Readmissions Similar for Endovascular, Open Lower-Limb Interventions

MILWAUKEE – Less invasive lower-extremity endovascular interventions do not reduce hospital readmissions among patients with peripheral artery disease, according to an analysis of the Cerner Health Facts database.

The 30-day readmission rate was 13.9% for patients who underwent open surgery and 15.3% for those who had an endovascular procedure.

Lead author Dr. Todd Vogel expressed surprise that the two approaches were relatively equal, adding that, "I thought with endo, we’re doing less, they’d come back more."

Patrice Wendling/IMNG Medical Media

The common practice of staging lower-limb endovascular interventions is creating concerns that use of hospital readmissions as a quality outcome measure for reimbursement may not accurately identify planned readmissions or quality of care.

Session moderator Dr. Patrick Geraghty said in an interview that lower-extremity intervention outcomes "are probably the most complex and difficult to define outcomes issue for all of vascular surgery," as compared with carotid and aortic aneurysms, and that this is already reflected in efforts proposed by the National Surgical Quality Improvement Program (NSQIP) and the Centers for Medicare and Medicaid Services (CMS).

"Lower-extremity readmission is going to be a real hot-button discussion because we already know it’s substantial," he said. "If I do a stent graft for someone with leg ischemia and the flow improves and they go home on post-op day 1, and I bring them back 10 days later for a planned debridement of a toe ulcer that we’d been looking at, was that bad? Was that poor care, something I should be penalized for?

"Or was it just good care, but it didn’t fit into CMS’s box of everything should be done within one admission and that any readmission is therefore bad?"

The current analysis is unique in that utilizes electronic medical record (EMR) data to provide real-world outcomes for lower-limb interventions, said Dr. Geraghty, a vascular surgeon with Barnes-Jewish Hospital in St. Louis.

"I think we’re seeing here maybe the first fruits of good EMR design, and it’s a prod for surgeons to look into EMR design and ask whether we can design EMR notes for vascular follow-up in the ER such that we pull good EMR data over great numbers of patients," he said at the annual meeting of the Midwestern Vascular Surgical Society.

Dr. Vogel said that the Cerner database is not as population based as Medicare, capturing observational patient EMR data on more than 84 million admissions and ambulatory visits at roughly 187 participating hospitals, albeit primarily urban. Cerner is the second largest EMR in the United States after Epic.

The analysis encompassed 1,458 elective first admissions with a diagnosis of peripheral artery disease (PAD) undergoing a lower-extremity procedure from October 2008 to December 2010. Of these, 777 had open surgery and 681 an endovascular procedure.

Intermittent claudication was the most common indication for any procedure, present in 56.2% of open and 43.8% of endovascular patients.

The overall readmission rate at 30 days was surprisingly high at 14.5%, and was also unexpectedly high for for those with claudication, at 10.2% in the open and 11.3% in the endovascular group, said Dr. Vogel, chief of vascular surgery at the University of Missouri Hospitals and Clinics, Columbia.

"The frightening number to think about is that, in the claudicant group, we have a 10% readmission rate within 30 days," he said, noting that rates were very similar between groups. "So that’s a number we should all begin to think about."

As expected, readmission rates in the open and endovascular groups increased with disease severity. Rates for rest pain and gangrene were 14% vs. 18.2%, and 22% vs. 24%, respectively.

In bivariate analysis, blacks were significantly more likely to be readmitted 30 days after discharge (odds ratio, 1.56), as were patients discharged to a skilled nursing facility or nursing home (OR, 2.59), he said.

There was a nonsignificant trend toward higher readmissions at teaching hospitals (OR, 1.20), while a hospital stay of more than 7 days was a strong, significant predictor of 30-day readmission (OR, 2.54).

Readmissions also were increased in patients with a Charlson Comorbidity Index score of 3-5 (OR, 1.56) or score of 6-10 (OR, 1.90), diabetes (OR, 1.41), or sepsis (OR, 2.99), he said.

The risk of 30-day readmission was increased more than fivefold among patients with poor liver function, as indicated by total bilirubin levels greater than 2 mg/dL (OR, 5.15) or AST over 100 U/L (OR, 5.56). Risk was also more than twofold higher among patients with renal disease, as indicated by hemoglobin (nadir) less than 8 g/dL (OR, 2.17) and serum creatinine of at least 2 mg/dL (OR, 2.07), as well as those dispensed a staggering 30 medications or more (OR, 2.63), Dr. Vogel reported.

