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Vogel TR, Kruse RL, Schlesselman C, Doss E, Camazine M, Popejoy LL. A qualitative study evaluating the discharge process for vascular surgery patients to identify significant themes for organizational improvement. Vascular 2024; 32:395-406. [PMID: 36287544 DOI: 10.1177/17085381221135267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
OBJECTIVE Transition from the hospital to an outpatient setting is a multifaceted process requiring coordination among a variety of services and providers to ensure a high-quality discharge. Vascular surgery patients comprise a complex population that experiences high unplanned readmission rates. We performed a qualitative study to identify themes for process improvement for vascular surgery patients. A validated discharge process, RED (Re-Engineered Discharge), was used to identify additional actionable themes to create a more efficient discharge process tailored specifically to the vascular surgery population. METHODS A prospective, qualitative analysis at a tertiary center using a semi-structured focus group interview guide was performed to evaluate the current discharge process and identify opportunities for improvement. Focus groups were Zoom recorded, transcribed into electronic text files, and were loaded into Dedoose qualitative software for analysis using a directed content analysis approach. Two researchers independently thematically coded each transcript, starting with accepted discharge components to identify new thematic categories. Prior to analysis, all redundancy of codes was resolved, and all team members agreed on text categorization and coding. RESULTS Eight focus groups with a total of 38 participants were conducted. Participants included physicians (n = 13), nursing/ancillary staff (n = 14), advanced nurse practitioners (n = 2), social worker/dietitian/pharmacist (n = 3), and patients (n = 6). Transcript analyses revealed facilitators and barriers to the discharge process. In addition to traditional RED components, unique concepts pertinent to vascular surgery patients included patient complexity, social determinants of health, technology literacy, complexity of ancillary services, discharge appropriateness, and use of advanced nurse practitioners for continuity. CONCLUSIONS Specific themes were identified to target and enhance the future vRED (vascular Re-Engineered Discharge) bundle. Thematic targets for improvement include increased planning, organization, and communication prior to discharge to address vascular surgery patients' multiple comorbidities, extensive medication lists, and need for complex ancillary services at the time of discharge. Other thematic barriers discovered to improve include provider awareness of patient health literacy, patient understanding of complex discharge instructions, patient technology barriers, and intrinsic social determinants of health in this population. To address these discovered barriers, organizational targets to improve include enhanced social support, the use of advanced nurse practitioners for education reinforcement, and increased coordination. These results provide a framework for future quality improvement targeting the vascular surgery discharge process.
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Affiliation(s)
- Todd R Vogel
- Department of Surgery, Division of Vascular Surgery, University of Missouri System, Columbia, MI, USA
| | - Robin L Kruse
- Department of Surgery, Division of Vascular Surgery, University of Missouri System, Columbia, MI, USA
| | - Chase Schlesselman
- Department of Surgery, Division of Vascular Surgery, University of Missouri System, Columbia, MI, USA
| | - Elizabeth Doss
- Sinclair School of Nursing, University of Missouri System, Columbia, MO, USA
| | - Maraya Camazine
- Department of Surgery, Division of Vascular Surgery, University of Missouri System, Columbia, MI, USA
| | - Lori L Popejoy
- Sinclair School of Nursing, University of Missouri System, Columbia, MO, USA
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2
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Gonzalez AA, Motaganahalli A, Saunders J, Dev S, Dev S, Ghaferi AA. Including socioeconomic status reduces readmission penalties to safety-net hospitals. J Vasc Surg 2024; 79:685-693.e1. [PMID: 37995891 DOI: 10.1016/j.jvs.2023.11.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/04/2023] [Accepted: 11/14/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE Medicare's Hospital Readmissions Reduction Program (HRRP) financially penalizes "excessive" postoperative readmissions. Concerned with creating a double standard for institutions treating a high percentage of economically vulnerable patients, Medicare elected to exclude socioeconomic status (SES) from its risk-adjustment model. However, recent evidence suggests that safety-net hospitals (SNHs) caring for many low-SES patients are disproportionately penalized under the HRRP. We sought to simulate the impact of including SES-sensitive models on HRRP penalties for hospitals performing lower extremity revascularization (LER). METHODS This is a retrospective, cross-sectional analysis of national data on Medicare patients undergoing open or endovascular LER procedures between 2007 and 2009. We used hierarchical logistic regression to generate hospital risk-standardized 30-day readmission rates under Medicare's current model (adjusting for age, sex, comorbidities, and procedure type) compared with models that also adjust for SES. We estimated the likelihood of a penalty and penalty size for SNHs compared with non-SNHs under the current Medicare model and these SES-sensitive models. RESULTS Our study population comprised 1708 hospitals performing 284,724 LER operations with an overall unadjusted readmission rate of 14.4% (standard deviation: 5.3%). Compared with the Centers for Medicare and Medicaid Services model, adjusting for SES would not change the proportion of SNHs penalized for excess readmissions (55.1% vs 53.4%, P = .101) but would reduce penalty amounts for 38% of SNHs compared with only 17% of non-SNHs, P < .001. CONCLUSIONS For LER, changing national Medicare policy to including SES in readmission risk-adjustment models would reduce penalty amounts to SNHs, especially for those that are also teaching institutions. Making further strides toward reducing the national disparity between SNHs and non-SHNs on readmissions, performance measures require strategies beyond simply altering the risk-adjustment model to include SES.
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Affiliation(s)
- Andrew A Gonzalez
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN; William Tierney Center for Health Services Research, Regenstrief Institute, Indianapolis, IN; Surgical Outcomes and Quality Improvement Center, Indiana University School of Medicine, Indianapolis, IN.
| | - Anush Motaganahalli
- William Tierney Center for Health Services Research, Regenstrief Institute, Indianapolis, IN
| | - Jordan Saunders
- William Tierney Center for Health Services Research, Regenstrief Institute, Indianapolis, IN; Catherine and Joseph Aresty Department of Urology, University of Southern California, Los Angeles, CA
| | - Sharmistha Dev
- William Tierney Center for Health Services Research, Regenstrief Institute, Indianapolis, IN; Richard L. Roudebush Veterans' Administration Medical Center, Indianapolis, IN; Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Shantanu Dev
- William Tierney Center for Health Services Research, Regenstrief Institute, Indianapolis, IN; College of Engineering, the Ohio State University, Columbus, OH
| | - Amir A Ghaferi
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
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Beucler A, Wheibe E, Gandhi SS, Blas JV, Carsten CG, Gray BH. Outcomes of Endovascular Treatment for Critical Limb Threatening Ischemia. Ann Vasc Surg 2024; 99:434-441. [PMID: 37922961 DOI: 10.1016/j.avsg.2023.09.077] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/21/2023] [Accepted: 09/24/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Critical limb threatening ischemia (CLTI), particularly in patients with ischemic ulceration has been associated with significant morbidity and mortality. Typically, endovascular therapy has been first-line therapy for our patients, but this strategy has come into question based upon the Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb Threatening Ischemia (BEST-CLI) trial data. METHODS AND RESULTS For comparative purposes, we evaluated outcomes from 150 CLTI patients with ischemic ulceration treated with endovascular-first therapy. The mean age was 72 years in this predominate male, Caucasian, ambulatory group. The major co-morbidities were smoking history in 49% and diabetes mellitus in 67%.` Anatomic scoring, using Society for Vascular Surgery criteria, revealed only 35.6% had favorable anatomy (Global Limb Anatomical Staging System stage of 0,1) for long-term patency compared to 64.4% of limbs with unfavorable anatomy for long-term patency (Global Limb Anatomical Staging System stage 2,3). Stents were used in 47% of cases. Reintervention occurred in 36% over 24 months follow-up. At 12 and 24 months, the Kaplan-Meier projections for survival was 0.80 (0.73, 0.87) and 0.69 (0.59, 0.79); amputation was 0.69 (0.61, 0.77) and 0.59 (0.46, 0.71); amputation-free survival (AFS) was 0.56 (0.48, 0.65) and 0.38 (0.27, 0.50), respectively. Amputation was more common in those with reinterventions (P = 0.033). Mortality was predicted with ankle brachial index ≤0.40 or ≥1.30 (P = 0.0019) and the presence of infection (P = 0.0047). AFS was predicted by the presence of any infection (P = 0.0001). CONCLUSIONS Despite technically successful endovascular treatment, patients who present with CLTI maintain a high-risk for limb loss and mortality. Amputation prevention must vigilantly address infection risk. These data correlate with outcomes from BEST-CLI trial enhancing applicability to patient-centered care.
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Affiliation(s)
- Adam Beucler
- Department of Vascular Surgery/Medicine, Prisma Health System, Greenville, SC
| | - Elias Wheibe
- University of Cincinnati, School of Medicine, Cincinnati, OH
| | - Sagar S Gandhi
- University of Cincinnati, School of Medicine, Cincinnati, OH
| | - Joseph Vv Blas
- University of Cincinnati, School of Medicine, Cincinnati, OH
| | | | - Bruce H Gray
- Department of Vascular Surgery/Medicine, Prisma Health System, Greenville, SC.
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Krafcik BM, Jarmel IA, Beach JM, Suckow BD, Stableford JA, Stone DH, Goodney PP, Columbo JA. Readmission After Lower Extremity Bypass Following Discharge to a Rehabilitation or Nursing Facility. J Surg Res 2023; 292:167-175. [PMID: 37619502 DOI: 10.1016/j.jss.2023.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 06/23/2023] [Accepted: 07/23/2023] [Indexed: 08/26/2023]
Abstract
INTRODUCTION Hospital readmission after lower extremity arterial bypass (LEB) is common. Patients are often discharged to a facility after LEB as a bridge to home. Our objective was to define the association between discharge to a facility and readmission after LEB. METHODS We used the Vascular Quality Initiative to study patients who underwent LEB from 2017 to 2022. The primary exposure was discharge location. The primary outcome was 30-d hospital readmission. RESULTS We included 6076 patients across 147 centers. The overall 30-d readmission rate was 18%. Readmission occurred among 15% of patients discharged home, 22% of patients discharged to a rehabilitation facility, and 25% of patients discharged to a nursing home. After controlling for patient and procedural factors, there was no significant association between discharge location and 30-d readmission (rehabilitation versus home odds ratio: 1.06, 95% confidence interval: 0.87-1.29; nursing facility versus home odds ratio: 1.21, 95% confidence interval: 0.99-1.47). Female sex, end-stage renal disease, diabetes, heart failure, pulmonary disease, smoking, preoperative functional impairment, tibial bypass target, critical limb threatening or acute ischemia, and postoperative complications including surgical site infection, change in renal function and graft thrombosis were associated with an increased likelihood of readmission. CONCLUSIONS Patients discharged home after LEB experienced a similar likelihood of readmission as those discharged to a facility. While discharge to a facility may aid in care transitions, it did not appear to lead to reduced 30-d readmissions. The recommended discharge location should be predicated on patient care needs and not as a perceived mechanism to reduce readmissions.
