Background-Readmission soon after hospital discharge is an expensive and often preventable event for patients with heart failure. We present a model approved by the National Quality Forum for the purpose of public reporting of hospital-level readmission rates by the Centers for Medicare & Medicaid Services. Methods and Results-We developed a hierarchical logistic regression model to calculate hospital risk-standardized 30-day all-cause readmission rates for patients hospitalized with heart failure. The model was derived with the use of Medicare claims data for a 2004 cohort and validated with the use of claims and medical record data. The unadjusted readmission rate was 23.6%. The final model included 37 variables, had discrimination ranging from 15% observed 30-day readmission rate in the lowest predictive decile to 37% in the upper decile, and had a c statistic of 0.60. The 25th and 75th percentiles of the risk-standardized readmission rates across 4669 hospitals were 23.1% and 24.0%, with 5th and 95th percentiles of 22.2% and 25.1%, respectively. The odds of all-cause readmission for a hospital 1 standard deviation above average was 1.30 times that of a hospital 1 standard deviation below average. State-level adjusted readmission rates developed with the use of the claims model are similar to rates produced for the same cohort with the use of a medical record model (correlation, 0.97; median difference, 0.06 percentage points). Conclusions-This claims-based model of hospital risk-standardized readmission rates for heart failure patients produces estimates that may serve as surrogates for those derived from a medical record model. (Circ Cardiovasc Qual Outcomes.

Context Coronary revascularization is among the most common hospital-based major interventional procedures performed in the United States. It is uncertain how new revascularization technologies, new clinical evidence from trials, and updated clinical guidelines have influenced the volume and distribution of coronary revascularizations over the past decade. Objective To examine national time trends in the rates and types of coronary revascularizations during 2001–2008. Design Serial cross-sectional study with time trends. Setting U.S. hospitals in the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample providing coronary revascularization, supplemented by Medicare hospital claims. Patients and Interventions Patients undergoing coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI) from 2001–2008. Main Outcome Measure Annual procedure rates. Results There was a 14% decrease (p<0.001) in the annual rate of coronary revascularizations between 2001 and 2008. The annual CABG rate decreased steadily from 1,742 CABGs per million adults per year in 2001–02 to 1,081 CABGs per million adults per year in 2007–08 (p<0.001), but PCI rates did not significantly change, from 3,827 PCI per million adults per year in 2001–02 to 3,667 PCI per million adults per year in 2007–08 (p=0.74). Between 2001 and 2008 the number of hospitals in the Nationwide Inpatient Sample providing CABG increased by 14% (p=0.03), while the number of PCI hospitals increased by 35% (p<0.001). The median CABG caseload per hospital declined by 28% (p<0.001), and the percentage of CABG hospitals providing fewer than 100 CABGs per year increased from 11% to 26% (p<0.001). Conclusions In U.S. hospitals from 2001–2008, there was a substantial decrease in CABG utilization rates, but PCI utilization rates remained unchanged.

Objective To evaluate the association between door-toballoon time and mortality in hospital in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction to assess the incremental mortality benefit of reductions in door-toballoon times of less than 90 minutes. Design Prospective cohort study of patients enrolled in the American College of Cardiology National Cardiovascular Data Registry, 2005-6. Setting Acute care hospitals. Participants 43 801 patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention. Main outcome measure Mortality in hospital.Results Median door-to-balloon time was 83 minutes (interquartile range 6-109, 57.9% treated within 90 minutes). Overall mortality in hospital was 4.6%. Multivariable logistic regression models with fractional polynomial models indicated that longer door-to-balloon times were associated with a higher adjusted risk of mortality in hospital in a continuous non-linear fashion (30 minutes=3.0%, 60 minutes=3.5%, 90 minutes=4.3%, 120 minutes=5.6%, 150 minutes=7.0%, 180 minutes =8.4%, P<0.001). A reduction in door-to-balloon time from 90 minutes to 60 minutes was associated with 0.8% lower mortality, and a reduction from 60 minutes to 30 minutes with a 0.5% lower mortality. Conclusion Any delay in primary percutaneous coronary intervention after a patient arrives at hospital is associated with higher mortality in hospital in those admitted with ST elevation myocardial infarction. Time to treatment should be as short as possible, even in centres currently providing primary percutaneous coronary intervention within 90 minutes.