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McGinigle KL, Spangler EL, Ayyash K, Arya S, Settembrini AM, Thomas MM, Dell KE, Swiderski IJ, Davies MG, Setacci C, Urman RD, Howell SJ, Garg J, Ljungvist O, de Boer HD. A framework for perioperative care for lower extremity vascular bypasses: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery. J Vasc Surg 2023; 77:1295-1315. [PMID: 36931611 DOI: 10.1016/j.jvs.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 03/17/2023]
Abstract
The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based suggestions for coordinated perioperative care for patients undergoing infrainguinal bypass surgery for peripheral artery disease. Structured around the ERAS core elements, 26 suggestions were made and organized into preadmission, preoperative, intraoperative, and postoperative sections.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily L Spangler
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Katie Ayyash
- Department of Perioperative Medicine (Merit), York and Scarborough Teaching Hospitals NHS Foundation Trust, York, United Kingdom
| | - Shipra Arya
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA
| | | | - Merin M Thomas
- Lenox Hill Hospital, Northwell Health, New Hyde Park, NY
| | | | | | - Mark G Davies
- Department of Surgery, Joe R. & Teresa Lozano Long School of Medicine, University of Texas Health Sciences Center, San Antonio, TX
| | - Carlo Setacci
- Department of Surgery Surgery, University of Siena, Siena, Italy
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Simon J Howell
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - Joy Garg
- Department of Vascular Surgery, Kaiser Permanente San Leandro, San Leandro, CA
| | - Olle Ljungvist
- Department of Surgery, Orebro University, Orebro, Sweden
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine, and Procedure Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
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Kim Y, Feldman ZM, Majumdar M, DeCarlo CS, Pendleton AA, Zacharias N, Mohapatra A, Dua A. Factors Influencing Hospital Readmission after Lower Extremity Bypass for Chronic Limb-Threatening Ischemia. Vasc Endovascular Surg 2023; 57:230-235. [PMID: 36468580 DOI: 10.1177/15385744221144389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objectives: Unplanned hospital readmission is a leading source of hospital resource expenditure, and preventing readmission may improve both patient quality of life and healthcare costs. The factors influencing hospital readmission after lower extremity bypass (LEB) for chronic limb-threatening ischemia (CLTI) remain incompletely investigated. Methods: A regional, multi-institutional database was retrospectively reviewed for all patients who underwent LEB for CLTI between 1995 to 2020. The primary outcome was unplanned hospital readmission up to 30 days following bypass. Results: A total of 1315 patients underwent LEB across all institutions, of whom 843 (64.1%) underwent bypass for CLTI. The 30-day hospital readmission rate was 25.3%, and the leading causes of readmission were wound-related complications (51.6%). There was no difference in age, sex, or race between readmitted and non-readmitted patients. Conduit type and bypass target were also similar between groups. Readmitted patients more frequently underwent LEB for tissue loss (58.2% vs 50.2%, P = 0.042). On multivariable analysis, wound infection (odds ratio [OR] 9.1, 95% confidence interval [CI] 6.2-13.2, P < 0.001) and non-infectious wound complications (OR 2.0, 95% CI 1.0-3.9, P = 0.041) were independently associated with hospital readmission. Factors not associated with hospital readmission included patient age, conduit type, distal bypass target, and other medical comorbidities. Conclusions: One quarter of patients are readmitted within 30 days following lower extremity bypass for chronic limb-threatening ischemia. Efforts to mitigate wound infection and non-infectious wound complications may decrease rates of unplanned hospital readmission.
