Hospital readmissions after elective lower extremity vascular procedures

Modified frailty index as an indicator for outcomes, discharge status, and readmission after lower extremity bypass surgery for critical limb ischemia

Frailty has been associated with poor postoperative outcomes. This study evaluated the 5-factor modified frailty index (mFI-5) to assess complications, mortality, discharge disposition, and readmission in patients undergoing lower extremity (LE) bypass for critical limb ischemia (CLI).The National Surgical Quality Improvement Program vascular module (2011-2017) was utilized to identify patients undergoing LE bypass for CLI. Adverse events included infectious complications, bleeding complications, prolonged ventilation, amputation, readmission, and death. Patients were divided into groups based on mFI-5 scores: mFI1 (0), mFI2 (0.2), mFI3 (0.4), and mFI4 (0.6-1). Data were analyzed using the Cochran-Mantel-Haenszel statistic for general association and multivariable logistic regression. About 11,530 patients undergoing bypass for CLI were identified (42% rest pain and 58% tissue loss; 23% mFI1, 31% mFI2, 27% mFI3, and 19% mFI4; 64% men and 36% women). An increase in mFI-5 was associated with higher 30-day mortality (mFI1 = 0.62%; mFI12 = 1.45%; mFI13 = 1.35%; and mFI14 = 3.09%; P < .0001). After adjustment for age, mFI4 was associated with increased mortality compared with mFI1 (odds ratio, 3.80; 95% confidence interval, 1.69-8.54). Increased mFI-5 was associated with bleeding complications, wound infections, urinary tract infections, prolonged ventilation, sepsis, unplanned reoperations, and discharge to nonhome destination (all P < .01). Compared with mFI1 (13.5%), mFI4 was associated with increased 30-day readmission (24.8%, P < .0001). In patients undergoing LE bypass for CLI, higher mFI-5 was associated with increased postoperative complications, in-hospital and 30-day mortality, nonhome discharge, and 30-day readmission. The mFI-5 as an easily calculated tool can identify patients at high risk for inferior outcomes. It should be incorporated into discharge planning after LE bypass for CLI.

Defining the 90-day cost structure of lower extremity revascularization for alternative payment model assessment

BACKGROUND

The U.S. healthcare system is undergoing a broad transformation from the traditional fee-for-service model to value-based payments. The changes introduced by the Medicare Quality Payment Program, including the establishment of Alternative Payment Models, ensure that the practice of vascular surgery is likely to face significant reimbursement changes as payments transition to favor these models. The Society for Vascular Surgery Alternative Payment Model taskforce was formed to explore the opportunities to develop a physician-focused payment model that will allow vascular surgeons to continue to deliver the complex care required for peripheral arterial disease (PAD).

METHODS

A financial analysis was performed based on Medicare beneficiaries who had undergone qualifying index procedures during fiscal year 2016 through the third quarter of 2017. Index procedures were defined using a list of Healthcare Common Procedural Coding (HCPC) procedure codes that represent open and endovascular PAD interventions. Inpatient procedures were mapped to three diagnosis-related group (DRG) families consistent with PAD conditions: other vascular procedures (codes, 252-254), aortic and heart assist procedures (codes, 268, 269), and other major vascular procedures (codes, 270-272). Patients undergoing outpatient or office-based procedures were included if the claims data were inclusive of the HCPC procedure codes. Emergent procedures, patients with end-stage renal disease, and patients undergoing interventions within the 30 days preceding the index procedure were excluded. The analysis included usage of postacute care services (PACS) and 90-day postdischarge events (PDEs). PACS are defined as rehabilitation, skilled nursing facility, and home health services. PDEs included emergency department visits, observation stays, inpatient readmissions, and reinterventions.

RESULTS

A total of 123,180 cases were included. Of these 123,180 cases, 82% had been performed in the outpatient setting. The Medicare expenditures for all periprocedural services provided at the index procedure (ie, professional, technical, and facility fees) were higher in the inpatient setting, with an average reimbursement per index case of $18,755, $34,600, and $25,245 for DRG codes 252 to 254, DRG codes 268 and 269, and DRG codes 270 to 272, respectively. Outpatient facility interventions had an average reimbursement of $11,458, and office-based index procedures had costs of $11,533. PACS were more commonly used after inpatient index procedures. In the inpatient setting, PACS usage and reimbursement were 58.6% ($5338), 57.2% ($4192), and 55.9% ($5275) for DRG codes 252 to 254, DRG codes 268 and 269, and DRG codes 270 to 272, respectively. Outpatient facility cases required PACS for 13.7% of cases (average cost, $1352), and office-based procedures required PACS in 15% of cases (average cost, $1467). The 90-day PDEs were frequent across all sites of service (range, 38.9%-50.2%) and carried significant costs. Readmission was associated with the highest average PDE expenditure (range, $13,950-$18.934). The average readmission Medicare reimbursement exceeded that of the index procedures performed in the outpatient setting.

