Jamie B. Smith

Hospital readmissions after elective lower extremity vascular procedures

Background This study evaluated risk factors associated with 30-day readmission after open and endovascular lower extremity revascularization. Methods Patients admitted with peripheral artery disease and lower extremity procedures were selected from national electronic medical record data, Cerner Health Facts® (2008–2014). Thirty-day readmission was determined. Logistic regression models identified characteristics independently associated with readmission. Results There were 2781 open and 2611 endovascular procedures. Readmission was 10.9% (9.6% open versus 12.3% endovascular, p<.0001). Greater disease severity was associated with readmission for both groups. Readmission factors for lower extremity bypass: blood transfusions (OR 2.25, 95% CI 1.62–3.13), hyponatremia (OR 1.72, 95% CI 1.15–2.57), heart failure (OR 1.57, 95% CI 1.07–2.29), bronchodilators (OR 1.50, 95% CI 1.13–2.00), black race (OR 1.43, 95% CI 1.03–1.99), and hypokalemia (OR 0.43, 95% CI 0.20–0.95). Readmission factors for endovascular procedures: vasodilators (OR 1.63, 95% CI 1.22–2.16), end-stage renal disease (OR 1.43, 95% CI 1.02–2.01), fluid and electrolyte disorders (OR 1.44, 95% CI 1.00–2.06), hypertension (OR 1.33, 95% CI 0.99–1.76), coronary artery disease (OR 1.31, 95% CI 1.02–1.67), and diuretics (OR 1.30, 95% CI 1.01–1.70). Conclusions Readmission after lower extremity revascularization is associated with disease severity for both procedures. Factors associated with readmission following lower extremity bypass included heart failure, transfusions, hyponatremia, black race, and bronchodilator use. Risk factors for endovascular readmissions were often chronic conditions including coronary artery disease, kidney disease, hypertension, and hypertensive medications. Awareness of risk factors may help providers identify high-risk patients who may benefit from increased surveillance and programs to lower readmission.

Preoperative assessment of computerized tomography angiography to predict success for crossing long Trans-Atlantic Inter-Society Consensus D lesions using the optical coherence tomography catheter

Objectives Optical coherence tomography chronic total occlusion catheter, the Ocelot (Avinger Inc., Redwood City, CA), has been utilized to cross Trans-Atlantic Inter-Society Consensus D lesions. This study evaluated the preoperative computerized tomography angiography of chronic total occlusions in the superficial femoral artery to predict clinical success. Methods We reviewed all patients who underwent lower extremity procedures with the Ocelot catheter from June 2014 to August 2016. Patients who had a preoperative computerized tomography angiography were evaluated. Final outcomes, plaque morphology, lesion length, calcium surface area, lesion location, and patient characteristics were analyzed. Results A total of 107 patients underwent lower extremity interventions with the Ocelot catheter. Seventy patients had a preoperative computerized tomography angiography scan prior to lower extremity intervention and 77% (54) had Trans-Atlantic Inter-Society Consensus D lesions that were crossed. Mean age was 62.8 years and 68.6% were male. Mean chronic total occlusion length was 182.7 mm (170.8 mm crossed vs. 222.6 mm uncrossed, p = 0.03). Calcium distribution differed significantly (p<.01): circumferential (14.8 vs. 12.5%); eccentric (85 vs. 62.5%); and complete calcium occlusion (0 vs. 25%) for lesions that were crossed and uncrossed, respectively. Significant differences (p<.0001) were found when calcium occlusion was less than 50% (87 vs. 31%), 51–75% (9.3 vs. 31.2%), and 76–100% (3.7 vs. 37.5%). Total calcium length in crossed lesion was 51.6 mm, and 92.8 mm in uncrossed lesions (p = 0.10). No significant differences were noted for patient gender, occlusion location (proximal, middle, and distal superficial femoral artery), and kidney function. Conclusion The Ocelot catheter is an effective method to cross long Trans-Atlantic Inter-Society Consensus D lesions. Superficial femoral artery lesions longer than 17 cm and focal plaque morphology, specifically a total cross-sectional area of calcium and a calcium surface area greater than 50% were most predictive of failure to cross Trans-Atlantic Inter-Society Consensus D superficial femoral artery lesions. Computerized tomography angiography is an effective tool to predict success for crossing chronic total occlusions using optical coherence tomography technology and a critical consideration for patient selection.

Risk Factors for Thirty-Day Readmissions After Lower Extremity Amputation in Patients With Vascular Disease

Understanding risk factors associated with readmission after lower extremity amputation may indicate targets for reducing readmission.

