AUCTORES
Globalize your Research
Research Article | DOI: https://doi.org/10.31579/2641-0419/253
1 Geisinger Heart Institute, Danville PA
2 Biostatistics Core Center for Health Research, Geisinger Health System, Danville PA
3 University of New Mexico, Albuquerque NM
*Corresponding Author: James C Blankenship, Division of Cardiology 1 University of New Mexico MC 10 5550 Albuquerque New Mexico.
Citation: Imran Baig, Amir Eslami DO, Andrea Berger MA, Cara Nordberg MPH, James Blankenship. (2022). Readmissions in the Year After Percutaneous Coronary Intervention. J. Clinical Cardiology and Cardiovascular Interventions, 5(4); Doi:10.31579/2641-0419/253
Copyright: © 2022 James C Blankenship, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 04 March 2022 | Accepted: 21 March 2022 | Published: 29 March 2022
Keywords: coronary artery disease; percutaneous coronary intervention; re-admission
Prior studies of readmission have evaluated correlates of 30-day readmission but have not evaluated correlates of readmission after 30 days. The study sought to evaluate factors associated with re-hospitalization within one year of undergoing percutaneous coronary intervention (PCI). We analyzed 6265 patients treated at Geisinger hospitals with PCI between January 2010 and December 2015. Correlates of readmission within 1 year were identified. Sub-groups were compared based on reason for readmission (related to versus not related to ischemic heart disease) and timing of readmission (1-30 days versus 31-365 days). Mean age was 64.3 years, 70% were male, and 98.8% were Caucasian. In the first year after PCI, 2,767 patients (44.2%) were re-admitted. Within 30 days 931 patients (14.9%) were readmitted; 1836 (29.3%) were readmitted between 31 and 365 days. Nine hundred fifty (15.2%). In summary, in an unselected patient cohort treated with PCI, approximately 44% of the patients were readmitted within one year. Two-thirds of these were admitted after the first month. Efforts to prevent the need for readmission should continue beyond the first month post-discharge and center on risk factor modification.
Ischemic heart disease related healthcare costs are amongst the highest for any disease entity in the United States. Approximately one in every six US health care dollars is spent on cardiovascular disease [1]. Hospital readmission rates are variable and add to the health care costs. With the high cost of ischemic heart disease and the additional cost of revascularization for this subset of patients, there is limited data on risk factors that correlate with readmission after percutaneous coronary intervention (PCI) [2-4]. Previous studies have reviewed 30-day readmissions post PCI. However, readmissions from 30 days to one-year post-PCI have received little attention. The purpose of this analysis was to identify patient and characteristics associated with hospital readmission in the year after PCI [5].
We studied 7,228 patients undergoing PCI at our medical center between January 1, 2010 and December 31, 2015. For patients with multiple PCI encounters during the study period only the first was included. Patients were excluded if they died during their hospital stay (n = 159), if the encounter was missing the admission and discharge date/time information due to PCI database and electronic health record (EHR) matching issues (n = 24), if they died within 365 days of their procedure without a readmission prior to death (n = 110), or if they were without follow-up in
the Geisinger Health System for 730 days after the original PCI discharge (n = 670). The remaining 6265 patients composed the study cohort.
Hospital readmissions (including emergency department visits and inpatient admissions) within 365 days of the PCI encounter discharge date were identified. Observation unit stays were excluded.
Descriptive statistics are provided for all 6265 patients, and for patients readmitted within 30 days, readmitted within 31-365 days, and not readmitted. Categorical variables are characterized using frequency counts and percentages. Continuous variables are characterized using means and standard deviations (S.D.) or medians and interquartile ranges (IQR). Characteristics of patients readmitted within 365 days were compared to those who were not readmitted using two-sample t-tests, Wilcoxon rank-sum tests, and Pearson’s chi-square, or Fisher’s exact tests, as appropriate. Multinomial logistic regression modeling was used to compare patients readmitted within 30 days, those readmitted within 31-365 days, and those that were not readmitted.
Due to the large number of study variables that were significantly associated with the readmission outcomes, bootstrap resampling was used for variable selection. Starting with 64 variables (Table 1), fast step-down selection keeping factors with significance levels < 0>
| Readmit vs Not Readmitted Model | 30 Day/31 to 365/Not Readmitted Model |
Age (Quadratic) | x | x |
Sex | x | |
Body Mass Index (Piecewise with knot at 30) | x | x |
Insurance Payers | x | x |
Current/Recent Smoker | x | |
Hypertension | x | x |
Dyslipidemia | ||
Family History of Premature coronary artery disease | ||
Prior myocardial infarction | x | |
Prior Heart Failure | x | x |
Prior Valve Surgery/Procedure | x | |
Prior percutaneous coronary intervention | ||
Prior Coronary artery bypass grafting | x | |
Currently on Dialysis | x | |
Cerebrovascular Disease | x | x |
Chronic Lung Disease | x | x |
Diabetes Mellitus | x | x |
Coronary artery disease Presentation | x | x |
Angina Classification within 2 Weeks | x | |
Heart Failure Within 2 Weeks | x | x |
Cardiomyopathy or LV Systolic Dysfunction | ||
Cardiogenic Shock Within 24 Hours | x | x |
Cardiac Arrest Within 24 Hours | ||
Fluoroscopy Time (Piecewise with knot at 19) | x | x |
Contrast Volume | ||
Procedure Diagnostic | x | x |
Intra-aortic balloon pump | ||
Arterial Access Site | x | x |
Left Main | ||
Proximal left anterior descending artery | ||
Distal left anterior descending artery | ||
Circumflex | ||
Right coronary artery | x | |
Ramus | ||
PCI Scheduling Status | x | x |
Cardiogenic Shock at Start of PCI | ||
Pre Creatinine (Piecewise with knot at 0.8) | x | x |
Pre Hemoglobin (Piecewise with knot at 15) | x | x |
Low Molecular Weight Heparin (any) | x | |
Unfractionated Heparin (any) at Procedure | ||
Aspirin at Procedure | ||
Bivalirudin at Procedure | x | |
Glycoprotein IIb/IIIa Inhibitors at Procedure | ||
Clopidogrel at Procedure | x | x |
Prasugrel at Procedure | ||
Ticagrelor at Procedure | x | x |
Angiotensin converting enzyme inhibitors/angiotensin receptor blockers s at Discharge | ||
Aspirin at Discharge | ||
Beta Blockers at Discharge | x | x |
Lipid-Lowering Agents (statins and non-statins) at Discharge | ||
Clopidogrel at Discharge | ||
Prasugrel at Discharge | x | x |
Ticagrelor at Discharge | x | x |
Culprit Lesion Identification | x | x |
Pre-Stenosis Percent | x | x |
Lesion Complexity | x | |
Length (mm) | ||
Thrombus | ||
Bifurcation | ||
Systolic Blood Pressure (Piecewise with knot at 120) | x | x |
Diastolic Blood Pressure (Piecewise with knot at 70) | x | |
Year of Intervention | x | x |
Charlson Comorbidity Index on procedure Date | x | x |
Duration of Index Hospitalization | x | x |
Table 1: Variables Used in Bootstrap Resampling for Variable Selection
not readmitted, and readmitted within 31-365 days vs. not readmitted. Variables selected in 50% or more of the 1000 repetitions for readmitted versus not readmitted were retained for a final multivariable logistic regression model. Variables retained in 50% or more of either the 30-day readmission versus not readmitted or 31-365-day readmission versus not readmitted model were retained for a final multivariable multinomial logistic regression model. Odds ratio estimates, 95% confidence intervals, and p-values are reported for the results of the multivariable models.
