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.

Does delayed operation increase morbidity and mortality? An analysis of emergency general surgery procedures.

BACKGROUND: Early operation is assumed to improve outcomes after emergency general surgery (EGS) procedures; however, few data exist to inform this opinion. We aimed to (1) characterize time-to-operation patterns among EGS procedures and (2) test the association between timing and patient outcomes. We hypothesize that patients receiving later operations are at greater risk for mortality and morbidity. METHODS: We performed a retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program data for adults aged 18 to 89 years who underwent nonelective intra-abdominal operations (appendectomy, cholecystectomy, small bowel resection, lysis of adhesions, and colectomy) from 2015 to 2020. The primary outcome was 30-day postoperative mortality. Secondary outcomes were serious morbidity and all morbidity. Admission-to-operation timing was calculated and classified as early (≤48 hours) or late (>48 hours). A multivariable logistic regression model adjusted risk estimates for age, comorbidities, frailty (Modified Frailty Index, 5-item score), and other confounders. RESULTS: Of 269,959 patients (mean age, 47.0 years; 48.0% male, 61.6% White), 88.7% underwent early operation, ranging from 70.36% (lysis of adhesions) to 98.67% (appendectomy). Unadjusted 30-day mortality was higher for late versus early operation (6.73% vs. 1.96%; p < 0.0001). After risk adjustment, late operation significantly increased risk for 30-day mortality (odds ratio [OR], 1.545; 95% confidence interval [CI], 1.451-1.644), serious morbidity (OR, 1.464; 95% CI, 1.416-1.514), and all morbidity (OR, 1.468; 95% CI, 1.417-1.520). This mortality risk persisted for all EGS procedures; risk of serious and any morbidity persisted for all procedures except cholecystectomy. CONCLUSION: Late operation significantly increased risk for 30-day mortality, serious morbidity, and all morbidity across a variety of EGS procedures. We believe that these findings will inform decisions regarding timing of EGS operations and allocation of surgical resources. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Pull-through procedure in children with Hirschsprung disease: A nationwide analysis on postoperative outcomes.

PURPOSE: No nationwide studies on hospital readmissions exist for children who have undergone pull-through operations for Hirschsprung disease. The study aim is to identify determinants of postoperative discharge outcomes and hospital readmissions in children with Hirschsprung disease. METHODS: The Nationwide Readmissions Database for 2010-2014 was queried for children (<18yo) with Hirschsprung disease and whom had undergone pull-through procedure, utilizing ICD-9 codes 751.3 and 48.40-69, respectively. Outcomes included complications and readmissions at 30-day and 1-year. Results were weighted for national estimates. RESULTS: The cohort consisted of 3635 patients, 75% male and 79% < 1 year of age. Readmission rates at 30 days and 1-year were 20% and 36%, respectively. Overall, the most common diagnoses for readmission were gastrointestinal disorders (46%) and infections (39%). All age groups had a ≥ 10% readmission rate for gastrointestinal disorders. Infants were more likely to be admitted for enterocolitis and infections (16% and 15%), while children (1-6 years old) were most commonly readmitted for electrolyte disturbances (12%). Total hospitalization cost was over $162 million with $24 million from readmissions. CONCLUSION: Pull-through procedure for Hirschsprung disease is associated with high readmissions and associated economic burden. Age specific interventions to prevent unnecessary readmissions could improve outcomes and curtail healthcare spending. TYPE OF STUDY: Retrospective Comparative Analysis. LEVEL OF EVIDENCE: Level III.