Hidden Readmissions after Carotid Endarterectomy and Stenting.

BACKGROUND: Historically, carotid procedures incur a readmission rate of approximately 6%; however, these studies are not nationally representative and are limited to tracking only the index hospitals. We sought to evaluate a nationally representative database for readmission rates (including different hospitals) after both carotid endarterectomy (CEA) and carotid artery stenting (CAS) and determine risk factors for poor outcomes including postoperative mortality and myocardial infarction. METHODS: This study was a retrospective analysis utilizing the 2010-2014 Nationwide Readmissions Database to query patients aged >18 years undergoing CEA or CAS. Outcomes included initial admission mortality, and 30-day readmission, including mortality and myocardial infarction (MI). Univariable analysis of 39 demographic, clinical, and hospital variables was conducted with significance set at P < 0.05. Significant variables were included in a multivariable logistic regression to identify independent risk factors for readmission. Results were weighted for national estimates. RESULTS: There were 527,622 patients undergoing carotid procedures and 13% (n = 69,187) underwent CAS. The 30-day readmission rate was 7% (n = 35,782), and of those, 25% (n = 8,862) were readmitted to a different hospital. When controlling for other factors, CAS was a risk factor for mortality at both index admission (odds ratio [OR] 2.29 [2.11-2.49]) and 30-day readmission (OR 1.48 [1.3-1.69]) and 30-day readmissions at both index hospital (OR 1.11 [1.07-1.14]) and different hospital (OR 1.38 [1.29-1.48]). Readmission to a different hospital increased mortality risk (OR 1.45 [1.29-1.63]) but did not have an effect on MI. Postoperative infections comprised 15% of readmissions while 6% of all readmissions were for stroke. CONCLUSIONS: Previously unreported, one in 4 readmissions after carotid procedures occur at a different hospital and this fragmentation of care could increase mortality risk after carotid procedures particularly for CAS which was also an independent risk factor for postoperative mortality and readmissions. Further validation is required to decrease unnecessary hospital after carotid procedures.

Readmission and reinjury patterns in pediatric assault victims.

INTRODUCTION: Repeated pediatric assault should be a never event. The purpose of this study was to evaluate the readmission and reinjury patterns in pediatric victims of assault including readmissions to different hospitals across the US. METHODS: The 2010-2014 Nationwide Readmissions Database was queried for all nonelective admissions for patients under the age of 18 years. Primary outcomes were readmission or reinjury within 1 year. Results were weighted for national estimates. RESULTS: Assault-related injury occurred in 46,294 pediatric patients with 11.4% of patients being readmitted within 1 year. Of those readmitted, 35.2% presented to a different hospital. Reinjury within 1 year occurred in about 1% of patients, with 14.8% of those presenting to a different hospital. Age < 13 years, firearm-injury, ISS > 15, female gender, and leaving AMA were found to be independent prognostic indicators of readmission within 1 year among pediatric assault patients. CONCLUSION: Care of children who are admitted and discharged for assault injuries is more fragmented that previously thought. Quality metrics fail to capture this previously hidden population. Our results identify treatable factors which could improve the care of children after assault.

Readmissions to an alternate hospital in patients undergoing vascular intervention for claudication and critical limb ischemia associated with significantly higher mortality.

BACKGROUND: Hospital readmissions with 30 days after vascular surgical interventions have been associated with increased morbidity, mortality, and cost. Readmission rates, now a Centers for Medicare and Medicaid Services quality measure, have been studied in databases that have excluded certain payer types and states and have not accounted for readmission to a hospital different from that of the index admission. More accurate and nationally representative data are needed, because this fragmentation of care could lead to flawed conclusions. The purpose of the present study was to examine the incidence and risk factors for readmission to a nonindex hospital for patients admitted for claudication or critical limb ischemia (CLI). We also examined how this disruption of patient care affects mortality. METHODS: The 2013 to 2014 Nationwide Readmissions Database was queried for all patients admitted for claudication or CLI who had undergone angioplasty, lower extremity bypass, or aortobifemoral bypass. The outcomes of interest were 30- and 365-day readmission rates to any hospital, 30- and 365-day readmission rates to a nonindex hospital, and mortality rates. Multivariable logistic regression was used to identify risk factors for readmission to a nonindex hospital. The most common readmission diagnoses and diagnosis-related groups were identified. RESULTS: A total of 92,769 patients had been admitted with peripheral vascular disease (33,055 with claudication and 59,714 with CLI). The 30- and 365-day readmission rate was 8.97% and 21.49% and 19.26% and 40.36%, for claudication and CLI, respectively. Of the 30- and 365-day readmissions, 20.47% and 24.92% had occurred at a nonindex hospital, respectively. Significantly higher mortality rates were found for patients with 30- or 365-day readmissions to different hospitals (odds ratio, 1.4 and 1.8, respectively). Multivariable analysis revealed that procedural indication and angioplasty are not significant risk factors for readmission to a different hospital. However, female sex, length of stay >7 days, and Charlson Comorbidity Index >3 remained significant risk factors for nonindex readmissions. The most common disease groups for nonindex readmission were "septicemia and disseminated infections" (6.5%), "heart failure" (6.4%), "other vascular procedures" (6.1%), and "amputation of lower limb except toes" (4.0%). CONCLUSIONS: Previously unreported, ≥1 in 4 readmissions after lower extremity vascular procedures for peripheral vascular disease will occur at a nonindex hospital. This fragmentation of care is associated with increased mortality and has serious implications for guiding outcome and quality measures. With a sizeable portion of patients missed by current metrics, concern exists that providers are using flawed data. Further study into social- and patient-specific risk factors might provide methods to prevent these readmissions and improve outcomes in this difficult patient population.