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Affiliation(s)
- Young Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, 609772Duke University Medical Center, Durham, NC, USA
| | - Zachary M Feldman
- Division of Vascular and Endovascular Surgery, Department of Surgery, 548305Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Monica Majumdar
- Division of Vascular and Endovascular Surgery, Department of Surgery, 548305Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Charles S DeCarlo
- Division of Vascular and Endovascular Surgery, Department of Surgery, 548305Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Anna Alaska Pendleton
- Division of Vascular and Endovascular Surgery, Department of Surgery, 548305Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Department of Surgery, 548305Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Abhisekh Mohapatra
- Division of Vascular and Endovascular Surgery, Department of Surgery, 548305Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, 548305Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
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Peres P, Lupson M, Dawson J. The benefits of a centralized remote surveillance program for vascular patients. J Vasc Surg 2023; 77:913-921. [PMID: 36356674 DOI: 10.1016/j.jvs.2022.10.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/30/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We aimed to assess the clinical and financial utility of a centralized remote surveillance program for vascular patients compared with traditional outpatient follow-up. METHODS In 2014, the Royal Adelaide Hospital Department of Vascular Surgery introduced a centralized remote surveillance program where suitable patients were monitored by remote imaging in lieu of traditional outpatient appointments (OPAs). Surveillance imaging was performed at a site local to the patient and was reviewed centrally by a dedicated surveillance nurse. We undertook a 5-year retrospective analysis of the program's prospectively maintained database since its inception. Costs for inpatient admissions and OPAs were retrieved from hospital financial databases. The surveillance database and electronic patient records were analyzed for number and outcome of surveillance scans, interventions, and OPAs. Additional savings in travel distance, fuel costs, and CO2 emissions were also calculated. RESULTS Over 5 years, 1262 patients underwent a mean of four scans per patient. A total of 3718 OPAs were saved, approximating 930 hours of clinic and consultant time, with associated savings of Australian (A)$1,524,900 (United States [US]$ 1,065,684) over 5 years (A$ 304,980 [US$ 213,137] per year). For every OPA avoided, each patient saved 197 km travel and A$87 (US$ 61) fuel costs, with an associated 115 kg of CO2 emissions saved. Over 5 years, this equated to savings of 248,173 km travel, A$ 110,136 (US$ 76,969) fuel costs, and 146 tons of CO2 emissions. A total of 134 surveillance-detected pathologies (10.6%) required intervention, a further 28 despite surveillance (2.2%), and three following surveillance cessation (0.2%). Subgroup analysis demonstrated that interventions despite surveillance were three times more expensive and incurred four times longer admissions than those due to surveillance. CONCLUSIONS Remote vascular surveillance, particularly applicable in our current COVID-19 pandemic climate, is associated with quantifiable financial, clinical, patient, and environmental beneficial outcomes and can be safely delivered to populations spanning large geographical areas such as those in Australia.
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Affiliation(s)
- Penelope Peres
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
| | - Marianne Lupson
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joseph Dawson
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Discipline of Surgery, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
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Nazari P, Golnari P, Ansari SA, Cantrell DR, Potts MB, Jahromi BS. Unplanned readmission after carotid stenting versus endarterectomy: analysis of the United States Nationwide Readmissions Database. J Neurointerv Surg 2023; 15:242-247. [PMID: 35169035 PMCID: PMC9985736 DOI: 10.1136/neurintsurg-2021-018523] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/01/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hospital readmissions are costly and reflect negatively on care delivered. OBJECTIVE To have a better understanding of unplanned readmissions after carotid revascularization, which might help to prevent them. METHODS The Nationwide Readmissions Database was used to determine rates and reasons for unplanned readmission following carotid endarterectomy (CEA) and carotid artery stenting (CAS). Trends were assessed by annual percent change, modified Poisson regression was used to estimate risk ratios (RR) for readmission, and propensity scores were used to match cohorts. RESULTS Analysis yielded 522 040 asymptomatic and 55 485 symptomatic admissions for carotid revascularization between 2010 and 2015. Higher 30-day readmission rates were noted after CAS versus CEA in both symptomatic (9.1% vs 7.7%, p<0.001) and asymptomatic (6.8% vs 5.7%, p<0.001) patients. Readmission rates trended lower over time, significantly so for 90-day readmissions in symptomatic patients undergoing CEA. The most common cause for 30-day readmission was stroke in both symptomatic (5.5%) and asymptomatic (3.9%) patients. Factors associated with a higher risk of readmission included age over 80; male gender; Medicaid health insurance; and increases in severity of illness, mortality risk, and comorbidity indices. Analysis of matched cohorts showed that CAS had higher readmission than CEA (RR=1.14 (95% CI 1.06 to 1.22); p<0.001) only in asymptomatic patients. Adverse events during initial admission which predicted 30-day readmission included acute renal failure and acute respiratory failure in asymptomatic patients; hematoma and cardiac events were additional predictive adverse events in symptomatic patients. CONCLUSIONS Readmission is not uncommon after carotid revascularization, occurs more often after CAS, and is predicted by baseline factors and by preventable adverse events at initial admission.
