Early Readmissions After ST‐Segment–Elevation Myocardial Infarction: Glass Ceiling or Room for Improvement?

M ortality attributable to ST-segment–elevation myocardial infarction (STEMI) has decreased significantly in recent years because of advances in medical therapy, widespread adoption of primary percutaneous coronary intervention, and improvement in healthcare processes. Nonetheless, readmissions after STEMI remain both costly and common, affecting 20% of patients admitted with this condition. In attempts to reduce both healthcare costs and improve quality of care, the Centers for Medicare and Medicaid Services established the Hospital Readmissions Reduction Program (HRRP), a program that financially penalizes hospitals with higher-than-expected rates of 30-day readmissions for several medical diagnoses, including STEMI. Whether the HRRP helps to accurately identify the underlying causes of readmissions is uncertain. Furthermore, data on the effectiveness of systems-based processes that may further reduce readmission rates after STEMI, such as universal access to health care, implementation of innovative remote monitoring and telehealth systems, and outpatient resources to support diet and medication adherence, are needed. In this issue of the Journal of the American Heart Association (JAHA), Kim et al report the rates, causes, and costs of readmissions after STEMI between 2010 and 2014 using the National Readmissions Database. There were 709 548 STEMI admissions during this period, and the 30-day readmission rate was observed to be 12.3%, substantially lower than the 20% readmission rate reported from discharges between 2005 and 2008. Importantly, readmission rates declined from 13.5% in 2010 to 10.9% in 2014, representing a 19% relative decrease. Female sex, AIDS, anemia, chronic kidney disease, collagen vascular disease, diabetes mellitus, hypertension, pulmonary hypertension, congestive heart failure, atrial fibrillation, and increased length of stay during index admission were identified as independent predictors of early readmission after STEMI. However, in addition to the inherent limitations of administrative data (eg, coding errors and identification of primary versus secondary diagnoses), the true underlying causes for readmission often remain elusive when using these types of administrative data sets. For example, angina and nonspecific chest pain compose 29% of the readmission diagnoses. These may be lower-acuity diagnoses, particularly in the setting of the recent definition of coronary anatomical characteristics, and may not necessarily be reflective of poor-quality care during the index admission. There remain many unanswered questions, such as whether access to health care that is not the emergency department plays a significant role in at least part of these lower-acuity readmissions. The authors do show that higher income levels are associated with lower readmission rates, whereas hospitals in urban settings are associated with higher readmission rates, but the causality roles remain unclear. Similarly, a recent National Cardiovascular Data Registry–based study demonstrated higher readmission rates after acute myocardial infarction (AMI) in hospitals providing care to socioeconomically disadvantaged populations. Kim et al demonstrated that higher-acuity diagnoses, such as heart failure and recurrent AMI, compose one quarter of the readmission diagnoses. Whether these admissions are largely attributable to the patient’s underlying comorbidities or other nonmeasured factors is uncertain. For example, how do factors such as medication adherence, adequate medication coverage, and access to outpatient support resources (eg, comprehensive cardiac rehabilitation and secondary prevention programs) contribute to these readmissions? Providers may prescribe the most effective and guidelinebased therapy, but if adherence is inadequate because of poor health literacy, lack of adequate social support, polypharmacy, or high costs, early readmissions are more likely to occur. In the MI FREEE (Post-Myocardial Infarction Free Rx Event and Economic Evaluation) trial, although elimination of drug copayments did not reduce the composite primary The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. From the University of Oklahoma Health Sciences Center, Oklahoma City, OK (B.M.H.); and VA New York Harbor Healthcare System (Manhattan Campus), NYU School of Medicine, New York, NY (B.S.). Correspondence to: Binita Shah, MD, MS, 423 E 23rd St, Office 12023-W, New York, NY 10010. E-mail: binita.shah@nyumc.org J Am Heart Assoc. 2018;7:e010506. DOI: 10.1161/JAHA.118.010506. a 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.