Thirty-day readmission rates and 30-day mortality rates were adjusted for patient characteristics listed in the Table.
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Bikdeli B, Wang Y, Jimenez D, et al. Pulmonary Embolism Hospitalization, Readmission, and Mortality Rates in US Older Adults, 1999-2015. JAMA. 2019;322(6):574–576. doi:10.1001/jama.2019.8594
Over the past 15 years, advances have occurred in the diagnosis and management of pulmonary embolism (PE).1 Computed tomographic pulmonary angiography (CTPA) is now the routine diagnostic test. The availability of risk stratification tools and non–vitamin K antagonist oral anticoagulants that do not require routine laboratory monitoring have facilitated early discharge of patients.2
The risk of developing PEs and experiencing adverse outcomes increases with age, partly because of the comorbidity burden and low cardiopulmonary reserve.3 Little is known about recent PE hospitalizations or about outcomes in older adults in the context of the improvements in diagnostics and therapeutics.
The Human Investigation Committee at Yale University exempted the study from review because all data were deidentified. We identified Medicare fee-for-service beneficiaries 65 years or older with a principal discharge diagnosis of PE (International Classification of Diseases [ICD], Ninth Revision codes: 415.1X, PE and infarction; 415.11, iatrogenic PE and infarction; 415.13, saddle embolus of pulmonary artery; and 415.19, other PE and infarction) from January 1999 through September 2015. These codes have high positive predictive values for PE.4 After October 2015, the codes were changed to ICD-10. To preserve the internal consistency for the trends, we did not include the fourth quarter of 2015.
Study outcomes included hospitalization rates per 100 000 beneficiary-years, length of stay (LOS); all-cause 30-day readmissions; and all-cause in-hospital, 30-day, and 1-year mortality. Because models for adjustment of LOS and in-hospital mortality have not been validated, unadjusted results are presented. We explored the changes in patient characteristics over time (Table). We used mixed-effects models with the Poisson link function and state-specific random intercepts to assess the hospitalization rates adjusted for demographics, and a logit link function and hospital-specific random intercepts to assess the 30-day and 1-year mortality and 30-day readmission rates, adjusted for patient characteristics. A 2-sided P < .05 was considered significant. Analyses were performed with SAS version 9.4 (SAS Institute Inc).
From 1999 through 2015, there were 810 969 patients with a principal discharge diagnosis of PE. Mean age did not change significantly (77.6 years). The prevalence of some comorbidities, including myocardial infarction and stroke, decreased. The prevalence of respiratory failure and malnutrition increased (P < .001 for trend for all; Table).
The adjusted PE hospitalization rate per 100 000 beneficiary-years was 120.0 (95% CI, 120.0-120.0) in 1999, peaked at 198.0 (95% CI, 194.4-201.6) in 2010, and was 187.2 (95% CI, 184.0-190.4) in 2015. Length of stay declined over time (from 7.7 to 5.0 days; P < .001 for trend). A significant decline was observed in adjusted 30-day readmission rates from 1999 through 2015 (from 15.5% to 13.6%; P = .005; Figure). From 1999 through 2015, unadjusted in-hospital (decline from 8.7% to 4.0%) and adjusted 30-day (decline from 12.7% to 9.4%) and 1-year (decline from 26.3% to 24.1%) mortality rates had a similar pattern (P < .001 for trend).
From 1999 through 2015 among older US adults, hospitalization rates for PE increased, but LOS, readmission rates, and short-term and 1-year mortality rates declined. Use of a more sensitive diagnostic modality (CTPA), which may lead to the diagnosis of anatomically small or incidental PEs with lower acuity of illness, may explain the trends.5 Alternatively, the trends, which are consistent with findings from Registro Informatizado de Enfermedad TromboEmbólica (RIETE)6—a prospective registry primarily from Europe—may reflect improvements in timeliness of diagnosis and therapeutics and in processes of care for older adults with PE. The mortality rates in the final years, when CTPA was routine, remained relatively stable, but LOS and 30-day readmission rates continued to decline.
This study had some limitations. It focused on fee-for-service beneficiaries with principal discharge diagnosis of PE and did not examine other subgroups. Data from 2016 or 2017 were not included because the codes changed to ICD-10, which may have affected the trends. No control condition was studied, so it is unknown whether the trends reflect general trends in hospitalizations, readmissions, and mortality.
Additional studies are required to determine the reasons behind the observed trends and strategies that may mitigate the residual risk of death or recurrence in older adults.
Accepted for Publication: May 30, 2019.
Corresponding Author: Harlan M. Krumholz, MD, SM, Center for Outcomes Research and Evaluation, One Church St, Ste 200, New Haven, CT 06510 (firstname.lastname@example.org).
Author Contributions: Dr Wang had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Bikdeli, Parikh, Monreal, Goldhaber, Krumholz.
Acquisition, analysis, or interpretation of data: Wang, Jimenez, Parikh, Goldhaber.
Drafting of the manuscript: Bikdeli.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Bikdeli, Wang, Jimenez, Goldhaber.
Administrative, technical, or material support: Bikdeli.
Conflict of Interest Disclosures: Dr Bikdeli reported receiving grants from the National Heart, Lung, and Blood Institute (NHLBI) and having served as a consulting expert (on behalf of the plaintiff) for litigation related to a specific type of inferior vena cava (IVC) filter. Dr Jimenez reported receiving personal fees from Bayer, Bristol-Myers Squibb, Daiichi Sankyo, LEO Pharma, Pfizer, and Sanofi-Aventis. Dr Monreal reported receiving grants from Sanofi and Bayer. Dr Goldhaber reported receiving grants from Janssen, Portola, Bristol-Myers Squibb, and Daiichi Sankyo and personal fees from Boehringer Ingelheim. Dr Krumholz reported that he has served as an expert witness (on behalf of the plaintiff) for litigation related to a specific type of IVC; received a research grant through Yale from Medtronic and the US Food and Drug Administration; is a recipient of a research agreement with Medtronic and Johnson & Johnson (Janssen) through Yale; works under contract with the Centers for Medicare & Medicaid Services; chairs a cardiac scientific advisory board for UnitedHealth; is a participant and participant representative of IBM Watson Health; serves on the board of Life Sciences and on the advisory boards of Element Science and Aetna; and is the founder of Hugo. No other disclosures were reported.
Funding/Support: Dr Bikdeli was supported by grant T32 HL007854 from the NHLBI.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The content is the responsibility of the authors and does not necessarily represent the views of the National Institutes of Health. The current study is the idea of the investigators and has not been prepared at the request of a third party.
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