Causes and implications of readmission after abdominal aortic aneurysm repair

Readmissions Following Endovascular Thoracic and Thoracoabdominal Aortic Repairs in The Vascular Implant Surveillance and Interventional Outcomes Network (VISION)

OBJECTIVES

Investigate readmission rates, diagnoses associated with readmission, and associations with mortality through 90-days post-operatively after elective endovascular thoracic and thoracoabdominal aortic repair overall and by extent of coverage.

METHODS

A cohort of index elective non-traumatic endovascular thoracic and thoracoabdominal aortic cases from 2010-2018 was derived from the Vascular Implant Surveillance and Interventional Outcomes Network. Cohort readmissions within 90-days postoperative were examined both overall and by Crawford extent (CE) of aortic coverage. Postoperative mortality was examined by reason for readmission and CE.

RESULTS

The cohort consisted of 2,093 patients who underwent endovascular thoracic and thoracoabdominal aortic repair (1,541 CE 0A/0B; 240 CE 1-3; 312 CE 4-5). Cumulative risk for 90-day readmission was 34.3% in CE 0A/0B repairs, 33.4% in CE4-5 repairs and 47.4% in CE 1-3 repairs. Compared to CE 0A/B, patients with CE 1-3 repairs experienced an increased risk of readmission within 90 days postoperatively after adjusting for preoperative factors (aHR 1.27(1.00,1.61) while the readmission risk for CE 4-5 repairs did not differ significantly (aHR 0.83 (0.64,1.06). Significant risk factors for 90-day readmission included COPD, dialysis dependence, limited ambulation, visceral/spinal ischemia, and in-hospital stroke. Discharge to home was protective against readmission (HR 0.65, CI 0.54-0.79). Patients with a readmission within 90-days had a 7.89-fold increase in 90-day mortality (HR 7.84; 5.17, 11.9) compared to those not readmitted.

CONCLUSIONS

Increasing extent of endovascular thoracic and thoracoabdominal aortic repair was associated with higher 90-day readmission rates. Readmission for all CE was associated with near 8-fold increased risk of mortality. Risk factors associated with increased risk for readmission included pulmonary insufficiency, renal disease, and poor functional status. These findings can inform stakeholders about investment of resources to improve processes of care that both target prevention and mitigate risk of readmission after elective endovascular thoracic and thoracoabdominal aortic repair.

Predictors of prolonged length of stay after elective carotid revascularization

OBJECTIVE

Postoperative day-one discharge is used as a quality-of-care indicator after carotid revascularization. This study identifies predictors of prolonged length of stay (pLOS), defined as a postprocedural LOS of >1 day, after elective carotid revascularization.

METHODS

Patients undergoing carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) in the Vascular Quality Initiative between 2016 and 2022 were included in this analysis. Multivariable logistic regression analysis was used to identify predictors of pLOS, defined as a postprocedural LOS of >1 day, after each procedure.

RESULTS

A total of 118,625 elective cases were included. pLOS was observed in nearly 23.2% of patients undergoing carotid revascularization. Major adverse events, including neurological, cardiac, infectious, and bleeding complications, occurred in 5.2% of patients and were the most significant contributor to pLOS after the three procedures. Age, female sex, non-White race, insurance status, high comorbidity index, prior ipsilateral CEA, non-ambulatory status, symptomatic presentation, surgeries occurring on Friday, and postoperative hypo- or hypertension were significantly associated with pLOS across all three procedures. For CEA, additional predictors included contralateral carotid artery occlusion, preoperative use of dual antiplatelets and anticoagulation, low physician volume (<11 cases/year), and drain use. For TCAR, preoperative anticoagulation use, low physician case volume (<6 cases/year), no protamine use, and post-stent dilatation intraoperatively were associated with pLOS. One-year analysis showed a significant association between pLOS and increased mortality for all three procedures; CEA (hazard ratio [HR],1.64; 95% confidence interval [CI], 1.49-1.82), TCAR (HR,1.56; 95% CI, 1.35-1.80), and TFCAS (HR, 1.33; 95%CI, 1.08-1.64) (all P < .05).

CONCLUSIONS

A postoperative LOS of more than 1 day is not uncommon after carotid revascularization. Procedure-related complications are the most common drivers of pLOS. Identifying patients who are risk for pLOS highlights quality improvement strategies that can optimize short and 1-year outcomes of patients undergoing carotid revascularization.

Readmission after thoracic endovascular aortic repair following blunt thoracic aortic injury

PURPOSE

Thoracic endovascular aortic repair (TEVAR) is increasingly utilized to treat blunt thoracic aortic injury (BTAI), but post-discharge outcomes remain underexplored. We examined 90-day readmission in patients treated with TEVAR following BTAI.

METHODS

Adult patients discharged alive after TEVAR for BTAI in the Nationwide Readmissions Database between 2016 and 2019 were included. Outcomes examined were 90-day non-elective readmission, primary readmission reasons, and 90-day mortality. As a complementary analysis, 90-day outcomes following TEVAR for BTAI were compared with those following TEVAR for acute type B aortic dissection (TBAD).

RESULTS

We identified 2085 patients who underwent TEVAR for BTAI. The median age was 43 years (IQR, 29-58), 65% of all patients had an ISS ≥ 25, and 13% were readmitted within 90 days. The main primary causes for readmission were sepsis (8.8%), wound complications (6.7%), and neurological complications (6.5%). Two patients developed graft thrombosis as primary readmission reasons. Compared with acute TBAD patients, BTAI patients had a significantly lower rate of readmission within 90 days (BTAI vs. TBAD; 13% vs. 29%; p < .001).

CONCLUSION

We found a significant proportion of readmission in patients treated with TEVAR for BTAI. However, the 90-day readmission rate after TEVAR for BTAI was significantly lower compared with acute TBAD, and the common cause for readmission was not related to residual aortic disease or vascular devices. This represents an important distinction from other patient populations treated with TEVAR for acute vascular conditions. Elucidating differences between trauma-related TEVAR readmissions and non-traumatic indications better informs both the clinician and patients of expected post-discharge course. Level of evidence/study type: IV, Therapeutic/care management.

Development and Validation of a Novel Preoperative Risk Score to Identify Patients at Risk for Nonhome Discharge after Elective Endovascular Aortic Aneurysm Repair (EVAR)

BACKGROUND

Nonhome discharge (NHD) to a rehabilitation or skilled nursing facility after elective endovascular aortic repair (EVAR) is uncommon. However, NHD after surgery has an important impact on patient quality of life and postdischarge outcomes. Understanding factors that put patients undergoing EVAR at high risk for NHD is essential to providing adequate preoperative counseling and shared decision making. This study aimed to identify independent predictors of NHD following elective EVAR and to create a clinically useful preoperative risk score.

METHODS

Elective EVAR cases were queried from the Society for Vascular Surgery Vascular Quality Initiative 2014-2018. A risk score was created by splitting the data set into two-thirds for development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. The score was then validated, and model performance assessed.

RESULTS

Overall, 24,426 patients were included and 932 (3.8%) required NHD. Multivariable analysis in the development group identified independent predictors of NHD, which were used to create a 20-point risk score. Patients were stratified into 3 groups based upon their risk score: low risk (0-7 points; n = 16,699) with an NHD rate of 1.8%, moderate risk (8-13 points; n = 7,315) with an NHD rate of 7.3%, and high risk (≥14 points; n = 412) with an NHD rate of 21.8%. The risk score had good predictive ability with c-statistic = 0.75 for model development and c-statistic = 0.73 in the validation dataset.

CONCLUSIONS

This novel risk score can predict NHD following EVAR using characteristics that can be identified preoperatively. Utilization of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.

Outcomes of early hospital readmission after kidney transplantation: Perspectives from a Canadian transplant centre

BACKGROUND

Early hospital readmissions (EHRs) after kidney transplantation range in incidence from 18%-47% and are important and substantial healthcare quality indicators. EHR can adversely impact clinical outcomes such as graft function and patient mortality as well as healthcare costs. EHRs have been extensively studied in American healthcare systems, but these associations have not been explored within a Canadian setting. Due to significant differences in the delivery of healthcare and patient outcomes, results from American studies cannot be readily applicable to Canadian populations. A better understanding of EHR can facilitate improved discharge planning and long-term outpatient management post kidney transplant.

AIM

To explore the burden of EHR on kidney transplant recipients (KTRs) and the Canadian healthcare system in a large transplant centre.

METHODS

This single centre cohort study included 1564 KTRs recruited from January 1, 2009 to December 31, 2017, with a 1-year follow-up. We defined EHR as hospitalizations within 30 d or 90 d of transplant discharge, excluding elective procedures. Multivariable Cox and linear regression models were used to examine EHR, late hospital readmissions (defined as hospitalizations within 31-365 d for 30-d EHR and within 91-365 d for 90-d EHR), and outcomes including graft function and patient mortality.

RESULTS

In this study, 307 (22.4%) and 394 (29.6%) KTRs had 30-d and 90-d EHRs, respectively. Factors such as having previous cases of rejection, being transplanted in more recent years, having a longer duration of dialysis pretransplant, and having an expanded criteria donor were associated with EHR post-transplant. The cumulative probability of death censored graft failure, as well as total graft failure, was higher among the 90-d EHR group as compared to patients with no EHR. While multivariable models found no significant association between EHR and patient mortality, patients with EHR were at an increased risk of late hospital readmissions, poorer kidney function throughout the 1st year post-transplant, and higher hospital-based care costs within the 1st year of follow-up.