Restricted cubic splines were used to assess non-linear relationships between continuous variables and outcomes. Non-linear relationships were included in the multivariable models as quadratic terms or piecewise linear terms, as appropriate. Missingness in variables used in the variable selection process did not exceed 1.3% for categorical variables and 5.8% for continuous variables. Missing values for categorical variables were imputed by random assignment to a category proportional to the frequencies in the non-missing observations. Missing values for continuous variables were imputed using non-missing median values by sex. Analysis was performed using R version 3.5.0, and SAS 9.4.
The study cohort included 6265 patients. Mean age was 64.3 years, 70% were male, and 98.8% were Caucasian. In the first year after PCI, 2,767 patients (44.2%) were re-admitted. Nine hundred thirty-one patients (14.9%) were readmitted within 30 days and 1836 (29.3%) were readmitted between 31 and 365 days.
Correlates of Readmission within 365 days: Factors associated with readmission within a year are listed in Table 2 and results of multivariable logistic regression modeling are in Table 3. These included co-morbidities (Charlston comorbidity score, age, body mass index, history of hypertension, heart failure, cerebrovascular disease, chronic lung disease, diabetes mellitus), status at time of percutaneous coronary intervention (i.e., clinical presentation), cardiogenic shock within 24 hours, pre-procedure creatinine, pre-procedure hemoglobin, systolic blood pressure), procedural factors (culprit lesion, pre-stenosis percentage, arterial access site), and post-procedural factors (beta-blockers at discharge, prasugrel at discharge, ticagrelor at discharge, and length of stay). Patients with Medicare were more likely to be readmitted than patients with Blue Cross/Blue Shield, Geisinger Health Plan, or other insurance.
| All Patients (n = 6265) | Readmitted within 1 Year | Not Readmitted (n = 3498) | Readmitted vs Not Readmitted P-Value | |||
| n | % | n | % | n | % |
|
Age, mean (SD) | 64.3 (12.2) | 65.3 (12.8) | 63.5 (11.7) | < 0> | |||
Male | 4401 | 70.2% | 1830 | 66.1% | 2571 | 73.5% | < 0> |
Body mass index, mean (SD) | 30.7 (6.8) | 30.3 (7.2) | 30.9 (6.4) | 0.0013 | |||
Insurance Payors |
|
|
|
|
|
| < 0> |
Blue cross/Blue Shield | 744 | 11.9% | 259 | 9.4% | 485 | 13.9% |
|
Geisinger Health | 2345 | 37.4% | 982 | 35.5% | 1363 | 39.0% |
|
Medicaid | 37 | 0.6% | 17 | 0.6% | 20 | 0.6% |
|
Medicare | 2215 | 35.4% | 1108 | 40.0% | 1107 | 31.6% |
|
Others | 924 | 14.7% | 401 | 14.5% | 523 | 15.0% |
|
Hypertension | 4908 | 78.3% | 2273 | 82.1% | 2635 | 75.3% | < 0> |
Dyslipidemia | 4746 | 75.8% | 2137 | 77.2% | 2609 | 74.6% | 0.0152 |
Family History of Premature Coronary Artery Disease | 2219 | 35.4% | 930 | 33.6% | 1289 | 36.8% | 0.0078 |
Prior Myocardial Infarction | 1410 | 22.5% | 698 | 25.2% | 712 | 20.4% | < 0> |
Prior Heart Failure | 653 | 10.4% | 389 | 14.1% | 264 | 7.5% | < 0> |
Prior Valve Surgery/Procedure | 109 | 1.7% | 68 | 2.5% | 41 | 1.2% | 0.0001 |
Prior Percutaneous Coronary Intervention | 1444 | 23.0% | 684 | 24.7% | 760 | 21.7% | 0.0052 |
Prior Coronary Artery Bypass Surgery | 871 | 13.9% | 462 | 16.7% | 409 | 11.7% | < 0> |
Currently on Dialysis | 112 | 1.8% | 86 | 3.1% | 26 | 0.7% | < 0> |