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Affiliation(s)
- Pouya Nazari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Pedram Golnari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sameer A Ansari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Donald R Cantrell
- Department of Radiology, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew B Potts
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Babak S Jahromi
- Department of Neurological Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Le ST, Prentice HA, Harris JE, Hsu JH, Rehring TF, Nelken NA, Hajarizadeh H, Chang RW. Decreasing Trends in Reintervention and Readmission After Endovascular Aneurysm Repair in a Multiregional Implant Registry. J Vasc Surg 2022; 76:1511-1519. [PMID: 35709865 DOI: 10.1016/j.jvs.2022.04.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 04/12/2022] [Accepted: 04/24/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES As endovascular aortic aneurysm repair (EVAR) matures into its third decade, measures such as long-term reintervention and readmission have become a focus of quality improvement efforts. Within a large United States integrated healthcare system, we describe time trends in the rates of long-term reinterventions utilization measures. METHODS Data from a US multiregional EVAR registry was used to perform a descriptive study of 3,891 adults who underwent conventional infrarenal EVAR for infrarenal abdominal aortic aneurysm between 2010 to 2019. Three-year follow-up was 96.7%. Outcomes included 1-, 3-, and 5-year graft revision (defined as a procedure involving placement of a new endograft component), secondary interventions (defined as a procedure necessary for maintenance of EVAR integrity, e.g., coil embolization and balloon angioplasty/stenting), conversion to open, interventions for type II endoleaks alone, and 90-day readmission. Crude cause-specific reintervention probabilities were calculated by operative year using the Aalen-Johansen estimator, with death as a competing risk and December 31, 2020 as the study end date. RESULTS Excluding interventions for type II endoleak alone, 1-year secondary intervention incidence decreased from 5.9% for EVARs in 2010 to 2.0% in 2019 (p<0.001) and 3-year incidence decreased from 7.2% to 3.6% from 2010 to 2017 (p=0.03). The 3-year incidences of graft revision (mean incidence 3.4%) and conversion to open remained fairly stable (mean incidence 0.6%) over time. The 3-year incidence of interventions for type II endoleak alone also decreased from 3.4% in 2010 to 0.7% in 2017 (p=0.01). 90-day readmission rates decreased from 19.3% for index EVAR in 2010 to 9.2% in 2019 (p=0.03). CONCLUSIONS Comprehensive data from a multiregional healthcare system demonstrates decreasing long-term secondary intervention and readmission rates over time in patients undergoing EVAR. These trends are not explained by evolving management of type II endoleaks and suggest improving graft durability, patient selection or surgical technique. Further study is needed to define implant and anatomic predictors of different types of long-term reintervention.
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Affiliation(s)
- Sidney T Le
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA; Department of Surgery, University of California San Francisco - East Bay, Oakland, CA, USA.
| | | | - Jessica E Harris
- Surgical Outcomes and Analysis, Kaiser Permanente, San Diego, CA, USA
| | - Jeffrey H Hsu
- Department of Vascular Surgery, Southern California Permanente Medical Group, Fontana, CA, USA
| | - Thomas F Rehring
- Department of Vascular Surgery, Colorado Permanente Medical Group, Denver, CO, USA
| | - Nicolas A Nelken
- Department of Vascular Surgery, Hawaii Permanente Medical Group, Honolulu, HI, USA
| | - Homayon Hajarizadeh
- Department of Vascular Surgery, Northwest Permanente Physicians and Surgeons, Clackamas, OR, USA
| | - Robert W Chang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA; Department of Vascular Surgery, The Permanente Medical Group, South San Francisco, CA, USA.
