Rehospitalization After Acute Myocardial Infarction : A Malaysian Longitudinal Study Presentation Slides by Dr Alia Daniella, presented on the 14th National Conference for Clinical Research (NCCR) 2021 Dr Wu Lien Teh Youth Investigator Awards (YIA) on 19th August 2021 Following are the links for this presentation on Zenodo Repository: Presentation Slides: https://zenodo.org/record/5348501 E-Poster: https://zenodo.org/record/5350400

1. Rehospitalization After Acute Myocardial Infarction:
A Malaysian Longitudinal Study
Presenter : Dr. Alia Daniella Abdul Halim, MD, MPH1,2
Co-Author : Datuk Prof. Dr. Awang Bulgiba Awang Mahmud, MPH, PhD2
Affiliation : 1Ministry of Health, Malaysia
2Faculty of Medicine, University of Malaya
NMRR 19-3553-52261

2. OUTLINE
• Introduction
• Objectives
• Methodology
• Results
• Discussion
• Conclusion
• Acknowledgement
• References

3. INTRODUCTION
• Rehospitalizations after acute
myocardial infarction (AMI) are
common, costly, and affect
patients’ quality of life.
• Between 2005 and 2015, there was
a 12.5% increase in cardiovascular
disease (CVD) mortality
worldwide1.
• On average, 50 people die from
ischaemic heart disease in
Malaysia every day2.
• In Malaysia, mean hospitalisation
cost of treating one AMI patient ~
RM 12,117 or USD 3,3663.

4. INTRODUCTION
DOSM. Statistics on Causes of Death Malaysia 2019. Department of Statistics Malaysia; 2019 30 October 2019.

5. INTRODUCTION
• Traditionally, hospital performance
indicators for AMI patients focused solely
on mortality rates.
• With the advancement of medicine, the
declining mortality rates have shifted the
focus towards rehospitalization to gauge
the performance of hospital care4.

6. INTRODUCTION
✓ Readmission rate = Performance
indicator
✓ Evaluated as part of the MSQH
Hospital Accreditation Standards5
✓ Suboptimal care in the previous
admission → unplanned readmission5
✓ Readmission of AMI is not well
understood in Malaysia
✓ No prior studies done before on AMI
readmission
✓ Quality of care received by AMI
patients during index hospitalizations
can prevent readmissions4,7
✓ Ease burden of a strained healthcare
system
✓ Crucial to address these gaps in
knowledge
✓ This knowledge will provide information
to policymakers to plan appropriate
intervention strategies to improve the
public hospitals’ healthcare delivery
system

7. INTRODUCTION
1in 6patients hospitalized with AMI will have
unplanned readmissions within 30 days
30-day Readmission Rate 20.2%6

8. OBJECTIVES
To determine the rate, pattern and predictors of rehospitalization after Acute Myocardial Infarction in MoH hospitals
To describe the socio-demographic characteristics of
all AMI patients who were readmitted after being
discharged in 2016 from MoH hospitals
To describe the pattern and time to readmissions after
being discharged following AMI in MoH hospitals
To compute the 30-day, 60-day, and 90-day
Readmission Rate of AMI in MoH hospitals
To determine the risk factors associated with 30-day
AMI readmission in MoH hospitals
GENERAL OBJECTIVE
SPECIFIC OBJECTIVE

9. METHODOLOGY
• Study design : Retrospective longitudinal study
• Source of data : population-based registry, ‘Sistem Maklumat
Rawatan Perubatan’ (SMRP) stored in the Malaysian Healthcare
Data Warehouse (MyHDW) database made available by the
Health Informatics Centre of Ministry of Health Malaysia.
• Study population : All inpatient discharges coded with ICD-10 of
I21 (Acute Myocardial Infarction) between 1st January 2016 to
31st December 2016 were reviewed.
• Outcome : any first readmission after index AMI admission
for AMI-specific cause in any public hospital within study
period.

