High readmission rate after heart valve surgery: A nationwide cohort study

doi:10.1016/j.ijcard.2015.04.078

International Journal of Cardiology

Volume 189, 15 June 2015, Pages 96-104

https://doi.org/10.1016/j.ijcard.2015.04.078 Get rights and content

Highlights

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A nationwide cohort study with patients after heart valve surgery is presented.
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Data are self-reported with linkage to Danish registries.
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Within 12 months of surgery, 56% of patients are readmitted, primarily acutely.
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Lower self-reported health status is associated with readmission.
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We present recommendations for follow-up strategies after heart valve surgery.

Abstract

Background

After heart valve surgery, knowledge on long-term self-reported health status and readmission is lacking. Thus, the optimal strategy for out-patient management after surgery remains unclear.

Methods

Using a nationwide survey with linkage to Danish registers with one year follow-up, we included all adults 6–12 months after heart valve surgery irrespective of valve procedure, during Jan–June 2011 (n = 867). Participants completed a questionnaire regarding health-status (n = 742), and answers were compared with age- and sex-matched healthy controls. Readmission rates and mortality were investigated.

Results

After valve surgery, the self-reported health was lower (Short Form-36 (SF-36) Physical Component Scale (PCS): 44.5 vs. 50.6 and Mental Component Scale (MCS): 51.9 vs. 55.0, p < 0.0001) and more were physically sedentary compared with healthy controls (11.1% vs. 15.2%). Clinical signs of anxiety and depression were present in 13.6% and 13.8%, respectively (Hospital Anxiety and Depression Scale score ≥ 8). Twelve months following discharge, 483 persons (56%) were readmitted. Readmission was associated with lower self-reported health (SF-36 PCS: 46.5 vs. 43.9, and MCS 52.2 vs. 50.7). Higher age (hazard ratio (95% CI): 1.3 (1.0–1.6)), male sex (1.2 (1.0–1.5)), mitral valve surgery (1.3 (1.0–1.6)), and infective endocarditis after surgery (1.8 (1.1–3.0), p: 0.01) predicted readmission, whereas higher age (2.3 (1.0–5.4)), higher comorbidity score (3.2 (1.8–6.0)), and infective endocarditis after surgery (3.2 (1.2–8.9)) predicted mortality.

Conclusions

6–12 months after heart valve surgery the readmission rate is high and the self-reported health status is low. Readmission is associated with low self-reported health. Therefore, targeted follow-up strategies post-surgery are needed.

Introduction

Heart valve surgery remains the ultimate treatment of heart valve disease. Heart valve surgery improves survival, quality of life and physical capacity for patients with symptoms or hemodynamically progressed heart valve disease [1], [2]. Guidelines regarding follow-up after heart valve surgery include medical assessment with anticoagulant therapy, echocardiography and rehabilitation [2] but evidence for systematic recommendations is limited both short-term and long-term. Consequently, the current after care planning does not focus on patient-reported outcomes and readmission which are parameters important to both patients and healthcare policy makers.

Undergoing valve surgery includes intersectional follow-up thus leaving the after care management challenged. Early discharge to a less specialized environment after cardiac surgery might include a risk of complications, such as atrial fibrillation [3]. After coronary artery bypass grafting 44% are readmitted within 2 years of surgery [4] but the readmission rate after valve surgery is sparsely reported. Mortality and short-term follow-up after heart valve surgery are thoroughly described [5], yet possibly leaving out important details regarding longer term patient status [6]. Comparing pre- and post-surgery, quality of life and physical capacity usually improve [7], [8]. Despite these benefits decreased physical function, anxiety, and depression might remain [9], being well-known independent predictors of long-term morbidity and mortality [10]. However, previous studies report short-term improvement, but the patient reported health-status long-term is lacking. Further, it has never been investigated whether an association between readmission and self-reported health such as perceived health, physical activity, anxiety and depression exists after heart valve surgery.

