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Hospital Readmission After Perioperative Acute Myocardial Infarction Associated With Noncardiac Surgery.

ABSTRACT: BACKGROUND:Acute myocardial infarction (AMI) is a major cardiovascular complication of noncardiac surgery. We aimed to evaluate the frequency, causes, and outcomes of 30-day hospital readmission after perioperative AMI. METHODS:Patients who were diagnosed with AMI during hospitalization for major noncardiac surgery were identified using the 2014 US Nationwide Readmission Database. Rates, causes, and costs of 30-day readmissions after noncardiac surgery with and without perioperative AMI were identified. RESULTS:Among 3?807?357 hospitalizations for major noncardiac surgery, 8085 patients with perioperative AMI were identified. A total of 1135 patients (14.0%) with perioperative AMI died in-hospital during the index admission. Survivors of perioperative AMI were more likely to be readmitted within 30 days than surgical patients without perioperative AMI (19.1% versus 6.5%, P<0.001). The most common indications for 30-day rehospitalization were management of infectious complications (30.0%), cardiovascular complications (25.3%), and bleeding (10.4%). In-hospital mortality during hospital readmission in the first 30 days after perioperative AMI was 11.3%. At 6 months, the risk of death was 17.6% and ?1 hospital readmission was 36.2%. CONCLUSIONS:Among patients undergoing noncardiac surgery who develop a perioperative MI, ?1 in 3 suffer from in-hospital death or hospital readmission in the first 30 days after discharge. Strategies to improve outcomes of surgical patients early after perioperative AMI are warranted.

SUBMITTER: Smilowitz NR

PROVIDER: S-EPMC5995321 | biostudies-literature | 2018 May

REPOSITORIES: biostudies-literature

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Hospital Readmission After Perioperative Acute Myocardial Infarction Associated With Noncardiac Surgery.

Smilowitz Nathaniel R NR Beckman Joshua A JA Sherman Scott E SE Berger Jeffrey S JS

Circulation 20180310 22

<h4>Background</h4>Acute myocardial infarction (AMI) is a major cardiovascular complication of noncardiac surgery. We aimed to evaluate the frequency, causes, and outcomes of 30-day hospital readmission after perioperative AMI.<h4>Methods</h4>Patients who were diagnosed with AMI during hospitalization for major noncardiac surgery were identified using the 2014 US Nationwide Readmission Database. Rates, causes, and costs of 30-day readmissions after noncardiac surgery with and without perioperati ...[more]

PMID: 29525764

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Project description:BackgroundPerioperative myocardial infarction is frequently attributed to type 2 myocardial infarction, a mismatch in myocardial oxygen supply-demand without unstable coronary artery disease. Our aim was to identify characteristics, management, and outcomes of perioperative type 1 versus type 2 myocardial infarction among surgical inpatients.MethodsAdults age ≥45 years hospitalized for noncardiac surgery were identified in the United States. Perioperative myocardial infarction were identified using International Classification of Diseases, 10th revision (ICD-10) codes. Clinical characteristics, invasive myocardial infarction management, mortality, and readmissions were assessed by myocardial infarction subtype.ResultsAmong 4,755,382 surgical hospitalizations, we identified 38,975 perioperative myocardial infarctions (0.82%), with type 2 infarction in 42%. Patients with type 2 myocardial infarction were older, more likely to be women, and less likely to have cardiovascular comorbidities compared with type 1 myocardial infarction. Fewer patients with type 2 myocardial infarction underwent invasive management than type 1 myocardial infarction (6.7% vs 28.8%, P < .001). Type 2 myocardial infarction mortality was lower than type 1 myocardial infarction mortality (12.1% vs 17.4%, P < .001; adjusted odds ratio [aOR] 0.51, 95% confidence interval [CI] 0.45-0.59). Invasive management of perioperative myocardial infarction was associated with lower mortality in type 1 (aOR 0.56, 95% CI 0.49-0.74) but not type 2 (aOR 1.19, 95% CI 0.77-1.85) myocardial infarction. Among survivors, there was no difference in 90-day hospital readmission between type 2 and type 1 perioperative myocardial infarction (36.5% vs 36.1%, P = .72).ConclusionsType 2 myocardial infarctions account for approximately 40% of perioperative myocardial infarctions. Patients with type 2 perioperative myocardial infarction are less likely to undergo invasive management and have lower mortality compared with those with type 1 perioperative myocardial infarction.

