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      Exploring the effects of transfers and readmissions on trends in population counts of hospital admissions for coronary heart disease: a Western Australian data linkage study

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          Abstract

          Objectives

          To develop a method for categorising coronary heart disease (CHD) subtype in linked data accounting for different CHD diagnoses across records, and to compare hospital admission numbers and ratios of unlinked versus linked data for each CHD subtype over time, and across age groups and sex.

          Design

          Cohort study.

          Data source

          Person-linked hospital administrative data covering all admissions for CHD in Western Australia from 1988 to 2013.

          Main outcome

          Ratios of (1) unlinked admission counts to contiguous admission (CA) counts (accounting for transfers), and (2) 28-day episode counts (accounting for transfers and readmissions) to CA counts stratified by CHD subtype, sex and age group.

          Results

          In all CHD subtypes, the ratios changed in a linear or quadratic fashion over time and the coefficients of the trend term differed across CHD subtypes. Furthermore, for many CHD subtypes the ratios also differed by age group and sex. For example, in women aged 35–54 years, the ratio of unlinked to CA counts for non-ST elevation myocardial infarction admissions in 2000 was 1.10, and this increased in a linear fashion to 1.30 in 2013, representing an annual increase of 0.0148.

          Conclusion

          The use of unlinked counts in epidemiological estimates of CHD hospitalisations overestimates CHD counts. The CA and 28-day episode counts are more aligned with epidemiological studies of CHD. The degree of overestimation of counts using only unlinked counts varies in a complex manner with CHD subtype, time, sex and age group, and it is not possible to apply a simple correction factor to counts obtained from unlinked data.

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          Most cited references16

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          Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events.

          Lasse Jespersen, Anders Hvelplund, Steen Abildstrøm … (2012)
          Patients with chest pain and no obstructive coronary artery disease (CAD) are considered at low risk for cardiovascular events but evidence supporting this is scarce. We investigated the prognostic implications of stable angina pectoris in relation to the presence and degree of CAD with no obstructive CAD in focus. We identified 11 223 patients referred for coronary angiography (CAG) in 1998-2009 with stable angina pectoris as indication and 5705 participants from the Copenhagen City Heart Study for comparison. Main outcome measures were major adverse cardiovascular events (MACE), defined as cardiovascular death, myocardial infarction, stroke or heart failure, and all-cause mortality. Significantly more women (65%) than men (32%) had no obstructive CAD (P< 0.001). In Cox's models adjusted for age, body mass index, diabetes, smoking, and use of lipid-lowering or antihypertensive medication, hazard ratios (HRs) associated with no obstructive CAD were similar in men and women. In the pooled analysis, the risk of MACE increased with increasing degrees of CAD with multivariable-adjusted HRs of 1.52 (95% confidence interval, 1.27-1.83) for patients with normal coronary arteries and 1.85 (1.51-2.28) for patients with diffuse non-obstructive CAD compared with the reference population. For all-cause mortality, normal coronary arteries and diffuse non-obstructive CAD were associated with HRs of 1.29 (1.07-1.56) and 1.52 (1.24-1.88), respectively. Patients with stable angina and normal coronary arteries or diffuse non-obstructive CAD have elevated risks of MACE and all-cause mortality compared with a reference population without ischaemic heart disease.
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            Thirty-day rehospitalizations after acute myocardial infarction: a cohort study.

            Elaine Jaffe, R Bell, Shannon Dunlay … (2012)
            Rehospitalization is a quality-of-care indicator, yet little is known about its occurrence and predictors after myocardial infarction (MI) in the community. To examine 30-day rehospitalizations after incident MI. Retrospective cohort study. Population-based registry in Olmsted County, Minnesota. 3010 patients who were hospitalized in Olmsted County with first-ever MI from 1987 to 2010 and survived to hospital discharge. Diagnoses, therapies, and complications during incident and subsequent hospitalizations were identified. Manual chart review was performed to determine the cause of all rehospitalizations. The hazard ratios and cumulative incidence of 30-day rehospitalizations were determined by using Cox proportional hazards regression models. Among 3010 patients (mean age, 67 years; 40.5% female) with incident MI (31.2% ST-segment elevation), 643 rehospitalizations occurred within 30 days in 561 (18.6%) patients. Overall, 30.2% of rehospitalizations were unrelated to the incident MI and 42.6% were related; the relationship was unclear in 27.2% of rehospitalizations. Angiography was performed in 153 (23.8%) rehospitalizations. Revascularization was performed in 103 (16.0%) rehospitalizations, of which 46 (44.7%) had no revascularization during the index hospitalization. After adjustment for potential confounders, diabetes, chronic obstructive pulmonary disease, anemia, higher Killip class, longer length of stay during the index hospitalization, and a complication of angiography or reperfusion or revascularization were associated with increased rehospitalization risk. The 30-day incidence of rehospitalization was 35.3% in patients who experienced a complication of angiography during the index MI hospitalization and 31.6% in those who experienced a complication of reperfusion or revascularization during the index MI hospitalization, compared with 16.8% in patients who had reperfusion or revascularization without complications. This study represents the experiences of a single community. Comorbid conditions, longer length of stay, and complications of angiography and revascularization or reperfusion are associated with increased 30-day rehospitalization risk after MI. Many rehospitalizations seem to be unrelated to the incident MI. National Institutes of Health.
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              All-cause readmission and repeat revascularization after percutaneous coronary intervention in a cohort of medicare patients.