The aim of this nationwide study was following heart valve surgery to (i) describe self-reported health status, readmission and mortality at 6–12 months, (ii) examine the association between self-reported health status and readmission, and (iii) investigate predictors of readmission and mortality.

Section snippets

Population

Using a nationwide survey with linkage to Danish registers, we identified all adults with heart valve surgery in Denmark during 1 January 2011–30 June 2011 from The Danish National Patient Register using the Danish SKS procedure codes KFG, KFK, KFM, KFJE and KFJF. These procedure codes include all kinds of valve surgery and procedures. The diagnoses were based on the Nordic Medico-Statistical Committee classification of Surgical Procedures (NOMESCO) coding.

Of the study population (n = 867), 742

Ethics

The study complies with The Declaration of Helsinki and was approved by the Danish Data Protection Agency (2011-41-6378, 2013-41-1643), and data were handled in accordance with the Act on Processing of Personal Data.

Participants

Of the total population, 63% were male, mean age at surgery was 69 years, and 54% were married at time of surgery (Table 1). The majority had aortic valve surgery (78%) or mitral valve surgery (24%). One third (27%) had concomitant coronary artery bypass grafting, and 5.5% (n = 48) had surgery of ≥ 2 valves. The length of stay was 9.6/8.0 (6–11) (mean/median (IQR)) days during the index hospitalization, and most (67%) were discharged directly from the operating hospital.

The response rate of the

Discussion

In this Danish nationwide cohort study, we found low self-reported health status, low physical activity level, and high readmission rates within the first 12 months following heart valve surgery. Further, we found a strong association between low self-reported health and readmission. This is the first study to describe the health status and readmission after heart valve surgery, stratify self-reported outcomes by readmission, and link data with readmission rate and mortality.

Notably, we found a

Conclusions

After heart valve surgery, self-reported health is lower than the general population, and low self-reported health is associated with readmission. Further, the readmission rate is considerably high within the first 12 months of surgery. The study highlights a lack of knowledge regarding management after heart valve surgery. Above all, individualized and targeted follow-up strategies after heart valve surgery are warranted.

Funding

This work was supported by the Danish Strategic Research Council (grant number: 10-092790).

Conflict of interest

None.

Acknowledgments

Thanks to the respondents for their important contributions. We are indebted to LCT and The National Institute of Public Health, University of Southern Denmark, for substantial contributions to data handling.