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Affiliation(s)
- Brianna M Krafcik
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Isabel A Jarmel
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Jocelyn M Beach
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Bjoern D Suckow
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Jennifer A Stableford
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Jesse A Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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Zil-E-Ali A, Ahmadzada M, Calisi O, Holcomb RM, Patel A, Aziz F. A Systematic Review and Meta-Analysis to Assess the Impact of Pre-existing Comorbidities on the 30-Day Readmission after Lower Extremity Bypass Surgery for Peripheral Artery Occlusive Disease. Ann Vasc Surg 2023; 91:10-19. [PMID: 36549476 DOI: 10.1016/j.avsg.2022.12.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 11/18/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Unplanned hospital readmissions after surgical operations are considered a marker for suboptimal care during index hospitalizations and are associated with poor patient outcomes and increased healthcare resource utilization. Patients undergoing lower extremity bypass (LEB) operations for severe peripheral arterial disease (PAD) have one of the highest readmission rates, among all the vascular and nonvascular surgical operations. This review is meant to evaluate the impact of pre-existing comorbidities (diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypertension (HTN), and coronary artery disease (CAD))-on the 30-day readmission rates among patients who underwent LEB for severe PAD. METHODS The review protocol was registered to the PROSPERO database (CRD42021261067). A systematic review of the English literature was performed using PubMed, Scopus, and the Cochrane Library databases from inception till April 2022. The review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and included only studies reporting on 30-day readmission following LEB for occlusive PAD. The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach and was reported as high, moderate, or low. The risk of bias was evaluated utilizing the Risk of Bias in Nonrandomized Studies - of Interventions (ROBINS-I) tool. A pooled odds ratio (OR) for each study was computed, and a P-value of <0.05 was designated as statistically significant. Interstudy heterogeneity was evaluated by Q-metric and quantified using Higgins I2 statistics. RESULTS Five studies reported data on 30-day readmission after LEB for occlusive PAD. A total of 19,739 patients were included. Readmission occurred among 3,559 (18%) patients. DM and COPD were reported by all 5 selected studies, and CHF and HTN were reported by 4 studies. CAD was least reported among the selected 5 pre-existing conditions, with only 2 studies mentioning it. HTN (OR, 1.35; 95% confidence interval (CI), 1.10-1.64; P ≤ 0.001; I2 = 52.20%), DM (OR, 1.52; 95% CI, 1.30-1.79; P ≤ 0.001; I2 = 74.51%), and CHF (OR, 1.85; 95% CI, 1.51-2.25; P ≤ 0.001; I2 = 50.48%) were all found to be associated with an increased risk of 30-day readmission, while the presence of COPD (OR, 1.16; 95% CI, 0.98-1.36; P = 0.09; I2 = 61.93%) and CAD (OR, 1.30; 95% CI, 0.94-1.78; P = 0.11; I2 = 51.01%) was not associated with early readmission on meta-analysis of the available studies. CONCLUSIONS The pre-existing comorbidities HTN, DM, and CHF increase the risk of 30-day readmission after LEB for occlusive PAD. The identification of these risk factors can help stratify the patients and further guide in understanding the variety of factors that contribute in hospital readmissions.
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Affiliation(s)
- Ahsan Zil-E-Ali
- Division of Vascular Surgery, Heart and Vascular Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA.
| | | | - Olivia Calisi
- Office of Medical Education, Pennsylvania State University College of Medicine, Hershey, PA
| | - Ryan M Holcomb
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | - Akshilkumar Patel
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | - Faisal Aziz
- Division of Vascular Surgery, Heart and Vascular Institute, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
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Doss ER, Vogel TR, Kruse RL, Camazine M, Schlesselman C, Popejoy LL. Discharge process challenges of an academic vascular surgery service: A qualitative study. Res Nurs Health 2023; 46:210-219. [PMID: 36582026 DOI: 10.1002/nur.22292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 11/23/2022] [Accepted: 12/14/2022] [Indexed: 12/31/2022]
Abstract
Vascular surgery patients have a high incidence of unplanned hospital readmissions and complications. Previous research has not fully examined specific elements of the hospital discharge process for vascular surgery patients to identify issues that may contribute to readmissions. The objective of this qualitative descriptive study was to explore challenges identified by healthcare providers and patients regarding the discharge process from an academic vascular surgery service. Data were collected from eight focus group interviews and analyzed for relevant themes. Patients and healthcare providers identified several challenges within the standard discharge process, including ineffective communication, insufficient time for discharge education, and limitations accessing providers with post-discharge concerns. These obstacles may be ameliorated in part by specialized coordinators, caregiver support, and use of adaptive strategies outside of the current discharge process. The discharge challenges described by study participants likely contribute to adverse post-hospitalization outcomes, including unplanned hospital readmissions. A multifaceted approach that incorporates standardized discharge processes, as well as informal problem-solving strategies, is recommended to improve hospital discharge and outcomes for vascular surgery patients.
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Affiliation(s)
- Elizabeth R Doss
- Sinclair School of Nursing, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Todd R Vogel
- Division of Vascular Surgery, School of Medicine, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Robin L Kruse
- Department of Family and Community Medicine, School of Medicine, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Maraya Camazine
- Division of Vascular Surgery, School of Medicine, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Chase Schlesselman
- Division of Vascular Surgery, School of Medicine, University of Missouri-Columbia, Columbia, Missouri, USA
| | - Lori L Popejoy
- Sinclair School of Nursing, University of Missouri-Columbia, Columbia, Missouri, USA
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7
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Doss ER, Popejoy LL. Interventions to Prevent Readmissions in Hospitalized Peripheral Vascular Surgery Patients: A Systematic Review. Clin Nurs Res 2023; 32:423-432. [PMID: 35369738 DOI: 10.1177/10547738221085612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A large proportion of peripheral vascular patients worldwide experience unplanned hospital readmissions after inpatient vascular surgery. This review was conducted to identify acute care and post-discharge interventions that may help in reducing unplanned vascular surgery readmissions. A computer-based search of four databases was conducted July 2021 for original research reports published 2000 to 2021. Eight studies met inclusion criteria, with interventions including multidisciplinary care teams, advance practice provider discharge coordination, individualized case management, home care nursing, early primary care provider or telephone follow-up, and telehealth driven follow up evaluated. Some reductions in readmission rates were associated with most interventions but were inconsistent across studies. Further research is necessary to clarify and validate these findings, incorporate patient perspectives, and explore the role of technology-based interventions. This work is key to improving the patient's experience, reduce healthcare costs, and strengthen the quality of vascular surgery care.
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Shchegolev AA, Papoyan SA, Mutaev MM, Syromyatnikov DD, Komarova DS. [Hybrid interventions for atherosclerotic lesions of the lower limb arteries]. Khirurgiia (Mosk) 2023:103-109. [PMID: 37707339 DOI: 10.17116/hirurgia2023091103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
Treatment of multilevel atherosclerotic lesions of the lower limb arteries is an acute problem in modern medicine. There is no a single treatment algorithm. Hybrid technologies are one of the possible treatment options. There are reasonable assumptions that these technologies can at least partially solve this problem. Minor trauma is an undoubted advantage of hybrid technologies. Therefore, these approaches are advisable in severe patients with various comorbidities and contraindications for traditional methods. Therefore, analysis of hybrid methods is of great interest for cardiovascular surgeons. Hybrid method is now recognized as one of the most effective and minimally traumatic treatment for patients with atherosclerotic lesions of the lower extremities.
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Affiliation(s)
- A A Shchegolev
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - S A Papoyan
- Pirogov Russian National Research Medical University, Moscow, Russia
- Inozemtsev Moscow City Clinical Hospital, Moscow, Russia
- Research Institute of Health Organization and Medical Management, Moscow, Russia
| | - M M Mutaev
- Pirogov Russian National Research Medical University, Moscow, Russia
- Inozemtsev Moscow City Clinical Hospital, Moscow, Russia
| | | | - D S Komarova
- Pirogov Russian National Research Medical University, Moscow, Russia
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Wang S, Zhu X. Predictive Modeling of Hospital Readmission: Challenges and Solutions. IEEE/ACM TRANSACTIONS ON COMPUTATIONAL BIOLOGY AND BIOINFORMATICS 2022; 19:2975-2995. [PMID: 34133285 DOI: 10.1109/tcbb.2021.3089682] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Hospital readmission prediction is a study to learn models from historical medical data to predict probability of a patient returning to hospital in a certain period, e.g. 30 or 90 days, after the discharge. The motivation is to help health providers deliver better treatment and post-discharge strategies, lower the hospital readmission rate, and eventually reduce the medical costs. Due to inherent complexity of diseases and healthcare ecosystems, modeling hospital readmission is facing many challenges. By now, a variety of methods have been developed, but existing literature fails to deliver a complete picture to answer some fundamental questions, such as what are the main challenges and solutions in modeling hospital readmission; what are typical features/models used for readmission prediction; how to achieve meaningful and transparent predictions for decision making; and what are possible conflicts when deploying predictive approaches for real-world usages. In this paper, we systematically review computational models for hospital readmission prediction, and propose a taxonomy of challenges featuring four main categories: (1) data variety and complexity; (2) data imbalance, locality and privacy; (3) model interpretability; and (4) model implementation. The review summarizes methods in each category, and highlights technical solutions proposed to address the challenges. In addition, a review of datasets and resources available for hospital readmission modeling also provides firsthand materials to support researchers and practitioners to design new approaches for effective and efficient hospital readmission prediction.
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Livingston KA, Koh E, Adlouni M, Hassan A, Gan W, Yijun zhang M, Falohun T, Peden EK, Rahimi M. Vasculink iPhone Application and Risk Prediction Model for Groin Complication in Vascular Surgery. Ann Vasc Surg 2022; 85:237-245. [DOI: 10.1016/j.avsg.2022.03.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/27/2022] [Accepted: 03/29/2022] [Indexed: 11/29/2022]
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Ho-Yan Lee M, Li PY, Li B, Shakespeare A, Samarasinghe Y, Feridooni T, Cuen-Ojeda C, Alshabanah L, Kishibe T, Al-Omran M. A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery. J Vasc Surg 2022; 76:581-594.e25. [DOI: 10.1016/j.jvs.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
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Gwilym BL, Ambler GK, Saratzis A, Bosanquet DC. Groin Wound Infection after Vascular Exposure (GIVE) Risk Prediction Models: Development, Internal Validation, and Comparison with Existing Risk Prediction Models Identified in a Systematic Literature Review. Eur J Vasc Endovasc Surg 2021; 62:258-266. [PMID: 34246547 DOI: 10.1016/j.ejvs.2021.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/29/2021] [Accepted: 05/08/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study aimed to develop and internally validate risk prediction models for predicting groin wound surgical site infections (SSIs) following arterial intervention and to evaluate the utility of existing risk prediction models for this outcome. METHODS Data from the Groin wound Infection after Vascular Exposure (GIVE) multicentre cohort study were used. The GIVE study prospectively enrolled 1 039 consecutive patients undergoing an arterial procedure through 1 339 groin incisions. An overall SSI rate of 8.6% per groin incision, and a deep/organ space SSI rate of 3.8%, were reported. Eight independent predictors of all SSIs, and four independent predictors of deep/organ space SSIs were included in the development and internal validation of two risk prediction models. A systematic search of the literature was conducted to identify relevant risk prediction models for their evaluation. RESULTS The "GIVE SSI risk prediction model" ("GIVE SSI model") and the "GIVE deep/organ space SSI risk prediction model" ("deep SSI model") had adequate discrimination (C statistic 0.735 and 0.720, respectively). Three other groin incision SSI risk prediction models were identified; both GIVE risk prediction models significantly outperformed these other risk models in this cohort (C statistic 0.618 - 0.629; p < .050 for inferior discrimination in all cases). CONCLUSION Two models were created and internally validated that performed acceptably in predicting "all" and "deep" groin SSIs, outperforming current existing risk prediction models in this cohort. Future studies should aim to externally validate the GIVE models.
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Affiliation(s)
- Brenig L Gwilym
- South East Wales Vascular Network, Royal Gwent Hospital, Newport, UK.
| | - Graeme K Ambler
- Centre for Surgical Research, University of Bristol, Bristol, UK
| | - Athanasios Saratzis
- NIHR Leicester Biomedical Research Centre, University of Leicester Department of Cardiovascular Sciences, Leicester, UK
| | - David C Bosanquet
- South East Wales Vascular Network, Royal Gwent Hospital, Newport, UK
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- Vascular and Endovascular Research Network (VERN), UK
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Konijn LC, Takx RA, de Jong PA, Spreen MI, Veger HT, Mali WP, van Overhagen H. Arterial calcification and long-term outcome in chronic limb-threatening ischemia patients. Eur J Radiol 2020; 132:109305. [DOI: 10.1016/j.ejrad.2020.109305] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 09/05/2020] [Accepted: 09/21/2020] [Indexed: 12/23/2022]
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Purba AKR, Luz CF, Wulandari RR, van der Gun I, Dik JW, Friedrich AW, Postma MJ. The Impacts of Deep Surgical Site Infections on Readmissions, Length of Stay, and Costs: A Matched Case-Control Study Conducted in an Academic Hospital in the Netherlands. Infect Drug Resist 2020; 13:3365-3374. [PMID: 33061483 PMCID: PMC7533242 DOI: 10.2147/idr.s264068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/04/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the impacts of deep surgical site infections (dSSIs) regarding hospital readmissions, prolonged length of stay (LoS), and estimated costs. PATIENTS AND METHODS We designed and applied a matched case-control observational study using the electronic health records at the University Medical Center Groningen in the Netherlands. We compared patients with dSSI and non-SSI, matched on the basis of having similar procedures. A prevailing topology of surgeries categorized as clean, clean-contaminated, contaminated, and dirty was applied. RESULTS Out of a total of 12,285 patients, 393 dSSI were identified as cases, and 2864 patients without SSIs were selected as controls. A total of 343 dSSI patients (87%) and 2307 (81%) controls required hospital readmissions. The median LoS was 7 days (P25-P75: 2.5-14.5) for dSSI patients and 5 days (P25-P75: 1-9) for controls (p-value: <0.001). The estimated mean cost per hospital admission was €9,016 (SE±343) for dSSI patients and €5,409 (SE±120) for controls (p<0.001). Independent variables associated with dSSI were patient's age ≥65 years (OR: 1.334; 95% CI: 1.036-1.720), the use of prophylactic antibiotics (OR: 0.424; 95% CI: 0.344-0.537), and neoplasms (OR: 2.050; 95% CI: 1.473-2.854). CONCLUSION dSSI is associated with increased costs, prolonged LoS, and increased readmission rates. Elevated risks were seen for elderly patients and those with neoplasms. Additionally, a protective effect of prophylactic antibiotics was found.