CONCLUSION

EHRs are associated with suboptimal outcomes after kidney transplant and increased financial burden on the healthcare system. The results warrant the need for effective strategies to reduce post-transplant EHR.

Risk factors for readmission after open abdominal aortic aneurysms repair and its outcome in chronic kidney disease patients

OBJECTIVE

Readmission after vascular procedures is a burden to hospitals and the Medicare system. Therefore, identifying risk factors leading to readmission is vital. We examined the frequency of and risk factors for 30-day readmission after open aneurysm repair (OAR) and explored post-operative outcomes with special attention for those with preexisting chronic kidney disease (CKD).

METHODS

Patients who underwent OAR were identified in the National Readmission Database (2016-2018). Demographic information and comorbidities were collected. Patients readmitted within 30 days after their index hospitalization were identified and compared to patients without readmission records.

RESULTS

A total of 5090 patients underwent OAR during the study timeframe with 488 patients (9.6%) were readmitted within 30 days. Females were more readmitted than males (F = 11.1% vs M = 9.0%, P < 0.001). Readmitted patients had more comorbidities (median ECI 12, P < 0.05), were on Medicare (73.7%, P < 0.001), had higher surgery admission cost ($146,844, P < 0.001), longer length of stay (8 days, P < 0.001), and were discharged to a lower level care facility (62.7%, P < 0.001). Comorbidities that predisposed patients for readmission include: peripheral arterial disease (OR 2.15, P < 0.01), asthma (OR 1.87, P < 0.01), chronic heart failure (OR 1.74, P < 0.05). On readmission visit, acute renal failure (23.8%) was the most common diagnosis, while intestinal surgery (13.7%) was the most common procedure. Patients with CKD (n = 968, 18.9% of total population) had double the mortality rate compared to non-CKD patients on surgery admission (10.4%, P < 0.001) and readmission (10.1%, P < 0.001).

CONCLUSION

Certain factors were noted to increase readmission rate, special attention need to be paid when dealing with such group of patients requiring OAR. Vascular surgeons should meticulously weigh benefits and risks when considering OAR in patients with CKD who are not a candidate for endovascular repair, and optimize their kidney function before considering such approach.

Long-term Mortality and Reintervention After Endovascular and Open Abdominal Aortic Aneurysm Repairs in Australia, Germany, and the United States

OBJECTIVE

To examine long-term outcomes after endovascular (EVAR) and open repairs (OAR) for intact abdominal aortic aneurysms in Australia, Germany, and the United States, using a unified study design.

BACKGROUND

Similarities and differences in long-term outcomes after EVAR versus OAR across countries remained unclear, given differences in designs across existing studies.

METHODS

We identified patients aged >65 years undergoing intact abdominal aortic aneurysm repairs during 2010-2017/2018. We compared long-term patient mortality and reintervention after EVAR and OAR using Kaplan-Meier analyses and Cox regressions. Propensity score matching was performed within each country to adjust for differences in baseline patient characteristics between procedure groups.

RESULTS

We included 3311, 4909, and 145363 patients from Australia, Germany, and the United States, respectively. The median patient age was 76 to 77 years, and most patients were males (77%-84%). Patient mortality was lower after EVAR than OAR within the first 60 days and became similar at 3-year follow-up (Australia 14.7% vs 16.5%, Germany 18.2% vs 19.7%, United States: 24.4% vs 24.4%). At the end of follow-up, patient mortality after EVAR was higher than OAR in Australia [ hazard ratio (HR) 95% CI: 1.21 (0.96-1.54)] but similar to OAR in Germany [HR 95% CI: 0.92 (0.80-1.07)] and the United States [HR 95% CI: 1.02 (0.99-1.05)]. The risk of reintervention after EVAR was more than twice that after OAR in Australia [HR 95% CI: 2.60 (1.09-6.15)], Germany [HR 95% CI: 4.79 (2.56-8.98)], and the United States [HR 95% CI: 2.67 (2.38-3.00)]. The difference in reintervention risk appeared early in German and United States patients.

CONCLUSIONS

This multinational study demonstrated important similarities in long-term outcomes after EVAR versus OAR across 3 countries. Variation in long-term mortality and reintervention comparisons indicates possible differences in patient profiles, surveillance, and best medical therapy across countries.

Closed-Loop Bowel Obstruction Years After an Open Abdominal Aortic Aneurysm Repair

A 68-year-old male has a significant past medical history of severe aortic stenosis, peripheral arterial disease, chronic kidney disease, and an abdominal aortic aneurysm treated with a bifurcated interposition aortobiiliac graft. He was admitted to the hospital for an elective one-vessel coronary artery bypass graft and placement of a bioprosthetic aortic valve. Postoperatively, he developed worsening abdominal pain, leukocytosis, and inability to tolerate nutrition by mouth. Computed tomography revealed moderately dilated loops of the small bowel with two transition points in the right lower quadrant. He was taken emergently to the operating room for an exploratory laparotomy, and a 28-cm necrotic jejunal loop was entrapped posterior to the right iliac segment of the graft. In a patient with an intra-abdominal synthetic vascular graft, a closed-loop bowel obstruction caused by entrapment by the vascular graft is exceptionally rare; however, it should be considered in the presence of bowel obstruction.

Mobile devices and wearable technology for measuring patient outcomes after surgery: a systematic review

Complications following surgery are common and frequently occur the following discharge. Mobile and wearable digital health interventions (DHI) provide an opportunity to monitor and support patients during their postoperative recovery. Lack of high-quality evidence is often cited as a barrier to DHI implementation. This review captures and appraises the current use, evidence base and reporting quality of mobile and wearable DHI following surgery. Keyword searches were performed within Embase, Cochrane Library, Web of Science and WHO Global Index Medicus databases, together with clinical trial registries and Google scholar. Studies involving patients undergoing any surgery requiring skin incision where postoperative outcomes were measured using a DHI following hospital discharge were included, with DHI defined as mobile and wireless technologies for health to improve health system efficiency and health outcomes. Methodological reporting quality was determined using the validated mobile health evidence reporting and assessment (mERA) guidelines. Bias was assessed using the Cochrane Collaboration tool for randomised studies or MINORS depending on study type. Overall, 6969 articles were screened, with 44 articles included. The majority (n = 34) described small prospective study designs, with a high risk of bias demonstrated. Reporting standards were suboptimal across all domains, particularly in relation to data security, prior patient engagement and cost analysis. Despite the potential of DHI to improve postoperative patient care, current progress is severely restricted by limitations in methodological reporting. There is an urgent need to improve reporting for DHI following surgery to identify patient benefit, promote reproducibility and encourage sustainability.

Characteristics and Outcomes of Pediatric Nonindex Readmission: Evidence From Florida Hospitals

OBJECTIVES

Increasing pediatric care regionalization may inadvertently fragment care if children are readmitted to a different (nonindex) hospital rather than the discharge (index) hospital. Therefore, this study aimed to assess trends in pediatric nonindex readmission rates, examine the risk factors, and determine if this destination difference affects readmission outcomes.

METHODS

In this retrospective cohort study, we use the Healthcare Cost and Utilization Project State Inpatient Database to include pediatric (0 to 18 years) admissions from 2010 to 2017 across Florida hospitals. Risk factors of nonindex readmissions were identified by using logistic regression analyses. The differences in outcomes between index versus nonindex readmissions were compared for in-hospital mortality, morbidity, hospital cost, length of stay, against medical advice discharges, and subsequent hospital visits by using generalized linear regression models.

RESULTS

Among 41 107 total identified readmissions, 5585 (13.6%) were readmitted to nonindex hospitals. Adjusted nonindex readmission rate increased from 13.3% in 2010% to 15.4% in 2017. Patients in the nonindex readmissions group were more likely to be adolescents, live in poor neighborhoods, have higher comorbidity scores, travel longer distances, and be discharged at the postacute facility. After risk adjusting, no difference in in-hospital mortality was found, but morbidity was 13% higher, and following unplanned emergency department visits were 28% higher among patients with nonindex readmissions. Length of stay, hospital costs, and against medical advice discharges were also significantly higher for nonindex readmissions.

CONCLUSIONS

A substantial proportion of children experienced nonindex readmissions and relatively poorer health outcomes compared with index readmission. Targeted strategies for improving continuity of care are necessary to improve readmission outcomes.

Identifying Children at Readmission Risk: At-Admission versus Traditional At-Discharge Readmission Prediction Model

The timing of 30-day pediatric readmissions is skewed with approximately 40% of the incidents occurring within the first week of hospital discharges. The skewed readmission time distribution coupled with delay in health information exchange among healthcare providers might offer a limited time to devise a comprehensive intervention plan. However, pediatric readmission studies are thus far limited to the development of the prediction model after hospital discharges. In this study, we proposed a novel pediatric readmission prediction model at the time of hospital admission which can improve the high-risk patient selection process. We also compared proposed models with the standard at-discharge readmission prediction model. Using the Hospital Cost and Utilization Project database, this prognostic study included pediatric hospital discharges in Florida from January 2016 through September 2017. Four machine learning algorithms—logistic regression with backward stepwise selection, decision tree, Support Vector machines (SVM) with the polynomial kernel, and Gradient Boosting—were developed for at-admission and at-discharge models using a recursive feature elimination technique with a repeated cross-validation process. The performance of the at-admission and at-discharge model was measured by the area under the curve. The performance of the at-admission model was comparable with the at-discharge model for all four algorithms. SVM with Polynomial Kernel algorithms outperformed all other algorithms for at-admission and at-discharge models. Important features associated with increased readmission risk varied widely across the type of prediction model and were mostly related to patients’ demographics, social determinates, clinical factors, and hospital characteristics. Proposed at-admission readmission risk decision support model could help hospitals and providers with additional time for intervention planning, particularly for those targeting social determinants of children’s overall health.