Cerebrovascular Disease | 645 | 10.3% | 387 | 14.0% | 258 | 7.4% | < 0> |
Chronic Lung Disease | 701 | 11.2% | 387 | 14.0% | 314 | 9.0% | < 0> |
Diabetes Mellitus | 2123 | 33.9% | 1088 | 39.3% | 1035 | 29.6% | < 0> |
CAD Presentation |
|
|
|
|
|
| < 0> |
No Symptoms, No Angina | 289 | 4.6% | 152 | 5.5% | 137 | 3.9% |
|
Non-STEMI | 1455 | 23.2% | 664 | 24.0% | 791 | 22.6% |
|
STEMI or Equivalent | 1542 | 24.6% | 660 | 23.9% | 882 | 25.2% |
|
Stable Angina | 917 | 14.7% | 332 | 12.0% | 585 | 16.7% |
|
Symptom Unlikely to be Ischemic | 58 | 0.9% | 21 | 0.8% | 37 | 1.1% |
|
Unstable Angina | 1998 | 31.9% | 933 | 33.8% | 1065 | 30.5% |
|
Missing | 6 | 0.1% | 5 | 0.2% | 1 | 0.0% |
|
Heart Failure Within 2 Weeks | 539 | 8.6% | 333 | 12.1% | 206 | 5.9% | < 0> |
Cardiomyopathy or LV Systolic Dysfunction | 626 | 10.0% | 331 | 12.0% | 295 | 8.4% | < 0> |
Cardiogenic Shock Within 24 Hours | 121 | 1.9% | 75 | 2.7% | 46 | 1.3% | < 0> |
Contrast Volume, mean (SD) | 177.3 (77.8) | 173.3 (77.8) | 180.4 (77.7) | 0.0005 | |||
Intra-aortic Balloon Pump | 160 | 2.6% | 96 | 3.5% | 64 | 1.8% | < 0> |
Arterial Access Site |
|
|
|
|
|
| < 0> |
Femoral | 2938 | 46.9% | 1413 | 51.1% | 1525 | 43.6% |
|
Radial | 3307 | 52.8% | 1345 | 48.6% | 1962 | 56.1% |
|
Brachial/Others | 18 | 0.3% | 8 | 0.3% | 10 | 0.3% |
|
Missing | 2 | 0.0% | 1 | 0.0% | 1 | 0.0% |
|
PCI Status |
|
|
|
|
|
| < 0> |
Elective | 1762 | 28.4% | 682 | 25.0% | 1080 | 31.1% |
|
Emergency | 1609 | 25.9% | 691 | 25.3% | 918 | 26.4% |
|
Salvage | 58 | 0.9% | 28 | 1.0% | 30 | 0.9% |
|
Urgent | 2777 | 44.7% | 1332 | 48.7% | 1445 | 41.6% |
|
Missing | 59 | 0.9% | 34 | 1.2% | 25 | 0.7% |
|
Cardiogenic Shock at Start of PCI | 126 | 2.0% | 69 | 2.5% | 57 | 1.6% | 0.0138 |
Pre PCI Creatinine, median (IQR) (n missing = 297) | 0.9 (0.8, 1.1) | 1.0 (0.8, 1.2) | 0.9 (0.8, 1.1) | < 0> | |||
Pre PCI Hemoglobin, mean (STD) | 13.7 (1.9) | 13.3 (2.0) | 14.0 (1.7) | < 0> | |||
Discharge Medication |
|
|
|
|
|
|
|
Aspirin | 6071 | 96.9% | 2665 | 96.3% | 3406 | 97.4% | 0.0165 |
Clopidogrel | 5191 | 82.9% | 2228 | 80.5% | 2963 | 84.7% | < 0> |
Ticagrelor | 486 | 7.8% | 247 | 8.9% | 239 | 6.8% | 0.0021 |
Lesions Characteristic |
|
|
|
|
|
|
|
Thrombus | 1916 | 30.6% | 792 | 28.6% | 1124 | 32.1% | 0.0028 |
Previous Analysis |
|
|
|
|
|
|
|
Year of Intervention |
|
|
|
|
|
| < 0> |
2010 | 1156 | 18.5% | 450 | 16.3% | 706 | 20.2% |
|
2011 | 1029 | 16.4% | 425 | 15.4% | 604 | 17.3% |
|
2012 | 933 | 14.9% | 370 | 13.4% | 563 | 16.1% |
|
2013 | 1061 | 16.9% | 523 | 18.9% | 538 | 15.4% |
|
2014 | 1098 | 17.5% | 524 | 18.9% | 574 | 16.4% |
|
2015 | 988 | 15.8% | 475 | 17.2% | 513 | 14.7% |
|
Charlson Comorbidity Index on Procedure Date |
|
|
|
|
|
| < 0> |
0 | 368 | 5.9% | 144 | 5.2% | 224 | 6.4% |
|
1 to 2 | 2159 | 34.5% | 802 | 29.0% | 1357 | 38.8% |
|
≥ 3 | 3738 | 59.7% | 1821 | 65.8% | 1917 | 54.8% |
|
Duration of Index Hospitalization |
|
|
|
|
|
| < 0> |
0 to 3 Days | 4472 | 71.4% | 1780 | 64.3% | 2692 | 77.0% |
|
4 to 7 Days | 1387 | 22.1% | 720 | 26.0% | 667 | 19.1% |
|
> 7 Days | 406 | 6.5% | 267 | 9.6% | 139 | 4.0% |
|
Table 2: Summary of patient and encounter characteristics overall and by readmitted and not readmitted, excluding those not used in bootstrap variable selection an excluding those without significant differences between those readmitted and not readmitted.