10. METHODOLOGY
• Universal sampling method was used due to availability of
secondary data.
• Readmission rate for n-days =
𝑁𝑜. 𝑜𝑓 𝐴𝑀𝐼 𝑟𝑒𝑎𝑑𝑚𝑖𝑠𝑠𝑖𝑜𝑛𝑠 1 𝐽𝑎𝑛 2016−31 𝐷𝑒𝑐 2016
𝑇𝑜𝑡𝑎𝑙 𝑛𝑜. 𝐴𝑀𝐼 𝑎𝑑𝑚𝑖𝑠𝑠𝑖𝑜𝑛𝑠 𝑓𝑜𝑟 𝑡ℎ𝑒 𝑝𝑎𝑟𝑡𝑖𝑐𝑢𝑙𝑎𝑟 𝑦𝑒𝑎𝑟
x 100%
• Time to 1st readmission = Date of 1st readmission – Date of 1st
discharge (index)
• Multiple logistic regression models were developed to identify the
possible risk factors of AMI readmission.

11. RESULTS
18,102
1,208
1,208 (mean age
58.34 years, 79.7%
males) were readmitted
within one year
> 50% of the
readmission occurred
within 30 days of
discharge (Mean age
58.69 ± 12.20)
A total of 18,102
patients survived index
AMI admission and was
discharged

12. RESULTS
Characteristics
First Readmission n = 1208 (%)
30 days 60 days 90 days > 90 days
Sex
Male 491 (80.5) 132 (77.6) 112 (83.6) 228 (77.6)
Female 119 (19.5) 38 (22.4) 22 (16.4) 66 (22.4)
Age Group
18 – 44 82 (13.4) 15 (8.8) 7 (5.2) 24 (8.2)
45 – 64 325 (53.3) 93 (54.7) 78 (58.2) 177 (60.2)
 65 203 (33.3) 62 (36.5) 49 (36.6) 93 (31.6)
Ethnicity
Malay 365 (59.8) 113 (66.5) 82 (61.2) 195 (66.3)
Chinese 92 (15.1) 19 (11.2) 18 (13.4) 31 (10.5)
Indian 102 (16.7) 27 (15.9) 21 (15.7) 47 (16.0)
Bumiputera Sabah & Sarawak 39 (6.4) 10 (5.9) 7 (5.2) 15 (5.1)
Others 12 (2.0) 1 (0.6) 6 (4.5) 6 (2.0)
Baseline characteristics of readmitted patients

13. RESULTS
Baseline characteristics of readmitted patients
Characteristics
First Readmission n = 1208 (%)
30 days 60 days 90 days > 90 days
Day of Index Admission
Weekend 187 (30.7) 41 (24.1) 37 (27.6) 76 (25.9)
Weekday 423 (69.3) 129 (75.9) 97 (72.4) 218 (74.1)
Length of Stay Index Admission
≤ 2 days 263 (43.1) 37 (21.8) 23 (17.2) 66 (22.4)
3 – 6 days 294 (48.2) 116 (68.2) 101 (75.4) 201 (68.4)
 7 days 53 (8.7) 17 (10.0) 10 (7.5) 27 (9.2)
Type of Hospital
Specialist Hospital 491 (80.5) 145 (85.3) 115 (85.8) 247 (84.0)
Non-Specialist Hospital 119 (19.5) 25 (14.7) 19 (14.2) 47 (16.0)
Availability of Cardiology Services
Available 64 (10.5) 11 (6.5) 14 (10.4) 33 (11.2)
Not Available 546 (89.5) 159 (93.5) 120 (89.6) 261(88.8)
Any Comorbidity
Yes 93 (15.2) 32 (18.8) 30 (22.4) 61 (20.7)
No 517 (84.8) 138 (81.2) 104 (77.6) 233 (79.3)

