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Structural Heart Disease Thirty-Day Readmissions After Transcatheter Aortic Valve Replacement in the United States Insights From the Nationwide Readmissions Database Dhaval Kolte, MD, PhD; Sahil Khera, MD; M. Rizwan Sardar, MD; Neil Gheewala, MD, MPH; Tanush Gupta, MD; Saurav Chatterjee, MD; Andrew Goldsweig, MD; Wilbert S. Aronow, MD; Gregg C. Fonarow, MD; Deepak L. Bhatt, MD, MPH; Adam B. Greenbaum, MD; Paul C. Gordon, MD; Barry Sharaf, MD; J. Dawn Abbott, MD Downloaded from http://circinterventions.ahajournals.org/ by guest on June 18, 2017 Background—Readmissions after cardiac procedures are common and contribute to increased healthcare utilization and costs. Data on 30-day readmissions after transcatheter aortic valve replacement (TAVR) are limited. Methods and Results—Patients undergoing TAVR (International Classification of Diseases-Ninth Revision-CM codes 35.05 and 35.06) between January and November 2013 who survived the index hospitalization were identified in the Nationwide Readmissions Database. Incidence, predictors, causes, and costs of 30-day readmissions were analyzed. Of 12 221 TAVR patients, 2188 (17.9%) were readmitted within 30 days. Length of stay >5 days during index hospitalization (hazard ratio [HR], 1.47; 95% confidence interval [CI], 1.24–1.73), acute kidney injury (HR, 1.23; 95% CI, 1.05–1.44), >4 Elixhauser comorbidities (HR, 1.22; 95% CI, 1.03–1.46), transapical TAVR (HR, 1.21; 95% CI, 1.05–1.39), chronic kidney disease (HR, 1.20; 95% CI, 1.04–1.39), chronic lung disease (HR, 1.16; 95% CI, 1.01–1.34), and discharge to skilled nursing facility (HR, 1.16; 95% CI, 1.01–1.34) were independent predictors of 30-day readmission. Readmissions were because of noncardiac causes in 61.8% of cases and because of cardiac causes in 38.2% of cases. Respiratory (14.7%), infections (12.8%), bleeding (7.6%), and peripheral vascular disease (4.3%) were the most common noncardiac causes, whereas heart failure (22.5%) and arrhythmias (6.6%) were the most common cardiac causes of readmission. Median length of stay and cost of readmissions were 4 days (interquartile range, 2–7 days) and $8302 (interquartile range, $5229–16 021), respectively. Conclusions—Thirty-day readmissions after TAVR are frequent and are related to baseline comorbidities, TAVR access site, and post-procedure complications. Awareness of these predictors can help identify and target high-risk patients for interventions to reduce readmissions and costs. (Circ Cardiovasc Interv. 2017;10:e004472. DOI: 10.1161/CIRCINTERVENTIONS.116.004472.) Key Words: aortic stenosis ◼ costs and cost analysis ◼ length of stay ◼ readmission ◼ rehospitalization ◼ transcatheter aortic valve implantation ◼ transcatheter aortic valve replacement T in 2015, ≈17.8% of Medicare patients were still readmitted to the hospital within 30 days.2 Unplanned readmissions are associated with increased healthcare expenditure and costs. Previous research has shown that readmission rates are influenced by patient and hospital characteristics, quality of inpatient and outpatient care, and local practice patterns.3 hirty-day readmission rates are considered a quality performance measure. The Centers for Medicare and Medicaid Services publicly reports 30-day readmission rates for cardiovascular diagnoses and procedures such as acute myocardial infarction, heart failure, percutaneous coronary intervention (PCI; as a pilot project between 2013 and 2014), and coronary artery bypass grafting.1 Initiatives such as the Hospital Readmissions Reduction Program under the Affordable Care Act have led to a significant decline in allcause 30-day readmission rates over the past few years.2 Yet, See Editorial by Swaminathan and Rao Since its initial Food and Drug Administration approval in November 2011, the number of transcatheter aortic valve Received September 3, 2016; accepted November 14, 2016. From the Division of Cardiology, Brown University, Providence, RI (D.K., M.R.S., A.G., P.C.G., B.S., J.D.A.); Division of Cardiology, New York Medical College, Valhalla (S.K., W.S.A.); Division of Cardiology, Northeast Ohio Medical University, Aultman Hospital, Canton (M.R.S.); Henry Ford Hospital, Detroit, MI (N.G., A.B.G.); Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (T.G.); Division of Cardiology, Temple University Hospital, Philadelphia, PA (S.C.); Division of Cardiology, University of California at Los Angeles (G.C.F.); and Division of Cardiology, Brigham and Women’s Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA (D.L.B.). Guest Editor for this article was Sunil V. Rao, MD. The Data Supplement is available at http://circinterventions.ahajournals.org/lookup/suppl/doi:10.1161/CIRCINTERVENTIONS.116.004472/-/DC1. Correspondence to J. Dawn Abbott, MD, Division of Cardiology, Department of Medicine, Warren Alpert Medical School of Brown University, 593 Eddy St, RIH APC814, Providence, RI 02903. E-mail [email protected] © 2016 American Heart Association, Inc. Circ Cardiovasc Interv is available at http://circinterventions.ahajournals.org 1 DOI: 10.1161/CIRCINTERVENTIONS.116.004472 2 Kolte et al Thirty-Day Readmissions After TAVR WHAT IS KNOWN • Thirty-day, all-cause readmission rates after transcatheter aortic valve replacement range from 14.6% to 20.9%. • Approximately 60% of the 30-day readmissions after transcatheter aortic valve replacement are because of noncardiac causes. WHAT THE STUDY ADDS • Length of stay >5 days during the index hospitaliza- Downloaded from http://circinterventions.ahajournals.org/ by guest on June 18, 2017 tion, acute kidney injury, presence of >4 Elixhauser comorbidities, transapical access, chronic kidney disease, chronic lung disease, and discharge to skilled nursing facility are independent predictors of 30-day readmission after transcatheter aortic valve replacement. • Cost of readmission accounts for an average of 16.4% of the total cost of the episode of care in patients who are readmitted. replacement (TAVR) procedures performed in the United States has increased rapidly.4 TAVR is now approved for patients with severe symptomatic aortic stenosis who are at prohibitive-risk, high-risk, or intermediate-risk for surgical aortic valve replacement (SAVR). This patient population is at an increased risk for readmissions inherent to the high burden of comorbidities and high rate of periprocedural complications. Thirty-day all-cause readmission rates after TAVR have ranged from 14.6% to 20.9% in previous studies.5–8 However, data on independent predictors of readmissions after TAVR in a nationally representative cohort are lacking. Furthermore, none of the previous studies provide information on costs of readmission episodes, which