Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.

OBJECTIVE: Readmission rates are expected to have an increasing effect on both the hospital bottom line and physician reimbursements. Safety net hospitals may be most vulnerable. We examined readmissions at 30 days, 90 days, and 1 year in a large safety net hospital to determine the magnitude and effect of short- and long-term readmission rates after lower extremity infrainguinal bypass in this setting.
METHODS: All nonemergent extremity infrainguinal bypass performed at a large safety net hospital between 2008 and 2016 were identified. Patient demographic, social, clinical, and procedural details were extracted from the electronic medical record. An analysis of patients readmitted at 30 days, 90 days, and 1 year was completed to determine the details of the readmission.
RESULTS: A total of 350 patients undergoing extremity infrainguinal bypass were identified. The most frequent indication was tissue loss (57%), followed by claudication (25.6%), and rest pain (17.4%). Patient insurance carriers included Medicare (61.7%), Medicaid (25.4%), and private (13%). The distal target was the popliteal and tibial artery in 52.6% and 47.4% cases, respectively. The majority of bypasses used autologous vein (73.1%). In-hospital complications included pulmonary complications (4.3%), urinary tract infection (3.1%), acute renal failure (2%), graft occlusion (2%), myocardial infarction (1.7%), bleeding (1.4%), surgical wound complications (1.1%), and stroke (0.9%). The 30-day readmission rate was 30% with the most common reasons for readmission being surgical wound complications, nonsurgical foot/leg wounds, nonextremity infectious causes, cardiac ischemia, and congestive heart failure. The 90-day readmission rate was 49.4% and the most common reasons for readmission from 31 to 90 days were nonsurgical foot/leg wounds, graft complications, surgical wound complications, cardiac ischemia, and contralateral leg morbidity. The readmission rate within 1 year was 72.2%. Readmission causes from 91 days to 1 year included graft complications, contralateral leg morbidity, nonextremity infectious, nonsurgical foot/leg wounds, cardiac ischemia, and congestive heart failure. A tibial bypass target was associated with 30-day (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.06-2.69; P = .029) and 90-day (OR, 1.77; 95% CI, 1.14-2.74, P = .011) readmission. Nonprivate insurance (OR, 2.31; 95% CI, 1.17-4.57, P = .016), and critical limb ischemia (OR, 1.77; 95% CI, 1.14-2.74; P = .035) were associated with 1-year readmission.
CONCLUSIONS: Short- and long-term readmission rates in a safety net setting are high. The 30-day rates in this study are higher than historically reported. This data sets baseline rates for 90-day and 1-year readmission for future analyses. Although the majority of short-term readmissions are related to the index procedure, long-term readmission rates are more frequently related to systemic comorbidities. Targeted patient interventions aimed at preventing the most common reasons for readmission may improve readmission rates, particularly among patients with nonprivate insurance. However, other risk factors, such as tibial target, may not be modifiable and a higher readmission rate may need to be accepted in this population.