Association Between Readmission Care Fragmentation and Outcomes after Interventions for Peripheral Arterial Disease.

Overview

abstract

OBJECTIVE: Lower extremity revascularization (LER) for peripheral artery disease (PAD) is complicated by the frequent need for readmission. However, it is unclear if readmission to a non-index LER facility (i.e., a facility different from the one where the LER was performed) compared to the index LER facility is associated with worse outcomes. METHODS: This was a national cohort study of older adults who underwent open, endovascular, or hybrid LER for PAD (January 1, 2010 - December 31, 2018) in the Vascular Quality Initiative who were readmitted within 90-days of their vascular procedure. This dataset was linked to Medicare claims and the American Hospital Association Annual Survey. The primary outcome was 90-day mortality and the secondary outcome was major amputation at 90-days after LER. The primary exposure was the location of the first readmission after LER (categorized as occurring at the index LER facility versus a non-index LER facility). Generalized estimating equations logistic regression models were used to assess the association between readmission location and 90-day mortality and amputation. RESULTS: Among 42,429 patients who underwent LER, 33.0% were readmitted within 90-days. Of those who were readmitted, 27.3% were readmitted to a non-index LER facility and 42.2% of all readmissions were associated with procedure-related complications. Compared to patients readmitted to the index LER facility, those readmitted to a non-index facility had a lower proportion of procedure-related reasons for readmission (21.5% vs 50.1%, p<0.001). Most of the patients readmitted to a non-index LER facility lived further than 31 miles from the index LER facility (39.2% vs 19.6%, p<0.001) and were readmitted to a facility with a total bed size under 250 (60.1% vs 11.9%, p<0.001). Readmission to a non-index LER facility was not associated with 90-day mortality or 90-day amputation. However, readmission for a procedure-related complication was associated with major amputation (90-day amputation: aOR 3.33 [95% CI, 2.89-3.82]). CONCLUSION: Readmission after LER for a procedure-related complication is associated with subsequent amputation. This suggests that quality improvement efforts should focus on understanding various types of procedure-related failure after LER and its role in limb salvage.