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Affiliation(s)
- Abdul Khairul Rizki Purba
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,University of Groningen, University Medical Center Groningen, Department of Medical Microbiology, Groningen, the Netherlands.,Department of Pharmacology and Therapy, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia.,Unit of Pharmacotherapy, -Epidemiology and -Economics (PTE2), Department of Pharmacy, Faculty of Science and Engineering, University of Groningen, Groningen, the Netherlands
| | - Christian F Luz
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology, Groningen, the Netherlands
| | | | - Ieneke van der Gun
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology, Groningen, the Netherlands
| | - Jan-Willem Dik
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology, Groningen, the Netherlands
| | - Alex W Friedrich
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology, Groningen, the Netherlands
| | - Maarten J Postma
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Department of Pharmacology and Therapy, Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia.,Unit of Pharmacotherapy, -Epidemiology and -Economics (PTE2), Department of Pharmacy, Faculty of Science and Engineering, University of Groningen, Groningen, the Netherlands.,Department of Economics, Econometrics and Finance, Faculty of Economics & Business, University of Groningen, Groningen, the Netherlands
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15
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Tong Y, Febrer G, Mao J, Wawryko P, Mao Y, Le-Bel G, How D, Philippe E, Zhou T, Zhang Z, Wang L, Germain L, Guidoin R. Limb salvage after aneurysmal degeneration of a cryopreserved vein allograft: Searching the autologous veins of the arm is worth the effort. Morphologie 2020; 104:202-213. [PMID: 32518049 DOI: 10.1016/j.morpho.2020.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 04/29/2020] [Accepted: 05/14/2020] [Indexed: 06/11/2023]
Abstract
CLINICAL DATA We hereby report a case of limb salvage involving a 64-year-old man who was hospitalized with ischemic foot ulcers for two months. Endarterectomy with patching and stenting of the left iliofemoral artery failed. A composite bypass of two segments of the endarterectomized superficial femoral artery and a cryopreserved saphenous vein graft was implanted one week later. On day 4 postoperatively, an infection (Staphylococcus epidermidis and Pseudomonas aeruginosa) was treated empirically with antibiotics. Four months later, the femoro-tibial bypass thrombosed and the patency was restored by thrombolysis. The aneurysmal cryopreserved vein was excised. Iterative complications followed and final success was attained after implantation of autologous cephalic and basilic veins. Four years later, this femoro-tibial is still patent. PATHOLOGICAL ANALYSES After a gross observation, the explant was dissected and the most significant sections were processed for histology, followed by analyses in scanning electron microscopy, light microscopy and transmission electron microscopy. RESULTS The explanted specimen showed a smooth flow surface proximally but a severe distortion distally, with an accumulation of poorly organized mural thrombi. The wall of the arterialized vein was accompanied with an important inflammatory reaction. The degradation of the collagen structure was evidenced in TEM. The fibrils of collagen were still individualized but were fragmented and did not display parallelly. The regular banding was preserved. The presence of Pseudomonas aeruginosa was shown inside the wall of the homologous vein. COMMENTS In case of sepsis, the most aggressive antibiotic treatments cannot fully eliminate the bacteremic colonizations within the wall of an alternative conduit. The cephalic and basilic autologous veins are proved to be preferable in absence of the autologous saphenous vein. The amputation was prevented and four years later the bypass is still patent. This is an outstanding result based upon the comorbidities of the patient. The most aggressive harvesting shall be recommended. This patient represented a considerable challenge and the clinical result is highly gratifying: the search for the autologous cephalic and basilic veins proved to be worth the effort.
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Affiliation(s)
- Yiwei Tong
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada; Comprehensive Breast Health Center, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, 200025 Shanghai, China
| | - Guillaume Febrer
- Service de chirurgie vasculaire, Département de chirurgie, Hôpital du Sacré-Cœur, Université de Montréal, Montréal (QC), Canada
| | - Jifu Mao
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada; Key Laboratory of Textile Science & Technology, Ministry of Education and College of Textiles, Donghua University, Shanghai, China
| | - Paul Wawryko
- Department of Pathology, University of Manitoba, Winnipeg (MB), Canada
| | - Ying Mao
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada; Key Laboratory of Textile Science & Technology, Ministry of Education and College of Textiles, Donghua University, Shanghai, China
| | - Gaëtan Le-Bel
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada
| | - Daniel How
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Eric Philippe
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada
| | - Tianyi Zhou
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada
| | - Ze Zhang
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada
| | - Lu Wang
- Key Laboratory of Textile Science & Technology, Ministry of Education and College of Textiles, Donghua University, Shanghai, China
| | - Lucie Germain
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada
| | - Robert Guidoin
- Département de chirurgie, Faculté de médecine, Université Laval ; Axe médecine régénératrice, Centre de recherche du CHU de Québec - Université Laval, Québec (QC), Canada.
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16
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Latz CA, Wang LJ, Boitano L, DeCarlo C, Pendleton AA, Sumpio B, Schwartz S, Dua A. Unplanned readmissions after endovascular intervention or surgical bypass for critical limb ischemia. J Vasc Surg 2020; 73:942-949.e1. [PMID: 32861862 DOI: 10.1016/j.jvs.2020.07.096] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 07/23/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE After surgery or other interventions, unplanned readmissions are associated with poor outcomes and drain health care resources. Patients with critical limb ischemia (CLI) are at particularly high risk of readmission, and readmissions result in increased health care costs. The primary aims of the study were to discover and compare the 30-day readmission rates of patients who underwent lower extremity surgical bypass (LEB) and endovascular infrainguinal endovascular intervention (IEI) for CLI and to evaluate the relationship between unplanned readmissions likely related to the primary procedure for IEI compared with LEB. METHODS The Targeted Vascular Module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify all infrainguinal LEB or IEI for CLI from 2015 to 2018. Those who were not eligible for the primary outcome of interest were excluded. The primary 30-day outcome was unplanned readmission. Univariate analyses for primary and secondary outcomes were performed using Fisher's exact and Wilcoxon rank-sum testing. Multivariate analysis was performed using inverse probability weighting and independent risk factors for readmission were identified with logistic regression. RESULTS There were 12,873 patients who met inclusion criteria. In the LEB cohort, there were 7270 (56.5%) patients, and in the IEI cohort, there were 5603 (43.5%) patients. Thirty percent (n = 1696) of the IEI cohort underwent a tibial intervention, and 49% (n = 3547) underwent a distal bypass. The IEI cohort was more likely to be high physiologic risk (P < .001) and to present with tissue loss (P < .001), whereas the LEB cohort was more likely to have high anatomic risk features (P < .001) and be performed under emergent conditions (P < .001). After multivariable analysis, LEB was found to be independently predictive for both unplanned readmissions due to any cause (adjusted odds ratio, 1.35; 95% confidence interval, 1.22-1.51; P < .001) and procedure-related unplanned interventions (adjusted odds ratio, 1.85; 95% confidence interval, 1.63-2.11; P < .001). Independent predictors of readmission were LEB, preoperative sepsis, severe chronic kidney disease, dependent functional status, insulin-dependent diabetes mellitus, high-risk physiologic features, African American race, preoperative steroid use, history of severe chronic obstructive pulmonary disease, and preoperative tissue loss. CONCLUSIONS LEB is independently associated with unplanned readmission from all causes and from procedure-related causes after adjusting for the measured confounders. More research is required to determine the economic burden of these readmissions.
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Affiliation(s)
- Christopher A Latz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Linda J Wang
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Laura Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Anna A Pendleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Brandon Sumpio
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Samuel Schwartz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, Mass
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17
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Smith EJT, Ramirez JL, Wu B, Zarkowsky DS, Gasper WJ, Finlayson E, Conte MS, Iannuzzi JC. Living in a Food Desert is Associated with 30-day Readmission after Revascularization for Chronic Limb-Threatening Ischemia. Ann Vasc Surg 2020; 70:36-42. [PMID: 32628994 DOI: 10.1016/j.avsg.2020.06.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Living in a food desert has been associated with increased cardiovascular risk; however, its impact on vascular surgery outcomes is unknown. This study hypothesized that living in a food desert would be associated with increased postoperative complications in patients undergoing revascularization for chronic limb-threatening ischemia (CLTI). METHODS This was a single-center retrospective analysis of open and endovascular infrainguinal revascularization for CLTI between April 2013 and December 2015. A food desert was defined using the US Department of Agriculture's Food Access Research Atlas. Bivariate analyses were performed appropriate to the data. Binary logistic regression was performed assessing the association of food desert status with 30-day postoperative complications. RESULTS In total, 152 cases were included, of which 17% (n = 26) resided in food deserts. Patients in the food desert cohort were less likely to be low income (27% vs. 54%, P = 0.01). Living in a food desert was associated with increased 30-day readmission [(39% vs. 20%, P = 0.04), unadjusted OR: 2.5 (CI: 1.0-6.2)]. FD cases also had a higher proportion of wound complications [12 (46%) vs. 28 (22%), P = 0.01)]. The overall wound complication rate was 27% with the majority being due to infections (63%). On multivariable analysis, food desert status remained associated with increased odds of 30-day readmission (OR: 2.7, CI: 1.2-8.4, P = 0.047). Reasons for readmission in the food desert group were all due to wound complications (100% vs. 72%, P = 0.08). CONCLUSIONS Living in a food desert was associated with nearly three times the odds of 30-day readmission after lower extremity revascularization for CLTI. This increase in readmission may be explained through increased wound complications. These findings support considering access to healthy food as a potential modifiable risk factor for adverse outcomes, particularly in CLTI revascularization.
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Affiliation(s)
- Eric J T Smith
- Department of Surgery, University of California, San Francisco, CA
| | - Joel L Ramirez
- Department of Surgery, University of California, San Francisco, CA
| | - Bian Wu
- Department of Surgery, University of California, San Francisco, CA
| | | | - Warren J Gasper
- Department of Surgery, University of California, San Francisco, CA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, CA
| | - Michael S Conte
- Department of Surgery, University of California, San Francisco, CA
| | - James C Iannuzzi
- Department of Surgery, University of California, San Francisco, CA.
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18
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Teja B, Raub D, Friedrich S, Rostin P, Patrocínio MD, Schneider JC, Shen C, Brat GA, Houle TT, Yeh RW, Eikermann M. Incidence, Prediction, and Causes of Unplanned 30-Day Hospital Admission After Ambulatory Procedures. Anesth Analg 2020; 131:497-507. [DOI: 10.1213/ane.0000000000004852] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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19
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A systematic review and meta-analysis of risk factors for and incidence of 30-day readmission after revascularization for peripheral artery disease. J Vasc Surg 2020; 70:996-1006.e7. [PMID: 31445653 DOI: 10.1016/j.jvs.2019.01.079] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 01/19/2019] [Indexed: 12/13/2022]
Abstract
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.