Depression Predicts Non-Home Discharge After Abdominal Aortic Aneurysm Repair

BACKGROUND

Mental health's impact on vascular surgical patients has long been overlooked. While outside the expertise of most surgeons, understanding the role that depression plays in the postoperative course could provide additional insight into opportunities to improve surgical outcomes and healthcare value. Additionally, non-home discharge (NHD) to a rehabilitation or skilled nursing facility after surgery is associated with impaired quality of life and higher postdischarge complications, readmissions, and mortality. We hypothesized that depression would be associated with an increased risk for NHD following abdominal aortic aneurysm (AAA) repair.

METHODS

Nonruptured AAA repair cases were identified from the National Inpatient Sample (NIS) using ICD-9 codes between 2005 and 2014. Depression, comorbidities, postoperative complications, and discharge destination were evaluated using statistical tests as appropriate to the data. A hierarchical multivariable logistic regression controlling for hospital level variation was used to examine the independent association between depression, and the primary outcome of NHD controlling for median income and confounders meeting P < 0.05 on univariate analysis.

RESULTS

There were 99,934 total cases analyzed, of which 4,755 (4.8%) were diagnosed with depression and 10,618 (11.9%) required NHD. Patients with depression were younger, more likely to be women, white, have diabetes, chronic obstructive pulmonary disease, hypertension, tobacco use, and more likely to experience a postoperative complication. On adjusted multivariable analysis, patients with depression were more likely to require NHD (odds ratio [OR] 1.87, 95% confidence interval [CI]: 1.68-2.08, c-statistic = 0.82). On stratified analysis by operative approach, depression had a larger effect estimate in endovascular repair (OR 2.19; 95% CI: 1.90-2.52) versus open repair (OR 1.60; 95% CI: 1.38-1.87).

CONCLUSIONS

In a nationally representative sample, patients with depression were more likely to require NHD after AAA repair. This study highlights the importance that depression plays in postoperative outcomes after AAA repair. Furthermore, addressing mental health preoperatively has the potential to improve outcomes in patients undergoing AAA repair.

Patients with depression are less likely to go home after critical limb revascularization

BACKGROUND

Although often overlooked during the preoperative evaluation, recent evidence has suggested that depression in patients with peripheral artery disease is associated with increased postoperative complications, including decreased primary and secondary patency after revascularization and an increased risk of major amputation and mortality. Postoperative nonhome discharge (NHD) is an important outcome for patients and has also been associated with other adverse outcomes; however, the effect that depression has on NHD after vascular surgery has remained unexplored. We hypothesized that depression would be associated with an increased risk of NHD after revascularization for chronic limb threatening ischemia (CLTI).

METHODS

Endovascular, open, and hybrid (combined open and endovascular) cases of revascularization for CLTI were identified from the 2012 to 2014 National (Nationwide) Inpatient Sample. CLTI, diagnoses of depression, and medical comorbidities were defined using the corresponding International Classification of Diseases, Ninth Revision, Clinical Modification codes. A hierarchical multivariable binary logistic regression controlling for hospital level variation and for confounders meeting P <.01 on bivariate analysis was used to examine the association between depression and NHD. A sensitivity analysis after coarsened exact matching for baseline characteristics that differed between the two groups was performed to reduce any imbalance.

RESULTS

A total of 64,817 cases were identified, of which 5472 (8.4%) included a diagnosis of depression and 16,524 (25.5%) NHD. The patients with depression were younger and more likely to be women and white, have multiple comorbidities and a nonelective admission, and experience a postoperative complication (P <.05). On unadjusted analyses, patients with depression had an 8% absolute increased risk of requiring NHD (32.1% vs 24.9%; P <.001). On multivariable analysis, patients with depression had an increased odds for NHD (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.40-1.61; c-statistic, 0.81) compared with those without depression. After stratification by operative approach, depression had a larger effect estimate in endovascular revascularization (OR, 1.57; 95% CI, 1.42-1.74) compared with open (OR, 1.45; 95% CI, 1.30-1.62). A test for interaction between depression and gender identified that men with depression had greater odds of NHD compared with women with depression (OR, 1.68; 95% CI, 1.51-1.88; vs OR, 1.37; 95% CI, 1.25-1.51; interaction P <.01). A sensitivity analysis after coarsened exact matching confirmed these findings.

CONCLUSIONS

To the best of our knowledge, the present study is the first to identify an association between depression and NHD after revascularization for CLTI. These results provide further evidence of the negative effects that comorbid depression has on patients undergoing revascularization for CLTI. Future studies should examine whether treating depression can improve the outcomes in this patient population.

Readmission and Utilization After Repair of Ruptured Abdominal Aortic Aneurysms in the United States

OBJECTIVES

Endovascular aneurysm repair (EVAR) has emerged as a less invasive alternative to open repair for ruptured Abdominal Aortic Aneurysms (rAAA), but comparisons to traditional open rAAA repair and late complications leading to readmission are limited.

MATERIALS AND METHODS

Hospitalizations for patients undergoing repair for rAAA were selected from the Nationwide Readmissions Database (NRD). In-hospital mortality, complications, 30-day readmission, readmission diagnoses, and charges were evaluated. Design-adjusted chi-square, Wilcoxon test, and logistic regression were used for analysis.

RESULTS

During 2014-2016, 3,629 open rAAA and 5,037 EVAR were identified. The index mortality rate was 21.4% for EVAR vs. 33.5% for open (p < .0001). Median index length of stay (LOS) was 4.9 days for EVAR vs. 8.6 days for open repair (p < 0.001). All-cause 30-day readmission after rAAA was higher following EVAR (18.9%) than open (14.3%, p = .007). Time to readmission and charges for readmission stays did not differ between procedure groups. Respiratory complications were more common following open repair than EVAR (20.4% vs 11.4%, respectively; p = .008). Patients who underwent open repair suffered more infectious complications than patients treated with EVAR during readmission (49.2% vs 39.8%, respectively; p = 0.054). In multivariable analysis, factors associated with readmission included having EVAR during the index stay (Odds ratio [OR] = 1.46, 95% confidence interval [CI] 1.14-1.88; p = .003), increased length of index stay (OR = 1.01; 95% CI 1.01-1.02; p = 0.002), chronic kidney disease (OR = 1.51; 95% CI 1.18-1.94; p = .001), and coronary artery disease (OR = 1.32; 95% CI 1.02-1.71; p = .034). Aggregate readmission charges totaled $79 million. Readmissions were most often infectious complications for both repair types.

CONCLUSIONS

EVAR was used more often than open repair for rAAA. In-hospital mortality and length of the index stay were significantly lower following EVAR. After multivariable adjustment, the odds of readmission were 1.5 times higher after EVAR, costing the health system more over time when prevalence and readmission are considered. Coronary artery disease, chronic kidney disease, and index length of stay were also associated with 30-day readmission. Further investigation into reasons why a less invasive procedure, EVAR, has a higher readmission rate and understanding post-discharge infectious complications may help lower overall health care utilization after rAAA.

A novel preoperative risk score for nonhome discharge after elective thoracic endovascular aortic repair

BACKGROUND

Nonhome discharge (NHD) to a rehabilitation or skilled nursing facility after vascular surgery is poorly described despite its large impact on patients. Understanding postsurgical NHD risk is essential to providing adequate preoperative counseling and shared decision making, particularly for elective surgeries. We aimed to identify independent predictors of NHD after elective thoracic endovascular aortic repair (TEVAR) for thoracic aortic aneurysms (TAA) and to create a clinically useful preoperative risk score.

METHODS

Elective TEVAR cases for descending TAA were queried from the Society for Vascular Surgery Vascular Quality Initiative from 2014 to 2018. A risk score was created by splitting the dataset into two-thirds for model development and one-third for validation. A parsimonious stepwise hierarchical multivariable logistic regression controlling for hospital level variation was performed in the development dataset, and the beta-coefficients were used to assign points for a risk score. This score was then cross-validated and model performance assessed.

RESULTS

Overall, 1469 patients were included and 213 (14.5%) required NHD. At baseline, patients who required NHD were more likely to be ≥80 years old (35.2% vs 19.4%), female (58.7% vs 40.6%), functionally dependent (42.3% vs 24.0%), and anemic (46.5% vs 27.8%), and to have chronic obstructive pulmonary disease (41.3% vs 33.4%), congestive heart failure (18.8% vs 11.1%), and American Society of Anesthesiologists class ≥4 (51.6% vs 39.8%; all P < .05). Multivariable analysis in the development group identified independent predictors of NHD that were used to create an 18-point risk score. Patients were stratified into three groups based upon their risk score: low risk (0-7 points; n = 563) with an NHD rate of 4.3%, moderate risk (8-11 points; n = 701) with an NHD rate of 17.0%, and high risk (≥12 points; n = 205) with an NHD rate of 34.2%. The risk score had good predictive ability with a c-statistic of 0.75 for model development and a c-statistic of 0.72 in the validation dataset.

