Implementation of Transitional Care Planning is Associated with Reduced Readmission Rates in Patients Undergoing Lower Extremity Bypass Surgery for Peripheral Arterial Disease

Targeted use of postoperative discharge phone calls to reduce early readmission rates

OBJECTIVES

Postoperative readmissions are common and costly. Office-initiated phone calls to patients shortly after discharge may identify concerns and allow for early intervention to prevent readmission. We sought to evaluate our 30-day readmission rate after the implementation of a standardized postoperative discharge phone call (PODPC) intervention, compared with a historical aggregated cohort.

METHODS

From July 2020 to 21, postoperative patients were prospectively identified at 48 hour after discharge. Medical assistants performed PODPCs, administering a survey designed to identify medical/surgical issues that could signify a complication and warrant escalation to a nurse practitioner (NP) for further management. Demographics, comorbidities, and procedure type were obtained retrospectively. Descriptive statistics were used to evaluate PODPC responses, frequency of escalation, readmission, and reasons. The electronic medical record identified a historical aggregated cohort (July 2018 to 2019) and the 30-day readmission rate. A χ2 analysis was used to compare readmission rates between the preintervention historical and PODPC intervention groups. Predictors of 30-day readmission were modeled with multivariable logistic regression.

RESULTS

Of 411 PODPCs conducted, 106 patients (26%) reported not feeling well; having concerns. Eighty-four PODPCs (20%) triggered escalation to a NP; of these, 60 patients (71%) were counseled over the phone by an NP, 16 (19%) were brought into clinic, 6 (7%) were sent to the emergency department, and 2 (2%) did not answer the NP call. Of 411 patients, 17% (n = 68) were readmitted within 30 days. Comparatively, the historical aggregated cohort readmission rate was significantly higher at 28% (n = 346; P < .001). On multivariable analysis, chronic obstructive pulmonary disease (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.01-3.65; P = .046), and feeling run down; having difficulty with movement; needing assistance for most activities (OR, 3.94; 95% CI, 2.09-7.43; P < .0001) were predictive of 30-day readmission when controlling for procedure type.

CONCLUSIONS

Although readmissions remained common (>15%), being in the intervention cohort was associated with a significantly lower readmission rate compared with the historical aggregated cohort. One-fifth of PODPCs identified a concern; however, >90% of these could be managed by an NP by phone or in clinic. This PODPC intervention holds promise as a viable mechanism for decreasing readmissions.

A Systematic Review and Meta-Analysis to Assess the Impact of Pre-existing Comorbidities on the 30-Day Readmission after Lower Extremity Bypass Surgery for Peripheral Artery Occlusive Disease

BACKGROUND

Unplanned hospital readmissions after surgical operations are considered a marker for suboptimal care during index hospitalizations and are associated with poor patient outcomes and increased healthcare resource utilization. Patients undergoing lower extremity bypass (LEB) operations for severe peripheral arterial disease (PAD) have one of the highest readmission rates, among all the vascular and nonvascular surgical operations. This review is meant to evaluate the impact of pre-existing comorbidities (diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension (HTN), and coronary artery disease (CAD))-on the 30-day readmission rates among patients who underwent LEB for severe PAD.

METHODS

The review protocol was registered to the PROSPERO database (CRD42021261067). A systematic review of the English literature was performed using PubMed, Scopus, and the Cochrane Library databases from inception till April 2022. The review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and included only studies reporting on 30-day readmission following LEB for occlusive PAD. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach and was reported as high, moderate, or low. The risk of bias was evaluated utilizing the Risk of Bias in Nonrandomized Studies - of Interventions (ROBINS-I) tool. A pooled odds ratio (OR) for each study was computed, and a P-value of <0.05 was designated as statistically significant. Interstudy heterogeneity was evaluated by Q-metric and quantified using Higgins I² statistics.

RESULTS

Five studies reported data on 30-day readmission after LEB for occlusive PAD. A total of 19,739 patients were included. Readmission occurred among 3,559 (18%) patients. DM and COPD were reported by all 5 selected studies, and CHF and HTN were reported by 4 studies. CAD was least reported among the selected 5 pre-existing conditions, with only 2 studies mentioning it. HTN (OR, 1.35; 95% confidence interval (CI), 1.10-1.64; P ≤ 0.001; I² = 52.20%), DM (OR, 1.52; 95% CI, 1.30-1.79; P ≤ 0.001; I² = 74.51%), and CHF (OR, 1.85; 95% CI, 1.51-2.25; P ≤ 0.001; I² = 50.48%) were all found to be associated with an increased risk of 30-day readmission, while the presence of COPD (OR, 1.16; 95% CI, 0.98-1.36; P = 0.09; I² = 61.93%) and CAD (OR, 1.30; 95% CI, 0.94-1.78; P = 0.11; I² = 51.01%) was not associated with early readmission on meta-analysis of the available studies.

CONCLUSIONS

The pre-existing comorbidities HTN, DM, and CHF increase the risk of 30-day readmission after LEB for occlusive PAD. The identification of these risk factors can help stratify the patients and further guide in understanding the variety of factors that contribute in hospital readmissions.