title: Readmissions after complex aneurysm repair are frequent, costly, and primarily at nonindex hospitals.
abstract: OBJECTIVE
  Readmissions after complex vascular surgery are not well studied. We sought to determine the rate of readmission after thoracic and thoracoabdominal aortic aneurysm repair (TAA/TAAAR) at our institution and to identify risk factors for and costs of readmission.
  
  
  METHODS
  Using a prospectively collected institutional database in conjunction with a Maryland statewide database, we reviewed index admissions and early readmissions for all patients who underwent TAA/TAAAR between 2002 and 2013 at the Johns Hopkins Hospital. Only Maryland residents were included to capture readmissions to any Maryland hospital.
  
  
  RESULTS
  We identified 115 Maryland residents (58% men; mean age, 65 ± 1.2 years) undergoing TAA/TAAAR (57% open repair). Early readmissions were frequent and occurred in 29% of patients. Of the readmitted patients, 79% (P < .001) were not readmitted to the index hospital where their operation was performed. Readmitted patients were not significantly different from nonreadmitted patients in age, gender, race, aneurysm type, and index length of stay. They were not different in preoperative comorbidities (including coronary artery disease, diabetes mellitus, smoking, renal insufficiency, and pulmonary disease), postoperative neurologic, renal, and cardiovascular complications, or 30-day or 5-year mortality. Multivariable analysis showed that significant risk factors for readmission were open repair (odds ratio, 3.12; 95% confidence interval, 1.12-9.54; P = .03) and postoperative pneumonia (odds ratio, 4.31; 95% confidence interval, 1.28-15.4; P = .02). Readmitted patients had significantly lower average income compared with the nonreadmitted cohort (U.S. $62,000 ± $4000 vs $73,000 ± $3000; P = .04). Striking differences were seen between patients readmitted to the index hospital where the operation was performed, and those who were readmitted to a nonindex hospital: patients readmitted to the index hospital were readmitted mainly for aneurysm-related surgical issues, whereas patients readmitted to the nonindex hospital were readmitted for medical morbidities. An aneurysm-related intervention was required in 75% of patients readmitted to the index hospital vs in 9% of patients readmitted to the nonindex hospital. Readmissions to a nonindex hospital cost significantly less than to the index hospital (U.S. $20,000 ± $4400 vs $42,000 ± $8800; P = .03) and were not associated with increased overall mortality.
  
  
  CONCLUSIONS
  Early readmissions after TAA/TAAA repair are frequent and often occur at hospitals other than the index institution. Risk factors for readmission include open repair and postoperative pneumonia but not pre-existing patient comorbidities. Readmissions to nonindex hospitals were related to medical morbidities that were associated with fewer interventions and lower costs compared with the index hospital. Focusing on preoperative risk factors in this group of patients may not lead to reduction in readmissions. Minimizing nonsurgical complications may reduce post-TAA/TAAAR readmissions and the high costs associated with repeat care.
authors.affiliation: Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Colorado Denver, Aurora, Colo.
authors.forename: Natalia O
authors.initials: NO
authors.lastname: Glebova
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Caitlin W
authors.initials: CW
authors.lastname: Hicks
authors.affiliation: Johns Hopkins Health System, Baltimore, Md.
authors.forename: Ryan
authors.initials: R
authors.lastname: Taylor
authors.affiliation: Department of Urology, The James Buchanan Brady Urological Institute, Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Tosoian
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md.
authors.forename: Kristine C
authors.initials: KC
authors.lastname: Orion
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md.
authors.forename: K Dean
authors.initials: KD
authors.lastname: Arnaoutakis
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md.
authors.forename: George J
authors.initials: GJ
authors.lastname: Arnaoutakis
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, Md. Electronic address: jhblack@jhmi.edu.
authors.forename: James H
authors.initials: JH
authors.lastname: Black
mesh_terms: D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000191:economics* / Q000401:mortality / Q000601:surgery*; D015142:Baltimore; D016009:Chi-Square Distribution; D015897:Comorbidity; D005260:Female; D017722:Hospital Charges; D017721:Hospital Costs; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D010359:Patient Readmission / Q000191:economics*; D011183:Postoperative Complications / Q000191:economics* / Q000401:mortality / Q000628:therapy*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D062606:Tertiary Care Centers / Q000191:economics*; D013997:Time Factors; D014656:Vascular Surgical Procedures / Q000009:adverse effects* / Q000191:economics* / Q000401:mortality