Redefining MI After Revascularization
Numerous definitions for diagnosing myocardial infarction (MI) after coronary revascularization are currently being used by clinicians. In 2013, the Society for Cardiovascular Angiography and Interventions (SCAI) convened an expert panel that proposed new, more meaningful criteria for diagnosing MI after PCI or CABG. “Having a standardized MI definition can help clinicians better identify patients with true complications after PCI or CABG who require urgent action,” says Issam D. Moussa, MD, FSCAI, lead author of the SCAI consensus document. “It would also better reflect the quality of coronary revascularization procedures and assist in the design of research trials aimed at developing effective prevention strategies.” New Criteria The new definition of MI differs from existing definitions in several ways, according to Dr. Moussa. “Both diagnose MI by detecting proteins in the blood that are released when the heart muscle is damaged,” he says. “The universal definition calls for a relatively small increase in cardiac troponin (up to five times the normal level), plus confirmation by an ECG, an imaging test, or symptoms. On the other hand, the new SCAI definition calls for a large increase in CK-MB (up to at least 10 times the normal level) in most cases.” If CK-MB is unavailable, SCAI’s new definition calls for a troponin level that is 70 times the normal level. If an ECG provides strong evidence of an MI, then the new definition allows for blood levels of CK-MB that are five times normal and troponin that is 35 times normal. “When patients are diagnosed with an MI, there are important implications to consider,” Dr. Moussa. “These diagnoses could lead to longer hospitalizations,...
Surgical Readmissions and Quality of Care
Throughout the United States, reducing the rates of hospital readmissions has become a top priority, as evidenced by CMS planning to include surgical procedures in the expansion of the penalty program. “The hospital readmissions reduction program is predicated on the notion that decreasing the frequency with which patients return to hospitals can improve care and lower costs,” says Thomas C. Tsai, MD, MPH. “However, using medical readmission rates as a measure of hospital quality has been controversial.” Hospitals vary substantially in their medical readmission rates, but these data generally do not correlate with the measures that are often used to identify high-quality hospitals, such as mortality. This raises the question of whether or not medical readmission rates actually measure hospital quality or if they instead reflect other factors that are unrelated to hospital care. The relationship between readmission rates and surgical care may be different than that of medical readmissions. Most patients undergo non-urgent major surgery when they’re clinically stable. As a result, surgical readmissions are more likely to result from complications of care received during index hospitalizations. “Clinicians have relatively little information on the types of hospitals that perform well or poorly with regard to surgical readmission rates,” says Dr. Tsai, “but we hypothesized that hospitals excelling in surgical care would generally have fewer readmissions.” A Comprehensive Analysis In a study published in the New England Journal of Medicine, Dr. Tsai and colleagues sought to determine the patterns of surgical readmissions among Medicare patients across a set of major procedures in a national sample of hospitals. The study team combined information from Medicare claims, the American Hospital Association...