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20
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Risk prediction of 30-day mortality after lower extremity major amputation. J Vasc Surg 2019; 70:1868-1876. [DOI: 10.1016/j.jvs.2019.03.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 03/04/2019] [Indexed: 12/21/2022]
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21
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Czobor NR, Lehot JJ, Holndonner-Kirst E, Tully PJ, Gal J, Szekely A. Frailty In Patients Undergoing Vascular Surgery: A Narrative Review Of Current Evidence. Ther Clin Risk Manag 2019; 15:1217-1232. [PMID: 31802876 PMCID: PMC6802734 DOI: 10.2147/tcrm.s217717] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/01/2019] [Indexed: 12/13/2022] Open
Abstract
Frailty is presumably associated with an elevated risk of postoperative mortality and adverse outcome in vascular surgery patients. The aim of our review was to identify possible methods for risk assessment and prehabilitation in order to improve recovery and postoperative outcome. The literature search was performed via PubMed, Embase, OvidSP, and the Cochrane Library. We collected papers published in peer-reviewed journals between 2001 and 2018. The selection criterion was the relationship between vascular surgery, frailty and postoperative outcome or mortality. A total number of 52 publications were included. Frailty increases the risk of non-home discharge independently of presence or absence of postoperative complications and it is related to a higher 30-day mortality and major morbidity. The modified Frailty Index showed significant association with elevated risk for post-interventional stroke, myocardial infarction, prolonged in-hospital stays and higher readmission rates. When adjusted for comorbidity and surgery type, frailty seems to impact medium-term survival (within 2 years). Preoperative physical exercising, avoidance of hypalbuminemia, psychological and cognitive training, maintenance of muscle strength, adequate perioperative nutrition, and management of smoking behaviours are leading to a reduced length of stay and a decreased incidence of readmission rate, thus improving the effectiveness of early rehabilitation. Pre-frailty is a dynamically changing state of the patient, capable of deteriorating or improving over time. With goal-directed preoperative interventions, the decline can be prevented.
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Affiliation(s)
- Nikoletta Rahel Czobor
- Medical Centre of Hungarian Defense Forces, Department of Anesthesiology and Intensive Care, Budapest, Hungary.,Semmelweis University, School of Doctoral Studies, Budapest, Hungary
| | - Jean-Jacques Lehot
- Claude-Bernard University, Health Services and Performance Research Lab (EA 7425 HESPER), Lyon, France.,Hôpital Neurologique Pierre Wertheimer, Department of Neuroanesthesia and Intensive Care, Hospices Civils de Lyon, Lyon, France
| | - Eniko Holndonner-Kirst
- Medical Centre of Hungarian Defense Forces, Department of Anesthesiology and Intensive Care, Budapest, Hungary
| | - Phillip J Tully
- University of Adelaide, Freemasons Foundation Centre for Men's Health, Adelaide, Australia
| | - Janos Gal
- Semmelweis University, Department of Anesthesiology and Intensive Care, Budapest, Hungary
| | - Andrea Szekely
- Semmelweis University, Department of Anesthesiology and Intensive Care, Budapest, Hungary.,Semmelweis University, Heart and Vascular Center of Városmajor, Budapest, Hungary
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22
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Hicks CW, Canner JK, Karagozlu H, Mathioudakis N, Sherman RL, Black JH, Abularrage CJ. Contribution of 30-day readmissions to the increasing costs of care for the diabetic foot. J Vasc Surg 2019; 70:1263-1270. [DOI: 10.1016/j.jvs.2018.12.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 12/04/2018] [Indexed: 12/22/2022]
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23
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Ochoa Chaar CI, Gholitabar N, Goodney P, Dardik A, Abougergi MS. One-Year Readmission after Open and Endovascular Revascularization for Critical Limb Ischemia. Ann Vasc Surg 2019; 61:25-32.e2. [PMID: 31376536 DOI: 10.1016/j.avsg.2019.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/07/2019] [Accepted: 07/11/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Lower extremity revascularization for critical limb ischemia (CLI) remains a subject of clinical equipoise. Readmissions and repeat lower extremity revascularization increase the cost of care and decrease the value of initial treatment. This study examines readmissions and repeat inpatient revascularization and major amputation up to 1 year after initial open and endovascular lower extremity revascularization. METHODS The 2014 Nationwide Readmissions Database (NRD) was reviewed. The NRD provides all subsequent readmissions of any hospitalization for the calendar year. A cohort of patients undergoing lower extremity revascularization in January only was selected based on International Classification of Diseases, Ninth Revision, Clinical Modification codes. Patients were divided into open and endovascular groups. Readmissions for repeat lower extremity revascularization (RFR) were identified based on procedural codes. Open and endovascular lower extremity revascularization were compared in terms of patient characteristics as well as readmissions, RFR, major amputation, and inpatient mortality at 1 year. Risk-adjusted outcomes accounting for differences in age, gender, income, and Charlson Comorbidity Index (CCI) were derived using regression analysis. RESULTS There were 1,668 open and 1,410 endovascular lower extremity revascularizations. Patients in the endovascular group were significantly older (P < 0.01), more likely to be women (P < 0.01), and had higher CCI (P < 0.01). Patients undergoing endovascular lower extremity revascularization had significantly higher readmission rate (49 vs. 33.7, P < 0.01) and higher mortality (10.4 vs. 5.3, P < 0.01). Readmitted patients after endovascular lower extremity revascularization had significantly higher mean number of repeat readmissions compared to open lower extremity revascularization (2.49 ± 0.12 vs. 2.13 ± 0.08, P = 0.01). There was no difference in RFR (P = 0.82) or major amputation (P = 0.19). Open revascularization was independently associated with decreased readmission (odds ratio = 0.55 [0.43-0.71]) compared to endovascular. However, there was no significant association between the type of lower extremity revascularization and major amputation or RFR. CONCLUSIONS Endovascular lower extremity revascularization for CLI is performed on older and sicker patients and seems to be associated with increased readmission at 1 year compared to open lower extremity revascularization. Regardless of the initial modality of treatment, patients are likely to undergo at least 1 revascularization during readmissions.
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Affiliation(s)
- Cassius Iyad Ochoa Chaar
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT.
| | - Navid Gholitabar
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Philip Goodney
- Section of Vascular Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Alan Dardik
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT
| | - Marwan S Abougergi
- Catalyst Medical Consulting, Clinical Research Consulting Firm, Columbia, SC
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24
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Bluemn EG, Flahive JM, Farber A, Bertges DJ, Goodney PP, Eldrup-Jorgensen J, Schanzer A, Simons JP. Analysis of Thirty-Day Readmission after Infrainguinal Bypass. Ann Vasc Surg 2019; 61:34-47. [PMID: 31349054 DOI: 10.1016/j.avsg.2019.04.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 04/02/2019] [Accepted: 04/18/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Vascular Study Group of New England (VSGNE) conducted a pilot study evaluating the feasibility of 30-day data collection in patients undergoing infrainguinal bypass (INFRA) which was subsequently expanded to include a limited number of additional sites within the Vascular Quality Initiative (VQI). The purpose of our study was to use these data to evaluate the incidence of 30-day readmission after infrainguinal bypass. A secondary goal of the study was to perform a critical appraisal of the data elements and definitions in the 30-day dataset. METHODS All infrainguinal bypass procedures performed during the pilot study period (7/2008 and 4/2016) were identified and merged with a dataset containing the 30-day data. Incidence and types of readmission were assessed. The primary endpoint was 30-day readmission, defined as any hospital readmission within 30 days of index operation; unplanned 30-day readmission was the secondary endpoint. Covariates tested for association with the primary and secondary endpoints included patient demographics, comorbidities, procedural, and postoperative characteristics. Variables significant on univariate screen (P < 0.2) were evaluated with logistic regression to identify independent determinants. RESULTS Of 9,847 infrainguinal bypass patients, 5,842 (59%) patients were identified with 30-day data, and 907 (16%) were readmitted within 30 days. Of readmissions, 675 (85%) were unplanned. Potentially modifiable independent determinants of any 30-day readmission included 30-day surgical site infection (SSI) (odds ratio [OR]: 10, 95% confidence interval [CI]: 8.2-12, P < 0.0001), postoperative acute kidney injury (OR: 1.7, 95% CI: 1.2-2.5, P = 0.002), and discharge anticoagulation (OR: 1.2, 95% CI: 1.04-1.5; P = 0.02). Predictors of unplanned 30-day readmission were very similar but identified in-hospital major amputation as an additional independent predictor (OR: 2.8, 95% CI: 1.6-4.9, P = 0.0002). CONCLUSIONS This study demonstrates the interest in, and value of, 30-day data collection in VSGNE/VQI and documents the frequency of readmission after infrainguinal bypass. Readmission within 30 days is strongly associated with SSI, stressing the importance of efforts to decrease this complication. Given that many other predictors are unmodifiable, 30-day readmission is only appropriate as a quality metric if it is risk adjusted using large, real-world datasets such as VQI. Lessons learned from this analysis can be used to select optimal 30-day data elements.
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Affiliation(s)
- Eric G Bluemn
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Julie M Flahive
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Alik Farber
- Divison of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA
| | - Daniel J Bertges
- Division of Vascular Surgery, University of Vermont Medical Center, Burlington, VT
| | - Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | | | - Andres Schanzer
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA
| | - Jessica P Simons
- Division of Vascular and Endovascular Surgery, University of Massachusetts Medical School, Worcester, MA.
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Trends in mortality, readmissions, and complications after endovascular and open infrainguinal revascularization. Surgery 2019; 165:1222-1227. [DOI: 10.1016/j.surg.2019.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/12/2019] [Accepted: 03/14/2019] [Indexed: 11/17/2022]
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Effect of an Evidence-based Inpatient Tobacco Dependence Treatment Service on 1-Year Postdischarge Health Care Costs. Med Care 2019; 56:883-889. [PMID: 30130271 PMCID: PMC6136961 DOI: 10.1097/mlr.0000000000000979] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: In 2014, the Medical University of South Carolina (MUSC) implemented a Tobacco Dependence Treatment Service (TDTS) consistent with the Joint Commission (JC) standards recommending that hospitals screen patients for smoking, provide cessation support, and follow-up contact for relapse prevention within 1 month of discharge. We previously demonstrated that patients exposed to the MUSC TDTS were approximately half as likely to be smoking one month after discharge and 23% less likely to have a 30-day hospital readmission. This paper examines whether exposure to the TDTS influenced downstream health care charges 12 months after patients were discharged from the hospital. Methods: Data from MUSC’s electronic health records, the TDTS, and statewide health care utilization datasets (eg, hospitalization, emergency department, and ambulatory surgery visits) were linked to assess how exposure to the MUSC TDTS impacted health care charges. Total health care charges were compared for patients with and without TDTS exposure. To reduce potential TDTS exposure selection bias, propensity score weighting was used to balance baseline characteristics between groups. The cost of delivering the MUSC TDTS intervention was calculated, along with cost per smoker. Results: The overall adjusted mean health care charges for smokers exposed to the TDTS were $7299 lower than for those who did not receive TDTS services (P=0.047). The TDTS cost per smoker was modest by comparison at $34.21 per smoker eligible for the service. Discussion: Results suggest that implementation of a TDTS consistent with JC standards for smoking cessation can be affordably implemented and yield substantial health care savings that would benefit patients, hospitals, and insurers.
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Levin SR, Arinze N, Siracuse JJ. Lower extremity critical limb ischemia: A review of clinical features and management. Trends Cardiovasc Med 2019; 30:125-130. [PMID: 31005554 DOI: 10.1016/j.tcm.2019.04.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 04/09/2019] [Indexed: 12/19/2022]
Abstract
Lower extremity critical limb ischemia (CLI) represents symptoms related to end-stage atherosclerotic peripheral arterial disease manifested by rest pain and tissue loss. It is associated with increased risk of limb amputation and cardiovascular-related mortality. The prevalence and cost of CLI are expected to increase with both the aging of the U.S. population and continued influence of smoking and diabetes. Treatments encompass measures to reduce cardiovascular risk and preserve limb viability. Despite increasing popularity of endovascular modalities, revascularization with either surgical bypass or endovascular intervention is the cornerstone of therapy. Adequate Level I data to guide decisions regarding optimal strategies to treat CLI, particularly in patients who are candidates for both open and percutaneous approaches, are currently lacking. Ongoing randomized controlled trials aim to resolve the clinical equipoise.
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Affiliation(s)
- Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, 88 E. Newton Street C520, Boston, MA 02118, United States
| | - Nkiruka Arinze
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, 88 E. Newton Street C520, Boston, MA 02118, United States
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston Medical Center, 88 E. Newton Street C520, Boston, MA 02118, United States.