CONCLUSIONS

The cost of PAD interventions extends beyond the index procedure and includes relevant spending during the long postoperative period. Despite the analysis challenges related to the breadth of vascular procedures and the site of service variability, the data identified potential cost-saving opportunities in the management of costly PDEs. Because of the vulnerability of the PAD patient population, alternative payment modeling using a bundled value-based approach will require reallocation of resources to provide longitudinal patient care extending beyond the initial intervention.

A systematic review and meta-analysis of risk factors for and incidence of 30-day readmission after revascularization for peripheral artery disease

OBJECTIVE

Readmission to the hospital after revascularization for peripheral artery disease (PAD) is frequently reported. No consensus exists as to the exact frequency and risk factors for readmission. This review aimed to determine the incidence of and risk factors for 30-day readmission after revascularization for PAD.

METHODS

PubMed/Medline (Ovid), Scopus, Web of Science, the Cochrane Library, and CINAHL were searched systematically from inception until May 20, 2018. Studies were eligible for inclusion if they included patients with diagnosed PAD undergoing revascularization and reported the readmission rate and a statistical evaluation of the association of at least one risk factor with readmission. Studies were excluded if data for other procedures could not be distinguished from revascularization. Two authors undertook study selection independently with the final inclusion decision resolved through consensus. The PRISMA and Meta-analyses of Observational Studies in Epidemiology guidelines were followed regarding data extraction and quality assessment, which was performed by two authors independently. Data were pooled using a random effects model.

RESULTS

The primary outcome was readmission within 30 days of revascularization. Fourteen publications reporting the outcomes of 526,008 patients were included. Reported readmission rates ranged from 10.9% to 30.0% with a mean of 16.4% (95% confidence interval [CI], 15.1%-17.9%). Meta-analyses suggested the following risk factors had a significant association with readmission: female sex (odds ratio [OR], 1.13; 95% CI, 1.05-1.21), black race (OR, 1.36; 95% CI, 1.28-1.46), dependent functional status (OR, 1.72; 95% CI, 1.43-2.06), critical limb ischemia (OR, 2.12; 95% CI, 1.72-2.62), emergency admission (OR, 1.75; 95% CI, 1.43-2.15), hypertension (OR, 1.39; 95% CI, 1.26-1.54), heart failure (OR, 1.82; 95% CI, 1.50-2.20), chronic pulmonary disease (OR, 1.19; 95% CI, 1.08-1.32), diabetes (OR, 1.47; 95% CI, 1.32-1.63), chronic kidney disease (OR, 1.93; 95% CI, 1.62-2.31), dialysis dependence (OR, 2.08; 95% CI, 1.75-2.48), smoking (OR, 0.83; 95% CI, 0.78-0.89), postoperative bleeding (OR, 1.70; 95% CI, 1.23-2.35), and postoperative sepsis (OR, 4.13; 95% CI, 2.02-8.47).

CONCLUSIONS

Approximately one in six patients undergoing revascularization for PAD are readmitted within 30 days of their procedure. This review identified multiple risk factors predisposing to readmission, which could potentially serve as a way to target interventions to reduce readmissions.

Association of postoperative glycemic control with outcomes after carotid procedures

Objective

There are limited data evaluating the impact of postoperative hyperglycemia in patients undergoing vascular procedures. This study evaluated the relationship between suboptimal glucose control and adverse outcomes after carotid artery stenting and carotid endarterectomy.

Methods

Patients admitted for elective carotid procedures were selected from the Cerner Health Facts® (2008–2015) database using ICD-9-CM diagnosis and procedure codes. We examined the relationship between patient characteristics, postoperative hyperglycemia (any value > 180 mg/dL), and complications with chi-square analysis. A multivariable model examined the association between patient characteristics, procedure type, and glucose control with infection, renal failure, stroke, respiratory and cardiac complications, and length of stay over 10 days.

