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Decubitus Ulcers In Patients Undergoing Vascular Operations Does Not Impact Mortality But Affects Resource Utilization
Castigliano M. Bhamidipati, DO, MSc, Amani D. Politano, MD, MS, Margaret C. Tracci, MD, JD, Kenneth J. Cherry, MD, FACS, John A. Kern, MD, FACS, Irving L. Kron, MD, FACS, Gilbert R. Upchurch, Jr., MD, FACS.
University of Virginia School of Medicine, Charlottesville, VA, USA.
OBJECTIVES: While it is anticipated that decubitus ulcers (DU) are detrimental to outcomes following vascular operations, the contemporary influence of preoperative DU in vascular surgery remains unknown. We examine this relationship to identify potential improvements towards better resource utilization.
METHODS: Using voluntary inpatient data from 2009, all adult patients who underwent either open or endovascular carotid repair, abdominal aortic aneurysm (AAA) repair, femoral artery to distal vessel revascularization, peripheral arterial stenting (PAS) or an above/below knee amputation were selected. Patients were stratified by the presence or absence (non-DU) of decubitus ulcer. Case-mix adjusted hierarchical models examined in-hospital mortality, any complication and discharge disposition.
RESULTS: A total of 538,808 cases were analyzed. DU was most prevalent among Caucasian male Medicare beneficiaries (P<0.001). Patients with DU were more likely to be admitted on a weekend and with Stage IV ulcerations (P<0.001, respectively). DU patients underwent more non-elective surgery (P<0.001). Wound, infectious, and procedural complications were more common in DU (P<0.001, respectively). Failure to rescue, defined as mortality following any complication, was more than doubled in DU (non-DU: 1.5%, DU: 3.2%, P<0.001). Similarly, unadjusted mortality was also doubled with DU (non-DU: 3%, DU: 6%, P<0.001). Following risk adjustment among all patients, neither presence of DU nor specific ulcer staging increased the adjusted odds of death. In DU patients, no specific vascular operation, body mass index threshold, or ulcer staging increased the adjusted odds of death. However, open and endovascular AAA repair, and PAS increased the adjusted odds of any complication (P<0.05, respectively). Having a DU increased the adjusted odds of discharge to an intermediate care facility by almost 3 fold (AOR 2.9, 95% CI [2.7-3.4], P<0.001). Additionally, when patients with DU were admitted from non-health care centers for elective surgery, they were 12 times more likely to go to a skilled nursing facility at discharge (AOR 12.04, 95% CI [7.1-20.3], P<0.001). These patients also had 1.6 times the total charges compared to their non-DU cohort (non-DU: $49,460±281, DU: $81,149±5855, P<0.001).
CONCLUSIONS: Contrary to common perception, preoperative decubitus ulcer does not adversely affect mortality following vascular surgery. However, patients with decubitus ulcers are at higher risk for complications and incur sizeable additional charges. Care costs, complications, and discharge disposition must be appropriately weighed in at-risk patients during operative planning.
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