CONCLUSIONS

This novel risk score can predict NHD after TEVAR for TAA using characteristics that can be identified preoperatively. The use of this score may allow for improved risk assessment, preoperative counseling, and shared decision making.

Unplanned early hospital readmissions in a vascular surgery population

Background

Patients who undergo vascular surgery are burdened by high early readmission rates. We examined the frequency and cause of early readmissions after elective and emergent admission to the vascular surgery service at our institution to identify modifiable targets for quality improvement.

Methods

Over a 5-year period, all patients admitted and readmitted to the vascular surgery service were identified. Medical records were then individually reviewed to identify baseline characteristics from the index admission and the most responsible diagnosis for readmission within 28 days of discharge.

Results

Of a total of 3324 patients, 421 (12.7%) were readmitted to our institution within 28 days of discharge. Forty-seven were found to have more than 1 readmission following their index admission. The readmission rate ranged from 11.8% to 14.1% over the 5-year study period, resulting in an average readmission rate of 12.7%. There were similar rates for men (12.9%) and women (12.3%). Of the readmitted cases, 236 (63.1%) were unplanned readmissions. The most common diagnoses for unplanned readmissions were worsening of peripheral arterial disease status including complications related to peripheral bypass graft (30.9%), surgical site infections (15.3%) and nonsurgical infections (14.8%).

Conclusion

To reduce readmission rates effectively, institutions must identify highrisk patients. In our study cohort, the most frequent pathology resulting in readmission was peripheral arterial disease. The most frequent preventable reason for readmission was surgical site infection. Interventions focused on early assessment of clinical status and wounds in addition to avoidance of infectious complications could help reduce readmission rates. Preventive resources can be efficiently targeted by focusing on subgroups at risk for readmission.

Hidden Readmissions after Carotid Endarterectomy and Stenting

BACKGROUND

Historically, carotid procedures incur a readmission rate of approximately 6%; however, these studies are not nationally representative and are limited to tracking only the index hospitals. We sought to evaluate a nationally representative database for readmission rates (including different hospitals) after both carotid endarterectomy (CEA) and carotid artery stenting (CAS) and determine risk factors for poor outcomes including postoperative mortality and myocardial infarction.

METHODS

This study was a retrospective analysis utilizing the 2010-2014 Nationwide Readmissions Database to query patients aged >18 years undergoing CEA or CAS. Outcomes included initial admission mortality, and 30-day readmission, including mortality and myocardial infarction (MI). Univariable analysis of 39 demographic, clinical, and hospital variables was conducted with significance set at P < 0.05. Significant variables were included in a multivariable logistic regression to identify independent risk factors for readmission. Results were weighted for national estimates.

RESULTS

There were 527,622 patients undergoing carotid procedures and 13% (n = 69,187) underwent CAS. The 30-day readmission rate was 7% (n = 35,782), and of those, 25% (n = 8,862) were readmitted to a different hospital. When controlling for other factors, CAS was a risk factor for mortality at both index admission (odds ratio [OR] 2.29 [2.11-2.49]) and 30-day readmission (OR 1.48 [1.3-1.69]) and 30-day readmissions at both index hospital (OR 1.11 [1.07-1.14]) and different hospital (OR 1.38 [1.29-1.48]). Readmission to a different hospital increased mortality risk (OR 1.45 [1.29-1.63]) but did not have an effect on MI. Postoperative infections comprised 15% of readmissions while 6% of all readmissions were for stroke.

CONCLUSIONS

Previously unreported, one in 4 readmissions after carotid procedures occur at a different hospital and this fragmentation of care could increase mortality risk after carotid procedures particularly for CAS which was also an independent risk factor for postoperative mortality and readmissions. Further validation is required to decrease unnecessary hospital after carotid procedures.

Machine learning in prediction of individual patient readmissions for elective carotid endarterectomy, aortofemoral bypass/aortic aneurysm repair, and femoral-distal arterial bypass

Objective:

Early hospital readmissions have been rising and are increasingly used for public reporting and pay-for-performance. The readmission problem is fundamentally different in surgical patients compared with medical patients. There is an opportunity to intervene preoperatively to decrease the risk of readmission postoperatively.

Methods:

A predictive model of 90-day hospital readmission for patients undergoing elective carotid endarterectomy, aortofemoral bypass/aortic aneurysm repair, and femoral-distal arterial bypass was developed using data from the Healthcare Cost and Utilization Project State Inpatient Database for Florida State. The model training followed a nested resampling method with subsampling to increase execution speed and reduce overfitting. The following predictors were used: age, gender, race, median household income, primary expected payer, patient location, admission type, Elixhauser–van Walraven Comorbidity Index, Charlson comorbidity score, main surgical procedure, length of stay, disposition of the patient at discharge, period of the year, hospital volume, and surgeon volume.

Results:

Our sample comprised data on 246,405 patients, of whom 30.3% were readmitted within 90 days. Readmitted patients were more likely to be admitted via emergency (47.2% vs 30%), included a higher percentage with a Charlson score greater than 3 (35.8% vs 18.7%), had a higher mean van Walraven score (8.32 vs 5.34), and had a higher mean length of hospital stay (6.59 vs 3.51). Endarterectomy was the most common procedure, accounting for 19.9% of all procedures. When predicting 90-day readmission, Shrinkage Discriminant Analysis was the best performing model (area under the curve = 0.68). Important variables for the best predictive model included length of stay in the hospital, comorbidity scores, endarterectomy procedure, and elective admission type. The survival analysis for the time to readmission after the surgical procedures demonstrated that the hazard ratios were higher for subjects who presented Charlson comorbidity score above three (2.29 (2.26, 2.33)), patients transferred to a short-term hospital (2.4 (2.23, 2.59)), home healthcare (1.64 (1.61, 1.68)), other type of facility (2.59 (2.54, 2.63)) or discharged against medical advice (2.06 (1.88, 2.26)), and those with greater length of stay (1.89 (1.86, 1.91)).

Conclusion:

The model stratifies readmission risk on the basis of vascular procedure type, which suggests that attempts to decrease vascular readmission should focus on emergency procedures. Given the current focus on readmissions and increasing pressure to prevent unplanned readmissions, this score stratifies patients by readmission risk, providing an additional resource to identify and prevent unnecessary readmissions.

Unplanned 30-day readmissions after endovascular aneurysm repair: An analysis using the Nationwide Readmissions Database

BACKGROUND

Endovascular aneurysm repair (EVAR) is the preferred method for addressing abdominal aortic aneurysms (AAAs), with proven reduction in perioperative morbidity and mortality. There are, however limited data examining the readmissions after EVAR that are associated with increased patient morbidity and cost. As EVAR use continues its dominance in the management of AAAs, it becomes imperative to identify and mitigate risk factors associated with unplanned hospital readmissions.

METHODS

The Nationwide Readmissions Database (NRD) was queried for all 30-day readmissions after an index EVAR procedure from 2012 to 2014. Preoperative patient demographics, hospital characteristics, readmission diagnosis, and costs were compared between those who were and were not readmitted within 30 days of the index operation. Multivariable logistic regression was used to identify potential risk factors associated with unplanned readmissions within 30 days.

RESULTS

We identified 120,646 patients who underwent an EVAR from 2012 to 2014 in the United States. The overall unplanned readmission rate during this period was 11.6% (n = 14,073) within 30 days of the index EVAR procedure. The readmission rate was the highest in 2012, with a rate of 12.3% (P = .02). Multivariate regression analysis showed that EVAR readmissions were significantly higher in patients who were of younger age (18 to 49 years) compared with other age groups (odds ratio [OR], 1.9-2.17; P < .001), female sex (OR, 1.367; P < .001), had Medicare (OR, 1.39) or Medicaid (OR, 1.25) insurance, or a combination of these. Underlying patient comorbidities significantly associated with readmissions included congestive heart failure (OR, 2.4), peripheral vascular disease (OR, 1.1), chronic pulmonary disease (OR, 1.2), cancer with no metastasis (OR, 1.5), metastatic cancer (OR, 2.2), renal failure (OR, 1.8), and diabetes (OR, 1.5).

CONCLUSIONS

The trend in 30-day readmission rates after EVAR has decreased slightly since 2012, but overall rates are at 11.6%, which is not insubstantial. Patient factors strongly associated with hospital readmission were younger age and patient comorbidities, including congestive heart failure, concurrent cancer diagnosis, renal failure, and diabetes.

Development of Postoperative Pneumonia After Endovascular Aortic Aneurysm Repair is Associated with an Increased Length of Intensive Care Unit Stay

Objective

Endovascular aortic aneurysm repair (EVAR) has increasingly replaced open aortic surgery for treatment of abdominal aortic aneurysms (AAA). One of the key advantages of EVAR is the reduced length of intensive care unit (ICU) stay and hospital stay. This study aimed to identify the risk factors associated with increased ICU length of stay (LOS) after EVAR.

Methods

The American College of Surgeons (ACS-NSQIP) database for the year 2013 was used. All patients who underwent EVAR were divided into two groups: ICU LOS <1 day vs. ≥1 day. Preoperative, intraoperative, and postoperative factors were compared between these two groups utilizing bivariate logistic regression analysis. Multivariable logistic regression analysis was then used to identify factors that were independently associated with ICU LOS ≥1 day after EVAR.