Results

Of the 4287 patients admitted for an asymptomatic carotid procedure, 788 (18%) underwent carotid artery stenting and 3499 (82%) underwent carotid endarterectomy. Most patients (87%) had optimal postoperative glucose control (80–180 mg/dL); 13% had suboptimal glucose control. On average, patients with suboptimal glucose control experienced: higher stroke rates (6.2% vs. 2.7%; p <  0.001); more cardiac complications (5.1% vs. 2.0%; p <  0.001); longer hospital stays (3.1 vs. 1.8 days; p < .001); higher rates of post-procedure infection (4.0% vs. 1.8%; p = .001); and more complications than patients with optimal glucose control. Multivariable logistic regression demonstrated that patients with suboptimal glucose control had higher odds of having an infectious (pneumonia, cellulitis, surgical site, etc.) complication (OR 1.91, 95% CI 1.10–3.34), renal failure (OR 3.36, 95% CI 1.95–5.78), respiratory complications (OR 1.81, 95% CI 1.21–2.71), stroke (OR 1.82, 95% CI 1.15–2.88), or length of stay > 10 days (OR 4.07, 95% CI 2.02–8.20).

Conclusions

Suboptimal glucose control was associated with adverse events after carotid artery stenting and carotid endarterectomy, independent of a diabetes diagnosis. Several adverse outcomes were associated with hyperglycemia, including stroke. Given the singular role of carotid procedures in preventing stroke, we suggest that incorporating rigorous post-operative glucose control into best medical treatment of carotid disease should be considered as a standard practice.

Cohort study of risk factors for 30-day readmission after abdominal aortic aneurysm repair

Background: We conducted a retrospective cohort study of thirty-day readmission after abdominal aortic aneurysm (AAA) repair. Patients and methods: Inpatients (2009-2016) undergoing elective AAA repair were selected from the multicenter Cerner Health Facts® database using ICD-9 procedure codes. We identified characteristics associated with 30-day readmission with chi-square analysis and logistic regression. Results: 4,723 patients undergoing elective AAA procedures were identified; 3,101 endovascular aneurysm repairs (EVAR) and 1,622 open procedures. Readmission differed by procedure type (6.5 % EVAR vs. 9.3 % open, p =.0005). Multivariable logistic regression found that patients undergoing EVAR were less likely to be readmitted (OR 0.71, 95 % CI 0.54-0.92) than patients undergoing open repair. The following risk factors were associated with 30-day readmission following any AAA repair: surgical site infection during the index admission (OR 2.79, 95 % CI 1.25-6.22), age (OR 1.03, 95 % CI 1.01-1.05), receipt of bronchodilators (OR 1.34, 95 % CI 1.06-1.70) or steroids (OR 1.45, 95 % CI 1.04-2.02), serum potassium > 5.2 mEq/L (OR 1.89, 95 % CI 1.16-3.06), and higher Charlson co-morbidity scores (OR 1.12, 95 % CI 1.04-1.21). Subgroup analysis revealed that age (OR 1.02, 95 % CI 1.01-1.04), higher Charlson comorbidity scores (OR 1.20, 95 % CI 1.09-1.33), and receipt of post-operative bronchodilators (OR 1.39, 95 % CI 1.03-1.88) were risk factors for 30-day readmission following EVAR. After open procedures, readmission was associated with surgical site infection during the index admission (OR 2.91, 95 % CI 1.17-7.28), chronic heart failure (OR 2.18, 95 % CI 1.22-3.89), and receipt of post-operative steroids (OR 1.92, 95 % CI 1.24-2.96). The most common infections were pneumonia after open procedures and urinary tract infection after EVAR. Conclusions: The risk factor most associated with 30-day readmission after elective AAA repair was surgical site infection. Awareness of these risk factors and vulnerable groups may help identify high-risk patients who could benefit from increased surveillance programs to reduce readmission.

Risk Factors for Thirty-Day Readmissions After Lower Extremity Amputation in Patients With Vascular Disease

BACKGROUND

Understanding risk factors associated with readmission after lower extremity amputation may indicate targets for reducing readmission.

OBJECTIVE

To evaluate factors associated with all-cause 30-day readmission after lower extremity amputation procedures.

DESIGN

Retrospective cohort study.

SETTING

Inpatient.

PATIENTS

A total of 2480 patients who had lower extremity amputations between 2008 and 2014 were selected from national electronic medical record database, Cerner Health Facts.

METHODS

Univariate analysis of demographics, diagnoses, postoperative medications, and laboratory results were examined. Multivariate logistic regression models were used to identify characteristics independently associated with readmission overall and by amputation location-above the knee (AKA) or below the knee (BKA).

