• 'Suboptimal' Secondary Prevention a Factor in Post-Thrombectomy Readmits?

    30-day readmissions similar to thrombolytics alone

    Readmissions in the 30 days following endovascular thrombectomy for acute ischemic stroke topped 12% in 2013-2014, according to an observational analysis.

    The median time to nonelective readmission was 9 days for those patients in the Nationwide Readmissions Database (NRD) who returned within 30 days, reported Deepak Bhatt, MD, MPH, of Brigham and Women's Hospital and Harvard Medical School in Boston, and colleagues in the Dec. 10 issue of JACC: Cardiovascular Interventions.

    The most common reasons for readmission were infection (17.2%), cardiac causes (17.0%), and recurrent stroke or transient ischemic attack (TIA, 14.8%).

    "The high incidence of readmission for cardiac causes and recurrent stroke suggests that secondary preventive measures for acute ischemic stroke, even in those undergoing EVT [endovascular thrombectomy], is suboptimal," Bhatt and colleagues wrote.

    "Arranging for early post-discharge follow-up, especially for those at increased risk such as older patients, may help mitigate this risk," they suggested, pointing to a nurse-led care transition program that almost halved 30-day readmissions in a 2016 study as an example.

    Endovascular thrombectomy was associated with the same risk of 30-day readmissions as thrombolysis alone (12.4% vs 12.6%, HR 0.98, 95% CI 0.91-1.05). Recurrent stroke or TIA was the most common reason for readmission after thrombolytic treatment alone (23.4%) but was less common with endovascular thrombectomy (absolute difference 8.6%, P<0.01).

    Getting both thrombolytic therapy and thrombectomy did not reduce the odds of 30-day readmission either. Instead, the independent predictors were: diabetes, coagulopathy, Medicare or Medicaid insurance, and gastrostomy tube placement during the index hospitalization.

    The investigators noted that the 12.4% rate of readmissions they found was slightly lower than the 14.4% reported in an older NRD study, perhaps due to that study being restricted to patients over 65 years of age.

    Bhatt and colleagues included all those in the NRD who got thrombectomy with or without IV thrombolysis and with no restriction on age. Of more than 2 million stroke hospitalizations in which the patient survived to discharge in 2013-2014, 0.5% had received endovascular thrombectomy.

    "These findings at face value raise concerns about the effectiveness of EVT and thrombolysis limiting disability in practice, the effectiveness of secondary prevention, and the effectiveness and efficiency of systems of care, particularly at the transitions," according to an accompanying editorial by Salvador Cruz-Flores, MD, MPH, of Texas Tech University Health Sciences Center El Paso.

    "However, given the limitations administrative datasets inherently have, we cannot clearly isolate the effects that acute interventions, secondary prevention, or transition of care processes have on readmission rate," he continued.

    These limitations included the potential for unmeasured confounding and coding errors, Bhatt's group acknowledged. The NRD also lacked post-discharge mortality data, a competing event for readmission.

    One important remaining question is whether endovascular therapy impacts the rate of readmissions when looking only at patients eligible for the procedure, Cruz-Flores said.

     

    Bhatt disclosed numerous ties to industry, including research funding from Abbott, Amarin, Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Idorsia, Ironwood, Ischemix, Lilly, Medtronic, PhaseBio, Pfizer, Regeneron, Roche, Sanofi, Synaptic, and The Medicines Company.

    Cruz-Flores reported consulting for and serving on clinical trial event adjudication committees for Novo Nordisk and Paraxel.

    Source:

    JACC: Cardiovascular Interventions

    Source Reference: Elgendy IY, et al "30-day readmissions after endovascular thrombectomy for acute ischemic stroke" JACC Cardiovasc Interv 2018; DOI: 10.1016/j.jcin.2018.09.006.

    JACC: Cardiovascular Interventions

    Source Reference: Cruz-Flores S "Does endovascular thrombectomy for ischemic stroke impact 30-day readmissions?" JACC Cardiovasc Interv 2018; DOI: 10.1016/j.jcin.2018.10.019

     

    Read the original article on Medpage Today:'Suboptimal' Secondary Prevention a Factor in Post-Thrombectomy Readmits?

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