[Insight into unplanned readmissions: meaning and possibilities of a classification]. / Inzicht in ongeplande heropnames: zin en mogelijkheden van een classificatie.

OBJECTIVE: We investigated whether a classification method for readmissions, first developed in the United Kingdom, can be applied to Dutch (re-)admission data and possibly used as an indicator of quality. DESIGN: Retrospective analysis of Dutch administrative hospital admission data supplied to the Dutch National Medical Registration database. METHOD: Readmissions are urgent inpatient admissions that occur within 30 days of discharge from a previous inpatient admission in the same hospital, with the latter being the index admission. Based on the original UK research, readmissions have been classified into seven categories: (A) complication following index admission; (B) anticipated but unpredictable hospital care; (C) patient or healthcare professional preference; (D) artefact; (E) related to a different body system; (F) related to the same body system; (G) social-economic, psychosocial or other indication. This classification was applied to admission data for 18 Dutch hospitals covering the period 2009-2013. RESULTS: Of a total of 1,633,466 admissions, 120,343 (7.37%) were followed by a readmission. The most common category contributing to readmissions was 'the same body system' (category F, 44.07%), followed by readmissions related to different body systems (category E, 27.85%). The most prominent avoidability categories 'complications following index admission (category A, 17.66%) and anticipated hospital care (category B, 5.31%) ended up in third and fourth place respectively. Finally, the joint share for categories C, D and G was 5.55%. The classification of readmissions differs only slightly between different types of hospitals (university, top clinical, general). Large differences in the classification distribution are found between clinical specialties. CONCLUSION: The classification system for readmissions can be applied well to Dutch admission data and offers an insight into the patterns of admissions and readmissions. Closer in-depth research may provide more evidence concerning the suitability of this classification system as an indicator of hospital quality.

CYP2C19 genotype-guided antiplatelet therapy in ST-segment elevation myocardial infarction patients-Rationale and design of the Patient Outcome after primary PCI (POPular) Genetics study.

RATIONALE: In patients with ST-segment elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (pPCI), the use of dual antiplatelet therapy is essential to prevent atherothrombotic complications. Therefore, patients are treated with acetylsalicylic acid and clopidogrel, prasugrel, or ticagrelor. Clopidogrel, however, shows a major interindividual variation in antiplatelet effect, which is correlated to an increase in atherothrombotic events in patients with high platelet reactivity. This interindividual variation is partly a result of CYP2C19 genetic variants. Ticagrelor and prasugrel reduce atherothrombotic events but increase bleeding rate and drug costs, as compared with clopidogrel. CYP2C19-based tailoring of antiplatelet therapy might be beneficial to STEMI patients. STUDY DESIGN: POPular Genetics (NCT01761786) is a randomized, open-label, multicenter trial involving 2,700 STEMI patients who undergo pPCI. Patients are randomized to CYP2C19 genotyping or routine ticagrelor or prasugrel treatment. In the genotyping group, *1/*1 (wild-type) patients receive clopidogrel, and patients carrying 1 or 2 *2 or *3 loss-of-function alleles receive ticagrelor or prasugrel. The primary net clinical benefit end point is the composite of death, (recurrent) myocardial infarction, definite stent thrombosis, stroke, and Platelet Inhibition and Patient Outcomes (PLATO) major bleeding at 1 year. Primary safety end point is the composite of (PLATO) major and minor bleeding. Cost-effectiveness and quality of life will be assessed by calculating quality-adjusted life-years, net costs per life-year, and per quality-adjusted life-year gained. CONCLUSION: The POPular Genetics study is the first large-scale trial comparing CYP2C19 genotype-guided antiplatelet therapy to a nontailored strategy in terms of net clinical benefit, safety, and cost-effectiveness.