Notably, patients with cardiac troponin levels above 0.2 mg/dL were not at significantly higher risk of readmission (OR, 1.75), although those with a white blood cell count greater than 15,000/mcL were (OR, 2.1), which goes along with the finding of sepsis, he said.
In multivariate logistic regression analysis adjusting for age, disease severity, and race, PAD severity dropped out but male gender (OR, 1.39), Charlson Comorbidity Index (OR 1.12), length of stay (OR, 1.25), AST (OR 2.89), and more than 30 dispensed medications (OR, 1.84) remained significant.
"I think these are the things we’re going to have to look at if we’re going to really address readmissions," Dr. Vogel said.
He highlighted a new algorithm created at the Dartmouth-Hitchcock Medical Center that describes strategies for both predicting and preventing readmissions in vascular surgery (J. Vasc. Surg. 2012 56:556-62).
"It’s fun to describe all this, but the next step is to create change," he added.
During a discussion of the study, Dr. Vogel said that it was possible to calculate specialty-specific readmission rates but that such an analysis had not been performed yet.
Society for Vascular Surgery (SVS) President Peter Gloviczki then rose from the audience to say that such an analysis is very important in light of a recent Medicare database analysis reporting that endovascular lower-extremity revascularization performed by vascular specialists results in higher costs, longer hospital stays, and more repeat revascularization procedures and amputations than the same procedure performed by interventional radiologists (J. Vasc. Interv. Radiol. 2012:23:3-9).
He went on to say that the controversial paper, which was sharply rebuked by past SVS President Richard Cambria, failed to define indications for the interventions or major vs. minor amputations.
"I think if your data show, not necessarily the outcome, but the case mix of the specialties and what we believe is the severity of disease that vascular surgeons take care of compared to radiologists, that would be very good because that is a way to answer with data, and not with rhetoric," Dr. Gloviczki said.
Dr. Vogel agreed that vascular surgeons, as a rule, treat sicker patients with heavier disease burden, subsequently leading to these various secondary outcomes, and that the Medicare analysis failed to adequately process the data.
"It was a very jaded view," he said.
Session comoderator Dr. Melina Kibbe, a vascular surgeon with Northwestern Memorial Hospital in Chicago, said that the current analysis is the first to use the Cerner database and "that this could be why we’re seeing different outcomes than what other people have reported because this is a more real-world database."
She went on to say that using lower-extremity readmissions as a quality measure is highly problematic because care of these patients, much like that for those with cancer, is often staged and extends for years.
Those thoughts were echoed by the newly elected president of the Midwestern Vascular Surgical Society, Dr. Timothy Kresowik. In an interview, he said, "I’d stay away from lower extremity to begin with. I think it’s just a terrible area to try to do performance measures, especially short-term performance measures, because the important thing to remember about lower-extremity bypass is the real issues are long term."
Dr. Vogel, Dr. Geraghty, Dr. Gloviczki, Dr. Kibbe, and Dr. Kresowik reported having no relevant conflicts of interest.