Nationwide study of six-month readmissions in critical limb ischemia: Predictors and impact of revascularization strategies

Abstract

Objective

There is a paucity of data regarding six-month readmissions in critical limb ischemia patients and the influence of management strategy during index-admission [endovascular, surgical, hybrid procedure, medical therapy, and amputation]. We aimed to investigate the incidence, predictors, and impact of management strategies on six-month readmission in patients with critical limb ischemia.

Methods

A secondary analysis of the Nationwide Readmissions Database (2016–2017) was conducted. Propensity score matching was performed for subgroup analysis.

Results

We identified 50,058 patients with primary diagnosis of critical limb ischemia. Six-month all-cause and critical limb ischemia-related readmission rate was 52.36% and 10.86%, respectively. The risk of all-cause readmission was lower with amputation but was similar among other subgroups. Patients receiving surgical [HR 0.62, CI(0.48–0.79), p < 0.001] and hybrid procedure [HR 0.65 (0.46–0.93), p = 0.02] had lower risk of unplanned critical limb ischemia-related readmission compared to endovascular, though the risk of unplanned revascularization/amputation during readmission was similar between the three strategies. The risk of non-critical limb ischemia-related readmission was higher with surgical [HR 1.13, CI(1.04–1.23), p = 0.003] and hybrid procedure [HR 1.17, CI(1.08–1.28), p < 0.001], driven by increased procedure-related/wound complications. Eventhough endovascular patients were older with more severe critical limb ischemia presentation, a lower proportion received home-health or placement upon discharge from index-admission. This could account for higher readmission without higher repeat revascularization in endovascular group.

Conclusion

The risk of critical limb ischemia and non-critical limb ischemia-related readmission differ according to the management strategy. Significant differences in discharge disposition exist depending on revascularization strategy. Study findings identify opportunities for reducing readmissions by focusing on nonprocedural aspects like wound-care, discharge planning and placement.

Keywords

Critical limb ischemia endovascular intervention peripheral hybrid revascularization peripheral vascular surgery

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References

Gerhard-Herman

Gornik

Barrett

, et al. 2016 AHA/ACC Guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2017; 135: e726–e779.

Shishehbor

White

Gray

, et al.

Critical limb ischemia. An expert statement.

2016; 68: 2002–2015.

Shishehbor

MH.

Acute and critical limb ischemia: when time is limb. Cleve Clin J Med 2014; 81: 209–216.

Agarwal

Sud

Shishehbor

MH.

Nationwide trends of hospital admission and outcomes among critical limb ischemia patients: from 2003. J Am College Cardiol 2016; 67: 1901–1913.

Bradbury

Adam

Bell

, et al. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: an intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg 2010; 51: 5S–17S.

Jaff

White

Hiatt

, et al. An update on methods for revascularization and expansion of the TASC lesion classification to include below-the-knee arteries: a supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Vasc Med 2015; 20: 465–478.

Jones

Dolor

Hasselblad

, et al. Comparative effectiveness of endovascular and surgical revascularization for patients with peripheral artery disease and critical limb ischemia: systematic review of revascularization in critical limb ischemia. Am Heart J 2014; 167: 489–498.

Menard

Farber

The BEST-CLI trial: a multidisciplinary effort to assess whether surgical or endovascular therapy is better for patients with critical limb ischemia. In: Seminars in Vascular Surgery 2014; 82–84.

Shishehbor

White

Gray

, et al. Critical limb ischemia: an expert statement. J Am Coll Cardiol 2016; 68: 2002–2015.

10.

Adam

Beard

Cleveland

, et al. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet 2005; 366: 1925–1934.

11.

Stegman

Shishehbor

MH.

Commentary: optimal revascularization for critical limb ischemia: one approach doesn’t always fit all. J Endovasc Ther 2015; 22: 482–484.

12.

Desai

Stevenson

LW.

Rehospitalization for heart failure: predict or prevent?

Circulation 2012; 126: 501–506.

13.

Goshima

Mills

Sr Hughes

JD.

A new look at outcomes after infrainguinal bypass surgery: traditional reporting standards systematically underestimate the expenditure of effort required to attain limb salvage. J Vasc Surg 2004; 39: 330–335.

14.

Joynt

Jha

AK.