14. RESULTS
Characteristics
First Readmission n = 1208 (%)
30 days 60 days 90 days > 90 days
DM
Yes 36 (5.9) 5 (2.9) 11 (8.2) 15 (5.1)
No 574 (94.1) 165 (97.1) 123 (91.8) 279 (94.9)
HPT
Yes 41 (6.7) 11 (6.5) 15 (11.2) 28 (9.5)
No 569 (93.3) 159 (93.5) 119 (88.8) 266 (90.5)
IHD
Yes 39 (6.4) 16 (9.4) 12 (9.0) 24 (8.2)
No 571 (93.6) 154 (90.6) 122 (91.0) 270 (91.8)
History of ICU/CCU/HDW Admission
Yes 544 (89.2) 141 (82.9) 114 (85.1) 241 (82.0)
No 66 (10.8) 29 (17.1) 20 (14.9) 53 (18.0)
Type of AMI
STEMI 70 (11.5) 15 (8.8) 13 (9.7) 21 (7.1)
NSTEMI 226 (37.0) 101 (59.4) 72 (53.7) 168 (57.1)
Unspecified 314 (51.5) 54 (31.8) 49 (36.6) 105 (35.7)
Baseline characteristics of readmitted patients

15. RESULTS
Distribution of
admitted and
readmitted AMI
patients according
to day of the week

16. RESULTS
After adjustment for potential confounders, age
≥ 65 years old (aOR 1.41; 95% CI 1.15, 1.74),
Indian ethnicity (aOR 1.39; 95% CI 1.12, 1.73),
≤ 2 days length of stay (aOR 1.41; 95% CI
1.13, 1.76) and diagnosed with STEMI (aOR
1.24; 95% CI 1.01, 1.53) or NSTEMI (aOR 1.15;
95% CI 1.02, 1.30) were associated with
increased risk of hospital readmission within a
year.
After adjustment for potential confounders,
≤ 2 days length of stay (aOR 1.85; 95% CI
1.37, 2.51) Intensive care unit, cardiac
care unit or high dependency ward
admission (aOR 1.35; 95% CI 1.04, 1.77)
were associated with increased risk of
readmission within 30 days.
Multiple logistic regression was conducted to identify possible predictors:
Readmitted within 30 days Readmitted within 1 year

17. DISCUSSION
• First study looking at AMI readmission in Malaysia.
• Readmission rate is a well-accepted method in measuring
the quality of healthcare in hospitals.
• The period of up to 30 days after AMI is a period where
patients are at highest risk of readmission due to a wide
variety of illnesses → ‘post-hospital syndrome’9.

18. DISCUSSION
• In US, 30-day readmission rate for AMI is 15.5% compared to 30-
day readmission rate for AMI in MoH hospitals at 3.37%8.
➢ Result interpreted with care → difference in readmission rates
between countries can be due to factors such as socio-
demographics, aging population, systemic differences in
healthcare systems, quality of care, accessibility and affordability
of healthcare10 → can be explored in future studies.
• Findings are in line with studies conducted elsewhere suggesting
that shorter length of stay and ICU admission are associated with
30-day AMI readmission11,12.

19. LIMITATION
• Does not capture readmissions to private
healthcare facilities - may be an under-estimation
of readmission rates and may not apply to private
patients who are generally in the upper-income
bracket.

20. CONCLUSION
• The results of this study will provide policymakers and healthcare
providers (HCP) a method to measure the quality of healthcare
provided by public hospitals in this country.
• Knowing the characteristics of readmitted patients will allow treating
clinicians to anticipate AMI readmissions better and be more vigilant in
terms of monitoring and management.
• Even though this study is not a formal economic assessment → AMI
readmissions has important economic ramifications.
• As the cost of healthcare continues to increase, tackling the problem of
AMI rehospitalization will help ease the burden of a strained healthcare
system.

21. ACKNOWLEDGEMENT
• We would like to thank the Director General of Health Malaysia for
his permission to present this poster.
• We would also like to express our gratitude to Dr. Md Khadzir
Sheikh Ahmad, Dr. Ismat Mohd Sulaiman and the team at the
Health Informatics Centre for their helpful assistance.

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23. THANK YOU!
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