image: This is Robert Yeh, MD, MSc, and Eric Secemsky, MD, MSc. view more
Credit: Beth Israel Deaconess Medical Center
BOSTON - Peripheral arterial disease (PAD), a vascular condition that prevents blood flow to the extremities, currently affects 8.5 million people in the United States. A study of nearly 62,000 hospitalizations nationwide has found that more than one in six patients with PAD who undergo revascularization procedures to restore blood flow to blocked leg arteries and other arteries outside of the heart are readmitted to the hospital within 30 days.
Led by researchers in the Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center (BIDMC), the large-scale analysis determined that 30 percent of readmissions following peripheral revascularization were related to complications associated with the procedure, while differences in hospital quality accounted only modestly for readmission risk.
The findings, which will be published in the Annals of Internal Medicine on December 5, suggest that strategies to help prevent readmissions should focus on high-risk patients with PAD, including those who live with other serious health conditions, such as diabetes. Interventions related to post-procedure care might halt the need for readmission, such as early clinic follow-up and post-discharge nursing.
Peripheral arterial disease prevents blood flow to the extremities and vessels outside the heart. PAD most commonly involves the legs, which can cause pain and difficulty walking and in advanced cases can lead to infection or amputation. Revascularization procedures - including surgical bypass operations and endovascular procedures in which balloons and stents are placed in the arteries with catheters to open blockages - can significantly improve patients' quality of life and disease outcomes. However, limited data from earlier research of older Medicare patients have suggested that, like patients who undergo coronary bypass surgery, patients with PAD who undergo lower extremity bypass surgery are at high risk for readmission.
"With this new study, our aim was to determine the burden of nationwide readmissions following both endovascular and surgical revascularization procedures for patients with peripheral arterial disease," said first author Eric A. Secemsky, MD, MSc, an investigator at the Smith Center at BIDMC and a vascular medicine and intervention fellow at Massachusetts General Hospital. "We also wanted to identify potential causes of readmissions, both at the patient and institutional level, in order to identify areas for intervention and prevention."
"In recent years, there has been an increased focus on preventing hospital readmissions as a way to improve health care quality and decrease costs," explained Robert Yeh, MD, MSc, the study's senior author, Director of the Smith Center for Outcomes Research in Cardiology at BIDMC and Associate Professor of Medicine at Harvard Medical School.
As part of the federal healthcare reform, The Centers for Medicare & Medicaid Services' (CMS) Hospital Readmissions Reduction Program (HRRP) financially penalizes hospitals for higher-than-expected readmissions for key conditions. "In this new work focused on patients with PAD, we confirmed that not only are readmissions expensive, averaging $11,000 per patient, but they also leave patients at risk for the development of further complications and potential setbacks to their recovery."
The authors used the Nationwide Readmissions Database, which includes data from 22 states and represents nearly 50 percent of all U.S. hospitalizations. Patients with public and private insurance, as well as patients who self-pay, are represented in the database.
"We found that in 2014, there were 61,961 hospitalizations during which a patient with PAD underwent a peripheral revascularization procedure to treat their condition and were later discharged," said Secemsky. "We were surprised to find that the 30-day hospital readmission rate was 17.6 percent, meaning that more than one in six PAD patients - whether they underwent bypass surgery or endovascular intervention - had to return to the hospital following their procedure."
Further analysis showed that nearly 30 percent of patients were readmitted due to procedural complications. "Some sort of issue related to the procedure, maybe a related infection or problem with a stent, was causing patients to have to return to the hospital," said Secemsky. In addition, approximately eight percent of patients developed sepsis, a bacterial infection of the bloodstream, and 7.5 percent of patients were readmitted as a result of complications related to diabetes, a common problem among patients with PAD.
The authors went on to assess whether differences in hospital quality contributed to variations in readmissions risk for patients with PAD. "Using data from the 1,085 hospitals included in this data set, we created a new analytic model to examine readmission rates between institutions that took into account differences in patient populations," explained Secemsky. These results found that differences in hospital quality accounted only modestly for readmission risk, suggesting that penalizing hospitals with greater than expected readmission rates may not be the only effective approach at reducing readmissions.
"Moving forward, as clinicians and researchers, we need to recognize the special needs of the PAD patient population," added Yeh. "If we can find ways to identify patients at highest risk of readmissions, we can implement practices or develop programs to help them better manage their condition outside the hospital and avoid the need for readmission."
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In addition to Secemsky and Yeh, coauthors include Changyu Shen, PhD, and Linda Valsdottir, MS, of the Smith Center for Outcomes Research; BIDMC investigators Marc Schermerhorn, MD, Brett J. Carroll, MD, and Bruce Landon, MD, MBA; and Kevin F. Kennedy, MS, of Saint Luke's Mid-America Heart Institute.
This research was supported by the Smith Center for Outcomes Research in Cardiology at Beth Israel Deaconess Medical Center.
About Beth Israel Deaconess Medical Center
Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School and consistently ranks as a national leader among independent hospitals in National Institutes of Health funding.
BIDMC is in the community with Beth Israel Deaconess Hospital-Milton, Beth Israel Deaconess Hospital-Needham, Beth Israel Deaconess Hospital-Plymouth, Anna Jaques Hospital, Cambridge Health Alliance, Lawrence General Hospital, MetroWest Medical Center, Signature Healthcare, Beth Israel Deaconess HealthCare, Community Care Alliance and Atrius Health. BIDMC is also clinically affiliated with the Joslin Diabetes Center and Hebrew Rehabilitation Center and is a research partner of Dana-Farber/Harvard Cancer Center and the Jackson Laboratory. BIDMC is the official hospital of the Boston Red Sox. For more information, visit http://www.bidmc.org.
Journal
Annals of Internal Medicine