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Do Shorter Hospital Stays Increase the Risk of Readmission and Mortality in Patients Undergoing High-Risk Vascular Surgery?
Benjamin S. Brooke, M.D., Ph.D.1, Philip P. Goodney, M.D.1, Mark F. Fillinger, M.D.1, Richard J. Powell, M.D.1, Lori L. Travis, M.S.2, Lee Lucas, Ph.D.2, David C. Goodman, M.D.3, Jack L. Cronenwett, M.D.1, David H. Stone, M.D.1.
1Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA, 2Maine Medical Center, Portland, ME, USA, 3Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.
Objectives: Health policy aimed at reducing length of stay (LOS) following vascular surgery has been broadly implemented to reduce costs. Many question, however, if early discharge may increase the risk of readmission or mortality, both important hospital quality metrics. To address this question, we examined the relationship between LOS and 30-day outcomes among patients undergoing a high-risk vascular surgery procedure, Thoracic Aortic Aneurysm (TAA) repair.
Methods: Using Medicare claims 2000-2007, we identified all patients who underwent elective thoracic endovascular aneurysm repair (TEVAR) and open repair for non ruptured TAA. For each procedure, we examined the correlation between LOS and 30-day readmission and mortality rates. Predictors of readmission were evaluated using logistic regression models controlling for patient comorbidities, perioperative complications and discharge location.
Results: Our sample included 13,155 patients, of which 10,803 (82%) underwent open TAA repair and 2,319 (18%) underwent TEVAR. Most patients were Caucasian (93%), male (56%) with a mean age of 74 years, and were discharged home (74%) following their procedures. Patients discharged home following TEVAR had lower mean LOS (5.2 days vs. 8.9 days; P<0.001) and 30-day readmission rates (18% vs. 20%; P<0.05) as compared to open TAA repair, although there was no difference in 30-day post-discharge mortality rates between procedures. Among patients who were discharged home, hospital LOS was directly related to 30-day readmission (Figure, Panel A) and 30-day post-discharge mortality (Figure, Panel B). In multivariable analysis, patients were more likely to be readmitted if they had a longer LOS (OR:1.15; 95%CI: 1.09-1.20; P<0.001), higher Charlson comorbidity score (OR:1.08; P<0.001), or any major post-operative complication (OR:1.10; P<0.05).
Conclusions: Patients discharged home with short LOS (<3 days for TEVAR, <7 days for open TAA repair) following high-risk vascular surgery are the least likely to be readmitted and had the lowest rates of 30 day mortality. While indirect, these data suggest (1) health policy aimed at early discharge is safe, even in high-risk surgery, and (2) quality measures based on readmission need to consider patient-level characteristics.
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