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Bath J, Smith JB, Kruse RL, Vogel TR. Cohort study of risk factors for 30-day readmission after abdominal aortic aneurysm repair. VASA 2018; 48:251-261. [PMID: 30539688 DOI: 10.1024/0301-1526/a000767] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Jonathan Bath
- 1 Division of Vascular Surgery, University of Missouri Hospitals & Clinics, Columbia, MO, USA
| | - Jamie B Smith
- 2 Department of Family & Community Medicine, University of Missouri, School of Medicine, Columbia, MO, USA
| | - Robin L Kruse
- 2 Department of Family & Community Medicine, University of Missouri, School of Medicine, Columbia, MO, USA
| | - Todd R Vogel
- 1 Division of Vascular Surgery, University of Missouri Hospitals & Clinics, Columbia, MO, USA
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Bath J, Dombrovskiy VY, Vogel TR. Impact of Patient Safety Indicators on readmission after abdominal aortic surgery. JOURNAL OF VASCULAR NURSING 2018; 36:189-195. [PMID: 30458941 DOI: 10.1016/j.jvn.2018.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 08/21/2018] [Accepted: 08/23/2018] [Indexed: 10/28/2022]
Abstract
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.
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Affiliation(s)
- Jonathan Bath
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, MO, USA
| | - Viktor Y Dombrovskiy
- Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Todd R Vogel
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, MO, USA.
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Syed MH, Hussain MA, Khoshhal Z, Salata K, Altuwaijri B, Hughes B, Alsaif N, de Mestral C, Verma S, Al-Omran M. Thirty-day hospital readmission and emergency department visits after vascular surgery: a Canadian prospective cohort study. Can J Surg 2018; 61:257-263. [PMID: 30067184 PMCID: PMC6066379 DOI: 10.1503/cjs.012417] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2017] [Indexed: 11/01/2022] Open
Abstract
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.
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Affiliation(s)
- Muzammil H Syed
- From the Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ont. (Syed, Hussain, Khoshhal, Salata, Altuwaijri, Hughes, Alsaif, de Mestral, Al-Omran); the Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ont. (Verma); Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont. (de Mestral, Verma, Al-Omran); the Faculty of Science, McMaster University, Hamilton, Ont. (Syed); the Department of Surgery, University of Toronto, Toronto, Ont. (Hussain, Khoshhal, Salata, de Mestral, Verma, Al-Omran); the King Saud University-Li Ka Shing Knowledge Institute Collaborative Research Program, St. Michael's Hospital, Toronto, Ont. (Verma, Al-Omran); the Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Khoshhal); and the Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (Al-Omran)
| | - Mohamad A Hussain
- From the Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ont. (Syed, Hussain, Khoshhal, Salata, Altuwaijri, Hughes, Alsaif, de Mestral, Al-Omran); the Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ont. (Verma); Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont. (de Mestral, Verma, Al-Omran); the Faculty of Science, McMaster University, Hamilton, Ont. (Syed); the Department of Surgery, University of Toronto, Toronto, Ont. (Hussain, Khoshhal, Salata, de Mestral, Verma, Al-Omran); the King Saud University-Li Ka Shing Knowledge Institute Collaborative Research Program, St. Michael's Hospital, Toronto, Ont. (Verma, Al-Omran); the Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Khoshhal); and the Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (Al-Omran)
| | - Zeyad Khoshhal
- From the Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ont. (Syed, Hussain, Khoshhal, Salata, Altuwaijri, Hughes, Alsaif, de Mestral, Al-Omran); the Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ont. (Verma); Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont. (de Mestral, Verma, Al-Omran); the Faculty of Science, McMaster University, Hamilton, Ont. (Syed); the Department of Surgery, University of Toronto, Toronto, Ont. (Hussain, Khoshhal, Salata, de Mestral, Verma, Al-Omran); the King Saud University-Li Ka Shing Knowledge Institute Collaborative Research Program, St. Michael's Hospital, Toronto, Ont. (Verma, Al-Omran); the Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Khoshhal); and the Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (Al-Omran)
| | - Konrad Salata
- From the Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ont. (Syed, Hussain, Khoshhal, Salata, Altuwaijri, Hughes, Alsaif, de Mestral, Al-Omran); the Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ont. (Verma); Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont. (de Mestral, Verma, Al-Omran); the Faculty of Science, McMaster University, Hamilton, Ont. (Syed); the Department of Surgery, University of Toronto, Toronto, Ont. (Hussain, Khoshhal, Salata, de Mestral, Verma, Al-Omran); the King Saud University-Li Ka Shing Knowledge Institute Collaborative Research Program, St. Michael's Hospital, Toronto, Ont. (Verma, Al-Omran); the Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Khoshhal); and the Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (Al-Omran)
| | - Beidaa Altuwaijri
- From the Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ont. (Syed, Hussain, Khoshhal, Salata, Altuwaijri, Hughes, Alsaif, de Mestral, Al-Omran); the Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ont. (Verma); Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont. (de Mestral, Verma, Al-Omran); the Faculty of Science, McMaster University, Hamilton, Ont. (Syed); the Department of Surgery, University of Toronto, Toronto, Ont. (Hussain, Khoshhal, Salata, de Mestral, Verma, Al-Omran); the King Saud University-Li Ka Shing Knowledge Institute Collaborative Research Program, St. Michael's Hospital, Toronto, Ont. (Verma, Al-Omran); the Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Khoshhal); and the Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (Al-Omran)
| | - Bertha Hughes
- From the Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ont. (Syed, Hussain, Khoshhal, Salata, Altuwaijri, Hughes, Alsaif, de Mestral, Al-Omran); the Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ont. (Verma); Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont. (de Mestral, Verma, Al-Omran); the Faculty of Science, McMaster University, Hamilton, Ont. (Syed); the Department of Surgery, University of Toronto, Toronto, Ont. (Hussain, Khoshhal, Salata, de Mestral, Verma, Al-Omran); the King Saud University-Li Ka Shing Knowledge Institute Collaborative Research Program, St. Michael's Hospital, Toronto, Ont. (Verma, Al-Omran); the Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Khoshhal); and the Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (Al-Omran)
| | - Norah Alsaif
- From the Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ont. (Syed, Hussain, Khoshhal, Salata, Altuwaijri, Hughes, Alsaif, de Mestral, Al-Omran); the Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ont. (Verma); Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont. (de Mestral, Verma, Al-Omran); the Faculty of Science, McMaster University, Hamilton, Ont. (Syed); the Department of Surgery, University of Toronto, Toronto, Ont. (Hussain, Khoshhal, Salata, de Mestral, Verma, Al-Omran); the King Saud University-Li Ka Shing Knowledge Institute Collaborative Research Program, St. Michael's Hospital, Toronto, Ont. (Verma, Al-Omran); the Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Khoshhal); and the Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (Al-Omran)
| | - Charles de Mestral
- From the Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ont. (Syed, Hussain, Khoshhal, Salata, Altuwaijri, Hughes, Alsaif, de Mestral, Al-Omran); the Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ont. (Verma); Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont. (de Mestral, Verma, Al-Omran); the Faculty of Science, McMaster University, Hamilton, Ont. (Syed); the Department of Surgery, University of Toronto, Toronto, Ont. (Hussain, Khoshhal, Salata, de Mestral, Verma, Al-Omran); the King Saud University-Li Ka Shing Knowledge Institute Collaborative Research Program, St. Michael's Hospital, Toronto, Ont. (Verma, Al-Omran); the Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Khoshhal); and the Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (Al-Omran)
| | - Subodh Verma
- From the Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ont. (Syed, Hussain, Khoshhal, Salata, Altuwaijri, Hughes, Alsaif, de Mestral, Al-Omran); the Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ont. (Verma); Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont. (de Mestral, Verma, Al-Omran); the Faculty of Science, McMaster University, Hamilton, Ont. (Syed); the Department of Surgery, University of Toronto, Toronto, Ont. (Hussain, Khoshhal, Salata, de Mestral, Verma, Al-Omran); the King Saud University-Li Ka Shing Knowledge Institute Collaborative Research Program, St. Michael's Hospital, Toronto, Ont. (Verma, Al-Omran); the Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Khoshhal); and the Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (Al-Omran)
| | - Mohammed Al-Omran
- From the Division of Vascular Surgery, St. Michael's Hospital, Toronto, Ont. (Syed, Hussain, Khoshhal, Salata, Altuwaijri, Hughes, Alsaif, de Mestral, Al-Omran); the Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ont. (Verma); Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont. (de Mestral, Verma, Al-Omran); the Faculty of Science, McMaster University, Hamilton, Ont. (Syed); the Department of Surgery, University of Toronto, Toronto, Ont. (Hussain, Khoshhal, Salata, de Mestral, Verma, Al-Omran); the King Saud University-Li Ka Shing Knowledge Institute Collaborative Research Program, St. Michael's Hospital, Toronto, Ont. (Verma, Al-Omran); the Department of Surgery, Taibah University, Madinah, Kingdom of Saudi Arabia (Khoshhal); and the Department of Surgery, King Saud University, Riyadh, Kingdom of Saudi Arabia (Al-Omran)
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Nejim B, Beaulieu RJ, Alshaikh H, Hamouda M, Canner J, Malas MB. A Unique All-Payer Rate-Setting System Controls the Cost but Not the Racial Disparity in Lower Extremity Revascularization Procedures. Ann Vasc Surg 2018; 52:116-125. [PMID: 29783031 DOI: 10.1016/j.avsg.2018.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 10/11/2017] [Accepted: 03/10/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with peripheral arterial disease often have high comorbidity burden that may complicate post-interventional course and drive increased health-care expenditures. Racial disparity had been observed in lower extremity revascularization (LER) patterns and outcomes. In 2014, Maryland adopted an all-payer rate-setting system to limit the rising hospitalization costs. This resulted in an aggregate payment system in which hospital compensation takes place as an overall per capita expenditure for hospital services. We sought to examine racial differences and other patient-level factors that might lead to discrepancies in LER hospital costs in the State of Maryland. METHODS We used International Classification of Diseases, Ninth Revision codes to identify patients who underwent infrainguinal open bypass (open) and endovascular repair (endo) in the Maryland Health Services Cost Review Commission database (2009-2015). Multivariable generalized linear model regression analysis was conducted to report cost differences adjusting for patient-specific demographics, comorbidities, and insurance status. Logistic regression analysis was used to assess quality metrics: intensive care unit (ICU) admission, 30-day readmission, protracted length of stay (pLOS) (endo: pLOS >9, open: pLOS > 10 days) and in-hospital mortality. RESULTS Among patients undergoing open, costs were higher for nonwhite patients (African-American [AA]: $6,092 [4,682-7,501], other: $3,324 [437-6,212]; both P ≤ 0.024), diabetics ($2,058 [837-3,279]; P < 0.001), and patients with Medicaid had an increased cost over Medicare patients by $4,325 (1,441-7,209). Critical limb ischemia (CLI) was associated with $5,254 (4,014-6,495) risk-adjusted cost increment. In addition, AA patients demonstrated higher risk-adjusted odds of ICU admission (adjusted odds ratio [aOR] [95% confidence interval {CI}]:1.65 [1.46-1.86]; P < 0.001) and pLOS (aOR [95% CI]: 1.56 [1.37-1.79]; P < 0.001) than their white counterparts. For patients undergoing endo, costs were higher for nonwhite patients (AA: $2,642 [1,574-3,711], other: $4,124 [2,091-6,157]; both P < 0.001). Patients with CLI and heart failure had increased costs after endo. AA patients were more likely to be readmitted or stayed longer after endo (1.16 [1.03-1.29], 1.34 [1.21-1.49]; both P < 0.010, respectively). The overall cost trend was rapidly increasing before all-payer rate policy implementation but it dramatically plateaued after 2014. CONCLUSIONS This study showed that the all-payer rate-setting system has curbed the LER rising costs, but these costs remained disproportionally higher for disadvantaged populations such as AA and Medicaid communities. This underpins the existing racial disparity in LER. AA patients had higher LER costs, most likely driven by extended hospitalization and ICU admission. Efforts could be directed to evaluate the contributing socioeconomic factors, invest in primary prevention of comorbid conditions that had shown to be associated with prohibitive costs, and identify mechanisms to overcome the existing racial disparity in LER within the promising cost-saving payment system at the State of Maryland.
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Affiliation(s)
- Besma Nejim
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Robert J Beaulieu
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Husain Alshaikh
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Mohammed Hamouda
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Joseph Canner
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD
| | - Mahmoud B Malas
- The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD.