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McGinigle KL, Spangler EL, Pichel AC, Ayyash K, Arya S, Settembrini AM, Garg J, Thomas MM, Dell KE, Swiderski IJ, Lindo F, Davies MG, Setacci C, Urman RD, Howell SJ, Ljungqvist O, de Boer HD. Perioperative care in open aortic vascular surgery: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery. J Vasc Surg 2022; 75:1796-1820. [PMID: 35181517 DOI: 10.1016/j.jvs.2022.01.131] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/03/2022] [Indexed: 12/12/2022]
Abstract
The Society for Vascular Surgery and the Enhanced Recovery After Surgery (ERAS®) Society formally collaborated and elected an international, multi-disciplinary panel of experts to review the literature and provide evidence-based recommendations related to all of the health care received in the perioperative period for patients undergoing open abdominal aortic operations (both transabdominal and retroperitoneal approaches, including supraceliac, suprarenal, and infrarenal clamp sites, for aortic aneurysm and aortoiliac occlusive disease). Structured around the ERAS® core elements, 36 recommendations were made and organized into preadmission, preoperative, intraoperative, and postoperative recommendations.
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Affiliation(s)
- Katharine L McGinigle
- Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Emily L Spangler
- Department of Surgery, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Adam C Pichel
- Department of Anaesthesia, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Katie Ayyash
- Department of Perioperative Medicine (Merit), York and Scarborough Teaching Hospitals NHS Foundation Trust, York, UK
| | - Shipra Arya
- Department of Surgery, School of Medicine, Stanford University, Palo Alto, CA
| | | | - Joy Garg
- Department of Vascular Surgery, Kaiser Permanente San Leandro, San Leandro, CA
| | - Merin M Thomas
- Lenox Hill Hospital, Northwell Health, New Hyde Park, NY
| | | | | | - Fae Lindo
- Stanford University Hospital, Palo Alto, CA
| | - Mark G Davies
- Department of Surgery, Joe R. & Teresa Lozano Long School of Medicine, University of Texas Health Sciences Center, San Antonio, TX
| | - Carlo Setacci
- Department of Surgery, University of Siena, Siena, Italy
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Simon J Howell
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK
| | - Olle Ljungqvist
- Department of Surgery, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Hans D de Boer
- Department of Anesthesiology, Pain Medicine and Procedure Sedation and Analgesia, Martini General Hospital Groningen, Groningen, the Netherlands
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Shaterian N, Alsadat Rahnemaei F, Ghavidel N, Abdi F. Elective cesarean section on maternal request without indication: reasons for it, and its advantages and disadvantages. CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2021. [DOI: 10.15452/cejnm.2020.11.0017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Yaman Aktas Y, Gok Uğur H, Sevcan Orak O. A randomized controlled study on the effectiveness of discharge training in patients following cardiac surgery. CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2021. [DOI: 10.15452/cejnm.2020.11.0037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Aasen DM, Bronsert MR, Rozeboom PD, Colborn KL, Henderson WG, Lambert-Kerzner A, Hammermeister KE, Meguid RA. Relationships between predischarge and postdischarge infectious complications, length of stay, and unplanned readmissions in the ACS NSQIP database. Surgery 2020; 169:325-332. [PMID: 32933745 DOI: 10.1016/j.surg.2020.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 08/08/2020] [Accepted: 08/12/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Postoperative complications, length of index hospital stay, and unplanned hospital readmissions are important metrics reflecting surgical care quality. Postoperative infections represent a substantial proportion of all postoperative complications. We examined the relationships between identification of postoperative infection prehospital and posthospital discharge, length of stay, and unplanned readmissions in the American College of Surgeons National Surgical Quality Improvement Program database across nine surgical specialties. METHODS The 30-day postoperative infectious complications including sepsis, surgical site infections, pneumonia, and urinary tract infection were analyzed in the American College of Surgeons National Surgical Quality Improvement Program inpatient data during the period from 2012 to 2017. General, gynecologic, vascular, orthopedic, otolaryngology, plastic, thoracic, urologic, and neurosurgical inpatient operations were selected. RESULTS Postoperative infectious complications were identified in 5.2% (137,014/2,620,450) of cases; 81,929 (59.8%) were postdischarge. The percentage of specific complications identified postdischarge were 