Sara Fernandes-Taylor

Predictors of surgical site infection after hospital discharge in patients undergoing major vascular surgery

OBJECTIVE Surgical site infection (SSI) is one of the most common postoperative complications after vascular reconstruction, producing significant morbidity and hospital readmission. In contrast to SSI that develops while patients are still hospitalized, little is known about the cohort of patients who develop SSI after discharge. In this study, we explore the factors that lead to postdischarge SSI, investigate the differences between risk factors for in-hospital vs postdischarge SSI, and develop a scoring system to identify patients who might benefit from postdischarge monitoring of their wounds. METHODS Patients who underwent major vascular surgery from 2005 to 2012 for aneurysm and lower extremity occlusive disease were identified from the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files. Patients were categorized as having no SSI, in-hospital SSI, or SSI after hospital discharge. Predictors of postdischarge SSI were determined by multivariable logistic regression and internally validated by bootstrap resampling. Risk scores were assigned to all significant variables in the model. Summative risk scores were collapsed into quartile-based ordinal categories and defined as low, low/moderate, moderate/high, and high risk. Multivariable logistic regression was used to determine predictors of in-hospital SSI. RESULTS Of the 49,817 patients who underwent major vascular surgery, 4449 (8.9%) were diagnosed with SSI (2.1% in-hospital SSI; 6.9% postdischarge SSI). By multivariable analysis, factors significantly associated with increased odds of postdischarge SSI include female gender, obesity, diabetes, smoking, hypertension, coronary artery disease, critical limb ischemia, chronic obstructive pulmonary disease, dyspnea, neurologic disease, prolonged operative time >4 hours, American Society of Anesthesiology class 4 or 5, lower extremity revascularization or aortoiliac procedure, and groin anastomosis. The model exhibited moderate discrimination (bias-corrected C statistic, 0.691) and excellent internal calibration. The postdischarge SSI rate was 2.1% for low-risk patients, 5.1% for low/moderate-risk patients, 7.8% for moderate/high-risk patients, and 14% for high-risk patients. In a comparative analysis, comorbidities were the primary driver of postdischarge SSI, whereas in-hospital factors (operative time, emergency case status) and complications predicted in-hospital SSI. CONCLUSIONS The majority of SSIs after major vascular surgery develop following hospital discharge. We have created a scoring system that can select a cohort of patients at high risk for SSI after discharge. These patients can be targeted for transitional care efforts focused on early detection and treatment with the goal of reducing morbidity and preventing readmission secondary to SSI.

General and Vascular Surgery Readmissions: A Systematic Review

Hospital readmissions following surgical procedures are disruptive for patients and their families and correlates with poor outcomes including reoperation or death. Whereas readmissions following hospitalization for acute medical conditions have been the subject of ongoing research and policy initiatives for many years, readmissions have received less attention in the surgical specialties. This is remarkable given the frequency of surgery in this country, the overall cost of surgical care, and the perceived association between surgical readmission and quality of care.(1–3) Moreover, the health care costs associated with readmissions are substantial. Unplanned readmissions have an economic impact estimated at

Clinical characteristics associated with readmission among patients undergoing vascular surgery