STEMI = ST elevation myocardial infarction, PCI = Percutaneous Coronary Intervention, SD = standard deviation, IQR = Inter-quartile range, CK-MB = Creatine Kinase-Myocardial Band
Readmission within 365 Days (n = 6265) | OR | 95% CI Upper, Lower | P-Value | |
Age Quadratic- Age 55 (Q1) one year increase | 0.974 | 0.965 | 0.983 | < 0> |
Age Quadratic- Age 64 (Median)one year increase | 0.991 | 0.984 | 0.998 | |
Age Quadratic- Age 73 (Q3) one year increase | 1.008 | 0.999 | 1.016 | |
Body Mass Index (1 unit increase for BMI < 30> | 0.958 | 0.939 | 0.978 | 0.0001 |
Body Mass Index (1 unit increase for BMI ≥ 30) | 1.007 | 0.995 | 1.020 | |
Insurance: Geisinger vs Blue Cross/Blue Shield | 1.181 | 0.980 | 1.422 | 0.0014 |
Insurance: Medicaid vs Blue Cross/Blue Shield | 1.397 | 0.689 | 2.832 | |
Insurance: Medicare vs Blue Cross/Blue Shield | 1.447 | 1.191 | 1.758 | |
Insurance: Others vs Blue Cross/Blue Shield | 1.198 | 0.969 | 1.480 | |
Hypertension | 1.350 | 1.174 | 1.552 | < 0> |
Prior Heart Failure | 1.328 | 1.086 | 1.624 | 0.0057 |
Cerebrovascular Disease | 1.663 | 1.390 | 1.989 | < 0> |
Chronic Lung Disease | 1.258 | 1.060 | 1.493 | 0.0085 |
Diabetes Mellitus | 1.268 | 1.120 | 1.434 | 0.0002 |
Coronary Disease Presentation: No Symptoms/No Angina vs Unlikely Ischemic | 1.754 | 0.943 | 3.262 | 0.0023 |
Coronary Disease Presentation: Non-STEMI vs Unlikely Ischemic | 1.477 | 0.825 | 2.645 | |
Coronary Disease Presentation: STEMI vs Unlikely Ischemic | 1.428 | 0.746 | 2.732 | |
Coronary Disease Presentation: Stable Angina vs Unlikely Ischemic | 1.327 | 0.738 | 2.386 | |
Coronary Disease Presentation: Unstable Angina vs Unlikely Ischemic | 1.815 | 1.022 | 3.223 | |
Cardiogenic Shock within 24 Hours | 1.593 | 1.030 | 2.464 | 0.0363 |
Fluoroscopy Time (1 minute increase for time ≥ 19) | 1.004 | 0.997 | 1.011 | |
Procedure Diagnostic | 1.288 | 1.048 | 1.583 | 0.0161 |
Arterial Access: Radial vs Femoral | 0.815 | 0.725 | 0.916 | 0.0024 |
Arterial Access: Brachial/Others vs Femoral | 1.095 | 0.417 | 2.874 | |
PCI Scheduling Status: Emergency vs Elective | 1.464 | 1.050 | 2.042 | 0.0062 |
PCI Scheduling Status: Salvage vs Elective | 0.933 | 0.482 | 1.805 | |
PCI Scheduling Status: Urgent vs Elective | 1.299 | 1.099 | 1.535 | |
Creatinine Pre-Procedure (0.1 increase for < 0> | 0.896 | 0.828 | 0.969 | 0.0005 |
Creatinine Pre-Procedure (0.1 increase for ≥ 0.8) | 1.017 | 1.007 | 1.027 | |
Hemoglobin Pre-Procedure (1 unit increase for < 15> | 0.906 | 0.867 | 0.946 | < 0> |
Hemoglobin Pre-Procedure (1 unit increase for ≥ 15) | 0.976 | 0.874 | 1.090 | |
Beta Blockers at Discharge | 0.822 | 0.688 | 0.983 | 0.0316 |
Prasugrel at Discharge | 1.317 | 1.033 | 1.679 | 0.0263 |
Ticagrelor at Discharge | 1.519 | 1.052 | 2.193 | 0.0257 |
Culprit Lesion Identification vs Unknown | 0.760 | 0.641 | 0.901 | 0.0016 |
Pre-Stenosis Percent (1 unit increase) | 0.993 | 0.987 | 0.999 | 0.0152 |
Systolic Blood Pressure (1 unit increase < 120> | 0.989 | 0.981 | 0.997 | 0.0269 |
Systolic Blood Pressure (1 unit increase ≥ 120) | 1.003 | 0.999 | 1.007 | |
Procedure Year: 2011 vs 2010 | 1.135 | 0.946 | 1.361 | < 0> |
Procedure Year: 2012 vs 2010 | 1.130 | 0.934 | 1.367 | |
Procedure Year: 2013 vs 2010 | 1.796 | 1.489 | 2.166 | |
Procedure Year: 2014 vs 2010 | 1.653 | 1.367 | 1.999 | |
Procedure Year: 2015 vs 2010 | 1.773 | 1.447 | 2.172 | |
Charlson Comorbidity Index on Cath Date (3 vs 0) | 1.359 | 1.000 | 1.848 | |
Length of Stay: (4-7 Days vs 0 to 3 Days) | 1.258 | 1.094 | 1.446 | < 0> |
Length of Stay: (> 7 Days vs 0 to 3 Days) | 1.712 | 1.331 | 2.201 | |
Table 3: Multivariable Binary Logistic Regression Results for Outcome of Readmitted within 365 Days and Not Readmitted
STEMI = ST elevation myocardial infarction, PCI = Percutaneous Coronary Intervention, SD = standard deviation, BMI = Body Mass Index
Acute coronary syndrome patients were more likely to be readmitted compared to patients with stable or unlikely ischemic presentations. Radial access patients were less likely to be readmitted compared to femoral access patients. Emergency and urgent procedure patients had higher odds of readmission compared to elective procedure patients. A non-linear association between systolic blood pressure and readmission was observed - as systolic pressure increased for patients with systolic pressure < 120>
Correlates of readmission Days 1-30 days versus Days 31 -334: Most characteristics associated with 1 to 30-day readmission by multivariable nominal logistic regression were also associated with admission from 31-334 days, but some differences were observed (Tables 4,5).