Results

A total of 2,468 patients (18.7% females, 81.3% males) were identified. Group 1 (ICU LOS <1 day) = 1,535 patients and Group 2 (ICU LOS ≥1 day) = 933 patients. Multivariable analysis identified the following factors to be associated with ICU LOS ≥1 day: ruptured AAA (OR 3.88, CI 1.97-7.65), the American Society of Anesthesiology (ASA) score of 4-5 (OR 2.82, CI 1.50-5.31), operative time ≥180 minutes (OR 2.10, CI 1.51-2.93), bilateral groin cut down (OR 1.37, CI 1.10-1.71), juxta-renal AAA (OR 1.65, CI 1.16-2.35), renal artery stent (OR 2.13, CI 1.42-3.21), aortic stent (OR 2.39, CI 1.60-3.55), emergency surgery (OR 2.56, CI 1.94-3.38), need for blood transfusion (OR 3.11, CI 2.08-4.65) and postoperative pneumonia (OR 7.04, CI 1.95-25.45).

Conclusion

Variables identified above can be used to predict the cohort of EVAR patients which will likely require ICU for ≥1 day. Development of postoperative pneumonia is associated with a 7.04 times increase in ICU LOS ≥1 day.

Frequency of 30-Day Readmission and Its Causes After Endovascular Aneurysm Intervention of Abdominal Aortic Aneurysm (from the Nationwide Readmission Database)

Endovascular aneurysm intervention (EVAI) is one of the most commonly performed vascular interventions for abdominal aortic aneurysm (AAA). Data regarding 30-day readmission rates after EVAI are poorly reported in the literature. We used the United States Nationwide Readmission Database from 2010 to 2014 to identify all patients ≥18 years who were readmitted within 30 days after a hospital discharge for EVAI of the AAA. Incidence, etiologies, predictors of 30-day readmission, and trends of readmission rates were analyzed. In 138,014 patients who survived to discharge after an EVAI procedure for AAA, 14,146 (10.24%) were readmitted within 30 days. Median time to readmission was 11 days. Cardiac causes (16.34%) followed by infections (15.40%) and vascular complications (12.86%) were common etiologies of readmission. Greater patient age, female sex, coexisting co-morbidities such as heart failure, atrial fibrillation, peripheral vascular disease, lung disease, and chronic kidney disease were independent predictors of 30-day readmission. In-hospital complications during an index admission such as major bleeding or vascular complications were also predictive of 30-day readmission. Trend analysis showed a progressive decline in readmission rates from 11.3% in 2010 to 9.6% in 2014 (p_trend <0.0001), 20% lower odds in 2014 compared with 2010 (odds ratio 0.80, 95% confidence interval 0.72 to 0.87, p <0.0001). In this contemporary study of EVAI for AAA, nearly 1 in 10 patients was readmitted within 30 days of discharge after an index admission. Cardiac complications and infections were common causes of readmission within 30 days.

Trajectory Modelling to Assess Trends in Long-Term Readmission Rate among Abdominal Aortic Aneurysm Patients

Introduction

The aim of the study was to use trajectory analysis to categorise high-impact users based on their long-term readmission rate and identify their predictors following AAA (abdominal aortic aneurysm) repair. Methods. In this retrospective cohort study, group-based trajectory modelling (GBTM) was performed on the patient cohort (2006-2009) identified through national administrative data from all NHS English hospitals. Proc Traj software was used in SAS program to conduct GBTM, which classified patient population into groups based on their annual readmission rates during a 5-year period following primary AAA repair. Based on the trends of readmission rates, patients were classified into low- and high-impact users. The high-impact group had a higher annual readmission rate throughout 5-year follow-up. Short-term high-impact users had initial high readmission rate followed by rapid decline, whereas chronic high-impact users continued to have high readmission rate.

Results

Based on the trends in readmission rates, GBTM classified elective AAA repair (n=16,973) patients into 2 groups: low impact (82.0%) and high impact (18.0%). High-impact users were significantly associated with female sex (P=0.001) undergoing other vascular procedures (P=0.003), poor socioeconomic status index (P < 0.001), older age (P < 0.001), and higher comorbidity score (P < 0.001). The AUC for c-statistics was 0.84. Patients with ruptured AAA repair (n=4144) had 3 groups: low impact (82.7%), short-term high impact (7.2%), and chronic high impact (10.1%). Chronic high impact users were significantly associated with renal failure (P < 0.001), heart failure (P = 0.01), peripheral vascular disease (P < 0.001), female sex (P = 0.02), open repair (P < 0.001), and undergoing other related procedures (P=0.05). The AUC for c-statistics was 0.71.

Conclusion

Patients with persistent high readmission rates exist among AAA population; however, their readmissions and mortality are not related to AAA repair. They may benefit from optimization of their medical management of comorbidities perioperatively and during their follow-up.

Impact of Patient Safety Indicators on readmission after abdominal aortic surgery

Patient safety is a critical component of health-care quality and measures created by the Agency for Healthcare Research and Quality (AHRQ) to identify hospitalizations with potentially preventable adverse events. This analysis evaluated whether Patient Safety Indicator (PSI) events after open surgical repair (OSR) or endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) were associated with increased risk of readmission. Patients undergoing elective repair of nonruptured AAA from 2009 to 2012 were selected in the Medicare Provider Analysis and Review files using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. To identify PSI events, we used the AHRQ PSI International Classification of Diseases, Ninth Revision, Clinical Modification numerator codes. Chi-square test, multivariable logistic regression analysis, nonparametric Wilcoxon rank sum test, and Kaplan-Meier survival analysis were used for statistics. A total of 66,923 patients undergoing elective AAA repair were evaluated: (1) 9,315 with OSR and (2) 57,608 with EVAR. The most frequent PSI events after OSR versus EVAR were postoperative respiratory failure (PSI, 11; 17.7% vs 1.8%; P < .0001); perioperative hemorrhage/hematoma (PSI, 9; 3.6% vs 2.6%; P < .0001); postoperative sepsis (PSI, 13; 3.5% vs 0.4%; P < .0001); accidental puncture or laceration (PSI, 15; 2.1% vs 0.6%; P < .0001); and postoperative acute kidney injury requiring dialysis (PSI, 10; 1.4% vs 0.2%; P < .0001). The overall 30-day readmission rate was 10.5%. The occurrence of any PSI event overall significantly increased 30-day readmission compared with no event cases (odds ratio [OR] = 1.71; 95% confidence interval [CI], 1.57-1.86). Likelihood of 30-day readmission was greater for postoperative acute kidney injury requiring dialysis (OR = 1.66; 95% CI, 1.28-2.15), postoperative respiratory failure (OR = 1.36; 95% CI, 1.22-1.52), perioperative hemorrhage (OR = 1.34; 95% CI, 1.18-1.52), and postoperative pressure ulcer (OR = 2.88; 95% CI, 1.99-4.17). Occurrence of any PSI event was associated with an increased total hospital and intensive care unit length of stay and total hospital charges (all P < .001). In conclusion, AHRQ PSI events may be used to identify patients at the greatest risk for readmission after AAA repair. The risk for 30-day readmission was 71% higher when a PSI event occurred and was not associated with the type of repair. Minimizing preventable PSI events may be beneficial to reducing hospital readmissions after open and endovascular AAA repair and to improving hospital resource utilization.

Nationally Representative Readmission Factors Associated with Endovascular versus Open Repair of Abdominal Aortic Aneurysm

BACKGROUND

Hospital readmissions are tied to financial penalties and thus significantly influence health-care policy. Many current studies on readmissions lack national representation by not tracking readmissions across hospitals. The recently released Nationwide Readmission Database is one of the most comprehensive national sources of readmission data available, making it an invaluable resource to understand this critically important health policy issue.

METHODS

The Nationwide Readmission Database for 2013 and 2014 was queried for adult patients with abdominal aortic aneurysm (441.4) undergoing endovascular (39.71) or open (38.44) repair. Outcomes examined were overall/initial admission mortality and overall/30-day readmissions. Multivariate logistic regression for these outcomes was also performed on multiple readmission factors.

RESULTS

Fifty-three thousand four hundred seventeen patients underwent abdominal aortic aneurysm repair (47,431 endovascular aortic repair [EVAR] versus 5,986 open surgical repair [OSR]). Significant differences were found for EVAR versus OSR on overall readmissions, initial admission cost, readmission costs, length of stay, days to readmission, and overall/initial admission mortality. Multivariate logistic regression analysis found that length of stay > 30, Charlson Comorbidity Index > 1, discharge disposition, and female sex were all significant predictors of 30-day readmission. Repair type was significantly associated with 30-day readmissions; however, it was not a significant factor for overall readmissions.

CONCLUSION

There are significant differences in costs, prognosis, and readmission rates for EVAR versus OSR. Given that these differences are being used to create "acceptable" readmission rates, disbursement quotas among hospitals, and subsequent penalties for providers outside the expected rates, it is only prudent to obtain the most accurate information to guide those policies.

LEVEL OF EVIDENCE

Care management/epidemiological, level IV.

Thirty-day hospital readmission and emergency department visits after vascular surgery: a Canadian prospective cohort study

BACKGROUND

Rates of hospital readmission following surgery can serve as a marker for quality of care. The aim of this study was to establish the rates and causes of readmission and emergency department visits after vascular surgery and to understand how these patients are managed.

METHODS

We conducted a prospective observational cohort study including all inpatients who underwent major vascular surgery between September 2015 and June 2016 at a tertiary vascular care centre in Toronto. Patients were followed at 30 days after discharge via telephone interview.