17.4 billion per year.(1) Although debatable, a significant portion of hospital readmissions may be preventable.(2,4) Consequently, in 2010, the Patient Protection and Affordable Care Act was passed which contained legislation mandating a national readmissions reduction program.(5) Shortly thereafter, the Centers for Medicare and Medicaid Services (CMS) developed and implemented policies to penalize readmission.(6) Specifically, these penalties reduce reimbursement to hospitals with higher-than-expected readmission rates. These penalties have been already implemented for three medical diagnoses: congestive heart failure, myocardial infarction, and pneumonia, and will be expanded to the surgical procedures including hip and knee arthroplasty beginning in 2015.(6) Comprehensive reviews have addressed global aspects of readmission or readmission of patients following medical hospitalization. However, there are no systematic reviews that address surgical readmissions. In a review of interventions aimed to reduce medical readmissions, Hansen et al concluded that no single intervention was consistently associated with a reduced risk, but did note that certain components (e.g. post discharge telephone call) were common to successful bundled interventions.(7) Kansagara et al performed a systematic review of risk prediction models for readmission and determined that current models perform poorly, concluding that efforts are needed to improve their performance, including measures of patient’s social support and detailed clinical data.(8) These analyses help underscore the need for research in surgical readmissions since: (1) there is no synthesis of the current literature describing surgical readmission, (2) medical readmissions are fundamentally different from surgical readmissions, and (3) there are no proven models for predicting or preventing surgical readmissions. In this review, recent studies of readmission within the surgical subspecialties of vascular, general, bariatric, and colorectal surgery are analyzed. Readmission rates and diagnoses as well as predictors of readmission are examined within these surgical fields to help create a foundation for future research that will ultimately improve the quality of surgical care.

Rehospitalization to Primary Versus Different Facilities Following Abdominal Aortic Aneurysm Repair

OBJECTIVE Readmission after a vascular surgery intervention is frequent, costly, and often considered preventable. Vascular surgery outcomes have recently been scrutinized by Medicare because of the high rates of readmission. We determined patient and clinical characteristics associated with readmission in a cohort of vascular surgery patients. METHODS From 2009 to 2013, the medical records of all patients (n = 2505) undergoing interventions by the vascular surgery service at a single tertiary care institution were retrospectively reviewed. Sociodemographic and clinical characteristics were examined for association with 30-day readmission to the same institution. RESULTS The 30-day readmission rate to the same institution was 9.7 % (n = 244). Procedures most likely to result in readmission were below-knee (25%), foot (22%), and toe amputations (19%), as well as lower extremity revascularization (22%). Patients covered by Medicaid (16.8%) and Medicare (10.0%) were most likely to be readmitted, followed by fee-for-service (9.5%), self-pay (8.0%), and health maintenance organizations (5.5%; P < .05). Patients urgently admitted were more likely to be readmitted (16.2%) than those electively admitted (9.1%; P < .01). Patient severity as rated using the All Patient Refined Diagnosis Related Groups software (3M Health Information Systems, Wallingford, Conn) predicted readmission (16.2% high vs 6.2% low severity; P < .01). Initial length of stay was longer for readmitted than nonreadmitted patients (8.5 vs 6.1 days, respectively; P < .01). Intensive care unit admission during the initial hospitalization was associated with higher readmission rates in univariable analysis (18.3% with vs 9.5% without intensive care unit stay; P < .05). Discharge destination was also a strong predictor of readmission (rehabilitation, 19.2%; skilled nursing facility, 16.2%; home, 6.2%; P < .01). The effects of urgent admission, proximity to hospital, length of stay, lower extremity open procedure or amputation, and discharge destination persisted in multivariable logistic regression (P < .05). CONCLUSIONS To reduce readmission rates effectively, institutions must identify high-risk patients. Efforts should focus on subgroups undergoing selected interventions (amputations, lower extremity revascularization), those with urgent admissions, and patients with extended hospital stays. Patients in need of postacute care upon discharge are especially prone to readmission, requiring special attention to discharge planning and coordination of postdischarge care. By focusing on subgroups at risk for readmission, preventative resources can be efficiently targeted.

Conceptualizing smartphone use in outpatient wound assessment: patients' and caregivers' willingness to use technology