Project description:BACKGROUND:Among patients undergoing noncardiac surgery, major vascular surgery is associated with a high risk of perioperative myocardial infarction (MI). Currently, there are no perioperative MI risk calculators accounting for intraoperative and postoperative risk factors in vascular surgery patients. We aimed to investigate specific risk factors for perioperative MI after major open vascular surgery to determine which patients are at highest risk of MI and the association of perioperative MI with perioperative transfusion. METHODS:This statewide, retrospective cohort study analyzed risk factors for perioperative MI in major open vascular surgery between July 2012 and December 2015 using the Michigan Surgical Quality Collaborative, a multicenter quality collaborative. Patients were identified using current procedure terminology codes including open abdominal aortic aneurysm repairs (oAAA), aortobifemoral bypasses (AFB), and lower extremity bypasses (LEB). Rates of myocardial infarction were described for each procedure. A priori, preoperative, intraoperative, and postoperative variables were evaluated using univariate and multivariable statistics after adjusting for intraoperative factors including anesthesia type, intraoperative blood loss, intraoperative transfusion, and intraoperative vasopressor medications. RESULTS:A total of 3,689 patients underwent major open vascular surgery, including 375 oAAA, 392 AFB, and 2,922 LEB procedures. The overall incidence of MI was 2.4%, varying from 1.8% for aortobifemoral bypass, 2.4% for lower extremity bypass, and 3.7% for open abdominal aortic aneurysm repair. Although preoperative risk factors for myocardial infarction included age, American Society of Anesthesiologists score, diabetes, coronary artery disease, congestive heart failure, use of beta blocker, lower preoperative hematocrit, and surgical priority (urgent/emergent cases), after adjusting for intraoperative risk factors, all preoperative risk factors were not significant with the exception of surgical priority. After adjusting for intraoperative factors, only surgical priority (odds ratio [OR] = 1.70, 95% confidence interval [CI] [1.01-2.85], P < 0.001) and postoperative transfusion (OR = 2.65, 95% CI [1.59-4.44], P < 0.001) was associated with myocardial infarction, and higher nadir hematocrit was inversely associated with myocardial infarction (OR = 0.89, 95% CI [0.85-0.94], P < 0.001). CONCLUSIONS:Among vascular surgery patients undergoing major open vascular surgery, surgical priority was the only preoperative risk factors independently associated with MI, and only postoperative variables such as nadir hematocrit and postoperative transfusion were associated with MI. This suggests minimizing intraoperative blood loss and prioritizing early intraoperative transfusion may be the potential targets for process improvement.

Project description:Importance:Major adverse cardiovascular and cerebrovascular events (MACCE) are a significant source of perioperative morbidity and mortality following noncardiac surgery. Objective:To evaluate national trends in perioperative cardiovascular outcomes and mortality after major noncardiac surgery and to identify surgical subtypes associated with cardiovascular events using a large administrative database of United States hospital admissions. Design, Setting, Participants:Patients who underwent major noncardiac surgery from January 2004 to December 2013 were identified using the National Inpatient Sample. Main Outcomes and Measures:Perioperative MACCE (primary outcome), defined as in-hospital, all-cause death, acute myocardial infarction (AMI), or acute ischemic stroke, were evaluated over time. Results:Among 10?581?621 hospitalizations (mean [SD] patient age, 65.74 [12.32] years; 5?975?798 female patients 56.60%]) for major noncardiac surgery, perioperative MACCE occurred in 317?479 hospitalizations (3.0%), corresponding to an annual incidence of approximately 150?000 events after applying sample weights. Major adverse cardiovascular and cerebrovascular events occurred most frequently in patients undergoing vascular (7.7%), thoracic (6.5%), and transplant surgery (6.3%). Between 2004 and 2013, the frequency of MACCE declined from 3.1% to 2.6% (P for trend <.001; adjusted odds ratio [aOR], 0.95; 95% CI, 0.94-0.97) driven by a decline in frequency of perioperative death (aOR, 0.79; 95% CI, 0.77-0.81) and AMI (aOR, 0.87; 95% CI, 0.84-0.89) but an increase in perioperative ischemic stroke from 0.52% in 2004 to 0.77% in 2013 (P for trend <.001; aOR 1.79; CI 1.73-1.86). Conclusions and Relevance:Perioperative MACCE occurs in 1 of every 33 hospitalizations for noncardiac surgery. Despite reductions in the rate of death and AMI among patients undergoing major noncardiac surgery in the United States, perioperative ischemic stroke increased over time. Additional efforts are necessary to improve cardiovascular care in the perioperative period of patients undergoing noncardiac surgery.

Project description:BackgroundReducing hospital readmission after acute myocardial infarction (AMI) has the potential to both improve quality and reduce costs. As such, readmission after AMI has been a target of financial penalties through Medicare. However, substantial concern exists about potential adverse effects and efficacious readmission-reduction strategies are not well validated.Methods and resultsWe started an AMI readmissions reduction program in November 2017. Between July 2016 and February 2019, hospital billing data were queried to detect all inpatient hospitalizations at the Massachusetts General Hospital for AMI. Thirty-day readmission was identified through hospital billing data, and mortality was extracted from our electronic health record. The data set was merged with claims data for patients in accountable care organizations to detect readmission at other hospitals. We performed segmented linear regression, adjusting for secular trend and case mix, to assess the independent association of our program on both outcome variables. After inclusion and exclusion criteria were applied, the study population included 2020 patients. The overall 30-day readmission rate was higher before the intervention than after the intervention (15.5% versus 10.7%, P=0.002). The overall 30-day mortality rate was similar in both time periods (1.8% versus 1.4%, P=0.457). The program was associated with initial reduction in 30-day readmission (-9.8%, P=0.0002) and 30-day mortality (-2.6%, P=0.041). The program did not change trend in 30-day readmission (+0.19% readmissions/mo, P=0.554) and trend in 30-day mortality (-0.21% deaths/mo, P=0.119).ConclusionsAn AMI readmissions reduction program that increases outpatient and emergency department (ED) access to cardiology care is associated with reduced 30-day readmission and 30-day mortality. Similar statistical techniques can be used to conduct a rigorous, mechanistic program evaluation of other quality improvement initiatives.

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Hospital Readmission After Perioperative Acute Myocardial Infarction Associated With Noncardiac Surgery.

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Hospital Readmission After Perioperative Acute Myocardial Infarction Associated With Noncardiac Surgery.

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