has important healthcare policy implications and is critical in assessing the overall costeffectiveness of TAVR. Thus, the main objectives of our study were to determine the incidence, predictors, causes, and costs of 30-day readmissions after TAVR in a real-world, nationally representative patient population in the United States. Knowledge of the independent predictors of 30-day readmissions can help identify and target high-risk patients for interventions to reduce rehospitalization and healthcare costs. Methods Data Source We used the 2013 Nationwide Readmissions Database (NRD), a publicly available database of all-payer hospital inpatient stays developed by the Agency for Healthcare Research and Quality as part of the Healthcare Cost and Utilization Project. The NRD is drawn from the State Inpatient Databases that contain reliable, verified patient linkage numbers that can be used to track a patient across hospitals within a State, while adhering to strict privacy guidelines. The 2013 NRD includes data from 21 states that are geographically dispersed and account for 49.3% of the total US resident population and 49.1% of all hospitalizations. The NRD includes all discharge records of patients treated in US community hospitals excluding rehabilitation and longterm acute care facilities. Discharge weights are provided to obtain national estimates. This study was deemed exempt by the Lifespan-Rhode Island Hospital Institutional Review Board as the NRD is a publicly available database that contains deidentified patient information. Study Population We used the International Classification of Diseases, Ninth Edition, Clinical Modification procedure codes 35.05 and 35.06 to identify all TAVR patients aged ≥18 years included in the 2013 NRD (n=14 071 across 219 centers). We excluded records of patients discharged in December 2013 (n=1239) because of unavailability of 30-day followup data on these cases. We further excluded patients who died during the index hospitalization (n=602 [in-hospital mortality, 4.7%]) and those with missing discharge disposition (n=2). Finally, if a patient underwent repeat TAVR within 30 days (n=7), the discharge record for the second procedure was excluded from the index cases to avoid duplication (these records were included as 30-day readmissions). For patients who underwent repeat TAVR after 30 days (n=14), the second discharge record was considered as a separate index procedure. This gave us a final sample size of 12 221 index TAVR procedures performed at 210 centers. Patient and Hospital Characteristics Baseline patient characteristics included were age, sex, primary expected payer, median household income, and relevant comorbidities (smoking, dyslipidemia, hypertension, diabetes mellitus, obesity, heart failure, known coronary artery disease, previous myocardial infarction, previous PCI, previous coronary artery bypass grafting, carotid artery disease, previous transient ischemic attack/stroke, atrial fibrillation, previous permanent pacemaker [PPM], previous implantable cardioverter defibrillator, peripheral vascular disease [PVD], anemia, chronic kidney disease [CKD], chronic lung disease [CLD], liver disease, coagulopathy, dementia, depression, hypothyroidism, fluid and electrolyte disorders, other neurological disorders, pulmonary circulation disorders, and cancer). Hospital characteristics such as location, teaching status, and bed size were also included. Other variables extracted were TAVR access site (endovascular versus transapical [TA]), in-hospital procedures (coronary angiography, PCI, and mechanical circulatory support), and in-hospital complications (conversion to SAVR, complete heart block, PPM placement, transient ischemic attack/stroke, acute myocardial infarction, cardiogenic shock, cardiac arrest, acute kidney injury [AKI], major bleeding, and vascular complications). The Healthcare Cost and Utilization Project Clinical Classification Software (CCS) and International Classification of Diseases, Ninth Edition, Clinical Modification codes used to define these variables are listed in Table I in the Data Supplement. Outcomes Measured Our primary outcome of interest for this study was 30-day, all-cause readmission. Readmissions were identified according to the methodology outlined by Healthcare Cost and Utilization Project.9 For patients who had multiple readmissions within 30 days, only the first readmission was included. Transfer to another hospital was not considered as a readmission. Both unplanned and planned readmissions were included. Planned readmissions after TAVR are expected to be extremely rare because unlike PCI, there is no staged procedure involved. Time to readmission was calculated as the number of days between hospital discharge after index TAVR procedure and the first day of hospital readmission. Two authors (D.K. and S.K.) independently reviewed the primary diagnosis of each readmission record and grouped them into clinically meaningful categories to determine the main cause of readmission. Discrepancies were resolved by mutual agreement. Causes of readmissions were classified as cardiac and noncardiac. Cardiac causes included heart failure, arrhythmias, conduction disorders, valve disorders including endocarditis, prosthesis-related mechanical complications, and aortic valve reintervention, hypertension/hypotension, pericarditis, coronary artery disease, acute myocardial infarction, and others. Noncardiac causes included respiratory (including pneumonia), infectious, bleeding, 3 Kolte et al Thirty-Day Readmissions After TAVR PVD, transient ischemic attack/stroke, renal, gastrointestinal, trauma, hematologic/neoplasms, endocrine/metabolic, neuropsychiatric, and others. Primary diagnosis categories and the corresponding CCS and International Classification of Diseases, Ninth Edition, Clinical Modification codes are listed in Table II in the Data Supplement. Secondary outcomes examined were length of stay (LOS) and total hospital costs. Costs were inflation adjusted using the US Bureau of Labor Statistics Consumer Price Index, with 2016 as the index base.10 Statistical Analysis Downloaded from http://circinterventions.ahajournals.org/ by guest on June 18, 2017 Baseline patient and hospital characteristics, in-hospital procedures, and in-hospital complications were compared between patients with and without 30-day readmission using Pearson χ2 test for categorical variables and Student t test for continuous variables. Cox proportional hazards regression was used to identify predictors of 30-day readmission. Variables with a P<0.2 on univariable analysis were entered into a multivariable regression model (method=ENTER) to identify independent predictors of 30-day readmission. A