CHICAGO – Lower-extremity revascularization or amputation was among the strongest predictors of 30-day vascular surgery readmission in what is being described as the largest single-center review in this setting to date.
Lower-extremity revascularization and amputations made up 63% of unplanned readmissions, though rates for endovascular lower-extremity revascularization were almost half that of open revascularization (8.2% vs. 15%).
Notably, below-knee amputations fared the worst, with a 30-day unplanned readmission rate of 24%, compared with 13.3% for above-knee amputations and 16.4% for foot amputation.
"Amputations and open lower-extremity revascularization had the highest rates of readmission in this analysis and therefore we need to focus our efforts and find additional postoperative [management] strategies for these two subgroups," Dr. Travis L. Engelbert said at the annual meeting of the annual meeting of the Midwestern Vascular Surgical Society.*
The analysis involved 2,505 patients who underwent vascular surgery at the University of Wisconsin Hospitals and Clinics in Madison from 2009 to mid-2013. The overall readmission rate was 9.7% (n = 244).
Of these, 147 patients (60.2%) were readmitted to the vascular surgery service.
The most common readmitting diagnosis was wound complication or infection in 37%, said Dr. Engelbert, a vascular surgeon at the university.
Patients whose index admission was urgent rather than elective had significantly higher readmission rates (14.6% vs. 6.9%; P less than .001), as did those living remotely rather than inside Dane County, where the university is located (12% vs. 8.8%; P = .02).
Not surprisingly, higher illness severity, as calculated using the 3M APR DRG software, was significantly associated with readmission (15.6% high vs. 4.3% low severity; P less than .001).
Patients who were readmitted had a longer initial length of stay (LOS) (8.5 days vs. 6.1 days; P less than .01), and were more likely to have an ICU admission (18.3% vs. 9.5% without ICU stay; P less than .05), he reported.
Based on insurance status, patients covered by Medicaid (16.8%) and Medicare (10%) were most likely to have an unplanned readmission, followed by fee-for-service patients (9.5%), self-pay (8%), and HMO (5.5%) patients (P = .02).
Dr. Engelbert observed that vascular surgery outcomes have come under scrutiny and that there has been some discussion of cutbacks in Medicare reimbursement given its high rates of readmission.
"This is already starting to happen for certain medical patient populations and if this were to happen, it would significantly affect a vascular service’s practice because a majority of our patients are covered by Medicare and have a higher readmission rate," he said.
The analysis suggests that vascular surgeons may also want to pay closer attention to discharge destination for their patients. Readmission rates were about three times higher for patients discharged to a rehabilitation facility or skilled nursing facility than for those discharged home (19.2% and 16.2% vs. 6.2%; P less than .01).
"The discharge destination matters," Dr. Engelbert said. "... we need to have improved coordination between hospitals and postdischarge destinations. And, we also might need to look at how these patients are cared for and if they are discharged to the appropriate level of care when they’re discharged to these skilled nursing and rehabilitation facilities."
The effects of discharge destination (odds ratio, 1.54 skilled nursing facility), index length of stay (OR, 1.03), insurance (OR, 0.43 HMO), and lower-extremity revascularization or amputation (OR, 2.35) persisted in multivariable logistic regression analysis that controlled for age, sex, race, proximity to hospital, clinic follow-up time, urgent vs. elective admission, insurance type, procedure type, length of stay, and discharge destination.
When asked by the audience what the university has done to reduce its vascular readmission rates, Dr. Engelbert said they have looked at using in-patient swabs to reduce infection and dedicated vascular nurse practitioners or case managers to ensure patients are being discharged to the appropriate level of care.
"I think further efforts need to focus on how we can reduce outpatient complications, through closer and quicker follow-up perhaps, as well as ways to use technology to monitor patients," he said.
One example of this is the use of outpatient remote wound analysis using smartphone photograph technology.
"Wound complications and subsequent readmissions are frequent, costly, and a significant burden to the patients," Dr. Engelbert said in an interview. "Hopefully, this method will reduce the severity of wound complications if they can be caught and treated at an earlier stage with digital photograph analysis."
One audience member argued that the vast majority of vascular problems could be cared for outpatient, but that vascular surgeons frequently aren’t told their patients have been readmitted until after they’ve been in the hospital for 2 or 3 days.