OBJECTIVE Reducing readmissions represents a unique opportunity to improve care and reduce health care costs and is the focus of major payers. A large number of surgical patients are readmitted to hospitals other than where the primary surgery was performed, resulting in clinical decisions that do not incorporate the primary surgeon and potentially alter outcomes. This study characterizes readmission to primary vs different hospitals after abdominal aortic aneurysm (AAA) repair and examines the implications with regard to mortality and cost. METHODS Patients who underwent open or endovascular aneurysm repair for AAA were identified from the Centers for Medicare and Medicaid Services Chronic Conditions Warehouse, a random 5% national sample of Medicare beneficiaries from 2005 to 2009. Outcomes for patients who underwent AAA repair and were readmitted within 30 days of initial discharge were compared based on readmission location (primary vs different hospital). RESULTS A total of 885 patients underwent AAA repair and were readmitted within 30 days. Of these, 626 (70.7%) returned to the primary facility, and 259 (29.3%) returned to a different facility. Greater distance from patient residence to the primary hospital was the strongest predictor of readmission to a different facility. Patients living 50 to 100 miles from the primary hospital were more likely to be readmitted to a different hospital compared with patients living <10 miles away (odds ratio, 8.50; P < .001). Patients with diagnoses directly related to the surgery (eg, wound infection) were more likely to be readmitted to the primary hospital, whereas medical diagnoses (eg, pneumonia and congestive heart failure) were more likely to be treated at a different hospital. There was no statistically significant difference in mortality between patients readmitted to a different or the primary hospital. Median total 30-day payments were significantly lower at different vs primary hospitals (primary,

30-day Readmission After Pancreatic Resection: A Systematic Review of the Literature and Meta-analysis

11,978 vs different,

Endovascular Versus Open Revascularization for Peripheral Arterial Disease.

11,168; P = .04). CONCLUSIONS Readmission to a different facility after AAA repair is common and occurs more frequently than for the overall Medicare population. Patients travelling a greater distance for AAA repair are more likely to return to different vs the primary hospital when further care is required. For AAA repair, quality healthcare may be achieved at marginally lower cost and with greater patient convenience for selected readmissions at hospitals other than where the initial procedure was performed.

Improving Patient-Centered Transitional Care after Complex Abdominal Surgery

BACKGROUND Information technology is transforming health care communication. Using smartphones to remotely monitor incisional wounds via digital photos as well as collect postoperative symptom information has the potential to improve patient outcomes and transitional care. We surveyed a vulnerable patient population to evaluate smartphone capability and willingness to adopt this technology. METHODS We surveyed 53 patients over a 9-mo period on the vascular surgery service at a tertiary care institution. Descriptive statistics were calculated to describe survey item response. RESULTS A total of 94% of recruited patients (50 of 53) participated. The cohort was 50% female, and the mean age was age 70 y (range: 41-87). The majority of patients owned cell phones (80%) and 23% of these cell phones were smartphones. Ninety percent of patients had a friend or family member that could help take and send photos with a smartphone. Ninety-two percent of patients reported they would be willing to take a digital photo of their wound via a smartphone (68% daily, 22% every other day, 2% less than every other day, and 8% not at all). All patients reported they would be willing to answer questions related to their health via a smartphone. Patients identified several potential difficulties with regard to adopting a smartphone wound-monitoring protocol including logistics related to taking photos, health-related questions, and coordination with caretakers. CONCLUSIONS Our survey demonstrates that an older patient cohort with significant comorbidity is able and willing to adopt a smartphone-based postoperative monitoring program. Patient training and caregiver participation will be essential to the success of this intervention.

A scoping review of patient-sharing network studies using administrative data

Objective: The aim of this study was to identify and compare common reasons and risk factors for 30-day readmission after pancreatic resection. Background: Hospital readmission after pancreatic resection is common and costly. Many studies have evaluated this problem and numerous discrepancies exist regarding the primary reasons and risk factors for readmission. Methods: Multiple electronic databases were searched from 2002 to 2016, and 15 relevant articles identified. Overall readmission rate was calculated from individual study estimates using a random-effects model. Study data were combined and overall estimates of odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each risk factor. Multivariable data were qualitatively synthesized. Results: The overall 30-day readmission rate was 19.1% (95% CI 17.4–20.7) across all studies. Infectious complications and gastrointestinal disorders, such as failure to thrive and delayed gastric emptying, together accounted for 58.9% of all readmissions. Demographic factors did not predict readmission. Heart disease (OR 1.37, 95% CI 1.12–1.67), hypertension (OR 1.44, 95% CI 1.09–1.91), and intraoperative blood transfusion (OR 1.45, 95% CI 1.15–1.83) were weak predictors of readmission, while any postoperative complications (OR 2.22, 95% CI 1.55–3.18) or severe complications (OR 2.84, 95% CI 1.65–4.89) were stronger predictors. Conclusions: Readmission after pancreatic resection is common and can largely be attributed to infectious complications and inability to maintain adequate hydration and nutrition. Focus on outpatient resources and follow-up to address these issues will prove valuable in reducing readmissions.

