ABC | Volume 113, Nº1, July 2019

Original Article Oliveira et al Readmission of patients with coronary syndrome Arq Bras Cardiol. 2019; 113(1):42-49 Table 4 – Multiple logistic regression of variables in patients with acute coronary syndrome in Aracaju, Brazil, 2017 Variables OR (95%CI) p value Male sex 0.78 (0.45; 1.38) 0.396 Public health care 0.46 (0.21; 0.98) 0.048 Elderly patients 1.11 (0.63; 1.99) 0.718 Black/pardo race 0.58 (0.34; 1.00) 0.050 Hypertension 1.72 (0.85; 3.73) 0.149 Dyslipidemia 1.69 (0.96; 3.04) 0.073 Diabetes mellitus 0.92 (0.53; 1.56) 0.749 Congestive heart failure 1.81 (1.01; 3.21) 0.042 Without statin for 180 days 0.76 (0.31; 1.70) 0.526 High school/higher education 1.56 (0.87; 2.85) 0.140 Smoking 1.43 (0.65; 2.99) 0.356 Alcohol consumption 1.93 (0.86; 4.22) 0.102 STEMI 1.30 (0.67; 2.61) 0.445 NSTEMI 0.97 (0.45; 2.13) 0.943 OR: Odds Ratio; STEMI: acute myocardial infarction with ST-segment elevation (STEMI); NSTEMI: acute myocardial infarction without ST-segment elevation (NSTEMI) between patients and healthcare staff at discharge and between the hospital and follow-up care. 26 The present study showed that users of private health services showed higher odds of readmissions as compared with those attending public healthcare facilities. Also, the study showed an association between having access to private health services and the capacity of having health insurance. Thus, the type of health care is related to patients’ socioeconomic status, race, educational attainment, family income and older age. 27 In addition, the income may be associated with educational attainment, which indicates that people with higher education attainment have higher income and greater odds to have access to private health services. Therefore, users of health insurance plans have greater access to a high variety of health services, 2,28 and an increase in the income is slightly associated with increasing acquisition of health insurance plans. According to a Brazilian household budget survey (POF, Pesquisa deOrçamentos Familiares) conducted in 2008-2009, 29 households spent an average of 5.9% of the family income with health care, including medications and health plans. 27,29 A Brazilian nation-wide study by Malta et al. 27 reported that in general, users of private health services are mostly women, white patients. Also, the use of health insurance plans is associated with socioeconomic status, reflected as race, educational attainment, family income and older age. On the other hand, the public system is characterized by a difficult access to treatment, including invasive therapies such as myocardial reperfusion and medical treatment. Also, due to improvements in notification and classification of these events, complex cases are prioritized to hospitalizations. 30,31 These findings corroborate previous results showing higher readmission rates in private health facilities than public ones. The main reasons of readmission were cardiac conditions (53%), mainly ACS, which accounted for 42.6% of the total. The high prevalence of cardiac causes of readmission was also reported by Khawaja et al. 9 (69%) evaluating 30-day readmission rates after percutaneous coronary intervention. Belitardo and Ayoub 1 also found a higher frequency of ACS (41.6%) among readmissions. First hospitalization and readmission may occur for the same diagnosis due to the lack of resolution of the primary cause, which characterizes an avoidable readmission. 1 Avoidable readmissions are considered those that are the result of a situation that if managed differently might have prevented the admission. 32 These findings were similar to those reported by Ricci et al. 8 showing a higher prevalence of cardiac causes of readmissions. Besides, increased risk of readmissions due to cardiac causes after the first ACS event has been reported. 7 In the study by Kwok et al., 33 although noncardiac causes were present in half of readmissions, cardiac causes were responsible for 46% of the cases, with chest pain of noncardiac origin and ACS the most prevalent diagnoses, respectively. Different risk predictors of hospital readmission have been described in the literature. This may be explained by different characteristics of the study populations, including the presence of comorbidities, and particularities of health care centers. Hospital readmissions may be related to several factors, such as patient’s clinical condition, family and social support, and the quality of health care received during and after hospitalization. The high readmission rates draw attention to the need for the development of actions during hospitalization, at discharge, and during follow-up, considering patients’ individual features, in order to reduce the number of readmissions. 20,34 47