random-effect term for hospital was also added to the model. Kaplan–Meier curve and log-rank test were used to compare 30-day readmission rates between groups. Data were complete for all variables except primary expected payer (0.1% missing) and median household income (1.1% missing). Missing values were replaced with the dominant category for these variables. Data on cost was missing for 166 index hospitalizations and 35 readmissions. Therefore, results of cost analysis are based on a sample size of 12 055 index hospitalizations and 2153 readmissions. Statistical analysis was performed with IBM SPSS Statistics 20.0 (IBM Corp, Armonk, NY). All P values were 2 sided with a significance threshold of P<0.05. Categorical variables are expressed as percentages and continuous variables as mean±SD or median (interquartile range [IQR]) as appropriate. Hazard ratio (HR) and 95% confidence interval (CI) are used to report the results of Cox regression analyses. Results Baseline Characteristics Baseline patient and hospital characteristics, in-hospital procedures, and in-hospital outcomes of TAVR patients who survived the index hospitalization (n=12 221) are summarized in Table 1. Mean age of the study cohort was 81.5±8.4 years with 49.1% women. The majority of the TAVR procedures were performed in large, urban, teaching hospitals. Compared with patients who were not readmitted within 30 days, those readmitted were older, had higher prevalence of diabetes mellitus, previous PCI, atrial fibrillation, anemia, CKD, CLD, and fluid/ electrolyte disorders, and lower prevalence of dyslipidemia, hypertension, previous coronary artery bypass grafting, and carotid artery disease. Patients who were readmitted within 30 days were more likely to have undergone TA-TAVR, had a higher incidence of certain in-hospital complications such as PPM placement, cardiac arrest, AKI, and major bleeding, had longer LOS and higher total hospital costs, and were more likely to have been discharged to SNF (Table 1). Incidence, Hospital Variation, and Predictors of 30-Day Readmission Of 12 221 TAVR patients who survived the index hospitalization, 2188 (17.9%) were readmitted within 30 days. Median time to readmission was 10 days (IQR, 4–18 days). Figure IA in the Data Supplement shows the distribution of hospitals according to number of TAVR procedures performed during the study period. For hospital-level variation in readmission rates, we restricted our analyses to hospitals performing ≥5 TAVRs. Thirty-day readmission rates varied significantly across hospitals (median, 17.6%; IQR, 11.8%–22.9%, and range 0%–50%) (Figure IIA in the Data Supplement). Similar results were seen when the analysis was restricted to hospitals performing ≥10 TAVRs (median, 17.6%; IQR, 12.6%–23.4%, and range 0%–50%; Figure IIB in the Data Supplement). On multivariable analysis, LOS >5 days during the index hospitalization (HR, 1.47; 95% CI, 1.24–1.73), AKI (HR, 1.23; 95% CI, 1.05–1.44), >4 Elixhauser comorbidities (HR, 1.22; 95% CI, 1.03–1.46), TA-TAVR (HR, 1.21; 95% CI, 1.05–1.39), CKD (HR, 1.20; 95% CI, 1.04–1.39), CLD (HR, 1.16; 95% CI, 1.01–1.34), and discharge to SNF (HR, 1.16; 95% CI, 1.01–1.34) were identified as independent predictors of 30-day readmission (Table 2; Figure III in the Data Supplement). Causes, LOS, and Costs of 30-Day Readmissions Of 2188 readmissions, 1352 (61.8%) were because of noncardiac causes and 836 (38.2%) were because of cardiac causes. Noncardiac causes included respiratory (14.7%), infections (12.8%), bleeding (7.6%), PVD (4.3%), renal (4.0%), gastrointestinal (3.9%), transient ischemic attack/stroke (3.6%), trauma (3.2%), hematologic/neoplasms (2.3%), endocrine/ metabolic (2.0%), neuropsychiatric (1.5%), and other (2.1%; Figure 1A). Heart failure (22.5%), arrhythmias (6.6% [atrial fibrillation 4.3%]), valve disorders including endocarditis, prosthesis-related mechanical complications, and aortic valve reintervention (2.1%), hypertension/hypotension (1.7%), conduction disorders (1.3%), coronary artery disease (0.9%), pericarditis (0.8%), and acute myocardial infarction (0.7%) were the most common cardiac causes of 30-day readmission (Figure 1B). Specifically, 0.6% patients had aortic valve reintervention and 2.9% underwent PPM placement during the readmission. Among patients readmitted within 30 days, 109 patients (5.0%) died. The mean LOS for readmissions was 5.9±5.5 days with a median of 4 days (IQR, 2–7 days). Total hospital cost of all 30-day readmissions was $29 115 721. Mean total hospital cost per readmission was $13 528±15 285 with a median of $8302 (IQR, $5229–16 021; Figure 2). Cost of readmission accounted for an average of 16.4%±12.2% of the total cost of the episode of care (index+readmission). Discussion In this comprehensive analysis of 30-day all-cause readmissions after TAVR in the United States, we report several important findings: (1) 17.9% of patients undergoing TAVR were readmitted within 30 days, and readmission rates varied significantly across hospitals, (2) LOS >5 days during the index hospitalization, AKI, presence of >4 Elixhauser comorbidities, TA-TAVR, CKD, CLD, and discharge to SNF were independent predictors of 30-day readmission, (3) consistent with previous data, more than three fifths of the readmissions were because of noncardiac causes,8 and (4) cost of readmission accounted for 16.4% of the total cost of the episode of care in patients who were readmitted. Thirty-day readmissions are considered a quality performance measure by the Centers for Medicare and Medicaid Services. Previous research has shown that 30-day readmission 4 Kolte et al Thirty-Day Readmissions After TAVR Table 1. Baseline Characteristics and In-Hospital Outcomes of TAVR Patients Discharged Alive After Index Hospitalization 30-d Readmission Overall No (n=10 033) Yes (n=2188) P Value Age, y 81.5±8.4 81.3±8.4 82.0±8.3 0.001 <85 55.4% 56.1% 51.8% <0.001 ≥85 44.6% 43.9% 48.2% 49.1 48.9 50.0 Women, % Primary expected payer 0.371 <0.001 Downloaded from http://circinterventions.ahajournals.org/ by guest on June 18, 2017 Medicare 91.6% 91.2% 93.5% Medicaid 0.7% 0.7% 0.8% Private 5.5% 5.8% 4.4% Uninsured 0.7% 0.7% 0.7% Other 1.5% 1.7% 0.6% 0–25th percentile 20.4% 20.5% 19.8% 26th–50th percentile 24.5% 24.5% 24.3% 51st–75th percentile 26.5% 26.4% 27.0% 76th–100th percentile 28.6% 28.6% 28.9% Smoking 27.5% 27.7% 26.2% 0.133 Dyslipidemia 63.3% 64.2% 59.2% <0.001 Hypertension 79.7% 80.4% 76.4% <0.001 Diabetes mellitus 33.9% 33.5% 35.9% 0.027 Obesity 14.9% 14.6% 15.9% 0.146 Heart failure 72.6% 72.5% 73.3% 0.413 Known CAD 68.6% 68.7% 68.1% 0.558 Previous MI 12.8% 13.0% 11.9% 0.171 Previous PCI 20.1% 19.6% 22.7% 0.001 Previous CABG 22.7% 23.4% 19.5% <0.001 Median household