title: Discharge Destination after Elective Femoropopliteal Bypass in Patients without Critical Ischemia.
abstract: Femoropopliteal bypass (FPB) remains a widely accepted treatment option for symptomatic leg ischemia, even in patients without features of critical limb ischemia (CLI). These patients are revascularized to improve symptoms of exertional limb pain and the goal of such treatment is to increase their ability to ambulate within the community. Therefore, the anticipated initial discharge disposition for a patient without CLI undergoing FPB is back to their home. This study examined the disposition at initial discharge of such patients. Data from the 2012 National Surgical Quality Improvement Program registry was queried for all elective FPB performed in patients without CLI. Analysis was limited to patients surviving to initial discharge who were living independently at home before surgery. Initial disposition was defined as to HOME or to a FACILITY (either rehabilitation or skilled nursing); these constituting the study groups. Univariate analysis and multivariable logistic regression were performed to identify patient risk factors for failure to discharge to home. In-hospital and postoperative events were also recorded and compared. Significance was defined at P ≤ 0.05. In National Surgical Quality Improvement Program 2012, 1060 cases of elective FPB in patients without CLI were found. The mean± SD age of the population was 65 ± 9 years; 359 (34%) of patients were female; 198 (19%) had a reported race other than white; and most (893, 84%) had hypertension. 60 (6%) patients failed to discharge to home (26 to rehabilitation, 34 to skilled nursing). On univariate analysis, age (FACILITY 68 ± 11 years vs HOME 65 ± 9 years, P = 0.009), female gender (55% vs 37%, P < 0.001), nonwhite race (30% vs 18%, P = 0.007), and a history of diabetes (48% vs 33%, P = 0.01), dialysis (5% vs 1.3%, P = 0.02) congestive heart failure (5% vs 1.1%, P = 0.01), or a stroke (cerebrovascular accident, 5% vs 2.6%, P = 0.01) were found to predict failure to discharge to home. On multivariate analysis, female gender [odds ratio (OR) = 2.4, 95% confidence interval = 1.4-4.1, P = 0.002], and a history of congestive heart failure (OR = 4.7, 1.2-18, 0.03] or cerebrovascular accident (OR = 3.4, 1.9-9.4, 0.02) independently predicted failure to discharge to home. FACILITY patients had higher rates of infectious complications (8.3% vs 1.4%, P < 0.001), myocardial infarction (3.3% vs 0.8%, P = 0.05), operative transfusion (22% vs 5.8%, P < 0.001), and unplanned reoperation (17% vs 2.4%, P < 0.001) during their initial hospitalization. Elective FPB results in a low but not negligible failure of initial return to the community in patients without CLI. Female gender and serious comorbidities predict initial discharge to a facility, which is associated with a complicated hospital course. Careful patient selection is important to achieve good outcomes in this population and furthermore study into the specific preoperative functional and socioeconomic factors predicting failure of early return to the community is warranted.
authors.affiliation: Vascular Surgery Service, Dwight David Eisenhower Army Medical Center, Fort Gordon, Georgia, USA.
authors.forename: David S
authors.initials: DS
authors.lastname: Kauvar
authors.forename: Candice L
authors.initials: CL
authors.lastname: Osborne
mesh_terms: D000368:Aged; D003266:Continuity of Patient Care / Q000458:organization & administration; D016208:Databases, Factual; D017558:Elective Surgical Procedures / Q000379:methods*; D005260:Female; D005263:Femoral Artery / Q000601:surgery; D005500:Follow-Up Studies; D006801:Humans; D007511:Ischemia / Q000503:physiopathology / Q000601:surgery*; D016015:Logistic Models; D035002:Lower Extremity / Q000098:blood supply* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010351:Patient Discharge; D011150:Popliteal Artery / Q000601:surgery; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome; D014654:Vascular Patency / Q000502:physiology; D014656:Vascular Surgical Procedures / Q000379:methods*