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Cartmell KB, Dooley M, Mueller M, Nahhas GJ, Dismuke CE, Warren GW, Talbot V, Cummings KM. Effect of an Evidence-based Inpatient Tobacco Dependence Treatment Service on 30-, 90-, and 180-Day Hospital Readmission Rates. Med Care 2018; 56:358-363. [PMID: 29401186 PMCID: PMC5851827 DOI: 10.1097/mlr.0000000000000884] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Smoking is a risk factor for hospitalization and interferes with patient care due to its effects on pulmonary function, wound healing, and interference with treatments and medications. Although benefits of stopping smoking are well-established, few hospitals provide tobacco dependence treatment services (TDTS) due to cost, lack of mandatory tobacco cessation standards and lack of evidence demonstrating clinical and financial benefits to hospitals and insurers for providing services. METHODS This study explored the effect of an inpatient TDTS on 30-, 90-, and 180-day hospital readmissions. To carry out this work, 3 secondary datasets were linked, which included clinical electronic health record data, tobacco cessation program data, and statewide health care utilization data. Odds ratios (ORs) were calculated using inverse propensity score-weighted logistic regression models, with program exposure as the primary independent variable and 30 (90 and 180)-day readmission rates as the dependent variable, and adjustment for putative covariates. RESULTS Odds of readmission were compared for patients who did and did not receive TDTS. At 30 days postdischarge, smokers exposed to the TDTS had a lower odds of readmission (OR=0.77, P=0.031). At 90 and 180 days, odds of readmission remained lower in the TDTS group (ORs=0.87 and 0.86, respectively), but were not statistically significant. DISCUSSION Findings from the current study, which are supported by prior studies, provide evidence that delivery of TDTS is a strategy that may help to reduce hospital readmissions.
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Affiliation(s)
- Kathleen B. Cartmell
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, USA
| | - Mary Dooley
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Martina Mueller
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Georges J. Nahhas
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Clara E. Dismuke
- Center for Health Disparities, Medical University of South Carolina, Charleston, SC, USA
| | - Graham W. Warren
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC, USA
| | | | - K. Michael Cummings
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, USA
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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Unplanned 30-day readmission in patients with diabetic foot wounds treated in a multidisciplinary setting. J Vasc Surg 2018; 67:876-886. [DOI: 10.1016/j.jvs.2017.07.131] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 07/23/2017] [Indexed: 11/20/2022]
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Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected. J Vasc Surg 2017; 66:1786-1791. [PMID: 28965800 DOI: 10.1016/j.jvs.2017.07.120] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 07/16/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Readmission rates are expected to have an increasing effect on both the hospital bottom line and physician reimbursements. Safety net hospitals may be most vulnerable. We examined readmissions at 30 days, 90 days, and 1 year in a large safety net hospital to determine the magnitude and effect of short- and long-term readmission rates after lower extremity infrainguinal bypass in this setting. METHODS All nonemergent extremity infrainguinal bypass performed at a large safety net hospital between 2008 and 2016 were identified. Patient demographic, social, clinical, and procedural details were extracted from the electronic medical record. An analysis of patients readmitted at 30 days, 90 days, and 1 year was completed to determine the details of the readmission. RESULTS A total of 350 patients undergoing extremity infrainguinal bypass were identified. The most frequent indication was tissue loss (57%), followed by claudication (25.6%), and rest pain (17.4%). Patient insurance carriers included Medicare (61.7%), Medicaid (25.4%), and private (13%). The distal target was the popliteal and tibial artery in 52.6% and 47.4% cases, respectively. The majority of bypasses used autologous vein (73.1%). In-hospital complications included pulmonary complications (4.3%), urinary tract infection (3.1%), acute renal failure (2%), graft occlusion (2%), myocardial infarction (1.7%), bleeding (1.4%), surgical wound complications (1.1%), and stroke (0.9%). The 30-day readmission rate was 30% with the most common reasons for readmission being surgical wound complications, nonsurgical foot/leg wounds, nonextremity infectious causes, cardiac ischemia, and congestive heart failure. The 90-day readmission rate was 49.4% and the most common reasons for readmission from 31 to 90 days were nonsurgical foot/leg wounds, graft complications, surgical wound complications, cardiac ischemia, and contralateral leg morbidity. The readmission rate within 1 year was 72.2%. Readmission causes from 91 days to 1 year included graft complications, contralateral leg morbidity, nonextremity infectious, nonsurgical foot/leg wounds, cardiac ischemia, and congestive heart failure. A tibial bypass target was associated with 30-day (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.06-2.69; P = .029) and 90-day (OR, 1.77; 95% CI, 1.14-2.74, P = .011) readmission. Nonprivate insurance (OR, 2.31; 95% CI, 1.17-4.57, P = .016), and critical limb ischemia (OR, 1.77; 95% CI, 1.14-2.74; P = .035) were associated with 1-year readmission. CONCLUSIONS Short- and long-term readmission rates in a safety net setting are high. The 30-day rates in this study are higher than historically reported. This data sets baseline rates for 90-day and 1-year readmission for future analyses. Although the majority of short-term readmissions are related to the index procedure, long-term readmission rates are more frequently related to systemic comorbidities. Targeted patient interventions aimed at preventing the most common reasons for readmission may improve readmission rates, particularly among patients with nonprivate insurance. However, other risk factors, such as tibial target, may not be modifiable and a higher readmission rate may need to be accepted in this population.
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Masoomi R, Shah Z, Quint C, Hance K, Vamanan K, Prasad A, Hoel A, Dawn B, Gupta K. A nationwide analysis of 30-day readmissions related to critical limb ischemia. Vascular 2017; 26:239-249. [PMID: 28836900 DOI: 10.1177/1708538117727955] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives There is paucity of information regarding critical limb ischemia-related readmission rates in patients admitted with critical limb ischemia. We studied 30-day critical limb ischemia-related readmission rate, its predictors, and clinical outcomes using a nationwide real-world dataset. Methods We did a secondary analysis of the 2013 Nationwide Readmissions Database. We included all patients with a primary diagnosis of extremity rest pain, ulceration, and gangrene secondary to peripheral arterial disease. From this group, all patients readmitted with similar diagnosis within 30 days were recorded. Results Of the total 25,111 index hospitalization for critical limb ischemia, 1270 (5%) were readmitted with a primary diagnosis of critical limb ischemia within 30 days. The readmission rate was highest (9.5%) for the group that did not have any intervention (revascularization or major amputation) and was lowest for surgical revascularization and major amputation groups (2.6% and 1.3%, P value <0.001 for all groups). Severity of critical limb ischemia at index admission was associated with a significantly higher rate of 30-day readmission. Critical limb ischemia-related readmission was associated with a higher rate of major amputation (29.6% vs. 16.2%, P<0.001), a lower rate of any revascularization procedure (46% vs. 62.6%, P<0.001), and a higher likelihood of discharge to a skilled nursing facility (43.2% vs. 32.2%, P<0.001) compared to index hospitalization. Conclusions In patients with primary diagnosis of critical limb ischemia, 30-day critical limb ischemia-related readmission rate was affected by initial management strategy and the severity of critical limb ischemia. Readmission was associated with a significantly higher rate of amputation, increased length of stay, and a more frequent discharge to an alternate care facility than index admission and thus may serve as a useful quality of care metric in critical limb ischemia patients.
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Affiliation(s)
- Reza Masoomi
- 1 Division of Cardiovascular Diseases, The University of Kansas Medical Center, Kansas City, USA
| | - Zubair Shah
- 1 Division of Cardiovascular Diseases, The University of Kansas Medical Center, Kansas City, USA
| | - Clay Quint
- 1 Division of Cardiovascular Diseases, The University of Kansas Medical Center, Kansas City, USA
| | - Kirk Hance
- 1 Division of Cardiovascular Diseases, The University of Kansas Medical Center, Kansas City, USA
| | | | - Anand Prasad
- 3 Department of Cardiovascular, UT Health San Antonio, San Antonio, USA
| | - Andrew Hoel
- 4 Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Buddhadeb Dawn
- 1 Division of Cardiovascular Diseases, The University of Kansas Medical Center, Kansas City, USA
| | - Kamal Gupta
- 1 Division of Cardiovascular Diseases, The University of Kansas Medical Center, Kansas City, USA
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Factors associated with hospital readmission following diverting ileostomy creation. Tech Coloproctol 2017; 21:641-648. [DOI: 10.1007/s10151-017-1667-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 07/08/2017] [Indexed: 12/24/2022]
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Kolte D, Kennedy KF, Shishehbor MH, Abbott JD, Khera S, Soukas P, Mamdani ST, Hyder ON, Drachman DE, Aronow HD. Thirty-Day Readmissions After Endovascular or Surgical Therapy for Critical Limb Ischemia. Circulation 2017; 136:167-176. [DOI: 10.1161/circulationaha.117.027625] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 04/25/2017] [Indexed: 11/16/2022]
Abstract
Background:
Thirty-day readmission rates have gained increasing importance as a key quality metric. A significant number of patients are hospitalized for the management of critical limb ischemia (CLI), but limited data are available on the incidence, predictors, and causes of 30-day readmission after hospitalization for CLI.
Methods:
Hospitalizations for a primary diagnosis of CLI during which patients underwent endovascular or surgical therapy (revascularization and/or amputation) and were discharged alive were identified in the 2013 to 2014 Nationwide Readmissions Databases. Incidence, reasons, and costs of 30-day unplanned readmissions were determined. Hierarchical logistic regression models were used to identify independent predictors of 30-day readmissions.
Results:
We included 60 998 (national estimate, 135 110) index CLI hospitalizations (mean age, 68.9±11.9 years; 40.8% women; 24.6% for rest pain, 37.2% for ulcer, and 38.2% for gangrene). The 30-day readmission rate was 20.4%. Presentation with ulcer or gangrene, age ≥65 years, female sex, large hospital size, teaching hospital status, known coronary artery disease, heart failure, diabetes mellitus, chronic kidney disease, anemia, coagulopathy, obesity, major bleeding, acute myocardial infarction, vascular complications, and sepsis were identified as independent predictors of 30-day readmission. Mode of revascularization was not independently associated with readmissions. Infections (23.5%), persistent or recurrent manifestations of peripheral artery disease (22.2%), cardiac conditions (11.4%), procedural complications (11.0%), and endocrine issues (5.7%) were the most common reasons for readmission. The inflation-adjusted aggregate costs of 30-day readmissions for CLI during the study period were $624 million.
Conclusions:
Approximately 1 in 5 patients hospitalized for CLI and undergoing revascularization is readmitted within 30 days. Risk of readmission is influenced by CLI presentation, patient demographics, comorbidities, and in-hospital complications, but not by the mode of revascularization.
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Affiliation(s)
- Dhaval Kolte
- From The Warren Alpert Medical School of Brown University, Providence, RI (D.K., J.D.A., P.S., S.T.M., O.N.H., H.D.A.); Saint Luke’s Mid America Heart Institute/University of Missouri–Kansas City (K.F.K.); Cleveland Clinic, OH (M.H.S.); New York Medical College, Valhalla (S.K.); and Massachusetts General Hospital, Boston (D.E.D.)
| | - Kevin F. Kennedy
- From The Warren Alpert Medical School of Brown University, Providence, RI (D.K., J.D.A., P.S., S.T.M., O.N.H., H.D.A.); Saint Luke’s Mid America Heart Institute/University of Missouri–Kansas City (K.F.K.); Cleveland Clinic, OH (M.H.S.); New York Medical College, Valhalla (S.K.); and Massachusetts General Hospital, Boston (D.E.D.)
| | - Mehdi H. Shishehbor
- From The Warren Alpert Medical School of Brown University, Providence, RI (D.K., J.D.A., P.S., S.T.M., O.N.H., H.D.A.); Saint Luke’s Mid America Heart Institute/University of Missouri–Kansas City (K.F.K.); Cleveland Clinic, OH (M.H.S.); New York Medical College, Valhalla (S.K.); and Massachusetts General Hospital, Boston (D.E.D.)
| | - J. Dawn Abbott
- From The Warren Alpert Medical School of Brown University, Providence, RI (D.K., J.D.A., P.S., S.T.M., O.N.H., H.D.A.); Saint Luke’s Mid America Heart Institute/University of Missouri–Kansas City (K.F.K.); Cleveland Clinic, OH (M.H.S.); New York Medical College, Valhalla (S.K.); and Massachusetts General Hospital, Boston (D.E.D.)
| | - Sahil Khera
- From The Warren Alpert Medical School of Brown University, Providence, RI (D.K., J.D.A., P.S., S.T.M., O.N.H., H.D.A.); Saint Luke’s Mid America Heart Institute/University of Missouri–Kansas City (K.F.K.); Cleveland Clinic, OH (M.H.S.); New York Medical College, Valhalla (S.K.); and Massachusetts General Hospital, Boston (D.E.D.)
