Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
OBJECTIVE
Readmission is associated with high mortality, morbidity, and cost. We used the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) to determine risk factors for readmission after lower extremity bypass (LEB).


METHODS
We identified all patients who received LEB in the 2011 ACS-NSQIP database. Multivariable logistic regression was used to assess independent predictors of 30-day readmission. We also identified our institutional contribution of LEB patients to the ACS-NSQIP from 2005 to 2011 to determine our institution's rate of readmission and readmission indications.


RESULTS
Among 5018 patients undergoing LEB, ACS-NSQIP readmission analysis was performed on 4512, excluding those whose readmission data were unavailable, who suffered a death on index admission, or who remained in the hospital at 30 days. Overall readmission rate was 18%, and readmission rate of those with NSQIP-captured complications was 8%. Multivariable predictors of readmission were dependent functional status (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.08-1.79), dyspnea (OR, 1.28; 95% CI, 1.02-1.60), cardiac comorbidity (OR, 1.46; 95% CI, 1.16-1.84), dialysis dependence (OR, 1.44; 95% CI, 1.05-1.97), obesity (OR, 1.28; 95% CI, 1.07-1.53), malnutrition (OR, 1.42; 95% CI, 1.12-1.79), critical limb ischemia operative indication (OR, 1.40; 95% CI, 1.10-1.79), and return to the operating room on index admission (OR, 8.0; 95% CI, 6.68-9.60). The most common postdischarge complications occurring in readmitted patients included wound complications (55%), multiple complications (22%), and graft failure (5%). Our institutional data contributed 465 LEB patients to the ACS-NSQIP from 2005 to 2012, with an overall readmission rate of 14%. Unplanned readmissions related to the original LEB (related unplanned) made up 75% of cases. The remainder 25% included readmissions that were planned staged procedures related to the original LEB (related planned, 11%) and admissions for a completely unrelated reason (unrelated unplanned, 14%). The most common readmission indications included wound infection (37%) and graft failure (10%). Readmissions were attributable to NSQIP-captured postdischarge complications in 44% of cases, an additional 44% had a non-NSQIP-defined reason for readmission, and the remainder (12%) included patients admitted for complications described in NSQIP but not meeting strict NSQIP criteria.


CONCLUSIONS
Readmissions are common after LEB. Optimization of select chronic conditions, closer follow-up of patients in poor health and those who required return to the operating room, and early detection of surgical site infections may improve readmission rates. Our finding that 25% of readmissions after LEB are not procedure related informs the broader discussion of how a readmission penalty affects vascular surgery in particular.
Department of Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
Jennifer Q
JQ
Zhang
Department of Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
Thomas
T
Curran
Department of Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
John C
JC
McCallum
Department of Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
Li
L
Wang
Department of Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
Mark C
MC
Wyers
Department of Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
Allen D
AD
Hamdan
Department of Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
Raul J
RJ
Guzman
Department of Vascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass. Electronic address: mscherme@bidmc.harvard.edu.
Marc L
ML
Schermerhorn
D000368:Aged; D016009:Chi-Square Distribution; D016208:Databases, Factual; D005260:Female; D006801:Humans; D016015:Logistic Models; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010359:Patient Readmission; D058729:Peripheral Arterial Disease / Q000401:mortality / Q000601:surgery*; D011183:Postoperative Complications / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D058996:Quality Improvement; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D058017:Vascular Grafting / Q000009:adverse effects* / Q000401:mortality