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Trunk stabilising exercises promote sternal stability in patients after median sternotomy for heart valve surgery: a randomised trial
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What is the effect of trunk stabilising exercises on sternal stability in women who have undergone heart valve surgery via median sternotomy?
Randomised controlled trial with concealed allocation, assessor blinding and intention-to-treat analysis.
Thirty-six women aged 40 to 50 years who had undergone heart valve surgery via median sternotomy 7 days before enrolment.
All participants in both groups received cardiac rehabilitation during hospitalisation and three times per week for 4 weeks after discharge. In addition, participants in the experimental group were prescribed a regimen of trunk stabilising exercises to be performed three times per week for 4 weeks. At each exercise session, each of 11 exercises were to be performed with five to ten repetitions.
The primary outcome was sternal separation (the distance between the two halves of the bisected sternum). The secondary outcome was the Sternal Instability Scale from 0 (no instability) to 3 (an unstable sternum with substantial movement or separation). Measures were taken before and after the 4-week intervention period.
After the 4-week intervention period, the experimental group had a greater decrease in sternal separation by 0.09 cm (95% CI 0.07 to 0.11). The experimental group was twice as likely to improve by at least one grade on the Sternal Instability Scale by 4 weeks (RR 2.00, 95% CI 1.07 to 3.75). The experimental group was almost three times as likely to have a clinically stable sternum (grade 0 on the Sternal Instability Scale) by 4 weeks (RR 2.75, 95% CI 1.07 to 7.04).
Trunk stabilising exercises were an effective and feasible method of promoting sternal stability in women who underwent heart valve surgery via median sternotomy.
NCT04632914.
Physical activity and serious adverse events in patients with atrial fibrillation and/or atrial flutter treated with catheter ablation
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Atrial fibrillation (AF) and atrial flutter (AFL) are cardiac arrhythmias associated with cardiovascular morbidity. Physical activity (PA) can trigger AF and AFL recurrence, but can also improve physical functional capacity in this patient group. Guidelines do not include concrete recommendations regarding PA for this patient group.
To assess the impact of the level of PA on risk of serious adverse events (SAEs) in patients with AF and/or AFL treated with catheter ablation.
A prospective cohort study including 462 patients with AF and/or AFL treated with catheter ablation from the CopenHeart Survey. The International Physical Activity Questionnaire (IPAQ) was used to explore patients’ self-reported level of PA. SAEs were identified in the Danish National Patient Register and the Danish Civil Registration System one year after study onset. Cox regression analysis was carried out to assess the risks of SAE.
During the one-year follow-up period, 98 patients (21.8%) experienced at least one SAE. Patients with a moderate-high PA level had a 36% lower risk of experiencing SAEs during the follow-up period, compared to patients in the low PA group, after adjusting for confounders.
A moderate-high vs. low level of PA was found to be associated with a lower incidence of SAEs in patients undergoing AF and/or AFL ablation.
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A prospective randomized controlled trial was conducted. Patients (n = 288) were randomly allocated to either post-discharge usual care or to care that provided TFU and access to a 24/7 hotline after AVR. Ancillary endpoints were time-to-event (readmission), proportion of avoidable versus unavoidable readmissions after AVR, and predictors of 30-DACR after AVR.
30-DACR was 22.3%. The structured TFU and 24/7 hotline intervention failed to reduce 30-DACR rates after AVR (P = 0.274). Symptoms of anxiety were significantly reduced 30 days after surgery (P = 0.031), an effect that did not persist one year after surgery (P = 0.108). Most readmissions occurred before 15 days post-discharge, and 75% of them were deemed to be unavoidable. Pleural drainage before hospital discharge (P = 0.027) and symptoms of anxiety before surgery (P = 0.003) were predictors of 30-DACR after AVR.
The TFU and 24/7 hotline had no effect on reducing 30-DACR after AVR. However, we did measure reduced symptoms of anxiety the first month after AVR. Anxiety reduction appeared to be an important target for intervention, because we found it to be a risk factor for readmission. Future research should focus on the effectiveness of interventions to prevent avoidable unplanned readmissions.
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A total of 34,564 cardiac patients were discharged of whom 16,712 patients completed the questionnaire. A total of 11,693 (36%) patients were readmitted for cardiac reasons at least once during the first year after index admission. The risk of readmission was predicted by anxiety (HR = 1.36 (CI:1.26–1.46)) and depression (HR = 1.42 (CI:1.31–1.55)). Higher scores reflected lower readmission risk on the physical (HR = 0.98 (CI:0.98–0.98)) health component of the SF-12.
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^☆: Prior abstract oral presentation: K.L. Sibilitz, May 9, 2014, EuroPrevent, European Society of Cardiology, Amsterdam (rapid fire).

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High readmission rate after heart valve surgery: A nationwide cohort study☆

Highlights

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Population

Ethics

Participants

Discussion

Conclusions

Funding

Conflict of interest

Acknowledgments

Am. J. Cardiol.

J. Thorac. Cardiovasc. Surg.

J. Thorac. Cardiovasc. Surg.

Am. J. Cardiol.

Ann. Thorac. Surg.

J. Chronic Dis.

Gen. Hosp. Psychiatry

Ann. Thorac. Surg.

Guidelines on the management of valvular heart disease: the Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology

Eur. Heart J.

Recommendations for the management of patients after heart valve surgery

Eur. Heart J.

Predictors of hospital readmission two years after coronary artery bypass grafting

Heart

A prospective study of changes in the quality of life of patients following mitral valve repair and replacement

Eur. J. Cardiothorac. Surg.

Patient experiences of recovery after heart valve replacement: suffering weakness, struggling to resume normality

BMC Nurs.