| | - Peter Soukas
- From The Warren Alpert Medical School of Brown University, Providence, RI (D.K., J.D.A., P.S., S.T.M., O.N.H., H.D.A.); Saint Luke’s Mid America Heart Institute/University of Missouri–Kansas City (K.F.K.); Cleveland Clinic, OH (M.H.S.); New York Medical College, Valhalla (S.K.); and Massachusetts General Hospital, Boston (D.E.D.)
| | - Shafiq T. Mamdani
- From The Warren Alpert Medical School of Brown University, Providence, RI (D.K., J.D.A., P.S., S.T.M., O.N.H., H.D.A.); Saint Luke’s Mid America Heart Institute/University of Missouri–Kansas City (K.F.K.); Cleveland Clinic, OH (M.H.S.); New York Medical College, Valhalla (S.K.); and Massachusetts General Hospital, Boston (D.E.D.)
| | - Omar N. Hyder
- From The Warren Alpert Medical School of Brown University, Providence, RI (D.K., J.D.A., P.S., S.T.M., O.N.H., H.D.A.); Saint Luke’s Mid America Heart Institute/University of Missouri–Kansas City (K.F.K.); Cleveland Clinic, OH (M.H.S.); New York Medical College, Valhalla (S.K.); and Massachusetts General Hospital, Boston (D.E.D.)
| | - Douglas E. Drachman
- From The Warren Alpert Medical School of Brown University, Providence, RI (D.K., J.D.A., P.S., S.T.M., O.N.H., H.D.A.); Saint Luke’s Mid America Heart Institute/University of Missouri–Kansas City (K.F.K.); Cleveland Clinic, OH (M.H.S.); New York Medical College, Valhalla (S.K.); and Massachusetts General Hospital, Boston (D.E.D.)
| | - Herbert D. Aronow
- From The Warren Alpert Medical School of Brown University, Providence, RI (D.K., J.D.A., P.S., S.T.M., O.N.H., H.D.A.); Saint Luke’s Mid America Heart Institute/University of Missouri–Kansas City (K.F.K.); Cleveland Clinic, OH (M.H.S.); New York Medical College, Valhalla (S.K.); and Massachusetts General Hospital, Boston (D.E.D.)
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Bodewes TCF, Soden PA, Ultee KHJ, Zettervall SL, Pothof AB, Deery SE, Moll FL, Schermerhorn ML. Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions. J Vasc Surg 2017; 65:484-494.e3. [PMID: 28126175 DOI: 10.1016/j.jvs.2016.08.093] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 08/30/2016] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Unplanned hospital readmissions following surgical interventions are associated with adverse events and contribute to increasing health care costs. Despite numerous studies defining risk factors following lower extremity bypass surgery, evidence regarding readmission after endovascular interventions is limited. This study aimed to identify predictors of 30-day unplanned readmission following infrainguinal endovascular interventions. METHODS We identified all patients undergoing an infrainguinal endovascular intervention in the targeted vascular module of the American College of Surgeons National Surgical Quality Improvement Program between 2012 and 2014. Perioperative outcomes were stratified by symptom status (chronic limb-threatening ischemia [CLI] vs claudication). Patients who died during index admission and those who remained in the hospital after 30 days were excluded. Indications for unplanned readmission related to the index procedure were evaluated. Multivariable logistic regression was used to identify preoperative and in-hospital (during index admission) risk factors of 30-day unplanned readmission. RESULTS There were 4449 patients who underwent infrainguinal endovascular intervention, of whom 2802 (63%) had CLI (66% tissue loss) and 1647 (37%) had claudication. The unplanned readmission rates for CLI and claudication patients were 16% (n = 447) and 6.5% (n = 107), respectively. Mortality after index admission was higher for readmitted patients compared with those not readmitted (CLI, 3.4% vs 0.7% [P < .001]; claudication, 2.8% vs 0.1% [P < .01]). Approximately 50% of all unplanned readmissions were related to the index procedure. Among CLI patients, the most common indication for readmission related to the index procedure was wound or infection related (42%), whereas patients with claudication were mainly readmitted for recurrent symptoms of peripheral vascular disease (28%). In patients with CLI, predictors of unplanned readmission included diabetes (odds ratio, 1.3; 95% confidence interval, 1.01-1.6), congestive heart failure (1.6; 1.1-2.5), renal insufficiency (1.7; 1.3-2.2), preoperative dialysis (1.4; 1.02-1.9), tibial angioplasty/stenting (1.3; 1.04-1.6), in-hospital bleeding (1.9; 1.04-3.5), in-hospital unplanned return to the operating room (1.9; 1.1-3.5), and discharge other than to home (1.5; 1.1-2.0). Risk factors for those with claudication were dependent functional status (3.5; 1.4-8.7), smoking (1.6; 1.02-2.5), diabetes (1.5; 1.01-2.3), preoperative dialysis (3.6; 1.6-8.3), procedure time exceeding 120 minutes (1.8; 1.1-2.7), in-hospital bleeding (2.9; 1.2-7.4), and in-hospital unplanned return to the operating room (3.4; 1.2-9.4). CONCLUSIONS Unplanned readmission after endovascular treatment is relatively common, especially in patients with CLI, and is associated with substantially increased mortality. Awareness of these risk factors will help providers identify patients at high risk who may benefit from early surveillance, and prophylactic measures focused on decreasing postoperative complications may reduce the rate of readmission.
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Affiliation(s)
- Thomas C F Bodewes
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Peter A Soden
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Klaas H J Ultee
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sara L Zettervall
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, George Washington University Medical Center, Washington, D.C
| | - Alexander B Pothof
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Frans L Moll
- Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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Siracuse JJ, Shah NK, Peacock MR, Tahhan G, Kalish JA, Rybin D, Eslami MH, Farber A. Thirty-day and 90-day hospital readmission after outpatient upper extremity hemodialysis access creation. J Vasc Surg 2017; 65:1376-1382. [DOI: 10.1016/j.jvs.2016.11.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/02/2016] [Indexed: 11/28/2022]
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Ashrafi M, Salvadi R, Foden P, Thomas S, Baguneid M. Pre-operative predictors of poor outcomes in patients undergoing surgical lower extremity revascularisation - Retrospective cohort study. Int J Surg 2017; 41:91-96. [PMID: 28344160 DOI: 10.1016/j.ijsu.2017.03.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/21/2017] [Accepted: 03/21/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Surgical lower extremity revascularisation (LER) can lead to poor outcomes that include delayed hospital discharge, in-hospital mortality, major amputations and readmissions. The aim of this study was to identify pre-operative predictors associated with these poor clinical outcomes. MATERIALS AND METHODS All patients (n = 635; mean age 69; male 67.4%) who underwent surgical LER over a 5 year period in a single tertiary vascular institution were identified. Patients considered to have suffered a poor outcome (Group A) included all in-hospital mortality and major amputations, delayed discharges with a length of stay (LOS) over one standard deviation above the mean or any readmission under any specialty within 12 months. Group A included 247 patients (38.9%) and the good outcome group included the remaining 388 patients (61.1%) from which a sample of 99 patients were selected as controls (Group B). RESULTS Mean LOS for the entire study group was 14.4 ± 17.5 days, 12 month readmission rate was 29.1% and in-hospital mortality and major amputation rate was 2.7% and 1.4%, respectively. Pre-admission residence other than own home (OR 9.0; 95% CI 1.2-70.1; P = 0.036), atherosclerotic disease burden (OR 2.2; 95% CI 1.3-3.8; P = 0.003) and tissue loss (OR 3.0; 95% CI 1.6-5.3; P < 0.001) were identified as independent, statistically significant pre-operative predictors of poor outcome. Following discharge, group B patients had a significantly higher rate of amputation free survival and graft infection free survival (P < 0.001) compared to group A. CONCLUSION Recognition of pre-operative predictors of poor outcome should inform case selection and identify high risk patients requiring intensive perioperative optimisation and post discharge follow up.
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Affiliation(s)
- Mohammed Ashrafi
- Department of Vascular and Endovascular Surgery, University Hospital of South Manchester, Manchester, UK
| | - Rohini Salvadi
- Department of Vascular and Endovascular Surgery, University Hospital of South Manchester, Manchester, UK
| | - Philip Foden
- Department of Medical Statistics, University Hospital of South Manchester, Manchester, UK
| | - Stephanie Thomas
- Department of Microbiology, University Hospital of South Manchester, Manchester, UK
| | - Mohamed Baguneid
- Department of Vascular and Endovascular Surgery, University Hospital of South Manchester, Manchester, UK.
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Agarwal S, Pitcavage JM, Sud K, Thakkar B. Burden of Readmissions Among Patients With Critical Limb Ischemia. J Am Coll Cardiol 2017; 69:1897-1908. [PMID: 28279748 DOI: 10.1016/j.jacc.2017.02.040] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 02/12/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Readmissions constitute a major health care burden among critical limb ischemia (CLI) patients. OBJECTIVES This study aimed to determine the incidence of readmission and factors affecting readmission in CLI patients. METHODS All adult hospitalizations with a diagnosis code for CLI were included from State Inpatient Databases from Florida (2009 to 2013), New York (2010 to 2013), and California (2009 to 2011). Data were merged with the directory available from the American Hospital Association to obtain detailed information on hospital-related characteristics. Geographic and routing analysis was performed to evaluate the effect of travel time to the hospital on readmission rate. RESULTS Overall, 695,782 admissions from 212,241 patients were analyzed. Of these, 284,189 were admissions with a principal diagnosis of CLI (primary CLI admissions). All-cause readmission rates at 30 days and 6 months were 27.1% and 56.6%, respectively. The majority of these were unplanned readmissions. Unplanned readmission rates at 30 days and 6 months were 23.6% and 47.7%, respectively. The major predictors of 6-month unplanned readmissions included age, female sex, black/Hispanic race, prior amputation, Charlson comorbidity index, and need for home health care or rehabilitation facility upon discharge. Patients covered by private insurance were least likely to have a readmission compared with Medicaid/no insurance and Medicare populations. Travel time to the hospital was inversely associated with 6-month unplanned readmission rates. There was a significant interaction between travel time and major amputation as well as travel time and revascularization strategy; however, the inverse association between travel time and unplanned readmission rate was evident in all subgroups. Furthermore, length of stay during index hospitalization was directly associated with the likelihood of 6-month unplanned readmission (odds ratio for log-transformed length of stay: 2.39 [99% confidence interval: 2.31 to 2.47]). CONCLUSIONS Readmission among patients with CLI is high, the majority of them being unplanned readmissions. Several demographic, clinical, and socioeconomic factors play important roles in predicting readmissions.
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Affiliation(s)
- Shikhar Agarwal
- Department of Cardiology, Section of Interventional Cardiology, Geisinger Medical Center, Danville, Pennsylvania.
| | - James M Pitcavage
- Institute for Advanced Application, Geisinger Health System, Danville, Pennsylvania
| | - Karan Sud
- Department of Internal Medicine, Mount Sinai St. Luke's Hospital, New York, New York
| | - Badal Thakkar
- Department of Internal Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
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Melvin JC, Smith JB, Kruse RL, Vogel TR. Risk Factors for 30-Day Hospital Re-Admission with an Infectious Complication after Lower-Extremity Vascular Procedures. Surg Infect (Larchmt) 2017; 18:319-326. [PMID: 28177854 DOI: 10.1089/sur.2016.234] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Joseph C Melvin
- 1 Division of Vascular Surgery, University of Missouri School of Medicine , Columbia, Missouri
| | - Jamie B Smith
- 2 Department of Family and Community Medicine, University of Missouri School of Medicine , Columbia, Missouri
| | - Robin L Kruse
- 2 Department of Family and Community Medicine, University of Missouri School of Medicine , Columbia, Missouri
| | - Todd R Vogel
- 1 Division of Vascular Surgery, University of Missouri School of Medicine , Columbia, Missouri
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Gavrilenko AV, Gavrilenko X, Al-yousef NN. Modern possibilities to predict surgical outcomes in patients with chronic lower limb ischemia. ACTA ACUST UNITED AC 2017. [DOI: 10.17116/kardio201710552-57] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Tan KW, Lo ZJ, Hong Q, Narayanan S, Tan GWL, Chandrasekar S. Use of Negative Pressure Wound Therapy for Lower Limb Bypass Incisions. Ann Vasc Dis 2017. [PMID: 29515700 PMCID: PMC5835432 DOI: 10.3400/avd.oa.17-00052] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objective: The use of negative pressure wound therapy (NPWT) for post-surgical cardiothoracic, orthopedic, plastic, and obstetric and gynecologic procedures has been described. However, there are no data regarding its use for lower limb bypass incisions. We aimed to investigate the outcomes of NPWT in preventing surgical site infection (SSI) in patients with lower limb arterial bypass incisions. Materials and Methods: We retrospectively used data of 42 patients who underwent lower limb arterial bypass with reversed great saphenous vein between March 2014 and June 2016 and compared conventional wound therapy and NPWT with regard to preventing SSI. Results: Twenty-eight (67%) patients underwent conventional wound therapy and 14 (33%) underwent NPWT. There were no statistical differences regarding patient characteristics and mean SSI risk scores between the two patient groups (13.7% for conventional wound therapy vs. 13.4% for NPWT; P=0.831). In the conventional group, nine instances of SSI (32%) and three (11%) of these required subsequent surgical wound debridement, whereas in the NPWT group, there was no SSI incidence (P=0.019). Secondary outcomes such as the length of hospital stay, 30-day readmission rate, and need for secondary vascular procedures were not statistically different between the two groups. Conclusion: The use of NPWT for lower limb arterial bypass incisions is superior to that of conventional wound therapy because it may prevent SSIs.
