Readmission Rates High After Revascularization for PAD

Tara Haelle

December 04, 2017

Rehospitalization is common among patients with peripheral arterial disease (PAD) after peripheral arterial revascularization, according to a study published online December 5 in the Annals of Internal Medicine. More than one sixth of patients were readmitted, costing more than $11,000 per readmission, primarily as a result of complications, sepsis, and diabetes.

"These findings highlight the large national health care burden resulting from readmissions after peripheral arterial revascularization," write Eric A. Secemsky, MD, from Beth Israel Deaconess Medical Center, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts, and colleagues.

"Procedural complications were the largest drivers of 30-day readmission, representing nearly 30% of all causes among the entire study group, 26% among patients with chronic limb ischemia, and 41% among those who had surgical interventions," the authors report. "Most of these complications were due to procedure-related infections."

An estimated 8.5 million people in the United States have PAD, usually older individuals with multiple comorbidities and lower anticipated life expectancies.

"There is increasing recognition that more intensive care of patients with [PAD] may reduce the need for amputation," the authors write. "As a result, the use of peripheral arterial revascularization has increased, and this increase has outpaced the reduction in bypass surgery."

The researchers used the Nationwide Readmissions Database to analyze data from 61,969 hospitalized adult patients with PAD at 1085 acute care hospitals. The data include uninsured patients and those from all payers, with information on more than 100 clinical and nonclinical variables for each hospitalization.

All patients had peripheral arterial revascularization and were discharged from January 1 to November 30, 2014.

"Peripheral arterial revascularization consisted of endovascular interventions, surgical interventions, and hybrid approaches (both interventions performed during the same admission)," the authors report. "Patients were allowed to contribute more than 1 admission as long as it occurred more than 30 days after any previously included admission or readmission."

Their analysis revealed that 17.6% of patients were readmitted within 30 days of discharge, mostly for procedural complications (28.0%), about half of which (14.7%) resulted from infections from revascularization. Readmissions resulting from complications were 40.5% for those who had surgical revascularization compared with 16.3% for those with endovascular revascularization.

Sepsis (8.3%), diabetes mellitus (7.5%), and gangrene (5.1%) were the next most common reasons for readmission. These readmissions were unplanned, but a separate 4.2% of patients had planned readmissions; the analysis excluded these patients. About one in five (21.0%) of the rehospitalized patients required another peripheral arterial revascularization (8.2%) or amputation of a lower extremity (11.7%), and 4.6% of readmitted patients died.

The unplanned readmission rate was slightly higher, at 21.3%, among the 31,538 patients with chronic limb ischemia (50.9% of all patients). Procedural complications (25.6%), diabetes (10.6%), and sepsis (9.8%) remained the biggest causes of rehospitalization. A quarter of these patients required another peripheral arterial revascularization or lower extremity amputation, and 5.2% died during rehospitalization.

To measure heterogeneity of risk for readmission across different hospitals, the researchers also measured risk-standardized readmission rates, which ranged from 10.0% to 27.3%. Readmissions cost a median $11,013 each overall (nationally weighted), but $12,394 among those with chronic limb ischemia. Median costs varied by procedure type as well: $10,541 for surgical revascularization, $11,567 for endovascular revascularization, and $11,796 for hybrid procedures.

Rehospitalized patients were more likely to be older, female, living in lower-income Zip codes, from higher populated counties, and insured by Medicare or Medicaid. They also had a median nine comorbidities compared with a median seven among those not readmitted. The most common comorbidities included chronic limb ischemia, obesity, hypertension, congestive heart failure, diabetes, and renal disease.

Readmitted patients also had longer and more costly index hospitalizations: a median 7 days costing a median $26,029 compared with 5 days costing $20,264 among those not readmitted.

"During the index hospitalization, readmitted patients had more in-hospital adverse events, specifically major bleeding, acute myocardial infarction, acute kidney injury, and sepsis," the authors report.

The study findings were limited by the possibility that the billing codes used to determine diagnoses and interventions led to misclassification bias. Further, the researchers could not determine which patients had died outside of the hospital after discharge.

"After standardizing for hospital case mix, we found a moderate range in hospital-specific readmission rates among the studied institutions," the authors write, noting that this differed from a previous study using Medicare data that found patient risk profiles played a bigger role in readmission rates. "Although penalizing outliers for excessive readmissions, as is mandated by the [Hospital Readmissions Reduction Program], may reduce readmission risk, the amount of variation seen in our analysis was not as great as that observed for currently penalized conditions, such as heart failure," they write.

The authors conclude by recommending improvements in postdischarge care for patients with PAD who undergo invasive treatment procedures.

The research was funded by the Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center. One author reports receiving personal fees from Abbott, Philips, and Cook, and one author reports receiving personal fees from RTI International, UpToDate, Evidera, and Freedman Healthcare Consulting. The remaining authors have disclosed no relevant financial relationships.

Ann Intern Med. Published online December 5, 2017. Abstract

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