Notably, patients with cardiac troponin levels above 0.2 mg/dL were not at significantly higher risk of readmission (OR, 1.75), although those with a white blood cell count greater than 15,000/mcL were (OR, 2.1), which goes along with the finding of sepsis, he said.

In multivariate logistic regression analysis adjusting for age, disease severity, and race, PAD severity dropped out but male gender (OR, 1.39), Charlson Comorbidity Index (OR 1.12), length of stay (OR, 1.25), AST (OR 2.89), and more than 30 dispensed medications (OR, 1.84) remained significant.

"I think these are the things we’re going to have to look at if we’re going to really address readmissions," Dr. Vogel said.

He highlighted a new algorithm created at the Dartmouth-Hitchcock Medical Center that describes strategies for both predicting and preventing readmissions in vascular surgery (J. Vasc. Surg. 2012 56:556-62).

"It’s fun to describe all this, but the next step is to create change," he added.

During a discussion of the study, Dr. Vogel said that it was possible to calculate specialty-specific readmission rates but that such an analysis had not been performed yet.

Patrice Wendling/IMNG Medical Media

Society for Vascular Surgery (SVS) President Peter Gloviczki then rose from the audience to say that such an analysis is very important in light of a recent Medicare database analysis reporting that endovascular lower-extremity revascularization performed by vascular specialists results in higher costs, longer hospital stays, and more repeat revascularization procedures and amputations than the same procedure performed by interventional radiologists (J. Vasc. Interv. Radiol. 2012:23:3-9).

He went on to say that the controversial paper, which was sharply rebuked by past SVS President Richard Cambria, failed to define indications for the interventions or major vs. minor amputations.

"I think if your data show, not necessarily the outcome, but the case mix of the specialties and what we believe is the severity of disease that vascular surgeons take care of compared to radiologists, that would be very good because that is a way to answer with data, and not with rhetoric," Dr. Gloviczki said.

Dr. Vogel agreed that vascular surgeons, as a rule, treat sicker patients with heavier disease burden, subsequently leading to these various secondary outcomes, and that the Medicare analysis failed to adequately process the data.

"It was a very jaded view," he said.

Session comoderator Dr. Melina Kibbe, a vascular surgeon with Northwestern Memorial Hospital in Chicago, said that the current analysis is the first to use the Cerner database and "that this could be why we’re seeing different outcomes than what other people have reported because this is a more real-world database."

She went on to say that using lower-extremity readmissions as a quality measure is highly problematic because care of these patients, much like that for those with cancer, is often staged and extends for years.

Those thoughts were echoed by the newly elected president of the Midwestern Vascular Surgical Society, Dr. Timothy Kresowik. In an interview, he said, "I’d stay away from lower extremity to begin with. I think it’s just a terrible area to try to do performance measures, especially short-term performance measures, because the important thing to remember about lower-extremity bypass is the real issues are long term."

Dr. Vogel, Dr. Geraghty, Dr. Gloviczki, Dr. Kibbe, and Dr. Kresowik reported having no relevant conflicts of interest.

MILWAUKEE – Less invasive lower-extremity endovascular interventions do not reduce hospital readmissions among patients with peripheral artery disease, according to an analysis of the Cerner Health Facts database.

The 30-day readmission rate was 13.9% for patients who underwent open surgery and 15.3% for those who had an endovascular procedure.

Lead author Dr. Todd Vogel expressed surprise that the two approaches were relatively equal, adding that, "I thought with endo, we’re doing less, they’d come back more."

Patrice Wendling/IMNG Medical Media

The common practice of staging lower-limb endovascular interventions is creating concerns that use of hospital readmissions as a quality outcome measure for reimbursement may not accurately identify planned readmissions or quality of care.

Session moderator Dr. Patrick Geraghty said in an interview that lower-extremity intervention outcomes "are probably the most complex and difficult to define outcomes issue for all of vascular surgery," as compared with carotid and aortic aneurysms, and that this is already reflected in efforts proposed by the National Surgical Quality Improvement Program (NSQIP) and the Centers for Medicare and Medicaid Services (CMS).

"Lower-extremity readmission is going to be a real hot-button discussion because we already know it’s substantial," he said. "If I do a stent graft for someone with leg ischemia and the flow improves and they go home on post-op day 1, and I bring them back 10 days later for a planned debridement of a toe ulcer that we’d been looking at, was that bad? Was that poor care, something I should be penalized for?

