Missed Readmissions to a Different Hospital in Patients with Peripheral Vascular Disease Associated with Significantly Higher Mortality
Rennier A Martinez, Joshua Parreco, Reagan Lindsay Ross
University of Miami, West Palm Beach, FL
Currently there is a need for accurate nationally representative studies on 30 day readmissions. 30 day readmission rates, which is now a quality outcome measured by CMS, have been previously studied on databases that exclude some payer types, states or certain important data points. Furthermore, current studies do not take into account readmissions that occur a hospital different from index admission. This gap allows for potentially flawed data. The purpose of this study is to examine incidence and risk factors for readmission to a different hospital in patients admitted for claudication or critical limb ischemia. We will look at how this fragmentation of care impacts mortality, amputation rates and overall conclusions regarding currently accepted peripheral vascular disease metrics.
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.
92,769 patients were admitted with peripheral vascular disease (33,055 with claudication and 59,714 with CLI). According to Table 1, 30-day readmission/any readmission rate was 8.97%/21.49% and 19.26%/40.36%, for claudication and CLI, respectively. 20.47%/24.92% of 30/365 day readmissions respectively occurred at another hospital. Significantly higher mortality rates were found for patients with 30 day/365 day readmissions to different hospitals with OR 1.4 and 1.8 respectively (Table 2). Multivariable analysis revealed that procedural indication and angioplasty are not a significant risk factor for readmission to a different hospital while female sex, LOS>7 days, hospital teaching status, and Medicaid/Private Insurance remained significant risk factor for this type of readmission. The five most common disease readmission groups found were other vascular procedures (12.6%), amputation of lower limb except toes (6.3%), sepsis (5.4%), heart failure (4.9%) and post op or other device infections (4.8%). Of the above groups the four most common diagnoses included "other post op infections," sepsis, atherosclerosis of native arteries with gangrene, and "other complications due to other vascular device, implant or graft."
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, given that 25% of patients undergoing lower extremity vascular procedures are being missed by current metrics. 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|
|Total||30 Day RA||30 Day RA to DH%||365 Day RA||365 Day RA to DH%|
|Peripheral Bypass Graft||45469||49.0||7006||15.4||1304||18.61||14817||32.59||3547||23.94|
|*Results have p values <0.01|
|Table 2. Univariable and Multivariable Analysis for Mortality|
|95% CI||95% CI|
|Peripheral Bypass Graft||0.712||0.67||0.76||0.001||1.01||0.922||1.106||0.835|
|LOS >30 days||3.993||3.566||4.47||0.001||2.139||1.896||2.414||0.001|
|LOS >7 days||3.118||2.932||3.317||0.001||1.773||1.655||1.899||0.001|
|RA 30 Days||2.655||2.484||2.84||0.001||1.171||1.063||1.291||0.001|
|RA 30 Day to DH||2.974||2.652||3.34||0.001||1.413||1.171||1.706||0.001|
|RA 365 days||2.923||2.747||3.109||0.001||1.899||1.742||2.071||0.001|
|RA 365 days to DH||2.139||1.965||2.33||0.001||0.985||0.86||1.127||0.823|
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