Outcomes associated with hyperglycemia after abdominal aortic aneurysm repair

Objective We evaluated the association between postoperative hyperglycemia and outcomes after abdominal aortic aneurysm (AAA) repair. Methods We used diagnosis and procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification) to identify patients who underwent open or endovascular repair of a nonruptured AAA from September 2008 to March 2014 from the Cerner Health Facts database (Cerner Corporation, North Kansas City, Mo). We evaluated the association between postoperative hyperglycemia (glucose concentration >180 mg/dL) and infections, in‐hospital mortality, readmission, patients’ characteristics, length of hospital stay, and medications. Multivariable logistic models examined the association of postoperative hyperglycemia with in‐hospital infection and mortality. Results Of 2478 patients, 2071 (83.5%) had good postoperative glucose control (80‐180 mg/dL), and 407 (16.5%) had suboptimal control (hyperglycemia). Patients who had postoperative hyperglycemia experienced longer hospital stays (9.5 vs 4.7 days; P < .0001), higher infection rates (18% vs 8%; P < .0001), higher in‐hospital mortality (8.4 vs 1.2%; P <.0001), and more acute complications (ie, acute renal failure, fluid and electrolyte disorders, respiratory complications). After adjusting for patients’ characteristics and medications, multivariable logistic regression models demonstrated that patients receiving postoperative insulin had nearly 1.6 times the odds of having an infectious complication (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.12‐2.2; P = .007) than those who did not. Hyperglycemic patients had 3.5 times the odds of in‐hospital mortality (OR, 3.48; 95% CI, 1.78‐6.80 [P = .0003]; 2.3% vs 1.2%; P < .001). When stratified by procedure type, patients with hyperglycemia who underwent endovascular repair had nearly 2 times the odds of an infectious complication (OR, 1.85; 95% CI, 0.98‐3.51; P = .05) and 7.5 times the odds of in‐hospital mortality (OR, 7.54; 95% CI, 1.95‐29.1; P = .003). Patients who underwent an open AAA repair and who had hyperglycemia had three times the odds of dying in the hospital (OR, 3.05; 95% CI, 1.29‐7.21; P = .01). Conclusions Among patients undergoing elective AAA repair, approximately one in six had postoperative hyperglycemia. After AAA repair in patients with and without diabetes, postoperative hyperglycemia was associated with adverse events, including in‐hospital mortality and infections. Compared with those who had open surgery, patients undergoing endovascular repair who had postoperative hyperglycemia had greater risk of infection and death. After controlling for insulin administration and postoperative hyperglycemia, a diabetes diagnosis was associated with lower odds of both infection and in‐hospital mortality. Our study suggests that hyperglycemia may be used as a clinical marker as it was found to be significantly associated with inferior outcomes after elective AAA repair. This retrospective study, however, cannot imply causation; further study using prospective methods is needed to elucidate the relationship between postoperative hyperglycemia and patient outcomes.

Dynamic Electronic Health Record Note Prototype: Seeing More by Showing Less

Introduction: Cluttered documentation may contribute adversely to physician readers’ cognitive load, inadvertently obscuring high-value information with less valuable information. We test the hypothesis that a novel, collapsible assessment, plan, subjective, objective (APSO) note design would be faster, more accurate, and more satisfying to use than a conventional electronic health record (EHR) subjective, objective, assessment, plan (SOAP) note for finding information needed for ambulatory chronic disease care. Methods: We iteratively developed physician clinic note prototypes with features designed to emphasize more important information and de-emphasize less clinically relevant information. Sixteen primary care physicians reviewed comparable clinic notes with the 4 note styles presented in random order to find key information in the notes during timed tasks. The 4 note styles were denoted A (traditional SOAP note), B (2-column APSO note), C (collapsible APSO note), and D (2-column collapsible APSO note). The 4 unique note styles were designed to have equal amounts of information in each section. We simulated their utility for clinical practice by imposing time limits and by interrupting 1 of the tasks with a typical clinical interruption. For each session, we recorded audio, computer-screen activity, eye tracking, and made field notes. We obtained usability ratings (System Usability Scale), new feature preference ratings, and performed semistructured post-task interviews with subsequent content analysis. We compared the effectiveness of the 4 note styles by measuring time on task, task success (accuracy), and effort as measured by NASA Task Load Index. Results: Note styles C and D were significantly faster than A and B for the Review of Systems and Physical Examination tasks, as we expected. Notes B and C had the best success (finding requested data) scores. Users strongly endorsed all the new note features incorporated into the new note prototypes. Previously expressed concerns about temporarily hiding parts of the note (using the accordion display design pattern) were allayed. Usability ratings for note A were worst but comparably better for note styles B, C, and D. Discussion: The new APSO note prototypes performed better than the traditional SOAP note format for speed, task success (accuracy), and usability for physician users acquiring information needed for a typical chronic disease visit in primary care. Moving Assessment and Plan to the top is 1 easily accomplished feature change. Innovative documentation displays of EHR data can safely improve information display without eliminating data from the record of the visit.