Nationally Representative Readmission Factors Associated with Endovascular versus Open Repair of Abdominal Aortic Aneurysm.

BACKGROUND: Hospital readmissions are tied to financial penalties and thus significantly influence health-care policy. Many current studies on readmissions lack national representation by not tracking readmissions across hospitals. The recently released Nationwide Readmission Database is one of the most comprehensive national sources of readmission data available, making it an invaluable resource to understand this critically important health policy issue. METHODS: The Nationwide Readmission Database for 2013 and 2014 was queried for adult patients with abdominal aortic aneurysm (441.4) undergoing endovascular (39.71) or open (38.44) repair. Outcomes examined were overall/initial admission mortality and overall/30-day readmissions. Multivariate logistic regression for these outcomes was also performed on multiple readmission factors. RESULTS: Fifty-three thousand four hundred seventeen patients underwent abdominal aortic aneurysm repair (47,431 endovascular aortic repair [EVAR] versus 5,986 open surgical repair [OSR]). Significant differences were found for EVAR versus OSR on overall readmissions, initial admission cost, readmission costs, length of stay, days to readmission, and overall/initial admission mortality. Multivariate logistic regression analysis found that length of stay > 30, Charlson Comorbidity Index > 1, discharge disposition, and female sex were all significant predictors of 30-day readmission. Repair type was significantly associated with 30-day readmissions; however, it was not a significant factor for overall readmissions. CONCLUSION: There are significant differences in costs, prognosis, and readmission rates for EVAR versus OSR. Given that these differences are being used to create "acceptable" readmission rates, disbursement quotas among hospitals, and subsequent penalties for providers outside the expected rates, it is only prudent to obtain the most accurate information to guide those policies. LEVEL OF EVIDENCE: Care management/epidemiological, level IV.

Nationally Representative Readmission Factors in Patients with Claudication and Critical Limb Ischemia.

BACKGROUND: Hospital readmissions are associated not only with increased mortality, morbidity, and costs but also, with current health-care reform, tied to significant financial and administrative penalties. Some studies show that patients undergoing vascular surgery may have higher than average readmission rates. The recently released Nationwide Readmission Database (NRD) is the most comprehensive national source of readmission data, gathering discharge information from 22 geographically dispersed states, accounting for 51.2% of the total U.S. resident population and 49.3% of all U.S. hospitalizations. The aim of this study is to use the power of the NRD and obtain nationally representative readmission information for patients admitted with claudication or critical limb ischemia (CLI) who underwent revascularization procedures. METHODS: The NRD was queried for all patients admitted for claudication (International Classification of Diseases Ninth Revision [ICD-9] 440.21) or CLI (ICD-9 440.22-440.24) and who underwent percutaneous transluminal angioplasty, peripheral bypass, or aortofemoral bypass. Patient demographics, comorbidities, length of stay (LOS), mortality, readmission rates, and associated costs were collected. Univariable and multivariable logistic regression analysis was implemented on claudication and CLI groups on all outcomes of interest. The most common readmission diagnosis codes and diagnosis groups were also identified. RESULTS: A total of 92,769 patients were admitted for peripheral vascular disease (33,055 with claudication and 59,714 with CLI). The 30-day readmission/any readmission rate was 8.97%/21.49% and 19.26%/40.36%, for claudication and CLI, respectively. Significant differences were found for claudication and CLI, respectively, on initial cost of admission ($18,548 vs. $29,148, P < 0.001), readmission costs ($14,726 vs. $17,681 P < 0.001), LOS (4 days vs. 9 days, P < 0.001), days to readmission (73 days vs. 59 days, P < 0.001), mortality during initial admission (256 vs. 1,363, P < 0.001), and mortality during any admission (538 vs. 3,838, P < 0.001). Univariate and multivariate logistic regression analysis found that claudication, CLI, angioplasty, peripheral bypass, aortofemoral bypass, female sex, age >65, Charlson Comorbidity Index, LOS, and primary expected payer status were all significant predictors of 30-day and overall readmissions at varying degrees. The 5 most common disease readmission groups found were other vascular procedures (12.6%), amputation of lower limb except toes (6.3%), sepsis (5.4%), heart failure (4.9%) and postoperative or other device infections (4.8%). Of the abovementioned groups, the 4 most common diagnoses included "other postoperative infections," sepsis, atherosclerosis of native arteries with gangrene, and "other complications due to other vascular device, implant, or graft." CONCLUSIONS: Our results demonstrate that there is a significant difference in readmission rates, cost, and morbidity between patients admitted for claudication and CLI. Furthermore, based on regression analysis, there are multiple other clear risk factors associated with worse clinical and economic outcomes. Further study is needed to predict which patients will require increased vigilance during their hospital stay to prevent readmissions and worse outcomes. LEVEL OF EVIDENCE: Care management/epidemiological, level IV.