MAIN OUTCOME MEASUREMENT

Readmission within 30 days of discharge.

RESULTS

More than one half of patients (1403, 57%) underwent BKA and 1077 (43%) underwent AKA. Readmission within 30 days was 22% (24.1% BKA versus 19.4% AKA, P = .005). In multivariable logistic regression, factors associated with 30-day readmission after any amputation included BKA (odds ratio [OR] 1.41, 95% confidence interval [CI] 1.15-1.74, P = .001), hypertension (OR 1.70, 95% CI 1.33-2.16), surgical-site infections (OR 1.44, 95% CI 1.02-2.04), heart failure (OR 1.39, 95% CI 1.10-1.75), discharge to a skilled nursing facility (OR 1.88, 95% CI 1.41-2.51), and emergency/urgent procedures (OR 1.32, 95% CI 1.04-1.67). At readmission, 13.3% of patients with a BKA required an AKA revision, and 21.3% had a diagnosis of surgical-site infection.

CONCLUSIONS

Risk factors for readmission after any amputation included cardiac comorbidities, associated postoperative medications, and discharge to a skilled nursing facility. The finding that acute arterial embolism or thrombosis and a BKA during the index admission was highly associated with readmission, combined with the high rates of 30-day conversion to an AKA when readmitted, suggests these patients more often develop stump complications or may be undertreated during the initial hospitalization.

LEVEL OF EVIDENCE

III.

Nationally Representative Readmission Factors in Patients with Claudication and Critical Limb Ischemia

BACKGROUND

Hospital readmissions are associated not only with increased mortality, morbidity, and costs but also, with current health-care reform, tied to significant financial and administrative penalties. Some studies show that patients undergoing vascular surgery may have higher than average readmission rates. The recently released Nationwide Readmission Database (NRD) is the most comprehensive national source of readmission data, gathering discharge information from 22 geographically dispersed states, accounting for 51.2% of the total U.S. resident population and 49.3% of all U.S. hospitalizations. The aim of this study is to use the power of the NRD and obtain nationally representative readmission information for patients admitted with claudication or critical limb ischemia (CLI) who underwent revascularization procedures.

METHODS

The NRD was queried for all patients admitted for claudication (International Classification of Diseases Ninth Revision [ICD-9] 440.21) or CLI (ICD-9 440.22-440.24) and who underwent percutaneous transluminal angioplasty, peripheral bypass, or aortofemoral bypass. Patient demographics, comorbidities, length of stay (LOS), mortality, readmission rates, and associated costs were collected. Univariable and multivariable logistic regression analysis was implemented on claudication and CLI groups on all outcomes of interest. The most common readmission diagnosis codes and diagnosis groups were also identified.

RESULTS

A total of 92,769 patients were admitted for peripheral vascular disease (33,055 with claudication and 59,714 with CLI). The 30-day readmission/any readmission rate was 8.97%/21.49% and 19.26%/40.36%, for claudication and CLI, respectively. Significant differences were found for claudication and CLI, respectively, on initial cost of admission ($18,548 vs. $29,148, P < 0.001), readmission costs ($14,726 vs. $17,681 P < 0.001), LOS (4 days vs. 9 days, P < 0.001), days to readmission (73 days vs. 59 days, P < 0.001), mortality during initial admission (256 vs. 1,363, P < 0.001), and mortality during any admission (538 vs. 3,838, P < 0.001). Univariate and multivariate logistic regression analysis found that claudication, CLI, angioplasty, peripheral bypass, aortofemoral bypass, female sex, age >65, Charlson Comorbidity Index, LOS, and primary expected payer status were all significant predictors of 30-day and overall readmissions at varying degrees. The 5 most common disease readmission groups found were other vascular procedures (12.6%), amputation of lower limb except toes (6.3%), sepsis (5.4%), heart failure (4.9%) and postoperative or other device infections (4.8%). Of the abovementioned groups, the 4 most common diagnoses included "other postoperative infections," sepsis, atherosclerosis of native arteries with gangrene, and "other complications due to other vascular device, implant, or graft."

CONCLUSIONS

Our results demonstrate that there is a significant difference in readmission rates, cost, and morbidity between patients admitted for claudication and CLI. Furthermore, based on regression analysis, there are multiple other clear risk factors associated with worse clinical and economic outcomes. Further study is needed to predict which patients will require increased vigilance during their hospital stay to prevent readmissions and worse outcomes.

LEVEL OF EVIDENCE

Care management/epidemiological, level IV.