| All Patients | Readmission within 30 Days | Readmission 31-365 Days | Not Readmitted | 30 Day Readmission vs Not Readmitted | 31-365 Day Readmission vs Not Readmitted P-Value | ||||
| n | % | n | % | n | % | n | % | ||
Age, mean (SD) | 64.3 (12.2) | 65.2 (13.1) | 65.4 (12.6) | 63.5 (11.7) | 0.0002 | < 0> | ||||
Male | 4401 | 70.2% | 578 | 62.1% | 1252 | 68.2% | 2571 | 73.5% | < 0> | < 0> |
Body Mass Index, mean (SD) | 30.7 (6.8) | 30.0 (7.2) | 30.5 (7.1) | 30.9 (6.4) | 0.0001 | 0.0676 | ||||
Insurance Payors |
|
|
|
|
|
|
|
| < 0> | < 0> |
Blue cross/Blue Shield | 744 | 11.9% | 92 | 9.9% | 167 | 9.1% | 485 | 13.9% |
|
|
Geisinger Health | 2345 | 37.4% | 314 | 33.7% | 668 | 36.4% | 1363 | 39.0% |
|
|
Medicaid | 37 | 0.6% | 9 | 1.0% | 8 | 0.4% | 20 | 0.6% |
|
|
Medicare | 2215 | 35.4% | 361 | 38.8% | 747 | 40.7% | 1107 | 31.6% |
|
|
Others | 924 | 14.7% | 155 | 16.6% | 246 | 13.4% | 523 | 15.0% |
|
|
Hypertension | 4908 | 78.3% | 764 | 82.1% | 1509 | 82.2% | 2635 | 75.3% | < 0> | < 0> |
Dyslipidemia | 4746 | 75.8% | 697 | 74.9% | 1440 | 78.4% | 2609 | 74.6% | 0.8613 | 0.0018 |
Family History of Premature Coronary Artery Disease | 2219 | 35.4% | 307 | 33.0% | 623 | 33.9% | 1289 | 36.8% | 0.0288 | 0.0348 |
Prior Myocardial Infarction | 1410 | 22.5% | 199 | 21.4% | 499 | 27.2% | 712 | 20.4% | 0.4935 | < 0> |
Prior Heart Failure | 653 | 10.4% | 130 | 14.0% | 259 | 14.1% | 264 | 7.5% | < 0> | < 0> |
Prior Valve Surgery/Procedure | 109 | 1.7% | 24 | 2.6% | 44 | 2.4% | 41 | 1.2% | 0.0020 | 0.0009 |
Prior PCI | 1444 | 23.0% | 196 | 21.1% | 488 | 26.6% | 760 | 21.7% | 0.6568 | < 0> |
Prior Coronary Artery Bypass Surgery | 871 | 13.9% | 123 | 13.2% | 339 | 18.5% | 409 | 11.7% | 0.2047 | < 0> |
Currently on Dialysis | 112 | 1.8% | 30 | 3.2% | 56 | 3.1% | 26 | 0.7% | < 0> | < 0> |
Cerebrovascular Disease | 645 | 10.3% | 124 | 13.3% | 263 | 14.3% | 258 | 7.4% | < 0> | < 0> |
Chronic Lung Disease | 701 | 11.2% | 131 | 14.1% | 256 | 13.9% | 314 | 9.0% | < 0> | < 0> |
Diabetes Mellitus | 2123 | 33.9% | 354 | 38.0% | 734 | 40.0% | 1035 | 29.6% | < 0> | < 0> |
Coronary Artery Disease Presentation |
|
|
|
|
|
|
|
| < 0> | < 0> |
No Symptoms, No Angina | 289 | 4.6% | 44 | 4.7% | 108 | 5.9% | 137 | 3.9% |
|
|
Non-STEMI | 1455 | 23.2% | 233 | 25.0% | 431 | 23.5% | 791 | 22.6% |
|
|
STEMI or Equivalent | 1542 | 24.6% | 266 | 28.6% | 394 | 21.5% | 882 | 25.2% |
|
|
Stable Angina | 917 | 14.7% | 91 | 9.8% | 241 | 13.2% | 585 | 16.7% |
|
|
Symptom Unlikely to be Ischemic | 58 | 0.9% | 12 | 1.3% | 9 | 0.5% | 37 | 1.1% |
|
|
Unstable Angina | 1998 | 31.9% | 285 | 30.6% | 648 | 35.4% | 1065 | 30.5% |
|
|
Missing | 6 | 0.1% | 0 | 0.0% | 5 | 0.3% | 1 | 0.0% |
|
|
Heart Failure Within 2 Weeks | 539 | 8.6% | 118 | 12.7% | 215 | 11.8% | 206 | 5.9% | < 0> | < 0> |
Cardiomyopathy or LV Systolic Dysfunction | 626 | 10.0% | 120 | 12.9% | 211 | 11.6% | 295 | 8.4% | < 0> | 0.0002 |
Cardiogenic Shock Within 24 Hours | 121 | 1.9% | 38 | 4.1% | 37 | 2.0% | 46 | 1.3% | < 0> | 0.0492 |
Cardiac Arrest Within 24 Hours | 142 | 2.3% | 28 | 3.0% | 39 | 2.1% | 75 | 2.1% | 0.1234 | 0.9772 |
Contrast Volume, mean (SD) | 177.3 (77.8) | 171.6 (76.1) | 174.2 (78.7) | 180.4 (77.7) | 0.0028 | 0.0074 | ||||
IABP | 160 | 2.6% | 42 | 4.5% | 54 | 2.9% | 64 | 1.8% | < 0> | 0.0094 |
Arterial Access Site |
|
|
|
|
|
|
|
| 0.0005 | < 0> |
Femoral | 2938 | 46.9% | 471 | 50.6% | 942 | 51.3% | 1525 | 43.6% |
|
|
Radial | 3307 | 52.8% | 456 | 49.0% | 889 | 48.4% | 1962 | 56.1% |
|
|
Brachial/Others | 18 | 0.3% | 4 | 0.4% | 4 | 0.2% | 10 | 0.3% |
|
|
Missing | 2 | 0.0% | 0 | 0.0% | 1 | 0.1% | 1 | 0.0% |
|
|
PCI Status |
|
|
|
|
|
|
|
| < 0> | 0.0001 |
Elective | 1762 | 28.4% | 174 | 18.9% | 508 | 28.0% | 1080 | 31.1% |
|
|
Emergency | 1609 | 25.9% | 270 | 29.3% | 421 | 23.2% | 918 | 26.4% |
|
|
Salvage | 58 | 0.9% | 16 | 1.7% | 12 | 0.7% | 30 | 0.9% |
|
|
Urgent | 2777 | 44.7% | 460 | 50.0% | 872 | 48.1% | 1445 | 41.6% |
|
|
Missing | 59 | 0.9% | 11 | 1.2% | 23 | 1.3% | 25 | 0.7% |
|
|
Cardiogenic Shock at Start of PCI | 126 | 2.0% | 37 | 4.0% | 32 | 1.8% | 57 | 1.6% | < 0> | 0.7307 |
Pre Creatinine, median (IQR) | 0.9 (0.8, 1.1) | 0.9 (0.8, 1.2) | 1.0 (0.8, 1.2) | 0.9 (0.8, 1.1) | < 0> | < 0> | ||||
Pre Hemoglobin, mean (STD) | 13.7 (1.9) | 13.2 (2.0) | 13.4 (2.0) | 14.0 (1.7) | < 0> | < 0> | ||||
Discharge Medication |
|
