Predictors of Unplanned 30 Day Readmission in Diabetic Foot Wounds
Courtenay M. Holscher, MD, Joseph K. Canner, MHS, Ronald L. Sherman, DPM MBA, Kathryn Hines, PA-C, Mahmoud B. Malas, MD MHS, James H. Black, III, MD, Nestoras Mathioudakis, MD MHS, Christopher J. Abularrage, MD.
Johns Hopkins, Baltimore, MD, USA.
OBJECTIVE - The Center for Medicare and Medicaid Services (CMS) uses rates of unplanned 30-day readmission as a quality measure to penalize hospitals for readmissions. While there is recognition of high readmission rates for diabetic foot wounds, little is known about patient-level risk factors. The goal of this study was to identify factors associated with unplanned readmission in patients enrolled in a multidisciplinary diabetic foot service.
METHODS - We studied a single-center cohort of patients in a multidisciplinary diabetic foot service since July 2012. For those with multiple wounds, the overall highest SVS WIfI staged wound was selected for analysis. Predictors of unplanned 30-day readmission were analyzed with chi-square and t-tests.
RESULTS - Over the study period, there were 336 admissions in 170 patients. The average age was 58±12 years and the majority were male (63%) and black (64%). 50% were insured by Medicare, 26% had Medicaid, and 22% had private insurance. 441 podiatric and 83 vascular surgeries (45 open and 37 endo) were performed. Of the 336 admissions, there were 62 (18%) unplanned 30-day readmissions. The average length of stay (LOS) for the initial admission was 9±8 days while the average unplanned readmission LOS was 8±8 days. The most common reasons for unplanned readmission were related to foot wound (34%), gastrointestinal (12%), surgical bypass wound (9%), and renal (7%) complications. Unplanned readmissions were not predicted by any demographic or socioeconomic variable. Unplanned readmissions were more likely in patients with arterial insufficiency (P=.04), worse University of Texas (UT) stage (P=.03), and higher SVS WIfI composite scores (P=.04; Table). There were lower wound healing rates in those with an unplanned readmission (48 vs. 68%, P=.003), but no differences in major amputation (8 vs. 11%, P=.25).
CONCLUSIONS - Patients with diabetic foot wounds associated with arterial insufficiency and increased WIfI or UT stage were more likely to have an unplanned 30-day readmission. While aggressive multidisciplinary care of patients with diabetic foot wounds was associated with excellent long-term outcomes, this comes with a significant LOS and rate of readmission. CMS penalization for unplanned readmission should take into account WIfI and/or UT staging.
|Unplanned Readmission (n=62)||Initial or Planned Admission (n=274)||P-value|
|Amputation||8 (12.9%)||27 (9.9%)|
|Arterial||21 (33.9%)||48 (17.5%)|
|Traumatic||1 (1.6%)||12 (4.4%)|
|Neuropathic||28 (45.2%)||174 (63.5%)|
|Pressure||4 (6.5%)||11 (4.0%)|
|UT Diabetic Wound Stage||.03|
|B||26 (41.9%)||133 (48.5%)|
|C||17 (27.4%)||55 (20.1%)|
|D||19 (30.7%)||61 (22.3%)|
|WIfI Composite Score||.04|
|1-4||17 (27.4%)||123 (44.9%)|
|5-9||40 (64.5%)||132 (38.2%)|
|Stage 5||5 (8.1%)||19 (6.9%)|
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