income 0.818 Comorbidities Carotid artery disease 7.2% 7.4% 6.0% 0.021 Previous TIA/stroke 12.9% 13.0% 12.5% 0.580 Atrial fibrillation 45.9% 44.8% 50.7% <0.001 Previous PPM 10.1% 10.2% 9.9% 0.737 Previous ICD 3.4% 3.5% 3.2% 0.516 Peripheral vascular disease 30.8% 30.6% 31.6% 0.355 Anemia 26.0% 25.5% 28.7% 0.002 Chronic kidney disease 35.3% 33.7% 42.7% <0.001 Chronic lung disease 34.5% 33.6% 39.0% <0.001 Liver disease 2.2% 2.1% 2.6% 0.166 Coagulopathy 24.4% 24.2% 25.5% 0.184 Dementia 7.8% 7.7% 8.5% 0.230 Depression 7.5% 7.7% 6.8% 0.165 Hypothyroidism 19.9% 19.7% 21.0% 0.149 Fluid and electrolyte disorders 29.7% 28.5% 35.4% <0.001 Other neurological disorders 6.8% 6.6% 7.6% 0.105 Pulmonary circulation disorders 0.9% 0.9% 1.2% 0.129 Cancer 3.6% 3.7% 3.0% 0.126 (Continued ) 5 Kolte et al Thirty-Day Readmissions After TAVR Table 1. Continued 30-d Readmission Overall No (n=10 033) Yes (n=2188) P Value No. of Elixhauser comorbidities 4.4±1.9 4.3±1.9 4.7±2.0 <0.001 ≤4 54.6% 56.3% 46.7% <0.001 >4 45.4% 43.7% 53.3% Hospital characteristics Bed size 0.039 Small 3.0% 2.8% 3.7% Medium 12.6% 12.8% 11.7% Large 84.4% 84.4% 84.5% Location 0.040 Downloaded from http://circinterventions.ahajournals.org/ by guest on June 18, 2017 Rural 0.8% 0.7% 1.1% Urban 99.2% 99.3% 98.9% Nonteaching 11.3% 11.4% 10.8% Teaching 88.7% 88.6% 89.2% Endovascular 68.9% 70.4% 62.4% Transapical 31.1% 29.6% 37.6% Coronary angiography 25.5% 25.4% 25.8% 0.714 PCI 3.5% 3.4% 4.0% 0.125 Mechanical circulatory support 1.9% 1.8% 2.4% 0.076 Surgical AVR 0.3% 0.2% 0.3% 0.557 Complete heart block 7.8% 7.8% 8.1% 0.558 PPM placement 9.2% 8.8% 11.3% <0.001 TIA/stroke 2.6% 2.6% 2.7% 0.821 AMI 2.8% 2.9% 2.5% 0.323 Cardiogenic shock 2.1% 2.2% 2.0% 0.658 Cardiac arrest 2.8% 2.5% 4.3% <0.001 AKI 18.2% 16.4% 26.5% <0.001 Major bleeding 17.1% 16.6% 19.5% 0.001 Teaching status 0.462 In-hospital procedures TAVR access <0.001 In-hospital outcomes Vascular complications 5.0% 4.8% 5.7% LOS, d 9.0±8.6 8.5±8.0 11.3±10.9 <0.001 ≤5 39.2% 41.9% 27.0% <0.001 >5 60.8% 58.1% 73.0% Home (self-care) 29.3% 30.9% 22.1% Short-term hospital 1.2% 1.2% 1.1% Skilled nursing facility 32.0% 30.1% 40.7% Home healthcare 37.5% 37.8% 36.2% 59 877±31 668 58 577±30 669 65 840±35 298 Discharge disposition Total hospital cost, US$ 0.109 <0.001 <0.001 AMI indicates acute myocardial infarction; AKI, acute kidney injury; AVR, aortic valve replacement; CABG, coronary artery bypass grafting; CAD, coronary artery disease; ICD, implantable cardioverter defibrillator; LOS, length of stay; MI, myocardial infarction; PCI, percutaneous coronary intervention; PPM, permanent pacemaker; TAVR, transcatheter aortic valve replacement; TIA, transient ischemic attack; and US$, United States dollar. 6 Kolte et al Thirty-Day Readmissions After TAVR Table 2. Independent Predictors of 30-Day Readmission After TAVR Univariable Multivariable Predictors HR (95% CI) P Value HR (95% CI) P Value LOS >5 d 1.91 (1.66–2.21) <0.001 1.47 (1.24–1.73) <0.001 Acute kidney injury 1.69 (1.46–1.95) <0.001 1.23 (1.05–1.44) 0.011 >4 Elixhauser comorbidities 1.47 (1.29–1.66) <0.001 1.22 (1.03–1.46) 0.026 Transapical TAVR 1.40 (1.23–1.60) <0.001 1.21 (1.05–1.39) 0.008 Chronic kidney disease 1.41 (1.24–1.60) <0.001 1.20 (1.04–1.39) 0.014 Chronic lung disease 1.23 (1.08–1.40) 0.002 1.16 (1.01–1.34) 0.034 Discharge to SNF 1.53 (1.34–1.74) <0.001 1.16 (1.01–1.34) 0.038 Downloaded from http://circinterventions.ahajournals.org/ by guest on June 18, 2017 Cardiac arrest 1.60 (1.15–2.22) 0.005 Fluid and electrolyte disorders 1.40 (1.22–1.60) <0.001 Major bleeding 1.29 (1.10–1.51) 0.002 Atrial fibrillation 1.23 (1.09–1.40) 0.001 Anemia 1.21 (1.05–1.39) 0.008 Heart failure 1.19 (1.03–1.38) 0.020 Age ≥85 y 1.14 (1.00–1.29) 0.045 Hypertension 0.86 (0.74–1.00) 0.044 Previous CABG 0.81 (0.69–0.96) 0.012 Dyslipidemia 0.80 (0.70–0.91) 0.001 CABG indicates coronary artery bypass grafting; CI, confidence interval; HR, hazard ratio; LOS, length of stay; SNF, skilled nursing facility; and TAVR, transcatheter aortic valve replacement. rates after cardiac procedures such as PCI, coronary artery bypass grafting, and SAVR range from 12.4% to 19.2%.11–14 In our study of 12 221 patients who underwent TAVR between January and November 2013, the 30-day all-cause readmission rate was 17.9%. Our results are comparable to data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry in which 30-day readmission rate was 17.4% among 12 182 Medicare patients who underwent TAVR between November 2011 and June 2013.6 Similarly, Murugiah et al7 and Nombela-Franco et al8 reported 30-day readmission rates of 20.9% and 14.6% after TAVR in cohorts of 14 722 Medicare fee-for-service beneficiaries and 720 patients at 2 centers, respectively. TAVR is currently approved for patients with severe symptomatic aortic stenosis who are at prohibitive-risk, high-risk, or intermediate-risk for SAVR. This patient population is at an increased risk for readmissions inherent to the high burden of comorbidities and high rate of periprocedural complications. Indeed, the presence of >4 Elixhauser comorbidities, specifically CKD and CLD, was identified as an independent predictor of 30-day readmission after TAVR in our study. TAVR has been shown to be at least as safe and effective as SAVR in patients with CKD and CLD.15–18 However, patients with CKD and CLD undergoing TAVR are at increased risk of procedural complications, mortality, and rehospitalization when compared with those without these conditions.17,18 In addition to patient comorbidities, TA-TAVR and AKI were also identified as independent predictors of 30-day readmission. TA-TAVR is an accepted approach in patients in whom vascular anatomy or severe PVD precludes safe transfemoral (TF) access. However, TA-TAVR is associated with higher mortality and prolonged recovery when compared with TF-TAVR, and unlike TF-TAVR, health-related quality of life after TA-TAVR is no better than SAVR.19,20 Our study showed that TA-TAVR is also associated with an increased risk of 30-day readmission. This association may be influenced by residual confounding as patients undergoing TA-TAVR are typically sicker with more complex PVD that cannot be captured completely in an administrative database such as the NRD. Nonetheless, alternate access such as direct aortic, subclavian, transcaval, and transcarotid should be considered in patients not suitable for TF-TAVR.21–23 Postprocedural AKI occurs in 12% to 57% of patients after TAVR and is associated with increased mortality.24,25 AKI also predicted increased 30-day readmission after TAVR in our study. Discharge to SNF and prolonged LOS, which may reflect frailty and high burden of comorbidities and in-hospital complications, were also associated with