|
|
|
|
|
|
|
|
|
Aspirin | 6071 | 96.9% | 901 | 96.8% | 1764 | 96.1% | 3406 | 97.4% | 0.3270 | 0.0099 |
Lipid Lowering Agents (Statins and Non-Statins) | 6028 | 96.2% | 893 | 95.9% | 1746 | 95.1% | 3389 | 96.9% | 0.1448 | 0.0012 |
Thienopyridines |
|
|
|
|
|
|
|
|
|
|
Clopidogrel | 5191 | 82.9% | 735 | 78.9% | 1493 | 81.3% | 2963 | 84.7% | < 0> | 0.0015 |
Ticagrelor | 486 | 7.8% | 95 | 10.2% | 152 | 8.3% | 239 | 6.8% | 0.0006 | 0.0545 |
Lesions and Devices |
|
|
|
|
|
|
|
|
|
|
Pre-Stenosis Percent, median (IQR) | 95 (90, 100) | 95 (90, 100) | 95 (90, 100) | 95 (90, 100) | 0.8073 | 0.0326 | ||||
Thrombus | 1916 | 30.6% | 302 | 32.4% | 490 | 26.7% | 1124 | 32.1% | 0.8592 | < 0> |
Previous Analysis |
|
|
|
|
|
|
|
|
|
|
Year of Intervention |
|
|
|
|
|
|
|
| < 0> | < 0> |
2010 | 1156 | 18.5% | 146 | 15.7% | 304 | 16.6% | 706 | 20.2% |
|
|
2011 | 1029 | 16.4% | 139 | 14.9% | 286 | 15.6% | 604 | 17.3% |
|
|
2012 | 933 | 14.9% | 115 | 12.4% | 255 | 13.9% | 563 | 16.1% |
|
|
2013 | 1061 | 16.9% | 171 | 18.4% | 352 | 19.2% | 538 | 15.4% |
|
|
2014 | 1098 | 17.5% | 184 | 19.8% | 340 | 18.5% | 574 | 16.4% |
|
|
2015 | 988 | 15.8% | 176 | 18.9% | 299 | 16.3% | 513 | 14.7% |
|
|
Charlson Comorbidity Index on Procedure Date |
|
|
|
|
|
|
|
| < 0> | < 0> |
0 | 368 | 5.9% | 40 | 4.3% | 104 | 5.7% | 224 | 6.4% |
|
|
1 to 2 | 2159 | 34.5% | 285 | 30.6% | 517 | 28.2% | 1357 | 38.8% |
|
|
≥ 3 | 3738 | 59.7% | 606 | 65.1% | 1215 | 66.2% | 1917 | 54.8% |
|
|
Duration of Index Hospitalization |
|
|
|
|
|
|
|
| < 0> | < 0> |
0 to 3 Days | 4472 | 71.4% | 536 | 57.6% | 1244 | 67.8% | 2692 | 77.0% |
|
|
4 to 7 Days | 1387 | 22.1% | 277 | 29.8% | 443 | 24.1% | 667 | 19.1% |
|
|
> 7 Days | 406 | 6.5% | 118 | 12.7% | 149 | 8.1% | 139 | 4.0% |
|
|
Table 4: Summary of Patient and Encounter Characteristics Overall and by Readmitted Days 1-30, Readmitted Days 31 - 365, and Not Readmitted, Excluding those not use in bootstrap variable selection
STEMI = ST elevation myocardial infarction, PCI = Percutaneous Coronary Intervention, SD = standard deviation, IQR = Inter-quartile range, CK-MB = Creatine Kinase-Myocardial Band, CCS= Canadian Cardiovascular Society Class
Readmission within 30 Days, Readmssion Between 31 and 365 Days, and Not Readmitted (n = 6265) | Readmission within 30 Days vs Not Readmitted | Readmission 31-365 Days vs Not Readmitted | ||||||
OR | 95% CI | P-Value | OR | 95% CI | P-Value | |||
Age Quadratic- Age 55 (Q1) one year increase | 0.966 | 0.953 | 0.978 | < 0> | 0.981 | 0.971 | 0.992 | < 0> |
Age Quadratic- Age 64 (Median) one year increase | 0.986 | 0.976 | 0.995 | 0.995 | 0.987 | 1.003 | ||
Age Quadratic- Age 73 (Q2) one year increase | 1.006 | 0.994 | 1.018 | 1.010 | 1.000 | 1.019 | ||
BMI (1 unit increase for BMI < 30> | 0.949 | 0.924 | 0.976 | 0.0001 | 0.964 | 0.943 | 0.986 | 0.0056 |
BMI (1 unit increase for BMI ≥ 30) | 0.995 | 0.978 | 1.014 | 1.012 | 0.998 | 1.025 | ||
Insurance: Geisinger vs Blue Cross/Blue Shield | 1.105 | 0.840 | 1.453 | 0.0838 | 1.213 | 0.980 | 1.502 | 0.0026 |
Insurance: Medicaid vs Blue Cross/Blue Shield | 2.014 | 0.836 | 4.850 | 1.034 | 0.432 | 2.479 | ||
Insurance: Medicare vs Blue Cross/Blue Shield | 1.333 | 1.003 | 1.771 | 1.482 | 1.187 | 1.851 | ||
Insurance: Others vs Blue Cross/Blue Shield | 1.301 | 0.960 | 1.762 | 1.139 | 0.892 | 1.454 | ||
Recent Smoker | 0.949 | 0.786 | 1.146 | 0.5874 | 1.158 | 1.001 | 1.340 | 0.0485 |
Hypertension | 1.550 | 1.259 | 1.907 | < 0> | 1.249 | 1.065 | 1.464 | 0.0062 |
Prior Myocardial Infarction | 0.943 | 0.773 | 1.150 | 0.5628 | 1.174 | 1.012 | 1.362 | 0.0344 |
Previous Coronary Bypass Surgery | 0.951 | 0.735 | 1.230 | 0.6993 | 1.222 | 1.012 | 1.474 | 0.0369 |
Cerebrovascular Disease | 1.576 | 1.232 | 2.016 | 0.0003 | 1.665 | 1.370 | 2.024 | < 0> |
Diabetes Mellitus | 1.237 | 1.036 | 1.478 | 0.0188 | 1.271 | 1.107 | 1.459 | 0.0007 |
Coronary disease Presentation: No Symptoms/No Angina vs Unlikely Ischemic | 0.950 | 0.416 | 2.168 | 0.0725 | 2.916 | 1.277 | 6.659 | 0.0012 |
Coronary disease Presentation: Non-STEMI vs Unlikely Ischemic | 0.792 | 0.374 | 1.676 | 2.189 | 0.998 | 4.800 | ||
Coronary disease Presentation: STEMI vs Unlikely Ischemic | 0.936 | 0.401 | 2.182 | 1.934 | 0.827 | 4.520 | ||
Coronary disease Presentation: Stable Angina vs Unlikely Ischemic | 0.632 | 0.296 | 1.349 | 1.998 | 0.912 | 4.378 | ||
