CHICAGO – As Medicare ratchets up penalties for readmissions and hospitals scrutinize procedures such as carotid interventions and lower extremity bypass that have traditionally high readmission rates, a four-phase model that assesses readmission risks could help vascular surgeons and their institutions keep patients from returning after vascular procedures, according to a presentation at a symposium on vascular surgery sponsored by Northwestern University.
“The rate of readmissions for vascular surgery is 50% higher than all other surgical interventions,” said Karen Ho, MD, of Northwestern University, Chicago. She noted that the reported readmission rates for abdominal aortic aneurysm (AAA) repair were 13.3% for endovascular and 12.8% for open (Ann Surg. 2012;256:595-605). For carotid endarterectomy (CEA), a large study reported a readmission rate of 9.6% (J Am Coll Cardiol. 2015;65:1398-1408), while a sampling of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database showed a 30-day readmission rate of 16.5% for lower extremity bypass (J Vasc Surg. 2014;60:1266-74).
Dr. Karen Ho
Dr. Ho said one model vascular specialists and hospitals could employ to curtail readmissions was first reported in 2012 by Benjamin S. Brooke, MD, of Dartmouth-Hitchcock Medical Center, Lebanon, N.H., and his colleagues (J Vasc Surg. 2012;56:556-62). This model focuses on the following four phases: 1) develop a deeper understanding of the patient’s preexisting health conditions before surgery; 2) target the in-hospital postoperative period for possible intervention; 3) focus on discharge planning; and 4) determine at the actual readmission event itself if the patient should go to an alternative setting.
“I think as surgeons we often focus on the patients, the procedure, and what goes on in the hospital, but discharge planning and execution is potentially just as important in preventing readmissions,” Dr. Ho said. “This includes things like medication reconciliation, involvement of family, the primary care doctor, the nursing home or rehab facility, and the timing and scheduling of follow-up visits.”
However, she noted that unaccounted factors can also contribute to readmission risk. These can include availability of family to provide support; history of substance abuse; functional status; socioeconomic status; and medical history.
Dr. Ho noted that understanding the reasons for readmission can help vascular specialists gain a deeper understanding of their underlying causes. For example, wound complications top the list in readmissions of numerous vascular procedures, including AAA repair and lower extremity revascularization, but other causes are linked to specific procedures. “If you look at the endovascular repair group in AAA repairs, aneurysm and graft complications were the third most common reason for unplanned 30-day readmission,” she said. A multivariate analysis showed that while preoperative comorbidities had a modest effect on readmission rates after AAA repair, postoperative factors such as complications extending patients’ length of stay and discharge to a setting other than home had a profound effect (Ann Surg. 2012;256:595-605).
In carotid procedures, Dr. Ho noted that carotid artery stenting and CEA had 30-day readmission rates of around 10% (Stroke. 2012;43:2408-16), although CEA seemed to have a slight advantage. Cardiac complications, headache, and bleeding were the top reasons for readmissions for carotid procedures, Dr. Ho said. “In a multivariate analysis, a history of coronary artery bypass and any postoperative complication were associated with readmission,” she said (Vasc Endovascular Surg. 2014;48:217-23).
However, many risk factors for readmission are nonmodifiable, such as patient age 80 and up, or a history of renal failure, heart failure, or diabetes – all characteristics that made patients more prone to readmission after carotid procedures.
Likewise in lower extremity revascularization, nonmodifiable risk factors – end-stage renal disease, heart failure, or tissue loss indication – were prime culprits for readmissions, Dr. Ho noted (J Vasc Surg. 2013;57:955-62). “But also the strongest predictors for readmission included surgical site infections postoperatively as well as graft complications,” she said.
“Risk prediction models for readmissions perform poorly, which makes it difficult to identify high risk and to implement clinically actionable plans to reduce readmissions,” Dr. Ho said. “It also raises the question of whether other important variables, such as social determinants, which may disproportionately affect disadvantaged patients, maybe should be included in these risk prevention models to increase their predicative value.”
Until or if Medicare adjusts its risk evaluation measures accordingly to more accurately reflect the influence of underlying variables such as socioeconomic status and medical history, vascular specialists and their institutions will be pressed to develop programs to reduce readmissions.
Dr. Ho had no relevant financial relationships to disclose.