increased rates of 30-day readmission.26,27 Strategies such as multidisciplinary evaluation of TAVR patients in collaboration with pulmonologists and nephrologists, consideration of alternate access other than TA-TAVR, prevention or reduction of AKI with intravenous hydration, and early discharge to home whenever possible, may help reduce readmission rates. The causes of 30-day readmission after TAVR were similar to those previously reported with 61.8% of patients being rehospitalized for noncardiac and 38.2% for cardiac diagnoses.8 Respiratory disorders (including pneumonia) and infections accounted for majority of the noncardiac causes of readmission. Previous studies have shown that 7 Kolte et al Thirty-Day Readmissions After TAVR Downloaded from http://circinterventions.ahajournals.org/ by guest on June 18, 2017 Figure 1. Causes of 30-day readmissions after transcatheter aortic valve replacement. Noncardiac (A) and cardiac (B) causes of 30-d readmissions after TAVR. AMI indicates acute myocardial infarction; CAD, coronary artery disease; PVD, peripheral vascular disease; and TIA, transient ischemic attack. infectious complications after TAVR are mainly associated with procedural factors such as surgical cut-down of the femoral artery, life-threatening bleeding, prolonged intensive care unit stay, and potentially the use of general anesthesia (compared with deep sedation).28,29 Thus, attention to these factors and implementation of effective strategies for reducing hospital-acquired infections may help lower readmission rates after TAVR. Approximately two fifths of readmissions after TAVR were because of cardiac causes, with heart failure being the most common reason accounting for 22.5% of all readmissions. Figure 2. Mean costs of index hospitalization and 30-day readmission after transcatheter aortic valve replacement (TAVR). Mean costs of index hospitalization of TAVR patients with and without 30-d readmission (blue) and mean costs of 30-d readmission (red) are shown. Heart failure is frequent in patients with severe aortic stenosis and remains the most common cause of rehospitalization and death after TAVR.30,31 In previous studies, 22.8% to 30.4% of all 30-day readmissions were because of heart failure.5,6,8 The high rate of heart failure rehospitalizations after TAVR may also be related to older age and high prevalence of coexisting comorbidities such as hypertension, coronary artery disease, anemia, atrial fibrillation, and CKD in patients with severe aortic stenosis. Early postdischarge follow-up and other interventions shown to be effective in reducing heart failure rehospitalizations may also be helpful in lowering 30-day heart failure readmissions after TAVR.32 Tachyarrhythmias were the second most frequent cardiac cause of 30-day readmission, with atrial fibrillation being the most common. In our study, 45.9% of patients had either preexisting or new-onset atrial fibrillation during the index hospitalization, both of which have been shown to be associated with worse outcomes in patients undergoing TAVR.33,34 Rates of aortic valve reintervention and PPM placement during 30-day readmission were relatively low. Cost-effectiveness analyses of data from the Placement of Aortic Transcatheter Valve (PARTNER) Cohort A and CoreValve US High Risk Pivotal trials have shown that in patients with severe aortic stenosis who are at high risk for surgery, TAVR (especially via TF approach) is an economically attractive strategy as compared with SAVR, with acceptable incremental costs.35,36 The estimated mean cost of follow-up hospitalizations was $18 122±58 142 (TF-TAVR) and 11 733±31 924 (TA-TAVR) for the SAPIEN heart valve system and $12 208±22 315 for the CoreValve system. Similarly, in the current study, the mean hospital cost of readmission was $13 528±15 285, which accounted for 16.4% of the total cost of the episode of care. Although reductions in the cost of index TAVR admissions can improve overall cost-effectiveness of TAVR when compared with SAVR, efforts to reduce unplanned rehospitalizations can help lower costs even further.36 Limitations Our study has certain limitations. First, our analysis is based on administrative data, which lacks clinical and laboratory variables. Information on STS score, valve type and size, echocardiographic findings such as aortic regurgitation/ paravalvular leak, and medications (eg, dual-antiplatelet therapy, anticoagulation) was not available. Second, causes of readmission were identified using the primary discharge diagnosis codes. However, most previous studies on 30-day readmission after cardiac procedures have also utilized a similar approach.5,7 Third, patients who are hospitalized in 1 state and readmitted to a hospital in another state are not tracked in the NRD; however, we expect that to be uncommon in patients undergoing TAVR. Last, because of unavailability of mortality data on TAVR patients who died outside the hospital or in the emergency room, we were unable to account for the influence of mortality on the rates of readmission. Despite these limitations, 30-day readmission rates in our study are comparable to those reported in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry. The NRD provides valuable information not completely captured in the TVT registry such 8 Kolte et al Thirty-Day Readmissions After TAVR as causes of noncardiac readmissions and costs of readmissions after TAVR. Conclusions Downloaded from http://circinterventions.ahajournals.org/ by guest on June 18, 2017 In a real-world, all-payer, nationally representative cohort of TAVR patients in the United States, 30-day readmission rates were 17.9% with significant variation across hospitals. High burden of comorbidities, particularly CKD and CLD, TATAVR, AKI, discharge to SNF, and longer LOS during the index hospitalization were associated with increased risk of 30-day readmission. Heart failure was the most common overall cause of readmission; however, more than three fifths of readmissions were because of noncardiac causes. Cost of readmission accounted for 16.4% of the total cost of the episode of care in patients who were readmitted. As the use of TAVR expands with the recent approval for intermediate-risk patients, and potentially even for low-risk patients in the near future, implementation of strategies to reduce readmissions would be crucial to reduce healthcare burden and maintain cost-effectiveness of TAVR. Utilization of 30-day risk-standardized readmission rates after TAVR as a performance metric may help incentivize hospitals to develop and implement institution-specific strategies to reduce readmissions. However, public reporting of such measures for TAVR should be avoided as this may lead to