Burden of Readmission High in PAD Patients Following Revascularization

More than one in six patients who undergo revascularization for PAD return to the hospital within 30 days, according to a nationwide cohort study. Researchers found few differences in readmission rates between hospitals, concluding instead that procedural and patient characteristics appear to be the primary drivers.

“We were really taken aback by how high this percentage [of readmissions] is across the country,” said the study’s lead author, Eric A. Secemsky, MD, MSc (Beth Israel Deaconess Medical Center, Boston, MA), in an interview with TCTMD. “These patients are complex, they have multiple comorbidities, and [they] tend to have had a lot of interaction with the healthcare system.”

The study was published online December 4, 2017, ahead of print in the Annals of Internal Medicine.

Infections, Sepsis Bring Many Patients Back

Secemsky and colleagues examined readmissions, causes, and costs in 61,969 PAD patients treated with surgical or endovascular revascularization at 1,085 US acute care hospitals participating in the Nationwide Readmissions Database.

The 30-day rate of unplanned readmission was 17.6%. The most frequent causes of unplanned readmissions were procedure-related complications (28%). Of these, more than half were due to infections directly associated with the revascularization procedure. Other common reasons for readmission were sepsis, diabetes complications, and gangrene. Additionally, procedure-related complications leading to readmission occurred at a higher rate among those treated with surgery compared with endovascular therapy (40.5% vs 16.3%).

Approximately one in five readmitted patients underwent another peripheral-artery revascularization or lower-extremity amputation, and 4.6% died. The median cost of a readmission was $11,013. Taken together, all readmissions amounted to a total cost of $401,112,036. Readmission costs by procedure type did not vary significantly.

Compared with patients who did not require readmission, those who did were more often older, female, on Medicare or Medicaid, resided in lower-income ZIP codes, and originated from counties with larger populations. Readmitted patients had more chronic comorbidities, including chronic limb ischemia, obesity, hypertension, congestive heart failure, diabetes, and renal disease.

Readmitted patients also differed from those who were not readmitted in that they had longer index hospitalizations (median 7 days vs 5 days) and were more often discharged to short-term, subacute nursing, or intermediate care facilities rather than directly home.

A subset of 31,538 patients in the study had critical limb ischemia (CLI). Among these patients, the 30-day rate of unplanned readmission was 21.3%. As with the study group as a whole, the primary cause of readmission in the CLI patients was procedural complications (25.6%), followed by diabetes complications, and sepsis.

Address Problems Early

The researchers also adjusted for case mix between hospitals and found only a modest influence on readmission. Secemsky noted that readmissions have become an important and much-studied component of healthcare that may be associated with financial penalties for hospitals with higher-than-expected rates. Although PAD revascularizations are not included in the Centers for Medicare & Medicaid Services’ readmission reduction plan, the agency has considered expanding it to include them, the study authors say.

To TCTMD, Secemsky said raising awareness of the high rate of readmissions is important, as is highlighting the need for patient-oriented interventions after discharge, such as routine phone calls and close clinic follow-up. These practices have been found to be effective in patients with heart failure and other conditions.

“Maybe we need to do these same kinds of things in PAD patients to make sure that we address any brewing concerns, including infection or bleeding complications,” he said. “We have to remember that having to be readmitted is very impactful on [patients’] daily quality of life and their ability to return to work. At the end of the day we want to improve both their care and quality of life.”