Objective
To determine the frequency, causes, predictors, and consequences of 30-day readmission after abdominal aortic aneurysm (AAA) repair.
Summary Background Data
CMS will soon reduce total Medicare reimbursements for hospitals with higher-than-predicted 30-day readmission rates after vascular surgical procedures including AAA repair. However, causes and factors leading to readmission in this population have never before been systematically analyzed.
Methods
We analyzed elective AAA repairs over a two-year period from the CMS Chronic Conditions Warehouse, a 5% national sample of Medicare beneficiaries.
Results
2481 patients underwent AAA repair – 1502 endovascular (EVAR) and 979 open. 30-day readmission rates were equivalent for EVAR (13.3%) and open repair (12.8%). While wound complication was the most common reason for readmission after both procedures, the relative frequency of other causes differed – e.g., bowel obstruction was common following open repair and graft complication after EVAR. In multivariate analyses, preoperative comorbidities had a modest effect on readmission; however, postoperative factors including serious complications leading to prolonged length of stay and discharge destination other than home had a profound influence on the probability of readmission. The one-year mortality in readmitted patients was 23.4% versus 4.5% in those not readmitted (p<0.001).
Conclusions
Early readmission is common after AAA repair. Adjusting for comorbidities, postoperative events predict readmission, suggesting that proactively preventing, detecting, and managing postoperative complications may provide an approach to decreasing readmissions, with the potential to reduce cost and possibly enhance long-term survival.
from 9.8% to 5.5% (P ¼ .004), and 1-year major amputation decreased from 25.4% to 18.2% (P < .001), with a corresponding odds ratio of 0.65 (95% CI, 0.517-0.838; P < .0001) as the volume increased. An increase in the chance of a revision surgery (10.6% vs 8.2%, P < .001) was seen with higher volume, with an increased odds ratio of 1.031 (95% CI, 1.005-1.057; P ¼ .018).Comment: Although the 30-day mortality for leg bypass is quite high in this series, this is another bit of evidence that outcomes for open vascular surgical procedures are better in hospitals with higher volumes of such procedures. The data have some limitations because it is unclear whether every procedure analyzed was an additional bypass, followed a failed endovascular procedure, or was a vein or prosthetic bypass. There are some additional oddities in the data, in that 54% of the patients treated with femoral distal bypass were supposedly treated for claudication. Nevertheless, the relationship between increasing volume and favorable outcomes for LEAB seems statistically solid. The data also suggest that benefits for limb salvage may be partly due to increased reintervention rates in higher-volume hospitals with perhaps better resources and willingness to attempt revisions rather than move to amputation.
Conclusions: Non-ST-elevation myocardial infarction (NSTEMI) is not a benign event after carotid endarterectomy (CEA) or carotid artery stent (CAS) placement.Summary: Most postoperative myocardial infarctions are NSTEMIs. The rates of periprocedural NSTEMI are not routinely measured after CEA or CAS. In this paper, the authors sought to evaluate the frequency of NSTEMI after CEA or CAS in overall clinical practice and determine relationships with in-hospital outcomes. NSTEMI frequency was determined using the Nationwide Inpatient Survey from 2002 to 2009. In-hospital outcomes assessed included mortality and composite of stroke, cardiac events, and mortality data. Of 1,083,688 patients who underwent CEA or CAS, 11,341 (1%) had documented NSTEMI during their hospitalization. With adjustment for constitutional variables and risk factors, NSTEMI was associated with higher rates of in-hospital mortality (odds ratio, 8.6; 95% confidence interval, 7.0-10.7; P # .001) and higher rates of the composite end point of stroke, cardiac events, and death (odds ratio, 14.6; 95% confidence interval, 13.0-16.5; P # .0001).Comment: The findings demonstrate perioperative NSTEMI after CEA or CAS is infrequent. In fact, the rate seems lower than expected, likely reflecting the limitations of the database used for the study. However, it does appear that patients with NSTEMI after CEA or CAS may be more likely to have in-hospital adverse outcomes and therefore a significantly increased burden of health care resource use. These data do not indicate NSTEMI was the cause of the adverse outcomes after CEA or CAS but do suggest that it is a mark of more overall postoperative morbidity severity after CEA or CAS.
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