Facility-Level Percutaneous Coronary Intervention Readmission Rates Are Not Associated With Facility-Level Mortality: Insights From the VA Clinical Assessment, Reporting, and Tracking (CART) Program.

BACKGROUND: Thirty-day readmission after percutaneous coronary intervention (PCI) is common, costly, and linked to poor patient outcomes. Accordingly, facility-level 30-day readmission rates have been considered as a potential quality measure. However, it is unknown whether facility-level 30-day readmission rates are associated with facility-level mortality. We sought to determine the effect of 30-day readmissions after PCI on mortality at both the patient and facility level in the Veterans Administration hospital system. METHODS AND RESULTS: We included all patients who underwent PCI in the Veterans Administration hospital system nationally from October 2007 through August 2012, comparing all-cause mortality rates between patients with and without 30-day readmissions following PCI. Patients were then aggregated at the hospital level to evaluate the correlation between hospital-level readmission rates with hospital-level 1-year mortality rates. Among 41 069 patients undergoing PCI at 62 sites, 12.2% were readmitted within 30 days of discharge. Patients with 30-day readmission had higher risk-adjusted mortality (hazard ratio 1.53, 95% CI 1.44-1.63, P<0.0001). Facilities varied widely in 30-day readmission rates (systemwide range of 6.6-19.4%, median 11.8%, interquartile range 10.0-13.2%); however, adjusted facility-level readmission rates were not correlated with adjusted 1-year mortality rates. CONCLUSIONS: Thirty-day readmissions after PCI are common and are a significant risk factor for mortality for individual patients even after robust statistical adjustment for clinical confounding. However, lack of correlation between readmission and mortality at the facility level suggests that quality improvement based on facility-level readmission rates will not modify mortality in this high-risk group.

Multiple primary cancers including mesothelioma of the tunica vaginalis: case report and literature review with primary care focus.

The development of multiple primary malignancies in an individual is rare and unfortunate, and the care of such a patient presents specific challenges. We report the diagnosis and progression of 3 histologically different primary cancers in 1 patient over the course of 15 years. At age 50 years, the patient received a diagnosis of transitional cell carcinoma of the bladder; treatment was successful. When the patient was 64 years old, mesothelioma of the tunica vaginalis was diagnosed, and computed tomography performed for staging purposes revealed a lung lesion, which was later diagnosed as adenocarcinoma. Treatment for the adenocarcinoma was also successful, but the patient continues to have recurrence of mesothelioma. To our knowledge, the present report is the first description of a case of 3 primary cancers that includes a mesothelioma of the tunica vaginalis. Because mesothelioma of the tunica vaginalis is rare, we reviewed the literature on its prevalence, presentation, management, and prognosis.