RESULTS

We enrolled 133 patients (94 men [70.7%] and 39 women [29.3%] with a mean age of 65.3 years). The most common index admission diagnosis was peripheral artery disease (67 patients [50.4%]). At 30 days, 19 patients (14.8%) had been readmitted or had visited the emergency department, most commonly after lower extremity revascularization (19.4%). Ten patients were readmitted a mean of 16.8 days following discharge; surgical site infection was the most common cause for readmission (3 patients). The most common treatment was antimicrobial therapy (4 patients). The mean hospital length of stay was 14.4 days. Nine patients presented to the emergency department a mean of 10.6 days after discharge; 6 reported a wound issue, and most (6 of 9) were managed with oral antibiotic treatment.

CONCLUSION

Early readmission/emergency department visits after lower extremity revascularization surgery in patients with peripheral artery disease are common and are often due to surgical site infection or wound-related issues. Follow-up within 7-10 days and a specialized wound care team may help reduce the occurrence of these events.

Common Sequences of Emergency Readmissions among High-Impact Users following AAA Repair

Introduction

The aim of the study was to examine common sequences of causes of readmissions among those patients with multiple hospital admissions, high-impact users, after abdominal aortic aneurysm (AAA) repair and to focus on strategies to reduce long-term readmission rate.

Methods

The patient cohort (2006–2009) included patients from Hospital Episodes Statistics, the national administrative data of all NHS English hospitals, and followed up for 5 years. Group-based trajectory modelling and sequence analysis were performed on the data.

Results

From a total of 16,973 elective AAA repair patients, 18% (n=3055) were high-impact users. The high-impact users among ruptured abdominal aortic aneurysm (rAAA) repair constituted 17.3% of the patient population (n=4144). There were 2 subtypes of high-impact users, short-term (7.2%) with initial high readmission rate following by rapid decline and chronic high-impact (10.1%) with persistently high readmission rate. Common causes of readmissions following elective AAA repair were respiratory tract infection (7.3%), aortic graft complications (6.0%), unspecified chest pain (5.8%), and gastrointestinal haemorrhage (4.8%). However, high-impact users included significantly increased number of patients with multiple readmissions and distinct sequences of readmissions mainly consisting of COPD (4.7%), respiratory tract infection (4.7%), and ischaemic heart disease (3.3%).

Conclusion

A significant number of patients were high-impact users after AAA repair. They had a common and distinct sequence of causes of readmissions following AAA repair, mainly consisting of cardiopulmonary conditions and aortic graft complications. The common causes of long-term mortality were not related to AAA repair. The quality of care can be improved by identifying these patients early and focusing on prevention of cardiopulmonary diseases in the community.

Elective Repair of Abdominal Aortic Aneurysm and the Risk of Colonic Ischaemia: Systematic Review and Meta-Analysis

INTRODUCTION

Colon ischaemia (CI) is a significant complication of open (OR) and endovascular (EVAR) repair of abdominal aortic aneurysm (AAA). With a rapid increase in EVAR uptake, contemporary data demonstrating the differing rates and outcomes of CI between EVAR and OR, particularly in the elective setting, are lacking. The aim was to characterise the risk and consequences of CI in elective AAA repair comparing EVAR with OR.

METHODS

A systematic review and meta-analysis of the literature was performed using the Cochrane collaboration protocol and reported according to the PRISMA guidelines. PubMed, MedLine, and EMBASE were searched for studies reporting CI rates after elective AAA repair. Ruptured AAAs were excluded from analysis.

RESULTS

Thirteen studies reporting specific outcomes of CI after elective AAA repair, containing 162,750 evaluable patients (78,151 EVAR and 84,599 OR) were included. All studies found a higher risk of CI with OR than with EVAR. Three studies performed confounder adjustment with CI rates of 0.5-1% versus 2.1-3.6% (EVAR vs. OR) and combined odds ratio of 2.7 (2.0-3.5) for the development of CI with OR versus EVAR. The majority of cases of CI occurred within 30 days and were associated with variable mortality (0-73%) and re-intervention rates (27-54%). GRADE assessment of evidence strength was very low for all outcomes. There was a high degree of heterogeneity between studies both methodologically and in terms of CI rates, re-intervention, mortality, and time to development of CI.

CONCLUSIONS

EVAR is associated with a reduced incidence of CI compared with OR.

Mortality after endovascular treatment of infrarenal abdominal aortic aneurysms – the newer the better?

Abstract. Although endovascular repair of infrarenal abdominal aortic aneurysms (EVAR) presents a delicate alternative treatment for abdominal aortic aneurysms (AAA) with lower perioperative mortality, its long-term efficacy remains a matter of concern. The purpose of this study was to evaluate the currently reported mortality evidence after EVAR and to examine the possible effect of aneurysm status and the study period on mortality rates. The PubMed and Cochrane bibliographical databases were thoroughly searched for studies reporting on more than 1 000 patients with non-ruptured or ruptured infrarenal AAA, treated with EVAR from August 1991 to September 2016. A total of 10 910 titles/abstracts were retrieved and 121 studies were deemed relevant. Twenty-six studies met the inclusion criteria and reported on 354 500 patients with a mean age of 74.6 years. Almost all of the studies referred to elective EVAR and the mean aneurysm size was 5.58 cm. The most common early complication for elective EVAR was perioperative bleeding (1.9 %), whereas hospital-acquired pneumonia was a major concern in urgent EVAR (28.5 %). Conversion rate to open surgery was 1.2 %. The 30-day all-cause mortality rate was 4.84 % (1.7 % for non- ruptured aneurysms, 33.8 % for ruptured aneurysms).The overall all-cause late mortality in a mean follow-up period of 23.8 months was 19.1 %. The aneurysm-related late mortality rate was 3.4 %. With respect to the time period of patient enrollment, studies reporting on patients recruited before 2006 were found to face more secondary complications and higher late mortality rates than patients enrolled after 2005.The endovascular treatment of large and anatomically suitable infrarenal AAA in selected patients remains a safe alternative to open repair. Our findings demonstrate that newer studies show better long-term outcomes than the older ones, proposing a possible improvement of EVAR techniques and perioperative care and providing encouraging evidence for a wider application of EVAR.

Hospital Teaching Status and Readmission after Open Abdominal Aortic Aneurysm Repair

BACKGROUND

Readmission after abdominal aortic aneurysm (AAA) repair to a different (nonindex) hospital has been shown to be associated with high mortality rates. Factors influencing this association remain unknown. The objective of this study was to determine the impact of hospital teaching status on nonindex hospital readmission and mortality.

METHODS

An observational analysis of the longitudinally linked California Office of Statewide Health Planning and Development database was conducted from 1995 to 2009. Patients who were readmitted within 30 days after open AAA repair were included. The primary outcome measured was mortality on readmission.

RESULTS

Over the 15-year study period, 3,475 readmissions after AAA were analyzed, of which 1,020 (29.4%) were to a nonindex hospital. After adjusting for age, race, gender, insurance, comorbidities, perioperative factors, and reason for readmission, nonindex readmission for patients undergoing their initial operation at a teaching hospital did not impact mortality (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.28-2.17, P = 0.63). Nonindex readmission for patients undergoing their initial operation at a nonteaching hospital, however, significantly increased mortality (OR 1.63, 95% CI 1.04-2.54, P = 0.03).

CONCLUSIONS

Readmission to a different hospital is associated with a higher mortality rate for patients undergoing AAA repair at nonteaching hospitals. This effect is not seen in patients having their initial operation performed at teaching hospitals, possibly due to infrastructure at these hospitals allowing for decreased impact from fragmentation of care. In cases where triage to an index hospital for readmission is not possible, communication at a high level between the index hospital and readmission hospital is paramount.

Perioperative Outcomes From the Prospective Multicenter Least Invasive Fast-Track EVAR (LIFE) Registry

Purpose: To determine the feasibility, perioperative resource utilization, and safety of a fast-track endovascular aneurysm repair (EVAR) protocol in well-selected patients. Methods: Between October 2014 and May 2016, the LIFE (Least Invasive Fast-track EVAR) registry ( ClinicalTrials.gov identifier NCT02224794) enrolled 250 patients (mean age 73±8 years; 208 men) in a fast-track EVAR protocol comprised of bilateral percutaneous access using the 14-F Ovation stent-graft, no general anesthesia, no intensive care unit (ICU) admission, and next-day discharge. The primary endpoint was major adverse events (MAE) through 30 days. The target performance goal for the MAE endpoint was 10.4%. Results: Vascular access, stent-graft delivery, and stent-graft deployment success were 100%. A total of 216 (86%) patients completed all elements of the fast-track EVAR protocol. Completion of individual elements was 98% for general anesthesia avoidance, 97% for bilateral percutaneous access, 96% for ICU avoidance, and 92% for next-day discharge. Perioperative outcomes included mean procedure time of 88 minutes, median blood loss of 50 mL, early oral nutrition (median 6 hours), early mobilization (median 8 hours), and short hospitalization (median 26 hours). Fast-track EVAR completers had shorter procedure time (p<0.001), less blood loss (p=0.04), faster return to oral nutrition (p<0.001) and ambulation (p<0.01), and shorter hospital stay (p<0.001). With 241 (96%) of the 250 patients returning for the 30-day follow-up, the MAE incidence was 0.4% (90% CI 0.1% to 1.8%), significantly less than the 10.4% performance goal (p<0.001). No aneurysm rupture, conversion to surgery, or aneurysm-related secondary procedure was reported. There were no type III endoleaks and 1 (0.4%) type I endoleak. Iliac limb occlusion was identified in 2 (0.8%) patients. The 30-day hospital readmission rate was 1.6% overall. Conclusion: A fast-track EVAR protocol was feasible in well-selected patients and resulted in efficient perioperative resource utilization with excellent safety and effectiveness.