"Or was it just good care, but it didn’t fit into CMS’s box of everything should be done within one admission and that any readmission is therefore bad?"

The current analysis is unique in that utilizes electronic medical record (EMR) data to provide real-world outcomes for lower-limb interventions, said Dr. Geraghty, a vascular surgeon with Barnes-Jewish Hospital in St. Louis.

"I think we’re seeing here maybe the first fruits of good EMR design, and it’s a prod for surgeons to look into EMR design and ask whether we can design EMR notes for vascular follow-up in the ER such that we pull good EMR data over great numbers of patients," he said at the annual meeting of the Midwestern Vascular Surgical Society.

Dr. Vogel said that the Cerner database is not as population based as Medicare, capturing observational patient EMR data on more than 84 million admissions and ambulatory visits at roughly 187 participating hospitals, albeit primarily urban. Cerner is the second largest EMR in the United States after Epic.

The analysis encompassed 1,458 elective first admissions with a diagnosis of peripheral artery disease (PAD) undergoing a lower-extremity procedure from October 2008 to December 2010. Of these, 777 had open surgery and 681 an endovascular procedure.

Intermittent claudication was the most common indication for any procedure, present in 56.2% of open and 43.8% of endovascular patients.

The overall readmission rate at 30 days was surprisingly high at 14.5%, and was also unexpectedly high for for those with claudication, at 10.2% in the open and 11.3% in the endovascular group, said Dr. Vogel, chief of vascular surgery at the University of Missouri Hospitals and Clinics, Columbia.

"The frightening number to think about is that, in the claudicant group, we have a 10% readmission rate within 30 days," he said, noting that rates were very similar between groups. "So that’s a number we should all begin to think about."

As expected, readmission rates in the open and endovascular groups increased with disease severity. Rates for rest pain and gangrene were 14% vs. 18.2%, and 22% vs. 24%, respectively.

In bivariate analysis, blacks were significantly more likely to be readmitted 30 days after discharge (odds ratio, 1.56), as were patients discharged to a skilled nursing facility or nursing home (OR, 2.59), he said.

There was a nonsignificant trend toward higher readmissions at teaching hospitals (OR, 1.20), while a hospital stay of more than 7 days was a strong, significant predictor of 30-day readmission (OR, 2.54).

Readmissions also were increased in patients with a Charlson Comorbidity Index score of 3-5 (OR, 1.56) or score of 6-10 (OR, 1.90), diabetes (OR, 1.41), or sepsis (OR, 2.99), he said.

The risk of 30-day readmission was increased more than fivefold among patients with poor liver function, as indicated by total bilirubin levels greater than 2 mg/dL (OR, 5.15) or AST over 100 U/L (OR, 5.56). Risk was also more than twofold higher among patients with renal disease, as indicated by hemoglobin (nadir) less than 8 g/dL (OR, 2.17) and serum creatinine of at least 2 mg/dL (OR, 2.07), as well as those dispensed a staggering 30 medications or more (OR, 2.63), Dr. Vogel reported.

Notably, patients with cardiac troponin levels above 0.2 mg/dL were not at significantly higher risk of readmission (OR, 1.75), although those with a white blood cell count greater than 15,000/mcL were (OR, 2.1), which goes along with the finding of sepsis, he said.

In multivariate logistic regression analysis adjusting for age, disease severity, and race, PAD severity dropped out but male gender (OR, 1.39), Charlson Comorbidity Index (OR 1.12), length of stay (OR, 1.25), AST (OR 2.89), and more than 30 dispensed medications (OR, 1.84) remained significant.

"I think these are the things we’re going to have to look at if we’re going to really address readmissions," Dr. Vogel said.

He highlighted a new algorithm created at the Dartmouth-Hitchcock Medical Center that describes strategies for both predicting and preventing readmissions in vascular surgery (J. Vasc. Surg. 2012 56:556-62).

"It’s fun to describe all this, but the next step is to create change," he added.

During a discussion of the study, Dr. Vogel said that it was possible to calculate specialty-specific readmission rates but that such an analysis had not been performed yet.

Patrice Wendling/IMNG Medical Media

Society for Vascular Surgery (SVS) President Peter Gloviczki then rose from the audience to say that such an analysis is very important in light of a recent Medicare database analysis reporting that endovascular lower-extremity revascularization performed by vascular specialists results in higher costs, longer hospital stays, and more repeat revascularization procedures and amputations than the same procedure performed by interventional radiologists (J. Vasc. Interv. Radiol. 2012:23:3-9).

