A US study that has stressed the importance of measuring rates of rehospitalisation following percutaneous coronary intervention (PCI) procedures has been welcomed by the European Society of Cardiology (ESC).
The research, published today in JACC Cardiovascular Interventions
¹, represents one of the first studies to explore PCI readmissions and highlights the need for similar studies to be initiated across Europe to improve patient care.
In the study, Dr Edward Hannan and colleagues from the School of Public Health at the University of New York, recorded hospital readmissions for 40,093 patients from New York State who underwent their first PCI procedure between January 1, 2007 and November 30, 2007. The retrospective review found that a total of 15.6% (6,254) of PCI patients were readmitted within 30 days, with further analysis revealing that 20.6% (1,285) of these readmissions were "staged".
Staging refers to the situation where cardiologists treat the culprit lesion responsible for the initial admission and then plan for patients to return to the hospital at a future date for treatment of additional lesions.
"Currently we've absolutely no idea of the number of patients in Europe who need readmission to hospitals after PCI," said Prof Eric Van Belle, an ESC spokesperson from the University of Lille, France. But the US finding that 12.4 % of PCI patients need to return for unplanned readmissions (that do not involve staging), he added, was much higher than he would have predicted and highlighted the need for improvements in care. "To allow us to both prevent readmissions by tailoring care to individual patients and produce guidelines around which patients require staging we need to gain a better handle on data in Europe."
Nevertheless, the question remains whether Europe has the infrastructure to identify patients who are likely to be readmitted to multiple hospitals.
In the US study investigators acknowledged that principle diagnoses such as "chronic ischemic heart disease", "atherosclerosis" and "chest pain" were not specific enough to determine the real reasons for admissions, leaving doubts over whether the readmission had been necessitated by a complication of the index procedure or some separate event.
"Achieving a better understanding of the reasons why patients need unplanned admissions would help cardiologists learn how to target interventions to patients at greatest risk of complications," said ESC spokesperson Prof Hans Erik Bøtker, from Aarhus University, Skejby, Denmark.
Increased knowledge would also enable hospitals to be adequately reimbursed for the care. "Payments to hospitals could be adjusted to take into account factors such as co-morbidities that are likely to require additional care to prevent repeat hospitalisation. The introduction of such systems would remove incentives for hospitals to discharge patients early," said Bøtker.The different health care reimbursement systems used in European countries, said Van Belle, influence whether hospitals offer "staged" readmissions. In some countries hospitals are reimbursed with one fee for a fixed time period regardless of the number of individual procedures or different admissions; while in other countries a separate fee is paid for each admission. The former approach discourages use of staged procedures, while the later serves to encourage them. Both systems, argued Van Belle, can fail to take into account the clinical needs of individual patients."For each patient a risk benefits analysis needs to be undertaken. For most people single procedures (where all the lesions are treated at the same time) carry less overall risks than multiple procedures.
However, in certain circumstances when a great number of lesions need to be treated staged care may be necessary to reduce excessive exposure to radiation," said Van Belle.
Clearly, he added, evidence based guidelines are needed to identify the patient groups who would benefit most from staged procedures. "We need to base our decisions on clinical evidence rather than being swayed by financial gain," said Van Belle.