Beaulieu Robert J, Grimm Joshua C, Lyu Heather, Abularrage Christopher J, Perler Bruce A
Johns Hopkins Hospital, Baltimore, Md.
Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins Hospital, Baltimore, Md.
J Vasc Surg. 2015 Jul;62(1):101-5. doi: 10.1016/j.jvs.2015.02.021. Epub 2015 Mar 28.
One goal of the Patient Protection and Affordable Care Act is to reduce hospital readmissions, with financial penalties applied for excessive rates of unplanned readmissions within 30 days among Medicare beneficiaries. Recent data indicate that as many as 24% of Medicare patients require readmission after vascular surgery, although the rate of readmission after limited digital amputations has not been specifically examined. The present study was therefore undertaken to define the rate of unplanned readmission among patients after digital amputations and to identify the factors associated with these readmissions to allow the clinician to implement strategies to reduce readmission rates in the future.
The electronic medical and billing records of all patients undergoing minor amputations (defined as toe or transmetatarsal amputations using International Classification of Diseases, Ninth Revision, codes) from January 2000 through July 2012 were retrospectively reviewed. Data were collected for procedure- and hospital-related variables, level of amputation, length of stay, time to readmission, and level of reamputation. Patient demographics included hypertension, diabetes, hyperlipidemia, smoking history, and history of myocardial infarction, congestive heart failure, peripheral arterial disease, chronic obstructive pulmonary disease, and cerebrovascular accident.
Minor amputations were performed in 717 patients (62.2% male), including toe amputations in 565 (72.8%) and transmetatarsal amputations in 152 (19.5%). Readmission occurred in 100 patients (13.9%), including 28 (3.9%) within 30 days, 28 (3.9%) between 30 and 60 days, and 44 (6.1%) >60 days after the index amputation. Multivariable analysis revealed that elective admission (P < .001), peripheral arterial disease (P < .001), and chronic renal insufficiency (P = .001) were associated with readmission. The reasons for readmission were infection (49%), ischemia (29%), nonhealing wound (19%), and indeterminate (4%). Reamputation occurred in 95 (95%) of the readmitted patients, including limb amputation in 64 (64%) of the patients (below knee in 58, through knee in 2, and above knee in 4).
Readmission after minor amputation was associated with limb amputation in the majority of cases. This study identified a number of nonmodifiable patient factors that are associated with an increased risk of readmission. Whereas efforts to reduce unplanned hospital readmissions are laudable, payers and regulators should consider these observations in defining unacceptable rates of readmission. Further, although beyond the scope of this study, it is not unreasonable to assume that pressure to reduce readmission rates in the population of patients with extensive comorbidity may induce practitioners to undertake amputation at a higher level initially to minimize the risk of readmission for reamputation and associated financial penalties and thus deprive the patient the chance for limb salvage.
《患者保护与平价医疗法案》的一个目标是降低医院再入院率，对于医疗保险受益人中30天内计划外再入院率过高的情况会处以经济处罚。近期数据表明，多达24%的医疗保险患者在血管手术后需要再次入院，不过有限的手指截肢术后的再入院率尚未得到专门研究。因此，本研究旨在确定手指截肢术后患者的计划外再入院率，并找出与这些再入院相关的因素，以便临床医生未来实施降低再入院率的策略。
回顾性分析了2000年1月至2012年7月期间所有接受小截肢手术（根据《国际疾病分类》第九版编码定义为脚趾或经跖骨截肢）患者的电子病历和计费记录。收集了与手术和医院相关的变量、截肢水平、住院时间、再入院时间以及再次截肢水平的数据。患者人口统计学资料包括高血压、糖尿病、高脂血症、吸烟史以及心肌梗死、充血性心力衰竭、外周动脉疾病、慢性阻塞性肺疾病和脑血管意外病史。
717例患者接受了小截肢手术（男性占62.2%），其中565例（72.8%）为脚趾截肢，152例（19.5%）为经跖骨截肢。100例患者（13.9%）再次入院，其中28例（3.9%）在30天内，28例（3.9%）在30至60天之间，44例（6.1%）在首次截肢后60天以上。多变量分析显示，择期入院（P <.001）、外周动脉疾病（P <.001）和慢性肾功能不全（P =.001）与再入院相关。再入院原因包括感染（49%）、缺血（29%）、伤口不愈合（19%）和不明原因（4%）。95例（95%）再入院患者进行了再次截肢，其中64例（64%）患者进行了肢体截肢（膝下截肢58例，膝上截肢2例，大腿截肢4例）。
在大多数情况下，小截肢术后再入院与肢体截肢相关。本研究确定了一些与再入院风险增加相关的不可改变的患者因素。虽然努力降低计划外医院再入院率值得称赞，但支付方和监管机构在定义不可接受的再入院率时应考虑这些观察结果。此外，尽管超出了本研究的范围，但可以合理假设，在患有广泛合并症的患者群体中，降低再入院率的压力可能会促使从业者最初进行更高水平的截肢，以尽量减少再次截肢导致的再入院风险以及相关的经济处罚，从而剥夺患者保肢的机会。
