Rates and predictors of readmission after minor lower extremity amputations

Abstract

OBJECTIVES One goal of the Patient Protection and Affordable Care Act is to reduce hospital readmissions, with financial penalties applied for excessive rates of unplanned readmissions within 30 days among Medicare beneficiaries. Recent data indicate that as many as 24% of Medicare patients require readmission following vascular surgery, although the rate of readmission following limited digital amputations has not been specifically examined. The present study was therefore undertaken to define the rate of unplanned readmission among patients following digital amputations, and to identify the factors associated with these readmissions to allow the clinician to implement strategies to reduce readmission rates in the future. METHODS The electronic medical and billing records of all patients undergoing minor amputations (defined as toe or transmetatarsal (TMA) amputations using ICD-9 codes from January 2000 through July 2012 were retrospectively reviewed. Data was collected for procedure, hospital-related variables, level of amputation, length of stay, time to readmission, level of re-amputation, and patient demographics including hypertension, diabetes, hyperlipidemia, smoking history, and history of myocardial infarction, congestive heart failure, PAD, COPD, and CVA. RESULTS Minor amputations were performed in 717 patients (62.2% male), including toe amputations in 565 (72.8%) and TMAs in 152 (19.5%). Readmission occurred in 100 (13.9 %) patients, including 28 within 30 days (3.9%), 28 between 30 and 60 days (3.9%) and 44 (6.1%) more than 60 days after the index amputation. Multivariable analysis revealed that elective admission (P<.001), PAD (P<.001) and chronic renal insufficiency (P=.001) were associated with readmission. The reasons for readmission were infection (49%), ischemia (29%), and non-healing wound (19%) and indeterminate (4%). Reamputation occurred in 95 (95%) of the readmitted patients, including limb amputation in 64 (64%) patients (below knee in 58, through knee in 2, and above knee in 4). CONCLUSION Readmission following minor amputation was associated with limb amputation in the majority of cases. Readmission following minor lower extremity amputation was affected by chronic renal insufficiency, history of peripheral artery bypass and manner of presentation, calling into question the ability of the surgeon to acutely mitigate readmission rates. As nearly half of the readmissions were for infection, this may represent an area for multi-disciplinary management to reduce readmission and subsequent reamputation rates. Further research is needed to establish evidence-based guidelines for acceptable readmission rates, especially in the era of increasing financial scrutiny for such occurrences.

Thirty-day hospital readmission and emergency department visits after vascular surgery: a Canadian prospective cohort study

“…Several authors have reported rates of readmission after individual vascular procedures, such as abdominal aortic aneurysm repair (8%-54%), [14][15][16] amputation (9%-18%), [17][18][19] and lower extremity bypass (12%-49%). 8,9,11,20,21 However, there are conflicting reports regarding readmission rates and reasons.…”

Análise dos fatores de risco relacionados às amputações maiores e menores de membros inferiores em hospital terciário

“…Lower limb amputations account for 85% of this total and have a major socioeconomic impact, with loss of the capacity to work, of socialization, and of quality of life, in addition to complications such as hematoma, infections, necrosis, contractures, neuromas, phantom pain, and re-admissions, making them a considerable public health problem. [2][3][4] Overall, 80% of all lower limb amputations are performed on adults. The main associated risk factors are diabetes mellitus, arterial hypertension, smoking, dyslipidemia, advanced age, chronic renal failure, hypercoagulability, and genetic factors.…”

Risk predictors for hospital readmission in a low socio-economic and underserved population

“…Past research on the association between smoking status and readmission rates has produced equivocal results. [26][27][28][29][30][31][32][33][34] Many studies have examined commonly collected demographic variables. It has been reported that increasing age could potentially serve as a predictor of all-cause hospital readmissions, especially in patients over the age of 65.…”