Krafcik Brianna M, Komshian Sevan, Lu Kimberly, Roberts Lauren, Farber Alik, Kalish Jeffrey A, Rybin Denis, Siracuse Jeffrey J
Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
J Vasc Surg. 2017 Dec;66(6):1786-1791. doi: 10.1016/j.jvs.2017.07.120. Epub 2017 Sep 29.
Readmission rates are expected to have an increasing effect on both the hospital bottom line and physician reimbursements. Safety net hospitals may be most vulnerable. We examined readmissions at 30 days, 90 days, and 1 year in a large safety net hospital to determine the magnitude and effect of short- and long-term readmission rates after lower extremity infrainguinal bypass in this setting.
All nonemergent extremity infrainguinal bypass performed at a large safety net hospital between 2008 and 2016 were identified. Patient demographic, social, clinical, and procedural details were extracted from the electronic medical record. An analysis of patients readmitted at 30 days, 90 days, and 1 year was completed to determine the details of the readmission.
A total of 350 patients undergoing extremity infrainguinal bypass were identified. The most frequent indication was tissue loss (57%), followed by claudication (25.6%), and rest pain (17.4%). Patient insurance carriers included Medicare (61.7%), Medicaid (25.4%), and private (13%). The distal target was the popliteal and tibial artery in 52.6% and 47.4% cases, respectively. The majority of bypasses used autologous vein (73.1%). In-hospital complications included pulmonary complications (4.3%), urinary tract infection (3.1%), acute renal failure (2%), graft occlusion (2%), myocardial infarction (1.7%), bleeding (1.4%), surgical wound complications (1.1%), and stroke (0.9%). The 30-day readmission rate was 30% with the most common reasons for readmission being surgical wound complications, nonsurgical foot/leg wounds, nonextremity infectious causes, cardiac ischemia, and congestive heart failure. The 90-day readmission rate was 49.4% and the most common reasons for readmission from 31 to 90 days were nonsurgical foot/leg wounds, graft complications, surgical wound complications, cardiac ischemia, and contralateral leg morbidity. The readmission rate within 1 year was 72.2%. Readmission causes from 91 days to 1 year included graft complications, contralateral leg morbidity, nonextremity infectious, nonsurgical foot/leg wounds, cardiac ischemia, and congestive heart failure. A tibial bypass target was associated with 30-day (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.06-2.69; P = .029) and 90-day (OR, 1.77; 95% CI, 1.14-2.74, P = .011) readmission. Nonprivate insurance (OR, 2.31; 95% CI, 1.17-4.57, P = .016), and critical limb ischemia (OR, 1.77; 95% CI, 1.14-2.74; P = .035) were associated with 1-year readmission.
Short- and long-term readmission rates in a safety net setting are high. The 30-day rates in this study are higher than historically reported. This data sets baseline rates for 90-day and 1-year readmission for future analyses. Although the majority of short-term readmissions are related to the index procedure, long-term readmission rates are more frequently related to systemic comorbidities. Targeted patient interventions aimed at preventing the most common reasons for readmission may improve readmission rates, particularly among patients with nonprivate insurance. However, other risk factors, such as tibial target, may not be modifiable and a higher readmission rate may need to be accepted in this population.
再入院率预计会对医院的收支底线和医生的报销产生越来越大的影响。安全网医院可能最为脆弱。我们研究了一家大型安全网医院30天、90天和1年的再入院情况，以确定在这种情况下下肢腹股沟下旁路手术后短期和长期再入院率的幅度及影响。
确定了2008年至2016年期间在一家大型安全网医院进行的所有非急诊下肢腹股沟下旁路手术。从电子病历中提取患者的人口统计学、社会、临床和手术细节。完成了对30天、90天和1年再入院患者的分析，以确定再入院的详细情况。
共确定了350例行下肢腹股沟下旁路手术的患者。最常见的指征是组织缺失（57%），其次是间歇性跛行（25.6%）和静息痛（17.4%）。患者的医保类型包括医疗保险（61.7%）、医疗补助（25.4%）和私人保险（13%）。分别有52.6%和47.4%的病例其远端目标血管是腘动脉和胫动脉。大多数旁路手术使用自体静脉（73.1%）。住院并发症包括肺部并发症（4.3%）、尿路感染（3.1%）、急性肾衰竭（2%）、移植物闭塞（2%）、心肌梗死（1.7%）、出血（1.4%）、手术伤口并发症（1.1%）和中风（0.9%）。30天再入院率为30%，再入院最常见的原因是手术伤口并发症、非手术性足部/腿部伤口、非肢体感染性病因、心脏缺血和充血性心力衰竭。90天再入院率为49.4%，31至90天再入院最常见的原因是非手术性足部/腿部伤口、移植物并发症、手术伤口并发症、心脏缺血和对侧腿部病变。1年内再入院率为72.2%。91天至1年的再入院原因包括移植物并发症、对侧腿部病变、非肢体感染、非手术性足部/腿部伤口、心脏缺血和充血性心力衰竭。以胫动脉为旁路目标与30天（比值比[OR]，1.69；95%置信区间[CI]，1.06 - 2.69；P = .029）和90天（OR，1.77；95% CI，1.14 - 2.74，P = .011）再入院相关。非私人保险（OR，2.31；95% CI，1.17 - 4.57，P = .016）和严重肢体缺血（OR，1.77；95% CI，1.14 - 2.74；P = .035）与1年再入院相关。
在安全网环境下，短期和长期再入院率都很高。本研究中的30天再入院率高于以往报道。这些数据为未来分析设定了90天和1年再入院的基线率。尽管大多数短期再入院与初次手术相关，但长期再入院率更常与全身性合并症相关。针对预防最常见再入院原因的有针对性患者干预措施可能会提高再入院率，特别是在非私人保险患者中。然而，其他风险因素，如以胫动脉为目标血管，可能无法改变，在这一人群中可能需要接受较高的再入院率。