73.4% of surgical site infections (range across specialties 63.7-93.1%); 34.9% of sepsis cases (27.4-58.1%); 26.5% of pneumonia cases (18.9%-36.3%); and 53.2% of urinary tract infections (48.3%-88.0%). The relative risk of readmission among patients with postdischarge versus predischarge surgical site infection, sepsis, pneumonia, or urinary tract infection was 5.13 (95% confidence interval: 4.90-5.37), 9.63 (8.93-10.40), 10.79 (10.15-11.45), and 3.32 (3.07-3.60), respectively. Over time, mean length of stay decreased but postdischarge infections and readmission rates significantly increased. CONCLUSION Most postoperative infectious complications were diagnosed postdischarge. These were associated with an increased risk of readmission. The trend toward shorter length of stay over time was observed along with an increase both in the percentage of infections detected after discharge and the rate of unplanned related postoperative readmissions over time. Postoperative surveillance of infections should extend beyond hospital discharge of surgical patients.
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Affiliation(s)
- Davis M Aasen
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, UCONN Health, Farmington, CT; Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
| | - Paul D Rozeboom
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Kathryn L Colborn
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, CO
| | - William G Henderson
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Anne Lambert-Kerzner
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
| | - Karl E Hammermeister
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO; Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO; Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, CO.
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Lomazzi C, Mascoli C, de Beaufort HW, Cao P, Weaver F, Milner R, Fillinger M, Verhoeven E, Grassi V, Gargiulo M, Trimarchi S, Piffaretti G. Gender Related Access Complications After TEVAR: Analysis from the Retrospective Multicentre Cohort GORE® GREAT Registry Study. Eur J Vasc Endovasc Surg 2020; 60:203-209. [DOI: 10.1016/j.ejvs.2020.04.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 03/14/2020] [Accepted: 04/09/2020] [Indexed: 11/16/2022]
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Half of Unplanned Readmissions Following One or Two-Level Anterior Cervical Decompression and Fusion Are Unrelated to Surgical Site. Spine (Phila Pa 1976) 2020; 45:573-579. [PMID: 31770318 DOI: 10.1097/brs.0000000000003330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
UNLABELLED MINI: In this study we analyze rates of readmission, and the timing and reasons for readmission after one to two level anterior cervical decompression and fusion. Among 18,833 patients who underwent anterior cervical decompression and fusion, 3% were readmitted to the hospital within 30 days. 39.5% of readmissions were for reasons related to surgical site. STUDY DESIGN Retrospective review of a national database. OBJECTIVE In this study we analyze rates of readmission, and the timing and reasons for readmission after one to two level anterior cervical decompression and fusion (ACDF). SUMMARY OF BACKGROUND DATA The safety profile of ACDF has been previously described with readmission rates typically between 2% and 4%. However no studies have investigated the primary diagnoses driving readmission, and whether these diagnoses are related to the surgical site. METHODS Demographics, comorbidities, and procedural characteristics were collected for all patients undergoing one or two-level ACDF for degenerative indications identified by Current Procedural Terminology (CPT) coding in the National Surgical Quality Improvement Program (NSQIP) database. The incidence of 30-day complications and readmissions was calculated, and the reasons for readmission as well as the timing of readmission were reviewed. Multivariate logistic regression analyses were performed to identify risk factors associated with complications or readmissions within 30 days of surgery. RESULTS Eighteen thousand eight hundred thirty three patients underwent ACDF (15,464 single-level and 3369 two-level, mean age 53.7 yrs, standard deviation [SD]: 11.6; 50% male). Postoperative complication rate of was 4.3% in two-level fusions and 3.5% in single-level fusion (P = 0.027). Five hundred sixty nine unplanned readmissions were identified (3.0%), of which 39.5% were related to the surgical site and 49.7% were unrelated to the surgical site (10.5% unknown cause of readmission). The most frequent reason for 30-day readmission was pneumonia (9.3%, mean time to readmission of 11.3 d) followed by dysphagia (7.4%, 6.3 d), and acute postoperative pain (7.2%, 11.4 d). CONCLUSION In this nationwide analysis of 18,833 ACDF cases, 3.0% of patients were readmitted within 30 days, of which at least 49.7% were for reasons unrelated to the surgical site. LEVEL OF EVIDENCE 3.