He went on to say that the controversial paper, which was sharply rebuked by past SVS President Richard Cambria, failed to define indications for the interventions or major vs. minor amputations.

"I think if your data show, not necessarily the outcome, but the case mix of the specialties and what we believe is the severity of disease that vascular surgeons take care of compared to radiologists, that would be very good because that is a way to answer with data, and not with rhetoric," Dr. Gloviczki said.

Dr. Vogel agreed that vascular surgeons, as a rule, treat sicker patients with heavier disease burden, subsequently leading to these various secondary outcomes, and that the Medicare analysis failed to adequately process the data.

"It was a very jaded view," he said.

Session comoderator Dr. Melina Kibbe, a vascular surgeon with Northwestern Memorial Hospital in Chicago, said that the current analysis is the first to use the Cerner database and "that this could be why we’re seeing different outcomes than what other people have reported because this is a more real-world database."

She went on to say that using lower-extremity readmissions as a quality measure is highly problematic because care of these patients, much like that for those with cancer, is often staged and extends for years.

Those thoughts were echoed by the newly elected president of the Midwestern Vascular Surgical Society, Dr. Timothy Kresowik. In an interview, he said, "I’d stay away from lower extremity to begin with. I think it’s just a terrible area to try to do performance measures, especially short-term performance measures, because the important thing to remember about lower-extremity bypass is the real issues are long term."

Dr. Vogel, Dr. Geraghty, Dr. Gloviczki, Dr. Kibbe, and Dr. Kresowik reported having no relevant conflicts of interest.

MILWAUKEE – Less invasive lower-extremity endovascular interventions do not reduce hospital readmissions among patients with peripheral artery disease, according to an analysis of the Cerner Health Facts database.

The 30-day readmission rate was 13.9% for patients who underwent open surgery and 15.3% for those who had an endovascular procedure.

Lead author Dr. Todd Vogel expressed surprise that the two approaches were relatively equal, adding that, "I thought with endo, we’re doing less, they’d come back more."

Patrice Wendling/IMNG Medical Media

The common practice of staging lower-limb endovascular interventions is creating concerns that use of hospital readmissions as a quality outcome measure for reimbursement may not accurately identify planned readmissions or quality of care.

Session moderator Dr. Patrick Geraghty said in an interview that lower-extremity intervention outcomes "are probably the most complex and difficult to define outcomes issue for all of vascular surgery," as compared with carotid and aortic aneurysms, and that this is already reflected in efforts proposed by the National Surgical Quality Improvement Program (NSQIP) and the Centers for Medicare and Medicaid Services (CMS).

"Lower-extremity readmission is going to be a real hot-button discussion because we already know it’s substantial," he said. "If I do a stent graft for someone with leg ischemia and the flow improves and they go home on post-op day 1, and I bring them back 10 days later for a planned debridement of a toe ulcer that we’d been looking at, was that bad? Was that poor care, something I should be penalized for?

"Or was it just good care, but it didn’t fit into CMS’s box of everything should be done within one admission and that any readmission is therefore bad?"

The current analysis is unique in that utilizes electronic medical record (EMR) data to provide real-world outcomes for lower-limb interventions, said Dr. Geraghty, a vascular surgeon with Barnes-Jewish Hospital in St. Louis.

"I think we’re seeing here maybe the first fruits of good EMR design, and it’s a prod for surgeons to look into EMR design and ask whether we can design EMR notes for vascular follow-up in the ER such that we pull good EMR data over great numbers of patients," he said at the annual meeting of the Midwestern Vascular Surgical Society.

Dr. Vogel said that the Cerner database is not as population based as Medicare, capturing observational patient EMR data on more than 84 million admissions and ambulatory visits at roughly 187 participating hospitals, albeit primarily urban. Cerner is the second largest EMR in the United States after Epic.

The analysis encompassed 1,458 elective first admissions with a diagnosis of peripheral artery disease (PAD) undergoing a lower-extremity procedure from October 2008 to December 2010. Of these, 777 had open surgery and 681 an endovascular procedure.

Intermittent claudication was the most common indication for any procedure, present in 56.2% of open and 43.8% of endovascular patients.

The overall readmission rate at 30 days was surprisingly high at 14.5%, and was also unexpectedly high for for those with claudication, at 10.2% in the open and 11.3% in the endovascular group, said Dr. Vogel, chief of vascular surgery at the University of Missouri Hospitals and Clinics, Columbia.

