Lin M J, Baky F, Housley B C, Kelly N, Pletcher E, Balshi J D, Stawicki S P, Evans D C
Department of Surgery, St. Luke's University Health Network, Bethlehem, PA, USA.
Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA.
J Postgrad Med. 2016 Oct-Dec;62(4):216-222. doi: 10.4103/0022-3859.188548.
Clinical information continues to be limited regarding changes in the temporal risk profile for readmissions during the initial postoperative year in vascular surgery patients. We set out to describe the associations between demographics, clinical outcomes, comorbidity indices, and hospital readmissions in a sample of patients undergoing common extremity revascularization or dialysis access (ERDA) procedures. We hypothesized that factors independently associated with readmission will evolve from "short-term" to "long-term" determinants at 30-, 180-, and 360-day postoperative cutoff points.
Following IRB approval, medical records of patients who underwent ERDA at two institutions were retrospectively reviewed between 2008 and 2014. Abstracted data included patient demographics, procedural characteristics, the American Society of Anesthesiologists score, Goldman Criteria for perioperative cardiac assessment, the Charlson comorbidity index, morbidity, mortality, and readmission (at 30-, 180-, and 360-days). Univariate analyses were performed for readmissions at each specified time point. Variables reaching statistical significance of P< 0.20 were included in multivariate analyses for factors independently associated with readmission.
A total of 450 of 744 patients who underwent ERDA with complete medical records were included. Patients underwent either an extremity revascularization (e.g. bypass or endarterectomy, 406/450) or a noncatheter dialysis access procedure (44/450). Sample characteristics included 262 (58.2%) females, mean age 61.4 ± 12.9 years, 63 (14%) emergent procedures, and median operative time 164 min. Median hospital length of stay (index admission) was 4 days. Cumulative readmission rates at 30-, 180-, and 360-day were 12%, 27%, and 35%, respectively. Corresponding mortality rates were 3%, 7%, and 9%. Key factors independently associated with 30-, 180-, and 360-day readmissions evolved over the study period from comorbidity and morbidity-related issues in the short-term to cardiovascular and graft patency issues in the long-term. Any earlier readmission elevated the risk of subsequent readmission.
We noted important patterns in the temporal behavior of hospital readmission risk in patients undergoing ERDA. Although factors independently associated with readmission were not surprising (e.g. comorbidity profile, cardiovascular status, and graft patency), the knowledge of temporal trends described in this study may help determine clinical risk profiles for individual patients and guide readmission reduction strategies. These considerations will be increasingly important in the evolving paradigm of value-based healthcare.
关于血管外科患者术后第一年再次入院的时间风险概况变化，临床信息仍然有限。我们着手描述接受常见肢体血管重建或透析通路（ERDA）手术患者样本中的人口统计学、临床结局、合并症指数与医院再入院之间的关联。我们假设与再入院独立相关的因素将在术后30天、180天和360天的时间节点从“短期”决定因素演变为“长期”决定因素。
在获得机构审查委员会（IRB）批准后，对2008年至2014年间在两家机构接受ERDA手术的患者病历进行回顾性审查。提取的数据包括患者人口统计学、手术特征、美国麻醉医师协会评分、围手术期心脏评估的戈德曼标准、查尔森合并症指数、发病率、死亡率和再入院情况（30天、180天和360天）。对每个指定时间点的再入院情况进行单因素分析。P<0.20达到统计学显著性的变量纳入与再入院独立相关因素的多因素分析。
744例接受ERDA手术且病历完整的患者中，共有450例被纳入。患者接受了肢体血管重建手术（如旁路手术或动脉内膜切除术，406/450）或非导管透析通路手术（44/450）。样本特征包括262例（58.2%）女性，平均年龄61.4±12.9岁，63例（14%）急诊手术，中位手术时间164分钟。中位住院时间（首次入院）为4天。30天、180天和360天的累积再入院率分别为12%、27%和35%。相应的死亡率分别为3%、7%和9%。与30天、180天和360天再入院独立相关的关键因素在研究期间从短期的合并症和发病率相关问题演变为长期的心血管和移植物通畅问题。任何较早的再入院都会增加随后再入院的风险。
我们注意到接受ERDA手术患者医院再入院风险的时间行为存在重要模式。虽然与再入院独立相关的因素并不令人意外（如合并症情况、心血管状况和移植物通畅性），但本研究中描述的时间趋势知识可能有助于确定个体患者的临床风险概况并指导降低再入院的策略。在不断发展的基于价值的医疗保健模式中，这些考虑因素将变得越来越重要。
