Systematic Review and Meta-analysis of the Impact of Surgeon-Physician Co-management Models on Short Term Outcomes for Vascular Surgery Inpatients

OBJECTIVE

As the population ages, vascular surgeons are treating progressively older, multimorbid patients at risk of peri-operative complications. An embedded physician has been shown to improve outcomes in general and orthopaedic surgery. This systematic review and meta-analysis aimed to investigate the impact of surgeon-physician co-management models on morbidity and mortality rates in vascular inpatients.

DATA SOURCES

PubMed, Scopus, Embase, conference abstract listings, and clinical trial registries.

REVIEW METHODS

Studies comparing adult vascular surgery inpatients under co-management with standard of care were eligible. The relative risks (RRs) of death, medical complications, and 30 day re-admission between co-management and standard care were calculated. The effect of co-management on the mean length of stay was calculated using weighted means. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies, and certainty assessment with the GRADE analysis tools.

RESULTS

No randomised controlled trials were identified. Eight single institution studies between 2011 and 2020 with 7 410 patients were included. All studies were observational using before-after methodology. Studies were of high to moderate risk of bias, and outcomes were of very low GRADE certainty of evidence. Co-management was associated with a statistically significant lower relative risk of death (RR 0.64, 95% confidence interval [CI] 0.44 - 0.92; p = .02), cardiac complications (RR 0.47, 95% CI 0.25 - 0.87; p = .02), and infective complications (RR 0.49, 95% CI 0.35 - 0.67; p < .001) in vascular inpatients. No statistically significant differences in length of stay (standard mean difference -0.6 days, 95% CI -1.44 - 0.24 days; p = .16) and 30 day re-admission (RR 0.96, 95% CI 0.84 - 1.08; p = .49) were noted.

CONCLUSION

Early results of physician and surgeon co-management for vascular surgery inpatients showed promising results from very low certainty data. Further well designed, prospective studies are needed to determine how to maximise the impact of physicians within a vascular service to improve patient outcomes while using hospital resources effectively.

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.

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

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.

Factors Influencing Hospital Readmission after Lower Extremity Bypass for Chronic Limb-Threatening Ischemia

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.

Comparison of 30-day planned and unplanned readmissions in a tertiary teaching hospital in China

PURPOSE

The purpose of this study was to analyze and compare the clinical characteristics of patients with 30-day planned and unplanned readmissions and to identify patients at high risk for unplanned readmissions. This will facilitate a better understanding of these readmissions and improve and optimize resource utilization for this patient population.

METHODS

A retrospective cohort descriptive study was conducted at the West China Hospital (WCH), Sichuan University from January 1, 2015, to December 31, 2020. Discharged patients (≥ 18 years old) were divided into unplanned readmission and planned readmission groups according to 30-day readmission status. Demographic and related information was collected for each patient. Logistic regression analysis was used to assess the association between unplanned patient characteristics and the risk of readmission.

RESULTS

We identified 1,118,437 patients from 1,242,496 discharged patients, including 74,494 (6.7%) 30-day planned readmissions and 9,895 (0.9%) unplanned readmissions. The most common diseases of planned readmissions were antineoplastic chemotherapy (62,756/177,749; 35.3%), radiotherapy sessions for malignancy (919/8,229; 11.2%), and systemic lupus erythematosus (607/4,620; 13.1%). The most common diseases of unplanned readmissions were antineoplastic chemotherapy (2038/177,747; 1.1%), age-related cataract (1061/21,255; 5.0%), and unspecified disorder of refraction (544/5,134; 10.6%). There were statistically significant differences between planned and unplanned readmissions in terms of patient sex, marital status, age, length of initial stay, the time between discharge, ICU stay, surgery, and health insurance.

CONCLUSION

Accurate information on 30-day planned and unplanned readmissions facilitates effective planning of healthcare resource allocation. Identifying risk factors for 30-day unplanned readmissions can help develop interventions to reduce readmission rates.

Nationwide database analysis of one-year readmission rates after open surgical or thoracic endovascular repair of Stanford Type B aortic dissection

OBJECTIVE

We examined readmissions and resource use during the first postoperative year in patients who underwent thoracic endovascular aortic repair or open surgical repair of Stanford type B aortic dissection.

METHODS

The Nationwide Readmissions Database (2016-2018) was queried for patients with type B aortic dissection who underwent thoracic endovascular aortic repair or open surgical repair. The primary outcome was readmission during the first postoperative year. Secondary outcomes included 30-day and 90-day readmission rates, in-hospital mortality, length of stay, and cost. A Cox proportional hazards model was used to determine risk factors for readmission.