inadvertent risk-averse behavior among operators and institutions as seen with PCI.37 Our findings do support future inclusion of TAVR in the bundled payment models proposed by the Centers for Medicare and Medicaid Services to promote high-quality cardiac care at a lower cost. Disclosures Dr Bhatt discloses the following relationships—Advisory Board: Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of Cardiovascular Patient Care; Chair: American Heart Association Quality Oversight Committee; Data Monitoring Committees: Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, Population Health Research Institute; Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/ Treasurer), WebMD (CME steering committees); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Research Funding: Amarin, Amgen, AstraZeneca, BristolMyers Squibb, Eisai, Ethicon, Forest Laboratories, Ischemix, Lilly, Medtronic, Pfizer, Roche, Sanofi Aventis, The Medicines Company; Royalties: Elsevier (Editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); Site Co-Investigator: Biotronik, Boston Scientific, St. Jude Medical; Trustee: American College of Cardiology; Unfunded Research: FlowCo, PLx Pharma, Takeda. The other authors report no conflicts. References 1. Medicare.gov. 30-day unplanned readmission and death measures. 2016. https://www.medicare.gov/hospitalcompare/Data/30-day-measures.html. Accessed August 7, 2016. 2. Obama B. United States health care reform: progress to date and next steps. JAMA. 2016;316:525–532. doi: 10.1001/jama.2016.9797. 3. Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418– 1428. doi: 10.1056/NEJMsa0803563. 4.Holmes DR Jr, Nishimura RA, Grover FL, Brindis RG, Carroll JD, Edwards FH, Peterson ED, Rumsfeld JS, Shahian DM, Thourani VH, Tuzcu EM, Vemulapalli S, Hewitt K, Michaels J, Fitzgerald S, Mack MJ; STS/ACC TVT Registry. Annual outcomes with transcatheter valve therapy: from the STS/ACC TVT Registry. J Am Coll Cardiol. 2015;66:2813– 2823. doi: 10.1016/j.jacc.2015.10.021. 5. Hannan EL, Samadashvili Z, Jordan D, Sundt TM 3rd, Stamato NJ, Lahey SJ, Gold JP, Wechsler A, Ashraf MH, Ruiz C, Wilson S, Smith CR. Thirtyday readmissions after transcatheter aortic valve implantation versus surgical aortic valve replacement in patients with severe aortic stenosis in New York State. Circ Cardiovasc Interv. 2015;8:e002744. doi: 10.1161/ CIRCINTERVENTIONS.115.002744. 6.Holmes DR Jr, Brennan JM, Rumsfeld JS, Dai D, O’Brien SM, Vemulapalli S, Edwards FH, Carroll J, Shahian D, Grover F, Tuzcu EM, Peterson ED, Brindis RG, Mack MJ; STS/ACC TVT Registry. Clinical outcomes at 1 year following transcatheter aortic valve replacement. JAMA. 2015;313:1019–1028. doi: 10.1001/jama.2015.1474. 7.Murugiah K, Wang Y, Desai NR, Nuti SV, Krumholz HM. Hospital variation in outcomes for transcatheter aortic valve replacement among Medicare beneficiaries, 2011 to 2013. J Am Coll Cardiol. 2015;66:2678– 2679. doi: 10.1016/j.jacc.2015.10.008. 8. Nombela-Franco L, del Trigo M, Morrison-Polo G, Veiga G, JimenezQuevedo P, Abdul-Jawad Altisent O, Campelo-Parada F, Biagioni C, Puri R, DeLarochellière R, Dumont E, Doyle D, Paradis JM, Quirós A, Almeria C, Gonzalo N, Nuñez-Gil I, Salinas P, Mohammadi S, Escaned J, Fernández-Ortiz A, Macaya C, Rodés-Cabau J. Incidence, causes, and predictors of early (≤30 days) and late unplanned hospital readmissions after transcatheter aortic valve replacement. JACC Cardiovasc Interv. 2015;8:1748–1757. doi: 10.1016/j.jcin.2015.07.022. 9.US Agency for Healthcare Research and Quality. Overview of Key Readmission Measures and Methods. 2012. http://www.hcupus.ahrq.gov/ reports/methods/methods.jsp. Accessed August 7, 2016. 10. US Bureau of Labor Statistics, Division of Consumer Prices and Price Indexes. Consumer Price Index - All Urban Consumers. 2016. http://data. bls.gov/pdq/SurveyOutputServlet. Accessed May 20, 2016. 11. Curtis JP, Schreiner G, Wang Y, Chen J, Spertus JA, Rumsfeld JS, Brindis RG, Krumholz HM. All-cause readmission and repeat revascularization after percutaneous coronary intervention in a cohort of medicare patients. J Am Coll Cardiol. 2009;54:903–907. doi: 10.1016/j.jacc.2009.04.076. 12.Hannan EL, Zhong Y, Lahey SJ, Culliford AT, Gold JP, Smith CR, Higgins RS, Jordan D, Wechsler A. 30-day readmissions after coronary artery bypass graft surgery in New York State. JACC Cardiovasc Interv. 2011;4:569–576. doi: 10.1016/j.jcin.2011.01.010. 13. Wasfy JH, Rosenfield K, Zelevinsky K, Sakhuja R, Lovett A, Spertus JA, Wimmer NJ, Mauri L, Normand SL, Yeh RW. A prediction model to identify patients at high risk for 30-day readmission after percutaneous coronary intervention. Circ Cardiovasc Qual Outcomes. 2013;6:429–435. doi: 10.1161/CIRCOUTCOMES.111.000093. 14. Murugiah K, Wang Y, Dodson JA, Nuti SV, Dharmarajan K, Ranasinghe I, Cooper Z, Krumholz HM. Trends in hospitalizations among medicare survivors of aortic valve replacement in the United States from 1999 to 2010. Ann Thorac Surg. 2015;99:509–517. doi: 10.1016/j.athoracsur.2014.08.045. 15.Nguyen TC, Babaliaros VC, Razavi SA, Kilgo PD, Guyton RA, Devireddy CM, Shults CC, Mavromatis K, Kanitkar M, Block P, Lerakis S, Thourani VH. Impact of varying degrees of renal dysfunction on transcatheter and surgical aortic valve replacement. J Thorac Cardiovasc Surg. 2013;146:1399–1406, discussion 1406. doi: 10.1016/j.jtcvs.2013.07.065. 16.Suri RM, Gulack BC, Brennan JM, Thourani VH, Dai D, Zajarias A, Greason KL, Vassileva CM, Mathew V, Nkomo VT, Mack MJ, Rihal CS, Svensson LG, Nishimura RA, O’Gara PT, Holmes DR Jr. Outcomes of patients with severe chronic lung disease who are undergoing transcatheter aortic valve replacement. Ann Thorac Surg. 2015;100:2136–2145, discussion 2145. doi: 10.1016/j.athoracsur.2015.05.075. 17.Szerlip M, Kim RJ, Adeniyi T, Thourani V, Babaliaros V, Bavaria J, Herrmann HC, Anwaruddin S, Makkar R, Chakravarty T, Rovin J, Creighton D, Miller DC, Baio K, Walsh E, Katinic J, Letterer R, Trautman L, Herbert M, Farkas R, Rudolph J, Brown D, Holper EM, Mack M. The outcomes of transcatheter aortic valve replacement in a cohort of patients with end-stage renal disease. Catheter Cardiovasc Interv. 2016;87:1314– 1321. doi: 10.1002/ccd.26347. 9 Kolte et al Thirty-Day Readmissions After TAVR Downloaded from http://circinterventions.ahajournals.org/ by guest on June 18, 2017 18. Dvir D, Waksman R, Barbash IM, Kodali SK, Svensson LG, Tuzcu EM, Xu K, Minha S, Alu MC, Szeto WY, Thourani VH, Makkar R, Kapadia S, Satler LF, Webb JG, Leon MB, Pichard AD. Outcomes of patients with chronic lung disease and severe aortic stenosis treated with transcatheter versus surgical aortic valve replacement or standard therapy: insights from the PARTNER trial (Placement of Aortic Transcatheter Valve). J Am Coll Cardiol. 