Prediction models for hospital readmissions in patients with heart disease: a systematic review and meta-analysis

Objective: To describe the discrimination and calibration of clinical prediction models, identify characteristics that contribute to better predictions and investigate predictors that are associated with unplanned hospital readmissions. Design: Systematic review and meta-analysis. Data source: Medline, EMBASE, ICTPR (for study protocols) and Web of Science (for conference proceedings) were searched up to 25 August 2020. Eligibility criteria for selecting studies: Studies were eligible if they reported on (1) hospitalised adult patients with acute heart disease; (2) a clinical presentation of prediction models with c-statistic; (3) unplanned hospital readmission within 6 months. Primary and secondary outcome measures: Model discrimination for unplanned hospital readmission within 6 months measured using concordance (c) statistics and model calibration. Meta-regression and subgroup analyses were performed to investigate predefined sources of heterogeneity. Outcome measures from models reported in multiple independent cohorts and similarly defined risk predictors were pooled. Results: Sixty studies describing 81 models were included: 43 models were newly developed, and 38 were externally validated. Included populations were mainly patients with heart failure (HF) (n=29). The average age ranged between 56.5 and 84 years. The incidence of readmission ranged from 3% to 43%. Risk of bias (RoB) was high in almost all studies. The c-statistic was 0.8 in 5 models. The study population, data source and number of predictors were significant moderators for the discrimination. Calibration was reported for 27 models. Only the GRACE (Global Registration of Acute Coronary Events) score had adequate discrimination in independent cohorts (0.78, 95% CI 0.63 to 0.86). Eighteen predictors were pooled. Conclusion: Some promising models require updating and validation before use in clinical practice. The lack of independent validation studies, high RoB and low consistency in measured predictors limit their applicability. Prospero registration number: CRD42020159839. Keywords: adverse events; cardiology; risk management

Bringing the pieces together:Integrating cardiac and geriatric care in older patients with heart disease

Due to the increasing aging population, the number of older cardiac patients is also expected to rise in the next decades. The treatment of older cardiac patients is complex due to the simultaneously presence of comorbidities and polypharmacy, and geriatric conditions such as functional impairment, fall risk and malnutrition. However, the assessment of geriatric conditions is not part of the medical routine in cardiology and therefore these conditions are frequently unrecognized although they have a significant impact on treatment and on outcomes. In addition, treatments are mostly based on single-disease oriented guidelines and inadequately take other conditions into account. This may lead to conflicting recommendations and treatments that do not address important outcomes for older patients such as daily functioning, symptom relief and quality of life. Thus, the care of older cardiac patients is currently suboptimal which increases the risk of functional loss, readmission and mortality. The overall aim of the work described in this thesis is to explore the integration of cardiac and geriatric care for older patients with heart disease. First, by examining how hospitalized older cardiac patients at high risk for adverse events could be identified. Second, by investigating lifestyle-related secondary prevention of cardiovascular complications in older cardiac patients. And third, by developing a transitional care intervention for older cardiac patients and evaluating the effect on unplanned hospital readmission and mortality