Causes and Implications of Readmission After Abdominal Aortic Aneurysm Repair

Abstract

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.

Thirty-day readmission and mortality among Medicare beneficiaries discharged to skilled nursing facilities after vascular surgery

“…The notable difference in mortality among readmitted patients is consistent with previous work demonstrating, for example, a 5-fold increase in mortality among readmitted patients who underwent AAA repair. 19,32 Although readmitted patients as well as patients who die within 60 days of a procedure have preexisting morbidity that predisposes to poorer outcomes, our study shows that many of the factors related to readmission and mortality are potentially modifiable complications of the surgical procedure.…”

“…In-hospital, postoperative complications defined in Greenblatt et al (2012) include cardiac complications, device failure, hemorrhage, neurological complication, respiratory complication, renal complication, venous thromboembolism, reoperation, and wound complication or surgical site infection; this definition avoids the accidental inclusion of comorbid/chronic conditions by using only those ICD-9 codes with the 99× prefix and/or an “acute” descriptor (as opposed to “chronic”). 19, 20 …”

Postdischarge complications are an important predictor of postoperative readmissions

“…1–5 Readmissions have been found to be associated with significantly increased mortality in vascular surgery, colon cancer, pancreatectomy, and elderly thyroid cancer patients. 4, 6, 7 Standardization of the discharge process, increased patient education and outpatient follow up have improved readmission rates in both medical and surgical patients. 7, 8 As more is known about which patients are at risk for readmission and what preventable diagnoses contribute to readmission, more specific interventions can be employed to further decrease post-operative readmissions.…”

“…2, 4, 6 Other factors which have been shown to increase readmission rates include later stage disease in colorectal cancer patients, need for emergent operation at index hospitalization and placement in skilled nursing facility or long term care facility at the time of discharge. 2, 4 Previous studies have described longer length of stay and post-operative complications as strong predictors of readmissions.…”

30-Day readmission after bariatric surgery in a publicly funded regionalized center of excellence system

“…Each year their total cost within the USA alone is estimated at $2.5 billion [1]. In addition to increased costs, readmissions are also associated with poorer outcomes for surgical patients [2][3][4]. Moreover, surgical readmissions are common as 30-day readmission rates after major abdominal surgery range from 9 to 17 % [5-9].…”