Society For Clinical Vascular Surgery

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Missed Readmissions to Different Hospitals in Patients with Peripheral Vascular Disease Significantly Associated With Higher Mortality
Rennier Martinez, MD, Joshua Parreco, MD, Allison Rice, MD, Nicholas Mouawad, MD
University of Miami, West Palm Beach, FL

Objectives
Thirty day readmission rates, which is now a quality outcome measured by CMS, have been previously studied on databases that exclude some payer types, certain states or important data points. Furthermore, current studies do not take into account readmissions that occur a hospital different from index admission. Up to one in four readmissions following vascular surgery procedures occur at a different institution. The purpose of this study is to examine incidence and risk factors for readmission to a different hospital in patients admitted for peripheral vascular disease. We will look at how this fragmentation of care impacts mortality, amputation rates and overall conclusions regarding currently accepted peripheral vascular disease metrics.
Methods
The 2010-2014 Nationwide Readmissions Database was queried for all patients admitted for claudication or critical limb ischemia whom underwent angioplasty, lower extremity bypass or aorto-bifemoral bypass. Outcomes of interest include: 30 day readmission rates, 30 day readmission rates to another hospital, mortality, and amputation rates. Multivariable logistic regression was used to identify risk factors for readmission to a different hospital. The most common readmission diagnosis was also identified.
Results
92,769 patients were admitted with peripheral vascular disease (33,055 with claudication and 59,714 with CLI). According to Table 1, 20.47%/24.92% of 30-day readmission/365 day readmission respectively occurred at another hospital. Significantly higher mortality rates were found for patients readmitted to different hospitals with OR 1.4 and 1.8 respectively. Multivariable analysis revealed that female sex, LOS>7 days, hospital teaching status, and Medicaid/Private Insurance to be significant risk factors for readmission to a different hospital. The five most common disease readmission groups found were “other vascular procedures”, amputation, sepsis, heart failure, and post op infections.
Conclusions
Previously unreported, one in four readmissions after lower extremity vascular procedures occur at a different hospital. This fragmentation of care increases mortality rates, and has serious implications for guiding outcome and quality measures. Of equal concern is the fact that we may be using flawed data when counseling patients. Further study into the social and patient specific risk factors may provide a way to prevent these readmissions and improve outcomes in this difficult patient population.

Table 1. 30/365 Day Readmission to Index and Different Hospital Based on Patient Characteristics
Total30 Day RA30 Day RA to DH%365 Day RA365 Day RA to DH%
Characteristicn% n% n%n%n%
Total927691001446715.5296120.473120333.64777624.92
Admission Dx
Claudication3305535.629668.9761020.57710521.49189026.60
CLI5971464.41150119.2235120.442409840.36588624.43
Interventions
Angioplasty3999743.1678016.9189928.011508837.72488132.35
Peripheral Bypass Graft4546949.0700615.4130418.611481732.59354723.94
Aortofemoral Bypass51815.661311.89916.15114022.0026723.42
Sex
Female3699239.9619516.7127620.601305335.29330425.31
Male5526859.6820514.8167320.391799332.56443424.64
Age
>655795362.5934716.1200021.402008834.66512625.52
<653430637.0505314.794818.761095831.94261223.84
CCI
CCI 1-24692451.5537111.4100618.731236026.34311525.20
CCI 3-53853542.7764919.8166721.791595641.41398824.99
CCI >551905.8138026.527620.00273052.6063523.26
LOS
LOS>7 days2739030.8663624.2133920.181314447.9931227.44
LOS<7days6325869.2776412.2161020.741790228.30742624.83
*Results have p values <0.01

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