Readmission for Critical Limb Ischemia Common and Largely Unplanned

Readmission rates among patients with chronic limb ischemia (CLI) are nearly 50% at 6 months and most of them are unplanned, new research suggests.

“That is a staggering number,” the study’s lead author, Shikhar Agarwal, MD, MPH (Geisinger Medical Center, Danville, PA), told TCTMD. “The other really important part of this is that CLI-related readmissions are only in part related to vascular disease. Many of these readmissions that we saw were related to comorbidities such as diabetes or sepsis, which obviously go along with the disease process. What it tells us is that we need to focus not only on treating the vascular illness in these patients, but also make sure we are taking care of their comorbidities.”

For the study, being published in the April 18, 2017, issue of the Journal of the American College of Cardiology, researchers looked at data from 212,241 CLI patients included in State Inpatient Databases in Florida, New York, and California from 2009 to 2013.

Mortality Higher When Admission Is Unplanned

At 30 days and 6 months, all-cause readmissions were 27.1% and 56.6%, respectively. Almost a quarter of the readmissions within 30 days were unplanned, while 47.7% that occurred within 6 months were unplanned. One-third of unplanned readmissions were due to primary CLI-related causes, with other reasons being postprocedure complications, septicemia, and diabetes-related nonvascular issues.

Patients who underwent surgical revascularization during the index hospitalization were more likely to be readmitted than those who underwent an endovascular procedure. Compared with planned admissions, unplanned returns to the hospital were associated with higher mortality.

Among the independent predictors of unplanned readmission at 6 months were age, female sex, black/Hispanic race, prior amputation, Charlson comorbidity index, and not being discharged directly home. 

There was a relationship between travel time and readmission as well, with patients who lived farther away having lower readmission rates. Agarwal said the study wasn’t powered to answer the question of why that happened and in fact, there was no indication that those patients had higher mortality than those who lived closer, but he said it may suggest the need to help those patients find physicians in their area who can oversee their CLI care since they may be either unable to return or unsure whether they need to do so.

Additionally, index length of stay was directly associated with risk of readmission. “That means that if you stayed in the hospital longer, you had a higher chance of readmission,” Agarwal said, noting that longer initial hospitalizations may simply be indicative of sicker patients from the start. “This may be a very easy way to predict whether you are going to be readmitted, so our feeling is that patients who are in the hospital longer the first time should be targeted with more intensive follow-up with either primary care doctors, cardiologists, or their vascular doctor to address the issues before they get out of control to the point that an unplanned readmission becomes necessary,” he observed.

Telemedicine Holds Promise in CLI

In an editorial accompanying the study, Mehdi H. Shishehbor, DO, PhD (Cleveland Clinic, Cleveland, OH), and Herbert D. Aronow, MD (Warren Alpert Medical School of Brown University, Providence, RI), stress that CLI treatment is complex and that while the “intent is to completely treat the condition during its index admission, complete healing of minor or major tissue loss after revascularization for CLI is an ongoing process whose resolution extends well beyond hospital discharge (frequently months).”

Shishehbor and Aronow also point out that reasons for readmissions in CLI patients are often difficult to parse, particularly in light of the fact that it is a disease that disproportionally impacts individuals in specific geographic regions who have lower socioeconomic status.

Reducing readmission rates, they say, will involve renewed focus on clinical factors that directly impact readmission likelihood, and improvement in communication and coordination between CLI teams and other healthcare providers who may encounter CLI patients but who may not be as adapt and educated in their care.

“The potential to remotely monitor wounds using digital photography, assess perfusion continuously with implantable oxygen sensors, and offer clinical input via virtual consultation is exciting and may herald a new era in CLI care,” they write.

For his part, Agarwal said he is a fan of telemedicine, noting that it is effective but underutilized. “We have to get used to these newer systems of care because they are convenient for the patient, they enable the patient to reach out to the physician earlier in the course of the disease, and they allow for more effective triage of the situation,” he told TCTMD. “But [telemedicine] does have a learning curve so the more you use it, the better you will get at it.”

The ability of patients with CLI to be seen by telemedicine consults even if they present to a local hospital without specialized vascular services, as the editorialists suggest, could go a long way in improving care, Agarwal added.

“We can connect to that patient through a telemedicine portal and we can examine them, talk to them, and make recommendations about whether they can be managed effectively in the local hospital or whether we need to transfer them,” he said.

Another potential benefit of telemedicine for patients with conditions such as CLI is that it may confer a feeling of empowerment. “We need ways that patients and their local physicians can feel empowered and less isolated,” Agarwal said. “Telemedicine is definitely one of these ways that we can do that.”