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Vogel TR, Smith JB, Kruse RL. Risk Factors for Thirty-Day Readmissions After Lower Extremity Amputation in Patients With Vascular Disease. PM R 2018; 10:1321-1329. [PMID: 29852287 PMCID: PMC6265125 DOI: 10.1016/j.pmrj.2018.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 05/06/2018] [Accepted: 05/08/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Understanding risk factors associated with readmission after lower extremity amputation may indicate targets for reducing readmission. OBJECTIVE To evaluate factors associated with all-cause 30-day readmission after lower extremity amputation procedures. DESIGN Retrospective cohort study. SETTING Inpatient. PATIENTS A total of 2480 patients who had lower extremity amputations between 2008 and 2014 were selected from national electronic medical record database, Cerner Health Facts. METHODS Univariate analysis of demographics, diagnoses, postoperative medications, and laboratory results were examined. Multivariate logistic regression models were used to identify characteristics independently associated with readmission overall and by amputation location-above the knee (AKA) or below the knee (BKA). MAIN OUTCOME MEASUREMENT Readmission within 30 days of discharge. RESULTS More than one half of patients (1403, 57%) underwent BKA and 1077 (43%) underwent AKA. Readmission within 30 days was 22% (24.1% BKA versus 19.4% AKA, P = .005). In multivariable logistic regression, factors associated with 30-day readmission after any amputation included BKA (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.15-1.74, P = .001), hypertension (OR 1.70, 95% CI 1.33-2.16), surgical-site infections (OR 1.44, 95% CI 1.02-2.04), heart failure (OR 1.39, 95% CI 1.10-1.75), discharge to a skilled nursing facility (OR 1.88, 95% CI 1.41-2.51), and emergency/urgent procedures (OR 1.32, 95% CI 1.04-1.67). At readmission, 13.3% of patients with a BKA required an AKA revision, and 21.3% had a diagnosis of surgical-site infection. CONCLUSIONS Risk factors for readmission after any amputation included cardiac comorbidities, associated postoperative medications, and discharge to a skilled nursing facility. The finding that acute arterial embolism or thrombosis and a BKA during the index admission was highly associated with readmission, combined with the high rates of 30-day conversion to an AKA when readmitted, suggests these patients more often develop stump complications or may be undertreated during the initial hospitalization. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Todd R Vogel
- Department of Surgery, Division of Vascular Surgery, University of Missouri Hospital & Clinics, One Hospital Drive, Columbia, MO 65212(∗).