A path forward on Medicare readmissions. N Engl J Med 2013; 368: 1175–1177.

15.

Nehler

Whitehill

Bowers

, et al. Intermediate-term outcome of primary digit amputations in patients with diabetes mellitus who have forefoot sepsis requiring hospitalization and presumed adequate circulatory status. J Vasc Surg 1999; 30: 509–518.

16.

Masoomi

Shah

Quint

, et al. A nationwide analysis of 30-day readmissions related to critical limb ischemia. Vascular 2018; 26: 239–249.

17.

Reed

Raeisi‐Giglou

Kafa

, et al. Hospital readmissions following endovascular therapy for critical limb ischemia: associations with wound healing, major adverse limb events, and mortality. J Am Heart Assoc 2016; 5: e003168.

18.

Shishehbor

Aronow

HD.

Readmissions for Critical limb ischemia: hear no evil?

J Am College Cardiol 2017; 69: 1909--1912.

19.

Agarwal

Pitcavage

Sud

, et al. Burden of readmissions among patients with critical limb ischemia. J Am Coll Cardiol 2017; 69: 1897–1908.

20.

Introduction to the HCUP Nationwide Readmissions Database (NRD), 2010–2016, https://www.hcup-us.ahrq.gov/db/nation/nrd/Introduction_NRD_2010-2016.jsp (accessed 22 December 2019).

21.

van Walraven

Austin

Jennings

, et al. A modification of the Elixhauser comorbidity measures into a point system for hospital death using administrative data. Medical Care 2009; 626–633.

22.

Jencks

Williams

Coleman

EA.

Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360: 1418–1428.

23.

Kolte

Kennedy

Shishehbor

, et al. Thirty-day readmissions after endovascular or surgical therapy for critical limb ischemia: analysis of the 2013 to 2014 Nationwide Readmissions Databases. Circulation 2017; 136: 167–176.

24.

Arhuidese

Nejim

Locham

, et al. Infrainguinal bypass surgery outcomes are worse in hemodialysis patients compared with patients with renal transplants. J Vasc Surg 2019; 69: 850–856.

25.

Bourrier

Ferguson

Embil

, et al. Peripheral artery disease: its adverse consequences with and without CKD. Am J Kidney Dis 2019;

26.

Shishehbor

MH.

Endovascular treatment of femoropopliteal lesions: so many options, little consensus. J Am College Cardiol 2015; 66: 2339--2342.

27.

Varela

Acin

, et al. Influence of surgical or endovascular distal revascularization of the lower limbs on ischemic ulcer healing. J Cardiovasc Surg 2011; 52: 381–389.

28.

Mii

Tanaka

Kyuragi

, et al. Aggressive wound care by a multidisciplinary team improves wound healing after infrainguinal bypass in patients with critical limb ischemia. Ann Vasc Surg 2017; 41: 196–204.

29.

Stewart

Hiatt

Regensteiner

, et al. Exercise training for claudication. N Engl J Med 2002; 347: 1941–1951.

30.

Antoniou

Chalmers

Georgiadis

, et al. A meta-analysis of endovascular versus surgical reconstruction of femoropopliteal arterial disease. J Vasc Surg 2013; 57: 242–253.

31.

Laird

Schneider

Tepe

, et al. Durability of treatment effect using a drug-coated balloon for femoropopliteal lesions: 24-month results of IN. PACT SFA. J Am College Cardiol 2015; 66: 2329–2338.

32.

Nguyen

B-N

Neville

Abugideiri

, et al. The effect of graft configuration on 30-day failure of infrapopliteal bypasses. J Vasc Surg 2014; 59: 1003–1008.

33.

Rosenfield

Jaff

White

, et al. Trial of a paclitaxel-coated balloon for femoropopliteal artery disease. N Engl J Med 2015; 373: 145–153.

34.

Tepe

Laird

Schneider

, et al. Drug-coated balloon versus standard percutaneous transluminal angioplasty for the treatment of superficial femoral and popliteal peripheral artery disease: 12-month results from the IN. PACT SFA randomized trial. Circulation 2015; 131: 495–502.

35.

Venkatachalam

Shishehbor

Gray

BH.

Basic data related to endovascular management of peripheral arterial disease in critical limb ischemia. Ann Vasc Surg 2012; 26: 1039–1051.

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