Adaptation and Implementation of a Transitional Care Protocol for Patients Undergoing Complex Abdominal Surgery

Objective: The aim of this study was to determine whether endovascular or open revascularization provides an advantageous approach to symptomatic peripheral arterial disease (PAD) over the longer term. Summary of Background Data: The optimal revascularization strategy for symptomatic lower extremity PAD is not established. Methods: We evaluated amputation-free survival, overall survival, and relative rate of subsequent vascular intervention after endovascular or open lower extremity revascularization for propensity-score matched cohorts of Medicare beneficiaries with PAD from 2006 through 2009. Results: Among 14,685 eligible patients, 5928 endovascular and 5928 open revascularization patients were included in matched analysis. Patients undergoing endovascular repair had improved amputation-free survival compared with open repair at 30 days (7.4 vs 8.9%, P = 0.002). This benefit persisted over the long term: At 4 years, 49% of endovascular patients had died or received major amputation compared with 54% of open patients (P < 0.001). An endovascular procedure was associated with a risk-adjusted 16% decreased risk of amputation or death compared with open over the study period (hazard ratio: 0.84; 95% confidence interval, 0.79–0.89; P < 0.001). The amputation-free survival benefit associated with an endovascular revascularization was more pronounced in patients with congestive heart failure or ischemic heart disease than in those without (P = 0.021 for interaction term). The rate of subsequent intervention at 30 days was 7.4% greater for the endovascular vs the open revascularization cohort. At 4 years, this difference remained stable at 8.6%. Conclusions: Using population-based data, we demonstrate that an endovascular approach is associated with improved amputation-free survival over the long term with only a modest relative increased risk of subsequent intervention.OBJECTIVE The aim of this study was to determine whether endovascular or open revascularization provides an advantageous approach to symptomatic peripheral arterial disease (PAD) over the longer term. SUMMARY OF BACKGROUND DATA The optimal revascularization strategy for symptomatic lower extremity PAD is not established. METHODS We evaluated amputation-free survival, overall survival, and relative rate of subsequent vascular intervention after endovascular or open lower extremity revascularization for propensity-score matched cohorts of Medicare beneficiaries with PAD from 2006 through 2009. RESULTS Among 14,685 eligible patients, 5928 endovascular and 5928 open revascularization patients were included in matched analysis. Patients undergoing endovascular repair had improved amputation-free survival compared with open repair at 30 days (7.4 vs 8.9%, P = 0.002). This benefit persisted over the long term: At 4 years, 49% of endovascular patients had died or received major amputation compared with 54% of open patients (P < 0.001). An endovascular procedure was associated with a risk-adjusted 16% decreased risk of amputation or death compared with open over the study period (hazard ratio: 0.84; 95% confidence interval, 0.79-0.89; P < 0.001). The amputation-free survival benefit associated with an endovascular revascularization was more pronounced in patients with congestive heart failure or ischemic heart disease than in those without (P = 0.021 for interaction term). The rate of subsequent intervention at 30 days was 7.4% greater for the endovascular vs the open revascularization cohort. At 4 years, this difference remained stable at 8.6%. CONCLUSIONS Using population-based data, we demonstrate that an endovascular approach is associated with improved amputation-free survival over the long term with only a modest relative increased risk of subsequent intervention.