| | - Jamie B Smith
- Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, MO(†)
| | - Robin L Kruse
- Department of Family and Community Medicine, University of Missouri, School of Medicine, Columbia, MO(‡)
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Dakour Aridi H, Locham S, Nejim B, Malas MB. Comparison of 30-day readmission rates and risk factors between carotid artery stenting and endarterectomy. J Vasc Surg 2017; 66:1432-1444.e7. [DOI: 10.1016/j.jvs.2017.05.097] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/05/2017] [Indexed: 11/30/2022]
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Nakazawa KR, Egorova NN, Power JR, Faries PL, Vouyouka AG. The Impact of Surgical Care Improvement Project Measures on In-Hospital Outcomes following Elective Vascular Procedures. Ann Vasc Surg 2017; 38:17-28. [DOI: 10.1016/j.avsg.2016.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 05/25/2016] [Accepted: 06/03/2016] [Indexed: 02/05/2023]
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Hicks CW, Bronsert M, Hammermeister KE, Henderson WG, Gibula DR, Black JH, Glebova NO. Operative variables are better predictors of postdischarge infections and unplanned readmissions in vascular surgery patients than patient characteristics. J Vasc Surg 2016; 65:1130-1141.e9. [PMID: 28017586 DOI: 10.1016/j.jvs.2016.10.086] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 10/11/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Although postoperative readmissions are frequent in vascular surgery patients, the reasons for these readmissions are not well characterized, and effective approaches to their reduction are unknown. Our aim was to analyze the reasons for vascular surgery readmissions and to report potential areas for focused efforts aimed at readmission reduction. METHODS The 2012 to 2013 American College of Surgeons National Quality Improvement Program (ACS NSQIP) data set was queried for vascular surgery patients. Multivariable models were developed to analyze risk factors for postdischarge infections, the major drivers of unplanned 30-day readmissions. RESULTS We identified 86,403 vascular surgery patients for analysis. Thirty-day readmission occurred in 8827 (10%), of which 8054 (91%) were unplanned. Of the unplanned readmissions, 61% (n = 4951) were related to the index vascular surgery procedure. Infectious complications were the most common reason for a surgery-related readmission (1940 [39%]), with surgical site infection being the most common type of infection related to unplanned readmission. Multivariable analysis showed the top five preoperative risk factors for postdischarge infections were the presence of a preoperative open wound, inpatient operation, obesity, work relative value unit, and insulin-dependent diabetes (but not diabetes managed with oral medications). Cigarette smoking was a weak predictor and came in tenth in the mode (overall C index, 0.657). When operative and postoperative factors were included in the model, total operative time was the strongest predictor of postdischarge infectious complications (odds ratio [OR] 1.2 for each 1-hour increase in operative time), followed by presence of a preoperative open wound (OR, 1.5), inpatient operation (OR, 2), obesity (OR, 1.8), and discharge to rehabilitation facility (OR, 1.7; P < .001 for all). Insulin-dependent diabetes, cigarette smoking, dialysis dependence, and female gender were also predictive, albeit with smaller effects (OR, 1.1-1.3 for all; P < .001). The overall fit of the multivariable model was fair (C statistic, 0.686). CONCLUSIONS Infectious complications dominate the reasons for unplanned 30-day readmissions in vascular surgery patients. We have identified preoperative, operative, and postoperative risk factors for these infections with the goal of reducing these complications and thus readmissions. Expected patient risk factors, such as diabetes, obesity, renal insufficiency, and cigarette smoking, were less important in predicting infectious complications compared with operative time, presence of a preoperative open wound, and inpatient operation. Our findings suggest that careful operative planning and expeditious operations may be the most effective approaches to reducing infections and thus readmissions in vascular surgery patients.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Michael Bronsert
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), School of Medicine, University of Colorado Denver, Aurora, Colo
| | - Karl E Hammermeister
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), School of Medicine, University of Colorado Denver, Aurora, Colo
| | - William G Henderson
- Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), School of Medicine, University of Colorado Denver, Aurora, Colo
| | - Douglas R Gibula
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado Denver, Aurora, Colo
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Natalia O Glebova
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado Denver, Aurora, Colo.
