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Factors Associated With Nonhome Discharge After Endovascular Aneurysm Repair
Sabrina Straus1, Jorge Gomez-Mayorga, MD
1, Andrew Sanders, MD
1, Divya Yadavalli, MD
1, Sara Allievi, MD
1, Katharine McGinigle, MD
2, Lars Stangenberg, MD
1, Marc Schermerhorn, MD
1.
1BIDMC, Boston, MA, USA,
2University of North Carolina School of Medicine, Chapel Hill, NC, USA.
Objective: Non-home discharge (NHD) has implications for patient care, readmission, and long-term mortality; nevertheless, existing literature lacks information regarding risks associated with NHD for patients undergoing endovascular aneurysm repair (EVAR). We aimed to identify preoperative factors influencing NHD after EVAR.
Methods: We identified adult patients who underwent elective EVAR in the Vascular Quality Initiative registry (2003-2022). We excluded patients who were not living at home preoperatively, and patients who died perioperatively or had missing domicile information. Our primary outcome was NHD which included discharge to a rehabilitation unit, skilled nursing facility, or other hospital. Multivariable logistic regression was used to identify preoperative factors associated with NHD. Kaplan-Meier methods and Cox-regression analyses were used to evaluate the impact of NHD on 5-year survival.
Results: The cohort included 63,042 patients, of which 832 died perioperatively and 418 had missing discharge information. From the remaining 61,792 patients, 3,155 (5.1%) had NHD. NHD patients were more likely to be older (78.4±8.15 vs 73.1±8.46), female (33.7% vs 18.2%), non-white (16.0% vs 11.7%), and have prior comorbidities. NHD patients had higher rates of postoperative complications (acute kidney disease: 11.9% vs 2.0%; myocardial infarction: 3.8% vs 0.5%; reintervention: 4.7% vs 0.5%). Multivariable analysis revealed many preoperative characteristics were associated with higher odds of NHD most notably, age (per additional decade: OR=2.14, 95% CI:1.95-2.37; P<.001), female sex (OR=1.62, 95% CI:1.40-1.88; P<.001) and aneurysm diameter >65mm (OR=1.68, 95% CI:1.35-2.10; P<.001), along with potentially modifiable factors including: anemia, COPD, CHF, weight, and diabetes (Table). In contrast, aspirin, statin, and ACE-inhibitor/ARB were associated with lower odds of NHD. Finally, NHD was associated with higher hazards of 5-year mortality (40% vs. 14%, aHR=2.13, 95% CI:1.86-2.44; P<.001).
Conclusions: Several factors were associated with higher odds of NHD, including non-modifiable factors such as female sex and larger aortic diameter, and potentially modifiable factors such as anemia, COPD, CHF, weight, and diabetes. Special attention should be given to populations with non-modifiable factors, and efforts at optimizing medical conditions with higher NHD likelihood seems appropriate to improve patient outcomes and quality of life.
Table: Pre-operative factors associated with non-home discharge in EVAR patients (Reference: home discharge)
| | | |
| OR | 95% CI | p-value |
| Age (per additional decade) | 2.14 | 1.95, 2.37 | <.001 |
| Female | 1.62 | 1.40, 1.88 | <.001 |
| White | 0.74 | 0.62, 0.90 | .002 |
| BMI Category (BMI) | | | |
| Normal (18.5-24) | - | - | |
| Underweight (<18.5) | 1.52 | 1.12, 2.03 | .006 |
| Overweight (25-29) | 0.85 | 0.72, 0.99 | .042 |
| Obese (30-39) | 0.93 | 0.77, 1.12 | 0.4 |
| Morbidly Obese (>40) | 1.58 | 1.09, 2.23 | .013 |
| Prior diabetes | 1.25 | 1.06, 1.47 | .008 |
| Prior myocardial infarction | 1.09 | 0.92, 1.28 | .3 |
| Prior congestive heart failure | 1.42 | 1.18, 1.70 | <.001 |
| Current smoker | 0.86 | 0.69, 1.07 | .2 |
| Prior chronic obstructive pulmonary disease | 1.53 | 1.33, 1.77 | <.001 |
| Renal function eGFR (ml/min/1.73 m²) | | | |
| > 45 | - | - | |
| 30-44 | 1.05 | 0.87, 1.27 | .6 |
| <30 | 1.33 | 1.05, 1.68 | .014 |
| Preoperative dialysis | 1.45 | 0.42, 3.76 | .5 |
| Anemia (<10 g/dL) | 2.55 | 2.07, 3.12 | <.001 |
| Aspirin | 0.8 | 0.69, 0.92 | .002 |
| Statin | 0.85 | 0.73, 0.99 | .03 |
| Beta Blocker | 1.07 | 0.93, 1.24 | .3 |
| P2Y Inhibitor | 0.98 | 0.8, 1.20 | 0.9 |
| Prior ACE inhibitor / ARB | 0.86 | 0.75, 0.98 | .03 |
| Prior anticoagulant | 1.08 | 0.90, 1.29 | .4 |
| Center Volume | | | |
| Medium (20-80%) | - | - | |
| Low (<20%) | 0.92 | 0.77, 1.10 | .4 |
| High (>80%) | 1.07 | 0.91, 1.26 | .4 |
| AAA diameter >65 mm | 2.03 | 1.73, 2.38 | <.001 |
| AAA Neck angle > 60 degrees | 1.09 | 0.85, 1.39 | .5 |
| Aortic neck diameter >30 mm | 1.27 | 0.99, 1.61 | .057 |
| Aortic Neck angle > 60 degrees | 1.32 | 0.97, 1.79 | .073 |
| Short aortic neck (length <15 mm) | 1.29 | 1.07, 1.54 | .006 |
| Prior EVAR | 0.52 | 0.45, 0.60 | <.001 |
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