Mortality and Graft Loss Attributable to Readmission After Kidney Transplantation: Immediate and Long-term Risk

BACKGROUND

After kidney transplantation, early readmission is independently associated with graft loss and mortality. The mechanism of this association is poorly understood. Understanding the timeline of risk, that is, during the readmission hospitalization versus periods postreadmission, will provide additional insights.

METHODS

We used national registry data to study 56 076 adult Medicare-primary first-time kidney transplant recipients from December 1999 to October 2011. Piecewise Cox proportional hazard models were used to estimate the association between graft loss, mortality, and readmission for 2 periods: readmission hospitalization and postreadmission.

RESULTS

During the readmission hospitalization, graft loss was substantially higher (deceased donor kidney transplant [DDKT] without delayed graft function [DGF] hazard ratio: 24.634.447.9, P < 0.001; with DGF: 10.815.221.4, P < 0.001; live donor kidney transplant [LDKT]: 18.136.774.2, P < 0.001) and mortality was substantially higher (DDKT without DGF: 14.120.830.7, P < 0.001; with DGF: 9.0312.818.0, P < 0.001; LDKT: 9.0018.241.3, P < 0.001). Immediately after readmission discharge, graft loss (DDKT without DGF: 2.082.402.77, P < 0.001; with DGF: 1.832.142.51, P < 0.001; LDKT: 2.002.503.13, P < 0.001), and mortality (DDKT without DGF: 2.162.432.73, P < 0.001; with DGF: 1.832.162.88, P < 0.001; LDKT: 1.902.342.88, P < 0.001) remained elevated, but much less so. After readmission, the hazard of graft loss remained, but decreased 19% per year for DDKT recipients (time varying coefficient 0.780.810.85, P < 0.001) and 14% per year for LDKT recipients (0.790.860.93, P < 0.001). The hazard of mortality remained, but decreased 14% per year for DDKT recipients (0.830.860.89, P < 0.001) and 9% per year for LDKT recipients (0.850.910.98, P < 0.001).

CONCLUSIONS

In conclusion, readmission is most strongly associated with graft loss and mortality during the readmission hospitalization, but also portends a lasting, albeit attenuated, risk postreadmission.

Thirty-day readmission and mortality among Medicare beneficiaries discharged to skilled nursing facilities after vascular surgery

BACKGROUND

Readmission within 30 d of an acute hospital stay is frequent, costly, and increasingly subject to penalties. Early readmission is most common after vascular surgery; these patients are often discharged to skilled nursing facilities (SNFs), making postacute care an essential partner in reducing readmissions. We characterize 30-day readmissions among vascular surgery patients discharged to SNF to provide evidence for this understudied segment of readmission after specialty surgery.

METHODS

We utilize the Centers for Medicare & Medicaid Services Chronic Conditions Warehouse, a longitudinal 5% national random sample of Medicare beneficiaries to study 30-day readmission or death after discharge to SNF following abdominal aortic aneurysm repair or lower extremity revascularization from 2005-2009. Descriptive statistics and logistic regression with Least Adaptive Shrinkage and Selection Operator were used for analysis.

RESULTS

Two thousand one hundred ninety-seven patients underwent an abdominal aortic aneurysm procedure or lower extremity revascularization at 686 hospitals and discharged to 1714 SNFs. Eight hundred (36%) were readmitted or had died at 30 d. In adjusted analysis, predictors of readmission or death at 30 d included SNF for-profit status (OR [odds ratio] = 1.2; P = 0.032), number of hospitalizations in the previous year (OR = 1.06; P = 0.011), number of comorbidities (OR = 1.06; P = 0.004), emergent procedure (OR = 1.69; P < 0.001), renal complication (OR = 1.38; P = 0.003), respiratory complication (OR = 1.45; P < 0.001), thromboembolic complication (OR = 1.57; P = 0.019), and wound complication (OR = 0.70; P = 0.017).

CONCLUSIONS

Patients discharged to SNF following vascular surgery have exceptionally high rates of readmission or death at 30 d. Many factors predicting readmission or death potentially modify decision-making around discharge, making early detection, discharge planning, and matching patient needs to SNF capabilities essential to improving outcomes.

Indications, risk factors, and outcomes of 30-day readmission after infrarenal abdominal aneurysm repair

OBJECTIVE

Reducing readmissions is an important target for improving patient care and enhancing health care quality and cost-effectiveness. The aim of this study was to assess rates, risk factors, and indications of 30-day readmission after open aortic repair (OAR) and endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs).

METHODS

A retrospective analysis of the Premier Healthcare Database from 2009 to 2015 was performed. Indications for readmission after the index procedure, risk factors, and outcomes of the index admission and rehospitalization were evaluated. Multivariate logistic models were used to assess the association between 30-day readmission and different patient and hospital factors.

RESULTS

A total of 33,332 AAA repair procedures were identified: 27,483 (82.5%) EVAR and 5849 (17.5%) OAR. The overall rate of 30-day readmission was 8.1%, and it was greater after OAR (12.9% vs 7.1% in EVAR; P < .001). In general, the most common specific readmission diagnoses were infectious complications (16.1%), followed by respiratory and cardiac complications (11.8% and 11.3%, respectively). After multivariate adjustment, OAR was associated with higher 30-day readmission compared with EVAR (adjusted odds ratio, 1.11; 95% confidence interval, 1.0-1.2; P = .04). Other risk factors of 30-day readmission included female gender, emergency and urgent procedures, certain patient comorbidities (dyslipidemia, congestive heart failure, history of transient ischemic attack, previous cardiac surgery, chronic obstructive pulmonary disease, asthma, chronic kidney disease, peripheral vascular disease, and history of malignant disease), and hemorrhage/shock/bleeding occurring during the index admission as well as nonhome discharge. Readmitted patients had an overall in-hospital mortality of 3.6% and paid a median rehospitalization cost of $7757.

CONCLUSIONS

Our study shows that around 8.1% of patients undergoing infrarenal AAA repair were readmitted within 30 days. Because many readmissions are unrelated to the index procedure or caused by factors that are nonmodifiable or nonidentifiable at discharge, efforts should focus on discharge planning and improving the decision process regarding discharge destination as well as postdischarge coordination of care for high-risk patients.

Association of Very Low-Volume Practice With Vascular Surgery Outcomes in New York

Importance

Little research has focused on very low-volume surgery, especially in the context of decreasing vascular surgery volume with the adoption of endovascular procedures.

Objective

To investigate the existence and outcomes of open abdominal aortic aneurysm repair (OAR) and carotid endarterectomy (CEA) performed by very low-volume surgeons in New York.

Design, Settings, and Participants

This cohort study examined inpatient data of patients undergoing elective OAR or CEA from 2000 to 2014 from all New York hospitals.

Exposures

Surgeons who performed 1 or less designated procedure per year on average were considered very low volume, as opposed to higher-volume surgeons.

Main Outcomes and Measures

Temporal trends of the existence of very low-volume practice were evaluated. Hierarchical logistic regression was used to compare in-hospital outcomes and health care resource use between patients treated by very low-volume surgeons and higher-volume surgeons for both OAR and CEA, adjusting for patient, surgeon, and hospital characteristics.

Results

There were 8781 OAR procedures and 68 896 CEA procedures included in the study. The mean (SD) patient age was 71.7 (8.4) years for OAR and 71.5 (9.1) years for CEA. A total of 614 surgeons performed OAR and 1071 performed CEA in New York during the study period. Of these, 318 (51.8%) and 512 (47.8%), respectively, were very low-volume surgeons. Very low-volume surgeons were less likely to be vascular surgeons. The number and proportion of very low-volume surgeons decreased over years. Compared with patients treated by higher-volume surgeons, those treated by very low-volume surgeons were more likely to have higher in-hospital mortality (odds ratio [OR], 2.09; 95% CI, 1.41-3.08) following OAR and higher risks of postoperative myocardial infarction (OR, 1.83; 95% CI, 1.03-3.26) and stroke (OR, 1.78; 95% CI, 1.21-2.62) following CEA. Patients treated by very low-volume surgeons also had greater health care resource use following both surgeries, including prolonged length of stay (OR, 1.37; 95% CI, 1.11-1.70) following OAR as well as higher charges (OR, 1.28; 95% CI, 1.01-1.62) and increased 30-day readmission (OR, 1.30; 95% CI 1.04-1.62) following CEA.

Conclusions and Relevance

The OAR and CEA procedures performed by very low-volume surgeons resulted in worse postoperative outcomes and greater lengths of stay. Although the percentage of very low-volume surgeons declined from 2000 to 2014, it remains concerning, given ready access to higher-volume surgeons. Future research is needed to understand the existence of this practice pattern in other surgical fields. Efforts to eliminate this practice pattern are warranted to ensure high-quality care for all patients.

