Glebova Natalia O, Hicks Caitlin W, Taylor Ryan, Tosoian Jeffrey J, Orion Kristine C, Arnaoutakis K Dean, Arnaoutakis George J, Black James H
Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado Denver, Aurora, Colo.
Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md.
J Vasc Surg. 2014 Dec;60(6):1429-37. doi: 10.1016/j.jvs.2014.08.092. Epub 2014 Oct 12.
Readmissions after complex vascular surgery are not well studied. We sought to determine the rate of readmission after thoracic and thoracoabdominal aortic aneurysm repair (TAA/TAAAR) at our institution and to identify risk factors for and costs of readmission.
Using a prospectively collected institutional database in conjunction with a Maryland statewide database, we reviewed index admissions and early readmissions for all patients who underwent TAA/TAAAR between 2002 and 2013 at the Johns Hopkins Hospital. Only Maryland residents were included to capture readmissions to any Maryland hospital.
We identified 115 Maryland residents (58% men; mean age, 65 ± 1.2 years) undergoing TAA/TAAAR (57% open repair). Early readmissions were frequent and occurred in 29% of patients. Of the readmitted patients, 79% (P < .001) were not readmitted to the index hospital where their operation was performed. Readmitted patients were not significantly different from nonreadmitted patients in age, gender, race, aneurysm type, and index length of stay. They were not different in preoperative comorbidities (including coronary artery disease, diabetes mellitus, smoking, renal insufficiency, and pulmonary disease), postoperative neurologic, renal, and cardiovascular complications, or 30-day or 5-year mortality. Multivariable analysis showed that significant risk factors for readmission were open repair (odds ratio, 3.12; 95% confidence interval, 1.12-9.54; P = .03) and postoperative pneumonia (odds ratio, 4.31; 95% confidence interval, 1.28-15.4; P = .02). Readmitted patients had significantly lower average income compared with the nonreadmitted cohort (U.S. $62,000 ± $4000 vs $73,000 ± $3000; P = .04). Striking differences were seen between patients readmitted to the index hospital where the operation was performed, and those who were readmitted to a nonindex hospital: patients readmitted to the index hospital were readmitted mainly for aneurysm-related surgical issues, whereas patients readmitted to the nonindex hospital were readmitted for medical morbidities. An aneurysm-related intervention was required in 75% of patients readmitted to the index hospital vs in 9% of patients readmitted to the nonindex hospital. Readmissions to a nonindex hospital cost significantly less than to the index hospital (U.S. $20,000 ± $4400 vs $42,000 ± $8800; P = .03) and were not associated with increased overall mortality.
Early readmissions after TAA/TAAA repair are frequent and often occur at hospitals other than the index institution. Risk factors for readmission include open repair and postoperative pneumonia but not pre-existing patient comorbidities. Readmissions to nonindex hospitals were related to medical morbidities that were associated with fewer interventions and lower costs compared with the index hospital. Focusing on preoperative risk factors in this group of patients may not lead to reduction in readmissions. Minimizing nonsurgical complications may reduce post-TAA/TAAAR readmissions and the high costs associated with repeat care.
复杂血管手术后的再入院情况尚未得到充分研究。我们试图确定我院胸主动脉和胸腹主动脉瘤修复术（TAA/TAAAR）后的再入院率，并找出再入院的风险因素及费用。
利用前瞻性收集的机构数据库并结合马里兰州全州数据库，我们回顾了2002年至2013年在约翰霍普金斯医院接受TAA/TAAAR的所有患者的首次入院和早期再入院情况。仅纳入马里兰州居民以获取其在任何马里兰州医院的再入院情况。
我们确定了115名接受TAA/TAAAR的马里兰州居民（58%为男性；平均年龄65±1.2岁）（57%为开放修复）。早期再入院情况较为常见，29%的患者出现了早期再入院。在再入院患者中，79%（P<.001）未回到其接受手术的首次入院医院。再入院患者在年龄、性别、种族、动脉瘤类型和首次住院时间方面与未再入院患者无显著差异。他们在术前合并症（包括冠状动脉疾病、糖尿病、吸烟、肾功能不全和肺部疾病）、术后神经、肾脏和心血管并发症或30天或5年死亡率方面也无差异。多变量分析显示，再入院的显著风险因素为开放修复（比值比，3.12；95%置信区间，1.12 - 9.54；P =.03）和术后肺炎（比值比，4.31；95%置信区间，1.28 - 15.4；P =.02）。与未再入院队列相比，再入院患者的平均收入显著更低（62,000美元±4000美元对73,000美元±3000美元；P =.04）。在回到接受手术的首次入院医院的再入院患者与回到非首次入院医院的患者之间存在显著差异：回到首次入院医院的患者主要因与动脉瘤相关的手术问题而再入院，而回到非首次入院医院的患者则因内科疾病而再入院。回到首次入院医院的患者中有75%需要进行与动脉瘤相关的干预，而回到非首次入院医院的患者中这一比例为9%。回到非首次入院医院的费用显著低于回到首次入院医院的费用（20,000美元±4400美元对42,000美元±8800美元；P =.03），且与总体死亡率增加无关。
TAA/TAAA修复术后的早期再入院情况较为常见，且常发生在非首次入院机构的其他医院。再入院的风险因素包括开放修复和术后肺炎，但不包括患者术前的合并症。回到非首次入院医院与内科疾病相关，与首次入院医院相比，干预较少且费用较低。关注这组患者的术前风险因素可能不会降低再入院率。尽量减少非手术并发症可能会降低TAA/TAAAR术后的再入院率以及与重复治疗相关的高昂费用。