2014;63:269–279. doi: 10.1016/j.jacc.2013.09.024. 19.Blackstone EH, Suri RM, Rajeswaran J, Babaliaros V, Douglas PS, Fearon WF, Miller DC, Hahn RT, Kapadia S, Kirtane AJ, Kodali SK, Mack M, Szeto WY, Thourani VH, Tuzcu EM, Williams MR, Akin JJ, Leon MB, Svensson LG. Propensity-matched comparisons of clinical outcomes after transapical or transfemoral transcatheter aortic valve replacement: a Placement of Aortic Transcatheter Valves (PARTNER)-I trial substudy. Circulation. 2015;131:1989–2000. doi: 10.1161/ CIRCULATIONAHA.114.012525. 20.Gada H, Kirtane AJ, Wang K, Lei Y, Magnuson E, Reynolds MR, Williams MR, Kodali S, Vahl TP, Arnold SV, Leon MB, Thourani V, Szeto WY, Cohen DJ; PARTNER Investigators. Temporal trends in quality of life outcomes after transapical transcatheter aortic valve replacement: a Placement of Aortic Transcatheter Valve (PARTNER) trial substudy. Circ Cardiovasc Qual Outcomes. 2015;8:338–346. doi: 10.1161/CIRCOUTCOMES.114.001335. 21. Mack MJ. Access for transcatheter aortic valve replacement: which is the preferred route? JACC Cardiovasc Interv. 2012;5:487–488. doi: 10.1016/j. jcin.2012.03.009. 22. Greenbaum AB, O’Neill WW, Paone G, Guerrero ME, Wyman JF, Cooper RL, Lederman RJ. Caval-aortic access to allow transcatheter aortic valve replacement in otherwise ineligible patients: initial human experience. J Am Coll Cardiol. 2014;63(25 pt A):2795–2804. doi: 10.1016/j.jacc.2014.04.015. 23. Mylotte D, Sudre A, Teiger E, Obadia JF, Lee M, Spence M, Khamis H, Al Nooryani A, Delhaye C, Amr G, Koussa M, Debry N, Piazza N, Modine T. Transcarotid transcatheter aortic valve replacement: feasibility and safety. JACC Cardiovasc Interv. 2016;9:472–480. doi: 10.1016/j. jcin.2015.11.045. 24. Généreux P, Kodali SK, Green P, Paradis JM, Daneault B, Rene G, Hueter I, Georges I, Kirtane A, Hahn RT, Smith C, Leon MB, Williams MR. Incidence and effect of acute kidney injury after transcatheter aortic valve replacement using the new valve academic research consortium criteria. Am J Cardiol. 2013;111:100–105. doi: 10.1016/j.amjcard.2012.08.057. 25. Arsalan M, Squiers JJ, Farkas R, Worley C, Herbert M, Stewart W, Brinkman WT, Ungchusri E, Brown DL, Mack MJ, Holper EM. Prognostic usefulness of acute kidney injury after transcatheter aortic valve replacement. Am J Cardiol. 2016;117:1327–1331. doi: 10.1016/j.amjcard.2016.01.037. 26.Lee DH, Buth KJ, Martin BJ, Yip AM, Hirsch GM. Frail patients are at increased risk for mortality and prolonged institutional care after cardiac surgery. Circulation. 2010;121:973–978. doi: 10.1161/ CIRCULATIONAHA.108.841437. 27. Schoenenberger AW, Stortecky S, Neumann S, Moser A, Jüni P, Carrel T, Huber C, Gandon M, Bischoff S, Schoenenberger CM, Stuck AE, Windecker S, Wenaweser P. Predictors of functional decline in elderly patients undergoing transcatheter aortic valve implantation (TAVI). Eur Heart J. 2013;34:684–692. doi: 10.1093/eurheartj/ehs304. 28. van der Boon RM, Nuis RJ, Benitez LM, Van Mieghem NM, Perez S, Cruz L, van Geuns RJ, Serruys PW, van Domburg RT, Dager AE, de Jaegere PP. Frequency, determinants and prognostic implications of infectious complications after transcatheter aortic valve implantation. Am J Cardiol. 2013;112:104–110. doi: 10.1016/j.amjcard.2013.02.061. 29. Tirado-Conte G, Freitas-Ferraz AB, Nombela-Franco L, Jimenez-Quevedo P, Biagioni C, Cuadrado A, Nuñez-Gil I, Salinas P, Gonzalo N, Ferrera C, Vivas D, Higueras J, Viana-Tejedor A, Perez-Vizcayno MJ, Vilacosta I, Escaned J, Fernandez-Ortiz A, Macaya C. Incidence, causes, and impact of in-hospital infections after transcatheter aortic valve implantation. Am J Cardiol. 2016;118:403–409. doi: 10.1016/j.amjcard.2016.05.012. 30. Himbert D, Vahanian A. Transcatheter aortic valve replacement for patients with heart failure. Heart Fail Clin. 2015;11:231–242. doi: 10.1016/j. hfc.2014.12.003. 31.Urena M, Webb JG, Eltchaninoff H, Muñoz-García AJ, Bouleti C, Tamburino C, Nombela-Franco L, Nietlispach F, Moris C, Ruel M, Dager AE, Serra V, Cheema AN, Amat-Santos IJ, de Brito FS, Lemos PA, Abizaid A, Sarmento-Leite R, Ribeiro HB, Dumont E, Barbanti M, Durand E, Alonso Briales JH, Himbert D, Vahanian A, Immè S, Garcia E, Maisano F, del Valle R, Benitez LM, García del Blanco B, Gutiérrez H, Perin MA, Siqueira D, Bernardi G, Philippon F, Rodés-Cabau J. Late cardiac death in patients undergoing transcatheter aortic valve replacement: incidence and predictors of advanced heart failure and sudden cardiac death. J Am Coll Cardiol. 2015;65:437–448. doi: 10.1016/j.jacc.2014.11.027. 32.Bradley EH, Curry L, Horwitz LI, Sipsma H, Wang Y, Walsh MN, Goldmann D, White N, Piña IL, Krumholz HM. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes. 2013;6:444–450. doi: 10.1161/ CIRCOUTCOMES.111.000101. 33.Chopard R, Teiger E, Meneveau N, Chocron S, Gilard M, Laskar M, Eltchaninoff H, Iung B, Leprince P, Chevreul K, Prat A, Lievre M, Leguerrier A, Donzeau-Gouge P, Fajadet J, Mouillet G, Schiele F; FRANCE-2 Investigators. Baseline characteristics and prognostic implications of pre-existing and new-onset atrial fibrillation after transcatheter aortic valve implantation: results from the FRANCE-2 Registry. JACC Cardiovasc Interv. 2015;8:1346–1355. doi: 10.1016/j.jcin.2015.06.010. 34. Biviano AB, Nazif T, Dizon J, Garan H, Fleitman J, Hassan D, Kapadia S, Babaliaros V, Xu K, Parvataneni R, Rodes-Cabau J, Szeto WY, Fearon WF, Dvir D, Dewey T, Williams M, Mack MJ, Webb JG, Miller DC, Smith CR, Leon MB, Kodali S. Atrial fibrillation is associated with increased mortality in patients undergoing transcatheter aortic valve replacement: insights from the Placement of Aortic Transcatheter Valve (PARTNER) Trial. Circ Cardiovasc Interv. 2016;9:e002766. doi: 10.1161/ CIRCINTERVENTIONS.115.002766. 35. Reynolds MR, Magnuson EA, Lei Y, Wang K, Vilain K, Li H, Walczak J, Pinto DS, Thourani VH, Svensson LG, Mack MJ, Miller DC, Satler LE, Bavaria J, Smith CR, Leon MB, Cohen DJ; PARTNER Investigators. Costeffectiveness of transcatheter aortic valve replacement compared with surgical aortic valve replacement in high-risk patients with severe aortic stenosis: results of the PARTNER (Placement of Aortic Transcatheter Valves) trial (Cohort A). J Am Coll Cardiol. 2012;60:2683–2692. doi: 10.1016/j.jacc.2012.09.018. 36. Reynolds MR, Lei Y, Wang K, Chinnakondepalli K, Vilain KA, Magnuson EA, Galper BZ, Meduri CU, Arnold SV, Baron SJ, Reardon MJ, Adams DH, Popma JJ, Cohen DJ; CoreValve US High Risk Pivotal Trial Investigators. Cost-effectiveness of transcatheter aortic valve replacement with a self-expanding prosthesis versus surgical aortic valve replacement. J Am Coll Cardiol. 2016;67:29–38. doi: 10.1016/j.jacc.2015.10.046. 