Quantifying the Impact of Care Fragmentation on Outcomes After Transcatheter Aortic Valve Implantation

The Center for Medicare & Medicaid Services has identified readmission as an important quality metric in assessing hospital performance and value of care. The aim of this study was to quantify the impact of "care fragmentation" on transcatheter aortic valve implantation (TAVI) outcomes. Readmission to nonindex hospitals was defined as any hospital other than the hospital where the TAVI was performed. In this multicenter, population-based, nationally representative study, a nationally weighted cohort of US adult patients who underwent TAVI in the National Readmission Database between 01/01/2010 and 9/31/2015 were analyzed. Patient characteristics, trends, and outcomes after 90-day nonindex readmission were evaluated. Thirty-day metric was used as a reference group for comparison. A weighted total of 51,092 patients met inclusion criteria. Overall, the 90-day readmission rate after TAVI was 27.6% (30-day reference group: 17.4%), and 42% of these readmissions were to nonindex hospitals. Noncardiac causes accounted for most nonindex readmissions, but major cardiac procedures were more likely performed at index hospitals during readmission within 90 days. Despite the high co-morbidity burden of patients readmitted to nonindex hospitals, unadjusted and risk-adjusted all-cause mortality, readmission length of stay and total hospital costs following nonindex readmission were lower compared with index readmission at 90 days. In conclusion, in this real world, nationally representative cohort of TAVI patients in the United States, care fragmentation remains prevalent and represent an enduring, residual target for future health policies. Although the impactful readmissions may be directed toward index hospitals, concerted efforts are needed to address mechanisms that increase care fragmentation.