Readmission and adverse outcomes after percutaneous coronary intervention in patients with dementia

Abstract

Background: As the population ages, clinicians increasingly encounter ischemic heart disease in patients with underlying dementia. Therefore, we quantified differences in inhospital adverse events and 30-day readmission rates among patients with and without dementia undergoing percutaneous coronary intervention (PCI).

Methods: Using the National Readmissions Database 2017-2018, we identified 755,406 index hospitalizations in which PCI was performed, of which 17,309 (2.3%) had a diagnosis of dementia. After propensity score matching patients with and without dementia, we assessed 30-day readmission and inhospital adverse events by Cox proportional hazards and logistic regression modeling and compared them with those of other common cardiac (pacemaker placement [PP]) and noncardiac (hip replacement surgery [HRS]) procedures.

Results: Thirty-day readmission was significantly higher in patients with dementia than patients without dementia (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.60-1.74). Patients with dementia also experienced higher odds of delirium (odds ratio [OR] 4.37, CI 3.69-5.16), inhospital mortality (OR 1.15, CI 1.01-1.30), cardiac arrest (OR 1.19, CI 1.01-1.39), acute kidney injury (OR 1.30, CI 1.21-1.39), and fall (OR 2.51, CI 2.06-3.07). On multivariable Cox modeling, dementia independently predicted 30-day readmission (HR 1.14, CI 1.07-1.20). The higher readmission risk with PCI (11%) among those with dementia was similar to that of patients undergoing PP (10%), but lower than in those undergoing HRS (41%).

Conclusion: Patients with dementia who undergo PCI experience significantly increased rates of inhospital delirium, mortality, kidney injury, falls, and 30-day readmission. These adverse outcomes should be considered during shared decision-making with patients and their families.

Keywords: PCI; coronary; dementia; readmission.

Figure 1.. Kaplan-Meier curves of 30-day readmission in patients with and without dementia

Kaplan-Meier curves show 30-day readmissions in all patients (Figure 1A), who were then stratified to male (Figure 1B) and female (Figure 1C) patients. A hazard ratio above 1 indicates that the hazard of 30-day readmission is higher in patients with dementia compared with those without dementia, and vice versa. The log-rank tests beneath the curves show the difference in the Kaplan-Meier curves between patients with and without dementia. In Figure 1A, the additional violet curve illustrates 30-day readmissions in patients without dementia prior to propensity score matching. In all figures, the red and blue curves represent 30-day readmissions in patients without dementia after propensity score matching and in patients with dementia (no change after propensity score matching), respectively.

Figure 2.. Potential risk factors of 30-day readmission in patients with dementia

Potential risk factors of 30-day readmission in patients with dementia. A hazard ratio greater than 1 denotes association with 30-day readmission and vice versa. The vertical lines for each potential risk factor represent the odds ratio whereas the perpendicular horizontal line shows the 95% confidence interval. The plots in model 1 on the left (Figure 2A) include baseline characteristics and clinical presentation while those in model 2 on the right (Figure 2B) also include outcomes at the index hospitalization. Figure 2 only includes a subset of the variables in the multivariable model for display purposes. Please refer to Supplementary Figure 6 for complete results of the model.

Figure 3.. Kaplan-Meier curves of 30-day readmissions after PCI, pacemaker placement, and hip replacement surgery in patients with dementia

Kaplan-Meier curves show 30-day readmissions after PCI (light red, dark red), pacemaker placement (light green, dark green), and hip replacement surgery (light blue, dark blue) in patients with and without dementia, respectively. Comparison of procedures represents head-to-head comparison of procedures in patients with dementia. Comparison within procedures represents comparison of patients with and without dementia within the cohort of patients who underwent each procedure. The numbers in the table showing number at risk are those for patients with dementia. Abbreviations: HRS = hip replacement surgery; PCI = percutaneous coronary intervention; PP = pacemaker placement