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Tahhan G, Farber A, Shah NK, Krafcik BM, Sachs TE, Kalish JA, Peacock MR, Siracuse JJ. Characterization of Planned and Unplanned 30-Day Readmissions Following Vascular Surgical Procedures. Vasc Endovascular Surg 2016; 51:17-22. [DOI: 10.1177/1538574416682176] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Thirty-day readmission is increasingly used as a quality of care indicator. Patients undergoing vascular surgery have historically been at high risk for readmission. We analyzed hospital readmission details to identify patients at high risk for readmission in order to better understand these readmissions and improve resource utilization in this patient population. Methods: A retrospective review and analysis of our medical center’s admission and discharge data were conducted from October 2012 to March 2015. All patients who were discharged from the vascular surgery service and subsequently readmitted as an inpatient within 30 days were included. Results: We identified 649 vascular surgery discharges with 135 (21%) readmissions. Common comorbidities were diabetes (56%), coronary artery disease (40%), congestive heart failure (CHF; 24%), and chronic obstructive pulmonary disease (19%). Index vascular operations included open lower extremity procedures (39%), diagnostic angiograms (35%), endovascular lower extremity procedures (16%), dialysis access procedures (7%), carotid/cerebrovascular procedures (7%), amputations (6%), and abdominal aortic procedures (5%). Average index length of stay (LOS) was 7.48 days (±6.73 days). Reasons for readmissions were for medical causes (43%), surgical complications (35.5%), and planned procedures (21.5%). Reasons for medical readmissions most commonly included malaise or failure to thrive (28%), unrelated infection (24%), and hypoxia/CHF complications (21%). Common surgical causes for readmission were surgical site infections (69%), graft failure (19%), and bleeding complications (8%). Of the planned readmissions, procedures were at the same site (79%), a different site (14%), and planned podiatry procedures (7%). Readmission LOS was on average 7.43 days (±7.22 days). Conclusion: Causes for readmission of vascular surgery patients are multifactorial. Infections, both related and unrelated to the surgical site, remain common reasons for readmission and represent an opportunity for improvement strategies. Improved understanding of readmissions following vascular surgery could help adjust policy benchmarks for targeted readmission rates and help reduce resource utilization.
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Affiliation(s)
- Georges Tahhan
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Boston, MA, USA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Boston, MA, USA
| | - Nishant K. Shah
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Boston, MA, USA
| | - Brianna M. Krafcik
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Boston, MA, USA
| | - Teviah E. Sachs
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Boston, MA, USA
| | - Jeffrey A. Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Boston, MA, USA
| | - Matthew R. Peacock
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Boston, MA, USA
| | - Jeffrey J. Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University, Boston, MA, USA
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Socioeconomic Factors Are Associated With Readmission After Lobectomy for Early Stage Lung Cancer. Ann Thorac Surg 2016; 102:1660-1667. [PMID: 27476821 DOI: 10.1016/j.athoracsur.2016.05.060] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 05/06/2016] [Accepted: 05/11/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Data regarding risk factors for readmissions after surgical resection for lung cancer are limited and largely focus on postoperative outcomes, including complications and hospital length of stay. The current study aims to identify preoperative risk factors for postoperative readmission in early stage lung cancer patients. METHODS The National Cancer Data Base was queried for all early stage lung cancer patients with clinical stage T2N0M0 or less who underwent lobectomy in 2010 and 2011. Patients with unplanned readmission within 30 days of hospital discharge were identified. Univariate analysis was utilized to identify preoperative differences between readmitted and not readmitted cohorts; multivariable logistic regression was used to identify risk factors resulting in readmission. RESULTS In all, 840 of 19,711 patients (4.3%) were readmitted postoperatively. Male patients were more likely to be readmitted than female patients (4.9% versus 3.8%, p < 0.001), as were patients who received surgery at a nonacademic rather than an academic facility (4.6% versus 3.6%; p = 0.001) and had underlying medical comorbidities (Charlson/Deyo score 1+ versus 0; 4.8% versus 3.7%; p < 0.001). Readmitted patients had a longer median hospital length of stay (6 days versus 5; p < 0.001) and were more likely to have undergone a minimally invasive approach (5.1% video-assisted thoracic surgery versus 3.9% open; p < 0.001). In addition to those variables, multivariable logistic regression analysis identified that median household income level, insurance status (government versus private), and geographic residence (metropolitan versus urban versus rural) had significant influence on readmission. CONCLUSIONS The socioeconomic factors identified significantly influence hospital readmission and should be considered during preoperative and postoperative discharge planning for patients with early stage lung cancer.
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Glebova NO, Bronsert M, Hammermeister KE, Nehler MR, Gibula DR, Malas MB, Black JH, Henderson WG. Drivers of readmissions in vascular surgery patients. J Vasc Surg 2016; 64:185-194.e3. [DOI: 10.1016/j.jvs.2016.02.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
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