37. McCabe JM, Waldo SW, Kennedy KF, Yeh RW. Treatment and outcomes of acute myocardial infarction complicated by shock after public reporting policy changes in New York. JAMA Cardiol. 2016;1:648–654. doi: 10.1001/jamacardio.2016.1806. Downloaded from http://circinterventions.ahajournals.org/ by guest on June 18, 2017 Thirty-Day Readmissions After Transcatheter Aortic Valve Replacement in the United States: Insights From the Nationwide Readmissions Database Dhaval Kolte, Sahil Khera, M. Rizwan Sardar, Neil Gheewala, Tanush Gupta, Saurav Chatterjee, Andrew Goldsweig, Wilbert S. Aronow, Gregg C. Fonarow, Deepak L. Bhatt, Adam B. Greenbaum, Paul C. Gordon, Barry Sharaf and J. Dawn Abbott Circ Cardiovasc Interv. 2017;10: doi: 10.1161/CIRCINTERVENTIONS.116.004472 Circulation: Cardiovascular Interventions is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2016 American Heart Association, Inc. All rights reserved. Print ISSN: 1941-7640. Online ISSN: 1941-7632 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circinterventions.ahajournals.org/content/10/1/e004472 Data Supplement (unedited) at: http://circinterventions.ahajournals.org/content/suppl/2017/01/16/CIRCINTERVENTIONS.116.004472.DC1 Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation: Cardiovascular Interventions can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation: Cardiovascular Interventions is online at: http://circinterventions.ahajournals.org//subscriptions/ SUPPLEMENTAL MATERIAL 1 Supplemental Tables: Table 1. International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9CM) Codes Used To Identify Baseline Comorbidities, Procedures and In-Hospital Outcomes Variable Code(s) Comorbidities Smoking Dyslipidemia V15.82, 30.51 272.0–4 Known CAD Prior MI Prior PCI Prior CABG 414.00–07 412 V45.82 V45.81 Carotid artery disease Prior TIA/stroke Atrial fibrillation Prior PPM Prior ICD 433.10 V12.54, 438.x 427.31 V45.01 V45.02 Dementia 290.xx, 294.1x, 294.2x, 294.8, 331.0–2, 331.82, 797 In-Hospital Procedures Endovascular TAVR Transapical TAVR Coronary angiography PCI Mechanical circulatory support In-Hospital Outcomes Surgical AVR Complete heart block PPM placement TIA/Stroke 35.05 35.06 88.55, 88.56, 37.22, 37.23 00.66, 36.01, 36.02, 36.05, 36.06, 36.07 37.61, 37.68, 39.65 35.21, 35.22 42.60 37.80–83, 00.50 431, 433.x1, 434.x1, 435.x, 344.6x, 997.01 AMI Cardiogenic shock 410.x1, 411.1 785.51 Cardiac arrest AKI 427.5 584.x 2 Major bleeding 430, 431, 432.x, 336, 362.43, 362.81, 363.61, 363.62, 363.72, 364.41, 3736.32, 377.42, 379.23; 423.0 + 37.0; 923.x + 729.71, 924.x + 729.72, 922.2–9 + 729.73; 456.0, 456.20, 530.7, 530.82, 531.00, 531.01, 531.20, 531.21, 531.40, 531.41, 531.60, 531.61, 532.00, 532.01, 532.20, 532.21, 532.40, 532.41, 532.60, 532.61, 533.00, 533.01, 533.20, 533.21, 533.40, 533.41, 533.60, 533.61, 534.00, 534.01, 534.20, 534.21, 534.40, 534.41, 534.60, 534.61, 569.3, 578.0, 578.1, 578.9, 568.81, 599.70, 599.71, 719.1x, 784.7, 784.8, 459, 998.11, 998.12, 285.1 + 998.00, 998.09, 785.50, 785.59, 276.52 + 00.17 + 99.0x Vascular complications 900–904, 998.2, 999.2, 997.7, 447.0, 868.04 + 39.31, 39.41, 39.49, 39.52, 39.56, 39.57, 39.59, 39.79 Hypertension, diabetes mellitus, obesity, heart failure, peripheral vascular disease, anemia, chronic kidney disease, chronic lung disease, liver disease, coagulopathy, depression, hypothyroidism, fluid and electrolyte disorders, other neurological disorders, pulmonary circulation disorders, and cancer were identified from the 29 Elixhauser comorbidities included in the Nationwide Readmissions Database. CAD = coronary artery disease, MI = myocardial infarction, PCI = percutaneous coronary intervention, CABG = coronary artery bypass grafting, TIA = transient ischemic attack, PPM = permanent pacemaker, ICD = implantable cardioverter defibrillator, AVR = aortic valve replacement, AKI = acute kidney injury 3 Table 2. Causes of 30-Day Readmissions Categorized According to Clinical Classifications Software (CCS) and/or International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) Codes in the Primary Diagnosis Position* Causes of Readmission CCS code(s) ICD-9-CM code(s) 122, 124, 125, 127, 128, 129, 130, 131, 133, 134 415.19, 997.3x Infections 2, 4, 135, 159, 197, 246 519.01, 780.62, 996.6x, 998.5x Bleeding 60, 153 280.0, 537.83, 569.85–86, 599.7x, 998.1x Peripheral vascular disease 114, 115, 116, 118, 248 415.11, 443.89, 997.2, 997.79 Genitourinary 156, 157, 158, 160, 161, 163, 165, 166 403.91, 458,21, 997.5, 996.73, 996.76 Gastrointestinal 138, 140, 141, 143, 145, 146, 147, 149, 151, 152, 154, 155, 250, 251 109, 112 996.82, 997.49 Trauma 226, 229, 230, 231, 233, 235, 239, 242, 244 997.99, 998.32, 998.83 Endocrine/metabolic 49, 50, 51, 52, 54, 55 — Neuropsychiatric 83, 84, 85, 93, 95, 653, 660, 661 780.97 Hematological/neoplasms 59, 14, 32, 42, 44 790.92 Others 199, 204, 209, 211, 252, 253, 254, 257 — 108 402.91, 404.11, 404.91, 404.93, 429.4, 997.1 — NON-CARDIAC Respiratory TIA/stroke CARDIAC Heart failure Arrhythmias 106, 107 4 — Conduction disorders 105 — Valve disordersy 96 Hyper/hypotension — 421.x, 996.02, 996.71, 996.72, 996.74 401.x, 458.0, 458.29, 458.9 Pericarditis — 420.x, 423.x CAD 101, 104 — AMI 100 — Others 102, 245 416.8 *CCS and ICD-9-CM codes listed are NOT all inclusive for each category, but represent the primary diagnosis codes present in the discharge record of TAVR patients who experienced 30day readmission in this study. y including endocarditis, prosthesis-related mechanical complications, and aortic valve re- intervention TIA = transient ischemic attack, CAD = coronary artery disease, AMI = acute myocardial infarction 5 Supplemental Figures and Figure Legends: Figure 1. TAVR Volume 6 Figure 2. Hospital Variation in 30-Day Readmission Rates After TAVR 7 Figure 3. Kaplan-Meier Curves for 30-Day Readmissions for Different Risk Factors 8 Figure Legends: Figure 1. TAVR Volume Histogram showing distribution of hospitals according to number of TAVR procedures performed during the study period Figure 2. Hospital Variation in 30-Day Readmission Rates After TAVR Hospitals performing ≥5 (A) or ≥10 (B) TAVRs were divided into deciles of 30-day readmission rates. Box plots depict median, interquartile range and range of 30-day readmission rates for hospitals in each decile. Figure 3. Kaplan-Meier Curves for 30-Day Readmissions for Different Risk Factors Kaplan-Meier curves showing 30-day readmission rates for TAVR patients with LOS >5 vs ≤5 days (A), AKI vs no AKI (B), >4 vs ≤4 Elixhauser comorbidities (C), TA vs endovascular TAVR (D), CKD vs no CKD (E), CLD vs no CLD (F), and discharge to SNF vs home (G). LOS = length of stay, AKI = acute kidney injury, CKD = chronic kidney disease, TA = transapical, CLD = chronic lung disease, SNF = skilled nursing facility. 9