Coronary disease Presentation: Unstable Angina vs Unlikely Ischemic | 0.988 | 0.472 | 2.068 | 2.767 | 1.271 | 6.024 | ||
Cardiogenic Shock within 24 Hours | 1.818 | 1.076 | 3.070 | 0.0254 | 1.414 | 0.855 | 2.338 | 0.1769 |
Fluoroscopy Time (1 minute increase for time < 19> | 0.977 | 0.961 | 0.994 | 0.0258 | 0.987 | 0.974 | 1.000 | 0.1376 |
Fluoroscopy Time (1 minute increase for time ≥ 19) | 1.007 | 0.997 | 1.017 | 1.002 | 0.994 | 1.009 | ||
Procedure Diagnostic | 1.461 | 1.094 | 1.950 | 0.0101 | 1.298 | 1.042 | 1.616 | 0.0201 |
Arterial Access: Radial vs Femoral | 0.886 | 0.745 | 1.054 | 0.1919 | 0.812 | 0.710 | 0.930 | 0.0104 |
Arterial Access: Brachial/Others vs Femoral | 1.947 | 0.580 | 6.540 | 0.770 | 0.233 | 2.543 | ||
PCI Scheduling Status: Emergency vs Elective | 1.690 | 1.049 | 2.723 | 0.0039 | 1.437 | 0.986 | 2.093 | 0.0352 |
PCI Scheduling Status: Salvage vs Elective | 1.361 | 0.597 | 3.103 | 0.681 | 0.303 | 1.534 | ||
PCI Scheduling Status: Urgent vs Elective | 1.609 | 1.241 | 2.085 | 1.213 | 1.004 | 1.465 | ||
Creatinine Pre-Procedure (0.1 increase for < 0> | 0.965 | 0.858 | 1.084 | 0.3804 | 0.890 | 0.812 | 0.976 | 0.0156 |
Creatinine Pre-Procedure (0.1 increase for ≥ 0.8) | 1.011 | 0.995 | 1.027 | 1.013 | 0.999 | 1.027 | ||
Hemoglobin Pre-Procedure (1 unit increase for < 15> | 0.898 | 0.844 | 0.954 | 0.0015 | 0.926 | 0.880 | 0.973 | 0.0036 |
Hemoglobin Pre-Procedure (1 unit increase for ≥ 15) | 1.001 | 0.850 | 1.179 | 0.970 | 0.854 | 1.100 | ||
Prasugrel at Discharge | 1.358 | 0.959 | 1.924 | 0.0849 | 1.331 | 1.014 | 1.745 | 0.0392 |
Ticagrelor at Discharge | 1.636 | 0.989 | 2.704 | 0.0550 | 1.519 | 1.001 | 2.306 | 0.0496 |
Culprit Lesion Identification vs Unknown | 0.743 | 0.580 | 0.952 | 0.0188 | 0.765 | 0.634 | 0.922 | 0.0050 |
Pre-Stenosis Percent (1 unit increase) | 0.992 | 0.983 | 1.000 | 0.0604 | 0.992 | 0.986 | 0.999 | 0.0219 |
Diastolic Blood Pressure (1 unit increase ≥ 70) | 1.005 | 0.992 | 1.018 | 1.006 | 0.996 | 1.016 | ||
Procedure Year: 2011 vs 2010 | 1.140 | 0.870 | 1.493 | < 0> | 1.155 | 0.941 | 1.417 | < 0> |
Procedure Year: 2012 vs 2010 | 1.085 | 0.816 | 1.444 | 1.160 | 0.936 | 1.437 | ||
Procedure Year: 2013 vs 2010 | 1.812 | 1.379 | 2.382 | 1.761 | 1.426 | 2.175 | ||
Procedure Year: 2014 vs 2010 | 1.703 | 1.282 | 2.263 | 1.507 | 1.207 | 1.882 | ||
Procedure Year: 2015 vs 2010 | 1.861 | 1.361 | 2.545 | 1.515 | 1.182 | 1.941 | ||
Charlson Comorbidity Index on Cath Date (1 to 2 vs 0) | 1.631 | 1.086 | 2.448 | 0.0180 | 0.945 | 0.703 | 1.270 | 0.2158 |
Charlson Comorbidity Index on Cath Date (3 vs 0) | 1.945 | 1.226 | 3.085 | 1.102 | 0.782 | 1.552 | ||
Length of Stay: (4-7 Days vs 0 to 3 Days) | 1.467 | 1.210 | 1.779 | < 0> | 1.157 | 0.988 | 1.355 | 0.0186 |
Length of Stay: (> 7 Days vs 0 to 3 Days) | 2.180 | 1.590 | 2.989 | 1.449 | 1.091 | 1.923 | ||
Table 5: Multivariable Multinomial Logistic Regression Results for Outcome of Readmitted within 30 Days, Readmitted Between 31 and 365 Days, and Not Readmitted
STEMI = ST elevation myocardial infarction, PCI = Percutaneous Coronary Intervention, SD = standard deviation, BMI = Body Mass Index
Factors correlating with later readmission, but NOT early readmission included smoking, prior MI, prior coronary artery bypass graft surgery, radial access, and creatinine. Factors associated with early readmission, but not later readmission included male gender, insurance status, pre-procedural angina classification, acute shock, radial access, beta blocker therapy at discharge, systolic blood pressure, and Charlson Co-morbidity Index.
The most important finding of this study is that the two-fifths of patients undergoing PCI were readmitted within one year of the procedure. Of those readmitted, one-third were readmitted within the first 30 days and two-thirds were readmitted over the next 11 months. Most studies of readmission after PCI focus only on 30-day re-admissions. Our study shows that a 30-day assessment is limited and under-estimates the burden of morbidity in post-PCI patients. Care of post-PCI patients beyond 30 days should be of interest to the interventionalist.
