title: Risk factors and indications for readmission after lower extremity amputation in the American College of Surgeons National Surgical Quality Improvement Program.
abstract: BACKGROUND
  Postoperative readmission, recently identified as a marker of hospital quality in the Affordable Care Act, is associated with increased morbidity, mortality, and health care costs, yet data on readmission after lower extremity amputation (LEA) are limited. We evaluated risk factors for readmission and postdischarge adverse events after LEA in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP).
  
  
  METHODS
  All patients undergoing transmetatarsal (TMA), below-knee (BKA), or above-knee amputation (AKA) in the 2011-2012 NSQIP were identified. Independent predischarge predictors of 30-day readmission were determined by multivariable logistic regression. Readmission indication and reinterventions, available in the 2012 NSQIP only, were also evaluated.
  
  
  RESULTS
  We identified 5732 patients undergoing amputation (TMA, 12%; BKA, 51%; AKA, 37%). Readmission rate was 18%. Postdischarge mortality rate was 5% (TMA, 2%; BKA, 3%; AKA, 8%; P < .001). Overall complication rate was 43% (in-hospital, 32%; postdischarge, 11%). Reoperation was for wound-related complication or additional amputation in 79% of cases. Independent predictors of readmission included chronic nursing home residence (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.0-1.7), nonelective surgery (OR, 1.4; 95% CI, 1.1-1.7), prior revascularization/amputation (OR, 1.4; 95% CI, 1.1-1.7), preoperative congestive heart failure (OR, 1.7; 95% CI, 1.2-2.4), and preoperative dialysis (OR, 1.5; 95% CI, 1.2-1.9). Guillotine amputation (OR, 0.6; 95% CI, 0.4-0.9) and non-home discharge (OR, 0.7; 95% CI, 0.6-1.0) were protective of readmission. Wound-related complications accounted for 49% of readmissions.
  
  
  CONCLUSIONS
  Postdischarge morbidity, mortality, and readmission are common after LEA. Closer follow-up of high-risk patients, optimization of medical comorbidities, and aggressive management of wound infection may play a role in decreasing readmission and postdischarge adverse events.
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: Thomas
authors.initials: T
authors.lastname: Curran
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: Jennifer Q
authors.initials: JQ
authors.lastname: Zhang
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: Ruby C
authors.initials: RC
authors.lastname: Lo
authors.affiliation: Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Margriet
authors.initials: M
authors.lastname: Fokkema
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: John C
authors.initials: JC
authors.lastname: McCallum
authors.affiliation: Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Dominique B
authors.initials: DB
authors.lastname: Buck
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Darling
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass. Electronic address: mscherme@bidmc.harvard.edu.
authors.forename: Marc L
authors.initials: ML
authors.lastname: Schermerhorn
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical / Q000009:adverse effects* / Q000401:mortality / Q000592:standards; D016009:Chi-Square Distribution; D015897:Comorbidity; D005260:Female; D006801:Humans; D016015:Logistic Models; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010351:Patient Discharge; D010359:Patient Readmission / Q000592:standards; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality / Q000601:surgery; D058996:Quality Improvement / Q000592:standards; D019984:Quality Indicators, Health Care / Q000592:standards; D012086:Reoperation; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States