An Evaluation Preoperative Hemoglobin A1c And The Association With Readmission After Lower Extremity Vascular Procedures
Jonathan Bath, MD, Jamie B. Smith, MS, Zachary A. Carel, BA, Robin L. Kruse, PhD, Todd R. Vogel, MD, MPH.
University of Missouri Hospital & Clinics, Columbia, MO, USA.
Objectives: Limited data evaluating pre-operative hemoglobin A1c (HbA1c) in patients undergoing vascular procedures for peripheral arterial disease (PAD) exists. This study evaluated the relationship of preoperative HbA1c on outcomes after open and endovascular lower extremity (LE) vascular procedures for peripheral artery disease (PAD).
Methods: We selected patients with PAD admitted for elective LE procedures between September 2008 and December 2015 from the Cerner Health Facts® database using ICD-9-CM diagnosis and procedure codes. Bivariable analysis and multivariable logistic models examined the association of patient characteristics, procedure type, and preoperative HbA1c (normal < 7%, high ≥ 7%) with postsurgical outcomes that included infection, renal failure, respiratory or cardiac complications, length of stay (LOS), in-hospital mortality, and readmission.
Results: 4,087 patients underwent a LE vascular procedure for PAD, 2,461 (60.2%) with a preoperative HbA1c recorded. The cohort was mostly male (60%), white (73%), and underwent endovascular intervention (77%). Patients with high HbA1c levels were more likely of black race (p < .02) and had significantly higher comorbidity (p < .0001). Elevated HbA1c was associated with diabetes (p < .0001), infections (p < .04), and cellulitis (p < .05). Multivariable logistic regression (adjusting for patient, hospital, and procedural characteristics) revealed that elevated HbA1c was significantly associated with 30-day readmission (OR = 1.32, 95% CI = 1.04-1.69), but was not associated with in-hospital infections, respiratory or cardiac complications, LOS, or in-hospital mortality. A diagnosis of diabetes alone was not predictive of complications or readmission.
Conclusions: HbA1c represents an important clinical marker for future readmission after lower extremity procedures and may be a marker for poor glucose control after discharge leading to 30-day readmission. Elevated HbA1c levels were not associated with in-hospital complications or in-hospital mortality suggesting that glucose levels are better controlled during hospitalization. Patients undergoing LE procedures for PAD should have HbA1c levels evaluated pre and post discharge. Consideration to deferring elective procedures with an elevated HbA1c is warranted until improved glucose control is achieved in the outpatient setting as HbA1c represents a possible indicator for outpatient complications and subsequent readmission.
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