RESULTS

During the study period, type B aortic dissection repair was performed in 6456 patients, of whom 3517 (54.5%) underwent thoracic endovascular aortic repair and 2939 (45.5%) underwent open surgical repair. Patients undergoing thoracic endovascular aortic repair were older (63 vs 59 years; P < .001) with fewer comorbidities (Elixhauser score of 11 vs 17; P < .001) than patients undergoing open surgical repair. Thoracic endovascular aortic repair was performed electively more often than open surgical repair (29% vs 20%; P < .001). In-hospital mortality was 9% overall and lower in the thoracic endovascular aortic repair cohort than in the open surgical repair cohort (5% vs 13%; P < .001). However, the 90-day readmission rate was comparable between the thoracic endovascular aortic repair and open surgical repair cohorts (28% vs 27%; P = .7). Freedom from readmission for up to 1 year was also similar between cohorts (P = .6). Independent predictors of 1-year readmission included length of stay more than 10 days (P = .005) and Elixhauser comorbidity risk index greater than 4 (P = .033).

CONCLUSIONS

Approximately one-third of all patients with type B aortic dissection were readmitted within 90 days after aortic intervention. Surprisingly, readmission during the first postoperative year was similar in the open surgical repair and thoracic endovascular aortic repair cohorts, despite marked differences in preoperative patient characteristics and interventions.

Perioperative care in open aortic vascular surgery: A Consensus Statement by the Enhanced Recovery after Surgery (ERAS®) Society and Society for Vascular Surgery

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.

Hospitalist Co-management of a Vascular Surgery Service Improves Quality Outcomes and Reduces Cost

INTRODUCTION

Hospitalists can be instrumental in management of inpatients with multiple comorbidities requiring complex medical care such as vascular surgery patients, as well as an expertise in health care delivery. We instituted a unique hospitalist co-management program and assessed length of stay, 30-day readmission rates and mortality, and performed an overall cost-analysis.

METHODS

Hospitalist co-management of vascular surgery inpatients was implemented beginning April 2019, and data was studied until March 2020. We compared this data to an eight-month period prior to implementing co-management (7/2018 - 3/2019). Patient-related outcomes that were assessed include length of stay, re-admission index, mortality index, case-mix index. Cost-analysis was performed to look at indirect and direct cost of care.

RESULTS

A total of 1,062 patients were included in the study 520 pre co-management and 542 patients were post-comanagement. Baseline case-mix index was 2.47, and post-comanagement was 2.46 (p>0.05). In terms of average length of stay (aLOS), the baseline aLOS was 5.16 days per patient, while after co-management it was significantly decreased by 1.25 days to 3.91 days (p<0.05). This improvement in length of stay opened an average of 2.4 telemetry beds per day. Similarly, excess days per patient which reflects the expected length of stay based on comorbidities, improved from -0.59 to -1.65, an improvement of -1.46.

CONCLUSIONS

Hospitalist co-management improves outcomes for vascular surgery inpatients, decreases length of stay, re-admission and mortality while providing a significant cost-savings. The overall average variable direct cost decreased by $1,732 per patient.

CONCLUSION

Hospitalist co-management improves outcomes for vascular surgery inpatients, decreases length of stay, re-admission and mortality while providing a significant cost-savings.

Risk factors associated with 30-day hospital readmission after carotid endarterectomy

OBJECTIVE

The current study evaluated all-cause 30-day readmissions after carotid endarterectomy.

METHODS

Patients undergoing carotid endarterectomy were selected from the Cerner Health Facts® database using ICD-9-CM procedure codes from their index admission. Readmission within 30 days of discharge was determined. Chi-square analysis determined characteristics of the index admission (demographics, diagnoses, postoperative medications, and laboratory results) associated with readmission. Multivariate logistic regression models were used to identify characteristics independently associated with readmission.

RESULTS

In total, 5257 patients undergoing elective carotid endarterectomy were identified. Readmission within 30 days was 3.1%. After multivariable adjustment, readmission was associated with end-stage renal disease (OR: 3.21, 95% CI: 1.01-10.2), hemorrhage or hematoma (OR: 2.34, 95% CI: 1.15-4.77), procedural complications (OR: 3.07, 95% CI: 1.24-7.57), use of bronchodilators (OR: 1.48, 95% CI: 1.03-2.11), increased Charlson index scores (OR: 1.22, 95% CI: 1.08-1.38), and electrolyte abnormalities (hyponatremia < 135 mEq/L (OR: 1.69, 95% CI: 1.07-2.67) and hypokalemia less than 3.7 mEq/L (OR: 2.26, 95% CI: 1.03-4.98)).