Assessing written communication during interhospital transfers of emergency general surgery patients

BACKGROUND

Poor communication causes fragmented care. Studies of transitions of care within a hospital and on discharge suggest significant communication deficits. Communication during transfers between hospitals has not been well studied. We assessed the written communication provided during interhospital transfers of emergency general surgery patients. We hypothesized that patients are transferred with incomplete documentation from referring facilities.

METHODS

We performed a retrospective review of written communication provided during interhospital transfers to our emergency department (ED) from referring EDs for emergency general surgical evaluation between January 1, 2014 and January 1, 2016. Elements of written communication were abstracted from referring facility documents scanned into the medical record using a standardized abstraction protocol. Descriptive statistics summarized the information communicated.

RESULTS

A total of 129 patients met inclusion criteria. 87.6% (n = 113) of charts contained referring hospital documents. 42.5% (n = 48) were missing history and physicals. Diagnoses were missing in 9.7% (n = 11). Ninety-one computed tomography scans were performed; among 70 with reads, final reads were absent for 70.0% (n = 49). 45 ultrasounds and x-rays were performed; among 27 with reads, final reads were missing for 80.0% (n = 36). Reasons for transfer were missing in 18.6% (n = 21). Referring hospital physicians outside the ED were consulted in 32.7% (n = 37); consultants' notes were absent in 89.2% (n = 33). In 12.4% (n = 14), referring documents arrived after the patient's ED arrival and were not part of the original documentation provided.

CONCLUSIONS

This study documents that information important to patient care is often missing in the written communication provided during interhospital transfers. This gap affords a foundation for standardizing provider communication during interhospital transfers.

Risk Factors for 30-Day Hospital Re-Admission with an Infectious Complication after Lower-Extremity Vascular Procedures

BACKGROUND

Lowering the 30-d re-admission rate after vascular surgery offers the potential to improve healthcare quality. This study evaluated re-admission associated with infections after open and endovascular lower extremity (LE) procedures for peripheral artery disease (PAD).

METHODS

Patients admitted for elective LE procedures for PAD were selected from the Cerner Health Facts^® database. Chi-square analysis evaluated the characteristics of the index admission associated with infection at 30-d re-admission. Multivariable logistic models were created to examine the association of patient and procedural characteristics with infections at re-admission. The microbiology data available at the time of re-admission were evaluated also.

RESULTS

A total of 7,089 patients underwent elective LE procedures, of whom 770 (10.9%) were re-admitted within 30 d. A total of 289 (37.5%) had a diagnosis of infection during the re-admission. These infections included surgical site (14.8%), cellulitis (13.6%), sepsis (8.8%), urinary tract (4.9%), and pneumonia (4.9%). Index stay factors associated with infection at re-admission were fluid and electrolyte disorders, kidney disease, diabetes, previous infection, and chronic anemia. Laboratory results associated with an infection during re-admission were post-operative hemoglobin <8 g/dL, blood urea nitrogen >20 mg/dL, platelet counts >400 × 10³/mcL, glucose >180 mg/dL, and white blood cell count >11.0 × 10³/mcL. Adjusted models demonstrated longer stay, chronic anemia, previous infection, treatment at a teaching hospital, and hemoglobin <8 g/dL to be risk factors for re-admission with infection. Infective organisms isolated during the re-admission stay included Staphylococcus, Enterococcus, Escherichia, Pseudomonas, Proteus, and Klebsiella.

CONCLUSIONS

Infectious complications were associated with more than one-third of all re-admissions after LE procedures. Predictors of re-admission within 30 d with an infectious complication were longer stay, greater co-morbidity burden, hospitalization in teaching facilities, hemoglobin <8 g/dL, and an infection during the index stay. Microbiology examination at re-admission demonstrated gram-negative bacteria in more than 40% of infections. Further evaluation of high-risk vascular patients prior to discharge and consideration of antibiotic administration for gram-negative organisms at the time of re-admission may improve outcomes.

Incidence of and risk factors for bowel ischemia after abdominal aortic aneurysm repair

BACKGROUND

Bowel ischemia is a rare but devastating complication after abdominal aortic aneurysm (AAA) repair. Its rarity has prohibited extensive risk-factor analysis, particularly since the widespread adoption of endovascular AAA repair (EVAR); therefore, this study assessed the incidence of postoperative bowel ischemia after AAA repair in the endovascular era and identified risk factors for its occurrence.

METHODS

All patients undergoing intact or ruptured AAA repair in the Vascular Study Group of New England (VSGNE) between January 2003 and November 2014 were included. Patients with and without postoperative bowel ischemia were compared and stratified by indication (intact and ruptured) and treatment approach (open repair and EVAR). Criteria for diagnosis were endoscopic or clinical evidence of ischemia, including bloody stools, in patients who died before diagnostic procedures were performed. Independent predictors of postoperative bowel ischemia were established using multivariable logistic regression analysis.

RESULTS

Included were 7312 patients, with 6668 intact (67.0% EVAR) and 644 ruptured AAA repairs (31.5% EVAR). The incidence of bowel ischemia after intact repair was 1.6% (open repair, 3.6%; EVAR, 0.6%) and 15.2% after ruptured repair (open repair, 19.3%; EVAR, 6.4%). Ruptured AAA was the most important determinant of postoperative bowel ischemia (odds ratio [OR], 6.4, 95% confidence interval [CI], 4.5-9.0), followed by open repair (OR, 2.9; 95% CI, 1.8-4.7). Additional predictive patient factors were advanced age (OR, 1.4 per 10 years; 95% CI, 1.1-1.7), female gender (OR, 1.6; 95% CI, 1.1-2.2), hypertension (OR, 1.8; 95% CI, 1.1-3.0), heart failure (OR, 1.8; 95% CI, 1.2-2.8), and current smoking (OR, 1.5; 95% CI, 1.1-2.1). Other risk factors included unilateral interruption of the hypogastric artery (OR, 1.7; 95% CI, 1.0-2.8), prolonged operative time (OR, 1.2 per 60-minute increase; 95% CI, 1.1-1.3), blood loss >1 L (OR, 2.0; 95% CI, 1.3-3.0), and a distal anastomosis to the femoral artery (OR, 1.7; 95% CI, 1.1-2.7). Bowel ischemia patients had a significantly higher perioperative mortality after intact (open repair: 20.5% vs 1.9%; P < .001; EVAR: 34.6% vs 0.9%; P < .001) as well as after ruptured AAA repair (open repair: 48.2% vs 25.6%; P < .001; EVAR: 30.8% vs 21.1%; P < .001).

CONCLUSIONS

This study underlines that although bowel ischemia after AAA repair is rare, the associated outcomes are very poor. The cause of postoperative bowel ischemia is multifactorial and can be attributed to patient factors and operative characteristics. These data should be considered during preoperative risk assessment and for optimization of both the patient and the procedure in an effort to reduce the risk of postoperative bowel ischemia.

Patient selection and perioperative outcomes are similar between targeted and nontargeted hospitals (in the National Surgical Quality Improvement Program) for abdominal aortic aneurysm repair

OBJECTIVE

The targeted vascular module in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) consists of self-selected hospitals that choose to collect extra clinical details for better risk adjustment and improved procedure-specific outcomes. The purpose of this study was to compare patient selection and outcomes between targeted and nontargeted hospitals in the NSQIP regarding the operative management of abdominal aortic aneurysm (AAA).

METHODS

We identified all patients who underwent endovascular aneurysm repair (EVAR) or open AAA repair from 2011 to 2013 and compared cases by whether the operation took place in a targeted or nontargeted hospital. EVAR and open repair as well as intact and ruptured aneurysms were evaluated separately. Only variables contained in both modules were used to evaluate rupture status and operation type. All thoracoabdominal aneurysms were excluded. Univariate analysis was performed for intact and ruptured EVAR and open repair grouped by complexity, defined as visceral involvement in open repair and a compilation of concomitant procedures for EVAR. Multivariable models were developed to identify effect of hospital type on mortality.

RESULTS

There were 17,651 AAA repairs identified. After exclusion of aneurysms involving the thoracic aorta (n = 352), there were 1600 open AAA repairs at targeted hospitals (21% ruptured) and 2725 at nontargeted hospitals (19% ruptured) and 4986 EVARs performed at targeted hospitals (6.7% ruptured) and 7988 at nontargeted hospitals (5.2% ruptured). There was no significant difference in 30-day mortality rates between targeted and nontargeted hospitals for intact aneurysms (EVAR noncomplex, 1.8% vs 1.4% [P = .07]; open repair noncomplex, 4.2% vs 4.5% [P = .7]; EVAR complex, 5.0% vs 3.2% [P = .3]; open repair complex, 8.0% vs 6.0% [P = .2]). For ruptured aneurysms, again there was no difference in mortality between the targeted and nontargeted hospitals (EVAR noncomplex, 23% vs 25% [P = .4]; open repair noncomplex, 38% vs 34% [P = .2]; EVAR complex, 29% vs 33% [P = 1.0]; open repair complex, 27% vs 41% [P = .09]). Multivariable analysis further demonstrated that having an operation at a targeted vs nontargeted hospital had no impact on mortality for both intact and ruptured aneurysms (odds ratio, 1.1 [0.9-1.4] and 1.0 [0.8-1.3], respectively).

CONCLUSIONS

This analysis highlights the similarities between targeted and nontargeted hospitals within the NSQIP for AAA operative management and suggests that data from the targeted NSQIP, in terms of AAA management, are generalizable to all NSQIP hospitals.