Only two factors over which clinicians have control were associated with likelihood of readmission. First, radial access (versus femoral access) had an odds ratio of .81 (p = 0.002) of re-admission. Multiple studies have demonstrated that radial access compared to femoral access decreases vascular complications and bleeding which might explain this correlation [6]. However, use of radial access correlated with reduced rates of late but not early re-admission which is inconsistent with the hypothesis that reduced rates of procedure-related vascular access complications or bleeding are responsible for the lower re-admission rates. The association with reduced late re-admissions may be due to unknown confounders related to co-morbidities, since femoral access was often reserved for older and sicker patients.
Second, beta-blockers at discharge were associated with an odds ratio of 0.82 (p = 0.03) of any readmission. The correlation was limited to readmissions within the first 30 days (odds ratio 0.74, p = 0.02) but not after 30 days (odds ratio 0.85, p = .11). This observation has been previously reported [7], but again we cannot exclude unknown confounders since the benefit of beta-blockers is unclear in patients without MI.
Several additional findings are of interest. Urgent and emergent PCI (linked to acute coronary syndromes) status was associated with a 30-46% excess rate of re-admission compared to elective (stable) PCI status. Patients discharged on ticagrelor or prasugrel had 31-52% excess re-admission rates compared to patients discharged on clopidogrel, perhaps because these drugs were used preferentially for acute coronary syndrome patients and because they increase bleeding risk compared to clopidogrel. Finally, length of stay of 4-7 days and > 7 days correlated with 26% and 71% increased risks of readmission, respectively, compared to shorter lengths of stay, presumably because length of stay is a marker for severity of the initial hospitalization and overall clinical status.
We are aware of only 1 other study that evaluated re-admissions up to 1 year after PCI [5]. That study was conducted in Denmark, where the National Health Service guarantees free hospital access. In the Danish cohort 50% of patients were re-admitted within 1 year compared to 44% in our study. Similar to our findings, the Denmark investigators concluded that readmission is common in the year following PCI, that many of the re-admissions are due to ischemic heart disease, that co-morbidities correlate most closely with readmission, and that we could identify few modifiable correlates of readmission. Both studies point to the importance of secondary risk factor modification and careful follow-up after PCI. Differences may be due in part to our inability to identify re-admissions to hospitals outside of our 13-hospital system, although we excluded patients lost-to follow-up from our initial cohort. Half of the Denmark patients were readmitted due to angina or myocardial infarction whereas two-thirds of our patients were readmitted with ischemia-related diagnoses. Both studies identified age, Charlson Comorbidity Index </=3, and diabetes as correlates of readmission. The Denmark study identified female gender as a correlate of readmission although our study did not, perhaps because of closer association with other demographic variables that were not available to the Denmark investigators. However, our study showed a 25% increased risk of readmission for women in the first 30 days that equalized over the next 11 months.
Readmission rates after PCI within 30 days have been extensively studied, perhaps because 30 days is the time window considered by the Center for Medicare and Medicaid Services Hospital Re-admission Reduction Program (HRRP). However, this focus may result in lack of focus on care of post-PCI patients over the next 11 months. Attendance at cardiac rehabilitation sessions, adherence to medications, and control of risk factors have all been shown to decrease morbidity and/or mortality after PCI [8-9]. Close follow-up by cardiovascular specialists is important to ensure these goals are met.
Our study has several limitations. We were unable to identify re-admissions to a non-Geisinger hospital, although Geisinger operates 13 hospitals in central and northeastern Pennsylvania where the population is very stable and where most patients treated at Geisinger return to Geisinger. The population included in this study was 98
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
