4%) attended BRIDGE. In patients with low CCI, attendance at BRIDGE was inversely associated with hospital readmission (adjusted hazard ratio = 0.82, 95% confidence interval [CI]: 0.69, 0.97, P = .02) and the composite endpoint (adjusted hazard ratio = 0.84, 95% CI: 0.72, 0.98, P = .02). Associations of BRIDGE attendance with both readmission and ED visit were significantly weaker in patients with high CCI (adjusted P, interaction = .007 and .03, respectively). Overall, BRIDGE attendance was associated with an 11% lower hazard of developing the composite endpoint (95% CI: 2%, 19%, P = .01). CONCLUSIONS: Attendance at a transitional care clinic is inversely associated with risk of readmission and a composite endpoint in cardiac patients with low CCI. Future research should investigate modified transitional care programs in patients with varying comorbidity burden.