CONCLUSIONS

Factors associated with readmission following carotid endarterectomy included younger age, increased comorbidity burden, end-stage renal disease, electrolyte disorders, the use of bronchodilators, and complications including bleeding (hemorrhage or hematoma). Of note, in this real-world study, only 40% of the patients received protamine, despite evidence-based literature demonstrating the reduced risk of bleeding complications. As healthcare moves towards quality of care-driven reimbursement, physician modifiable targets such as protamine utilization to reduce bleeding are greatly needed to reduce readmission, and failure to reduce preventable physician-driven complications after carotid interventions may be associated with decreased reimbursement.

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.

Postoperative Remote Automated Monitoring and Virtual Hospital-to-Home Care System Following Cardiac and Major Vascular Surgery: User Testing Study

Background

Cardiac and major vascular surgeries are common surgical procedures associated with high rates of postsurgical complications and related hospital readmission. In-hospital remote automated monitoring (RAM) and virtual hospital-to-home patient care systems have major potential to improve patient outcomes following cardiac and major vascular surgery. However, the science of deploying and evaluating these systems is complex and subject to risk of implementation failure.

Objective

As a precursor to a randomized controlled trial (RCT), this user testing study aimed to examine user performance and acceptance of a RAM and virtual hospital-to-home care intervention, using Philip’s Guardian and Electronic Transition to Ambulatory Care (eTrAC) technologies, respectively.

Methods

Nurses and patients participated in systems training and individual case-based user testing at two participating sites in Canada and the United Kingdom. Participants were video recorded and asked to think aloud while completing required user tasks and while being rated on user performance. Feedback was also solicited about the user experience, including user satisfaction and acceptance, through use of the Net Promoter Scale (NPS) survey and debrief interviews.

Results

A total of 37 participants (26 nurses and 11 patients) completed user testing. The majority of nurse and patient participants were able to complete most required tasks independently, demonstrating comprehension and retention of required Guardian and eTrAC system workflows. Tasks which required additional prompting by the facilitator, for some, were related to the use of system features that enable continuous transmission of patient vital signs (eg, pairing wireless sensors to the patient) and assigning remote patient monitoring protocols. NPS scores by user group (nurses using Guardian: mean 8.8, SD 0.89; nurses using eTrAC: mean 7.7, SD 1.4; patients using eTrAC: mean 9.2, SD 0.75), overall NPS scores, and participant debrief interviews indicated nurse and patient satisfaction and acceptance of the Guardian and eTrAC systems. Both user groups stressed the need for additional opportunities to practice in order to become comfortable and proficient in the use of these systems.

Conclusions

User testing indicated a high degree of user acceptance of Philips’ Guardian and eTrAC systems among nurses and patients. Key insights were provided that informed refinement of clinical workflow training and systems implementation. These results were used to optimize workflows before the launch of an international RCT of in-hospital RAM and virtual hospital-to-home care for patients undergoing cardiac and major vascular surgery.

Avoidable 30-day readmissions in patients undergoing vascular surgery

Background

Vascular surgery has one of the highest unplanned 30-day readmission rates of all surgical specialties. The degree to which these may be avoidable and the optimal strategies to reduce their occurrence are unknown. The aim of this study was to identify and classify avoidable 30-day readmissions in patients undergoing vascular surgery in order to plan targeted interventions to reduce their occurrence, improve outcomes and reduce cost.

Methods

A retrospective analysis of discharges over a 12-month period from a single tertiary vascular unit was performed. A multidisciplinary panel conducted a manual case-note review to identify and classify those 30-day unplanned emergency readmissions deemed avoidable.

Results

An unplanned 30-day readmission occurred in 72 of 885 admissions (8·1 per cent). These unplanned readmissions were deemed avoidable in 36 (50 per cent) of these 72 patients, and were most frequently due to unresolved medical issues (19 of 36, 53 per cent) and inappropriate admission with the potential for outpatient management (7 of 36, 19 per cent). A smaller number were due to inadequate social care provision (4 of 36, 11 per cent) and the occurrence of other avoidable adverse events (4 of 36, 11 per cent).

Conclusion

Half of all 30-day readmissions following vascular surgery are potentially avoidable. Multidisciplinary coordination of inpatient care and the transition from hospital to community care after discharge need to be improved.