1. Connie N. Hess, MD, Bimal R. Shah, MD, MBA, S. Andrew Peng, MS, Laine Thomas, PhD, Matthew T. Roe, MD, MHS, Eric D. Peterson, MD, MPH Relationship of Early Physician Follow-up and 30-Day Readmission after NSTEMI Among Older Patients

2. Disclosures C.N. Hess: None. S. Peng: None. L. Thomas: None. M.T. Roe: Bristol Myers Squibb, Eli Lilly, Hoffmann- La Roche, Novartis. Astrazeneca, Helsinn Pharmaceuticals, KAI Pharmaceuticals, Merck & Co., Sanofi-Aventis, Orexigen, Regeneron. B.R. Shah: None. E.D. Peterson: Eli Lilly, Janssen Pharmaceuticals.

4. Background  Strategies to reduce readmissions have focused on transitions of care processes.  Prior data suggest that early physician follow-up after hospitalization for heart failure may reduce readmissions. 1  Whether this strategy is effective for acute myocardial infarction (AMI) patients is unknown. 1 Hernandez, AF et al. JAMA. 2010;303:1716-1722

5. Objectives  To characterize hospital variation in early physician follow-up after discharge for non-ST- segment elevation myocardial infarction (NSTEMI)  To examine the relationship between rates of early physician follow-up and risk of readmission

6. Methods: Data sources and study population  Clinical data from CRUSADE registry linked with longitudinal Medicare claims data from 2003-2006 NSTEMI pts ≥65 years surviving to hospital discharge (n= 42,568) Patients discharged home (n= 31,789) Transfer to acute care facility (n= 4,474) Transfer to skilled nursing facility/hospice (n= 6,305) Analysis population: n= 27,852 patients at 228 sites Non-index admissions (n= 949) Hospitals w/o PCI & CABG (n= 3,849) Hospitals with < 25 pts remaining (n= 927)

7. Methods: Definitions and outcome  Early physician follow-up  MD visit within 7 days of discharge  Primary outcome: 30-day all-cause readmission

8. Methods: Statistical analyses  Logistic regression with hospital as random effect to examine hospital-level early follow-up and 30-day readmission  Adjustment models: 1) Patient demographic and clinical characteristics 2) #1 + hospital features (bed size, region, academic status) 3) #2 + treatment features (discharge medications, revascularization)

9. Variation in hospital-level early physician follow-up Hospital early physician follow-up Number of hospitals

10. Results: Patient characteristics Hospital Q1 (n=6129) Hospital Q2 (n=6759) Hospital Q3 (n=7626) Hospital Q4 (n=5358) Hospital early follow-up (%) <17.817.8-23.223.3-28.9>28.9 Demographics Age, median, y 76.0 77.0 Female sex (%)43.744.344.843.9 Race (%) White89.287.882.583.6 Black6.17.38.58.3 Clinical characteristics Diabetes Mellitus33.4 33.234.535.5 Prior MI 28.430.031.831.6 Renal insufficiency 14.014.915.616.2 Signs of heart failure (%) 25.824.325.328.0 Transfer-in status (%) 31.031.124.115.3 In-hospital treatment Cardiac cath (%) 78.077.675.073.8 PCI (%) 46.145.24443.6 CABG (%)12.110.8109.8

11. Hospital characteristics Hospital Q1 (n=57) Hospital Q2 (n=57) Hospital Q3 (n=57) Hospital Q4 (n=57) Region Northeast (%) South (%) Midwest (%) West (%) 22.8 36.8 1.8 28.1 31.6 33.3 7.0 17.5 35.1 28.1 19.3 17.5 24.6 38.6 15.8 Teaching hospital (%) 22.838.626.331.6 Median # hospital beds 374.0431.0352.0391.0 Median length of stay (days) 5.3 5.45.5 Transfer-in patients (%) 12.110.8109.8

12. Unadjusted 30-day readmission by hospital-level early physician follow-up 30-day readmission (%) p = 0.13

13. Model 1 Quartile 2 Quartile 3 Quartile 4 Model 2 Quartile 2 Quartile 3 Quartile 4 Model 3 Quartile 2 Quartile 3 Quartile 4 Adjusted 30-day readmission by hospital-level early physician follow-up

14. Study limitations  Observational study - residual confounding  No data regarding non-physician post- discharge medical contacts  Limited to follow-up w/in 7 days and readmission w/in 30 days  Hospital-level measure insensitive  Low overall rates of early follow-up

15. Conclusions  1 in 5 older NSTEMI patient readmitted within 30 days of discharge  Most patients not seen in follow-up by a physician within 7 days of discharge  Overall hospital rate of early physician follow-up low but variable  No association between early physician follow- up and 30-day readmission demonstrated

16. Future directions  Prospective assessment of early physician follow-up and readmission  Examination of other strategies to reduce readmission after AMI  Effectiveness of early follow-up as part of bundled strategy rather than isolated intervention

17. Thank you