              Jeptha Curtis, Geoffrey Schreiner, Yongfei Wang … (2009)
              The purpose of this study was to report on the all-cause readmission and repeat revascularization rates after percutaneous coronary intervention (PCI). Although PCIs are frequently performed, 30-day rates of readmission and repeat revascularization after PCI are not known. Retrospective analysis of a cohort of Medicare fee-for-service admissions associated with a PCI in 2005. Primary outcomes were 30-day all-cause readmission rates and 30-day readmission rates associated with a revascularization procedure. A total of 315,241 PCI procedures performed at 1,108 hospitals were included in the analysis. The all-cause 30-day readmission rate was 14.6%, and the all-cause 30-day mortality rate was 1.0%. All-cause 30-day mortality among readmitted patients was higher than patients who were not readmitted (3.6% vs. 0.6%; p < 0.001). The 30-day readmission rate of acute myocardial infarction (AMI) patients was significantly higher than that of non-AMI patients (AMI 17.5%, non-AMI 13.6%, p < 0.001). Among all patients readmitted within 30 days after the index PCI, 27.5% had an associated revascularization procedure (PCI 25.8%, coronary artery bypass grafting 1.7%). The median readmission rates varied across hospitals, from 8.9% in the lowest decile to 22.0% in the highest decile. A substantial proportion of PCI patients are readmitted within 30 days of discharge, and readmission rates vary widely across hospitals. Readmissions within 30 days of an index PCI procedure were associated with a significantly higher 30-day mortality rate, and more than one-quarter of such readmissions resulted in a repeat revascularization procedure. These findings warrant further attention to determine whether these readmissions are preventable.
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                Author and article information

                Journal
                Journal ID (nlm-ta): BMJ Open
                Journal ID (iso-abbrev): BMJ Open
                Journal ID (hwp): bmjopen
                Journal ID (publisher-id): bmjopen
                Title: BMJ Open
                Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                ISSN (Electronic): 2044-6055
                Publication date Collection: 2017
                Publication date (Electronic): 17 November 2017
                Volume: 7
                Issue: 11
                Electronic Location Identifier: e019226
                Affiliations
                [1 ] departmentSchool of Population and Global Health , The University of Western Australia , Crawley, Western Australia, Australia
                [2 ] departmentSchool of Medicine , The University of Western Australia , Crawley, Western Australia, Australia
                [3 ] departmentSchool of Biomedical Sciences , The University of Western Australia , Crawley, Western Australia, Australia
                [4 ] departmentHealth Group , Australian Institute of Health and Welfare , Canberra, Australia
                Author notes
                [Correspondence to ] Dr Derrick Lopez; derrick.lopez@ 123456uwa.edu.au
                Author information
                http://orcid.org/0000-0003-3639-0787
                Article
                Publisher ID: bmjopen-2017-019226
                DOI: 10.1136/bmjopen-2017-019226
                PMC ID: 5701992
                PubMed ID: 29151055
                SO-VID: b43042bc-45ac-4f1d-b58b-540f6ad68c20
                Copyright © © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
                License:

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                Date received : 21 August 2017
                Date accepted : 13 October 2017
                Categories
                Subject: Epidemiology
                Subject: Research
                Subject: 1506
                Subject: 1692
                Custom metadata
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                ScienceOpen disciplines: Medicine
                Keywords: coronary heart disease,cardiac epidemiology
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: coronary heart disease, cardiac epidemiology

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