Thirty-Day Readmissions After Endovascular or Surgical Therapy for Critical Limb Ischemia

Study Questions:

What are the incidence, predictors, causes, and expense of all-cause 30-day readmission after hospitalization for critical limb ischemia (CLI) treated with endovascular or surgical therapy?

Methods:

The authors reviewed hospitalizations for a primary diagnosis of CLI during which patients underwent endovascular or surgical therapy (revascularization and/or amputation) and were discharged alive and were within the 2013-2014 Nationwide Readmissions Databases. Incidence, reasons, and costs of 30-day unplanned readmissions were determined. Hierarchical logistic regression models were used to identify independent predictors of 30-day readmissions.

Results:

There were 60,998 index CLI hospitalizations (mean age, 68.9 ± 11.9 years; 40.8% women; 24.6% for rest pain, 37.2% for ulcer, and 38.2% for gangrene). Thirty-day readmission rate was 20.4%. Presentation with ulcer or gangrene, age ≥65 years, female sex, large hospital size, teaching hospital status, known coronary artery disease, heart failure, diabetes mellitus, chronic kidney disease, anemia, coagulopathy, obesity, major bleeding, acute myocardial infarction, vascular complications, and sepsis were identified as independent predictors of 30-day readmission. Mode of revascularization was not independently associated with readmissions. Infections (23.5%), persistent or recurrent manifestations of PAD (22.2%), cardiac conditions (11.4%), procedural complications (11.0%), and endocrine issues (5.7%) were the most common reasons for readmission. The inflation-adjusted aggregate costs of 30-day readmissions for CLI during the study period were $624 million.

Conclusions:

Approximately one in five patients hospitalized for CLI and undergoing revascularization is readmitted within 30 days. Risk of readmission is influenced by CLI presentation, patient demographics, comorbidities, and in-hospital complications, but not by the mode of revascularization.

Perspective:

CLI was defined as chronic (≥2 weeks) ischemic rest pain, nonhealing wound/ulcers, or gangrene in one or both legs attributable to objectively proven occlusive PAD. The cost of all-cause 30-day re-hospitalization following treatment for CLI was over $10,000 per patient. The authors suggested that implementation of multidisciplinary CLI teams and wound teams, remote monitoring of wound healing and limb perfusion, and measures aimed at reducing procedural complications and infections may represent potential strategies to decrease readmissions and lower healthcare costs. Among the limitation of the design is not including deaths within the index hospitalization, patients may have had a prior procedure on the same limb >30 days prior to index admission, and that the sickest of patients were referred to the high-volume teaching hospitals.

Clinical Topics: Cardiac Surgery, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine

Keywords: Amputation, Anemia, Cardiac Surgical Procedures, Comorbidity, Coronary Artery Disease, Diabetes Mellitus, Endovascular Procedures, Gangrene, Geriatrics, Health Care Costs, Heart Failure, Ischemia, Myocardial Infarction, Myocardial Revascularization, Obesity, Patient Discharge, Patient Readmission, Peripheral Vascular Diseases, Renal Insufficiency, Chronic, Sepsis, Ulcer, Wound Healing, Vascular Diseases


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