"The frightening number to think about is that, in the claudicant group, we have a 10% readmission rate within 30 days," he said, noting that rates were very similar between groups. "So that’s a number we should all begin to think about."

As expected, readmission rates in the open and endovascular groups increased with disease severity. Rates for rest pain and gangrene were 14% vs. 18.2%, and 22% vs. 24%, respectively.

In bivariate analysis, blacks were significantly more likely to be readmitted 30 days after discharge (odds ratio, 1.56), as were patients discharged to a skilled nursing facility or nursing home (OR, 2.59), he said.

There was a nonsignificant trend toward higher readmissions at teaching hospitals (OR, 1.20), while a hospital stay of more than 7 days was a strong, significant predictor of 30-day readmission (OR, 2.54).

Readmissions also were increased in patients with a Charlson Comorbidity Index score of 3-5 (OR, 1.56) or score of 6-10 (OR, 1.90), diabetes (OR, 1.41), or sepsis (OR, 2.99), he said.

The risk of 30-day readmission was increased more than fivefold among patients with poor liver function, as indicated by total bilirubin levels greater than 2 mg/dL (OR, 5.15) or AST over 100 U/L (OR, 5.56). Risk was also more than twofold higher among patients with renal disease, as indicated by hemoglobin (nadir) less than 8 g/dL (OR, 2.17) and serum creatinine of at least 2 mg/dL (OR, 2.07), as well as those dispensed a staggering 30 medications or more (OR, 2.63), Dr. Vogel reported.

Notably, patients with cardiac troponin levels above 0.2 mg/dL were not at significantly higher risk of readmission (OR, 1.75), although those with a white blood cell count greater than 15,000/mcL were (OR, 2.1), which goes along with the finding of sepsis, he said.

In multivariate logistic regression analysis adjusting for age, disease severity, and race, PAD severity dropped out but male gender (OR, 1.39), Charlson Comorbidity Index (OR 1.12), length of stay (OR, 1.25), AST (OR 2.89), and more than 30 dispensed medications (OR, 1.84) remained significant.

"I think these are the things we’re going to have to look at if we’re going to really address readmissions," Dr. Vogel said.

He highlighted a new algorithm created at the Dartmouth-Hitchcock Medical Center that describes strategies for both predicting and preventing readmissions in vascular surgery (J. Vasc. Surg. 2012 56:556-62).

"It’s fun to describe all this, but the next step is to create change," he added.

During a discussion of the study, Dr. Vogel said that it was possible to calculate specialty-specific readmission rates but that such an analysis had not been performed yet.

Patrice Wendling/IMNG Medical Media

Society for Vascular Surgery (SVS) President Peter Gloviczki then rose from the audience to say that such an analysis is very important in light of a recent Medicare database analysis reporting that endovascular lower-extremity revascularization performed by vascular specialists results in higher costs, longer hospital stays, and more repeat revascularization procedures and amputations than the same procedure performed by interventional radiologists (J. Vasc. Interv. Radiol. 2012:23:3-9).

He went on to say that the controversial paper, which was sharply rebuked by past SVS President Richard Cambria, failed to define indications for the interventions or major vs. minor amputations.

"I think if your data show, not necessarily the outcome, but the case mix of the specialties and what we believe is the severity of disease that vascular surgeons take care of compared to radiologists, that would be very good because that is a way to answer with data, and not with rhetoric," Dr. Gloviczki said.

Dr. Vogel agreed that vascular surgeons, as a rule, treat sicker patients with heavier disease burden, subsequently leading to these various secondary outcomes, and that the Medicare analysis failed to adequately process the data.

"It was a very jaded view," he said.

Session comoderator Dr. Melina Kibbe, a vascular surgeon with Northwestern Memorial Hospital in Chicago, said that the current analysis is the first to use the Cerner database and "that this could be why we’re seeing different outcomes than what other people have reported because this is a more real-world database."

She went on to say that using lower-extremity readmissions as a quality measure is highly problematic because care of these patients, much like that for those with cancer, is often staged and extends for years.

Those thoughts were echoed by the newly elected president of the Midwestern Vascular Surgical Society, Dr. Timothy Kresowik. In an interview, he said, "I’d stay away from lower extremity to begin with. I think it’s just a terrible area to try to do performance measures, especially short-term performance measures, because the important thing to remember about lower-extremity bypass is the real issues are long term."

Dr. Vogel, Dr. Geraghty, Dr. Gloviczki, Dr. Kibbe, and Dr. Kresowik reported having no relevant conflicts of interest.