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Affiliation(s)
| | - Zhiwen Joseph Lo
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Qiantai Hong
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Sriram Narayanan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Glenn Wei Leong Tan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Sadhana Chandrasekar
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
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Gracon ASA, Liang TW, Easterday TS, Weber DJ, Butler J, Slaven JE, Lemmon GW, Motaganahalli RL. Institutional Cost of Unplanned 30-Day Readmission Following Open and Endovascular Surgery. Vasc Endovascular Surg 2016; 50:398-404. [DOI: 10.1177/1538574416666227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Vascular surgical patients have a high rate of readmission, and the cost of readmission for these patients has not been described. Herein, we characterize and compare institutional index hospitalization and 30-day readmission cost following open and endovascular vascular procedures. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify inpatient open and endovascular procedures at a single institution, from January 2011 through June 2012. Variable and fixed costs for index hospitalization and unplanned 30-day readmissions were obtained using SAP BusinessObjects. Patient characteristics and outcome variables were analyzed using Student t tests or Wilcoxon rank-sum nonparametric tests for continuous variables and Fisher exact tests for categorical variables. Results: One thousand twenty-six inpatient procedures were included in the analysis. There were 605 (59%) open and 421 (41%) endovascular procedures with a 30-day unplanned readmission rate of 16.9% and 17.8%, respectively ( P = .679). The mean index hospitalization costs for open and endovascular procedures were US$27 653 and US$23 999, respectively ( P = .146). The mean costs for 30-day unplanned readmission for open and endovascular procedures were US$19 117 and US$17 887, respectively ( P = .635). Among open procedures, the mean cost for patients not readmitted was US$28 321 compared to US$31 115 for those readmitted ( P = .003). Among endovascular procedures, the mean cost for patients not readmitted was US$26 908 compared to US$32 262 for those readmitted ( P = .028). Conclusion: The cost of index hospitalization and 30-day unplanned readmission are similar for open and endovascular procedures. Readmitted patients had a higher mean index hospitalization cost irrespective of open or endovascular procedure.
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Affiliation(s)
- Adam S. A. Gracon
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, IN, USA
| | - Tiffany W. Liang
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, IN, USA
| | | | - Daniel J. Weber
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, IN, USA
| | - James Butler
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, IN, USA
| | - James E. Slaven
- Department of Biostatistics, Indiana University School of Medicine, IN, USA
| | - Gary W. Lemmon
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, IN, USA
- Division of Vascular Surgery, Indiana University School of Medicine, IN, USA
| | - Raghu L. Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, IN, USA
- Division of Vascular Surgery, Indiana University School of Medicine, IN, USA
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Glebova NO, Bronsert M, Hammermeister KE, Nehler MR, Gibula DR, Malas MB, Black JH, Henderson WG. Drivers of readmissions in vascular surgery patients. J Vasc Surg 2016; 64:185-194.e3. [DOI: 10.1016/j.jvs.2016.02.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
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Gonzalez AA, Cruz CG, Dev S, Osborne NH. Indication for Lower Extremity Revascularization and Hospital Profiling of Readmissions. Ann Vasc Surg 2016; 35:130-7. [PMID: 27311949 DOI: 10.1016/j.avsg.2016.01.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 01/19/2016] [Accepted: 01/22/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Surgical readmissions are common, costly, and the focus of national quality improvement efforts. Given the relatively high readmission rates among vascular patients, pay-for-performance initiatives such as Medicare's Hospital Readmissions Reduction Program (HRRP) have targeted vascular surgery for increased scrutiny in the near future. Yet, the extent to which institutional case mix influences hospital profiling remains unexplored. We sought to evaluate whether higher readmission rates in vascular surgery are a reflection of worse performance or of treating sicker patients. METHODS This retrospective observational cohort study of the national Medicare population includes 479,047 beneficiaries undergoing lower extremity revascularization (LER) in 1,701 hospitals from 2005 to 2009. We employed hierarchical logistic regression to mimic Center for Medicare and Medicaid Services methodology accounting for age, gender, preexisting comorbidities, and differences in hospital operative volume. We estimated 30-day risk-standardized readmission rates (RSRR) for each hospital when including (1) all LER patients; (2) claudicants; or (3) high-risk patients (rest pain, ulceration, or tissue loss). We stratified hospitals into quintiles based on overall RSRR for all LERs and examined differences in RSRR for claudicants and high-risk patients between and within quintiles. Next, we evaluated differences in case mix (the proportion of claudicants and high-risk patients treated) across quintiles. Finally, we simulated differences in the receipt of penalties before and after adjusting for hospital case mix. RESULTS Readmission rates varied widely by indication: 7.3% (claudicants) vs. 19.5% (high risk). Even after adjusting for patient demographics, length of stay, and discharge destination, high-risk patients were significantly more likely to be readmitted (odds ratio 1.76, 95% confidence interval 1.71-1.81). The Best hospitals (top quintile) under the HRRP treated a much lower proportion of high-risk patients compared with the Worst hospitals (bottom quintile) (20% vs. 56%, P < 0.001). In the absence of case-mix adjustment, we observed a stepwise increase in the proportion of hospitals penalized as the proportion of high-risk patients treated increased (35-60%, P < 0.001). However, after case-mix adjustment, there were no differences between quintiles in the proportion of hospitalized penalized (50-46%, P = 0.30). CONCLUSION Our findings suggest that the differences in readmission rates following LER are largely driven by hospital case mix rather than true differences in quality.
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Affiliation(s)
- Andrew A Gonzalez
- Department of Surgery, University of Illinois Hospital & Health Sciences System, Chicago, IL.
| | - Celeste G Cruz
- Department of Surgery, University of Illinois Hospital & Health Sciences System, Chicago, IL
| | - Shantanu Dev
- Department of Statistics, University of Illinois at Urbana-Champaign, Champaign, IL
| | - Nicholas H Osborne
- Institute for Healthcare Policy and Innovation, North Campus Research Complex, University of Michigan, Ann Arbor, MI; Section of Vascular Surgery, University of Michigan, Ann Arbor MI
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Jones CE, Richman JS, Chu DI, Gullick AA, Pearce BJ, Morris MS. Readmission rates after lower extremity bypass vary significantly by surgical indication. J Vasc Surg 2016; 64:458-464. [PMID: 27139788 DOI: 10.1016/j.jvs.2016.03.422] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 03/09/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Readmission rates after vascular surgery are among the highest within surgical specialties, and lower extremity bypass has the highest readmission rate of vascular surgery procedures. We analyzed how 30-day readmissions and risk factors for readmissions vary by indication for lower extremity bypass. METHODS We queried the 2012-2014 American College of Surgeons National Surgical Quality Improvement Program procedure-targeted vascular cohort to identify all patients who underwent lower extremity bypass. Emergent procedures and planned readmissions were excluded. Patients were stratified by surgical indication: claudication, critical limb ischemia rest pain (CLI RP), critical limb ischemia tissue loss (CLI TL), and other. The χ2 and Wilcoxon rank sum tests were used to test the differences between categorical and continuous variables, respectively. Logistic regression was used to estimate odds ratios for predictors of readmission adjusted for preoperative factors that were selected a priori. RESULTS The overall 30-day readmission rate among the 6112 patients who underwent lower extremity bypass was 14.8%. Readmission rates varied significantly on the basis of the indication for surgery. In unadjusted comparisons, 18.8% of patients with CLI TL were readmitted compared with 16.5% with CLI RP, 9.4% with claudication, and 8.2% with other indications (P < .001). After adjustment for preoperative factors, 30-day readmissions were higher for patients with CLI TL (odds ratio, 1.67; 95% confidence interval, 1.35-2.06) and CLI RP (odds ratio, 1.70; 95% confidence interval, 1.38-2.09) compared with patients with claudication. CONCLUSIONS The 30-day readmission rates after lower extremity bypass vary significantly by surgical indication. Because lower extremity bypasses are performed for multiple indications, if readmission rates are publically reported and hospitals can be penalized for higher than expected readmission rates, the expected readmission rates should be adjusted for surgical indication.
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Affiliation(s)
- Caroline E Jones
- Department of Surgery, University of Alabama-Birmingham, Birmingham, Ala
| | - Joshua S Richman
- Department of Surgery, University of Alabama-Birmingham, Birmingham, Ala
| | - Daniel I Chu
- Department of Surgery, University of Alabama-Birmingham, Birmingham, Ala
| | - Allison A Gullick
- Department of Surgery, University of Alabama-Birmingham, Birmingham, Ala
| | - Benjamin J Pearce
- Department of Surgery, University of Alabama-Birmingham, Birmingham, Ala
| | - Melanie S Morris
- Department of Surgery, University of Alabama-Birmingham, Birmingham, Ala.
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Women undergoing aortic surgery are at higher risk for unplanned readmissions compared with men especially when discharged home. J Vasc Surg 2016; 63:1496-1504.e1. [PMID: 27106246 DOI: 10.1016/j.jvs.2015.12.054] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 12/21/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Women undergoing vascular surgery have higher morbidity and mortality. Our study explores gender-based differences in patient-centered outcomes such as readmission, length of stay (LOS), and discharge destination (home vs nonhome facility) in aortic aneurysm surgery. METHODS Patients were identified from the American College of Surgeons National Surgical Quality Improvement Project database (2011-2013) undergoing abdominal, thoracic, and thoracoabdominal aortic aneurysms (N = 17,763), who were discharged and survived their index hospitalization. The primary outcome was unplanned readmission, and secondary outcomes were discharge to a nonhome facility, LOS, and reasons for unplanned readmission. Univariate, multivariate, and stratified analyses based on gender and discharge destination were used. RESULTS Overall, 1541 patients (8.7%) experienced an unplanned readmission, with a significantly higher risk in women vs men (10.8% vs 8%; P < .001) overall (Procedure subtypes: abdominal aortic aneurysm [10.1% vs 7.7%; P < .001], thoracic aortic aneurysm [14.1% vs 13.5%; P = .8], and thoracoabdominal aortic aneurysm [14.8% vs 10%; P = .051]). The higher odds of readmission in women compared with men persisted in multivariate analysis after controlling for covariates (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.05-1.4). Similarly, the rate of discharge to a nonhome facility was nearly double in women compared with men (20.6% vs 10.7%; P < .001), but discharge to a nonhome facility was not a significant predictor of unplanned readmission. Upon stratification by discharge destination, the higher odds of readmissions in women compared with men occurred in patients who were discharged home (OR, 1.2; 95% CI, 1.02-1.4) but not in those who were discharged to a nonhome facility (OR, 1.06; 95% CI, 0.8-1.4). Significant differences in LOS were seen in patients who were discharged home. No gender differences were found in reasons for readmission with the three most common reasons being thromboembolic events, wound infections, and pneumonia. CONCLUSIONS Gender disparity exists in the risk of unplanned readmission among aortic aneurysm surgery patients. Women who were discharged home have a higher likelihood of unplanned readmission despite longer LOS than men. These data suggest that further study into the discharge planning processes, social factors, and use of rehabilitation services is needed for women undergoing aortic procedures to decrease readmissions.
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Burket MW. Drug-Eluting Stents Are the Default Strategy for Superficial Femoral Artery Intervention NowResponse to Burket. Circulation 2016; 133:320-9; discussion 329. [DOI: 10.1161/circulationaha.115.018034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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