Analysis of Thirty-Day Readmission after Infrainguinal Bypass

Background: The Vascular Study Group of New England (VSGNE) conducted a pilot study evaluating the feasibility of 30-day data collection in patients undergoing infrainguinal bypass (INFRA) which was subsequently expanded to include a limited number of additional sites within the Vascular Quality Initiative (VQI). The purpose of our study was to use these data to evaluate the incidence of 30-day readmission after infrainguinal bypass. A secondary goal of the study was to perform a critical appraisal of the data elements and definitions in the 30-day dataset. Methods: All infrainguinal bypass procedures performed during the pilot study period (7/2008 and 4/2016) were identified and merged with a dataset containing the 30-day data. Incidence and types of readmission were assessed. The primary endpoint was 30-day readmission, defined as any hospital readmission within 30 days of index operation; unplanned 30-day readmission was the secondary endpoint. Covariates tested for association with the primary and secondary endpoints included patient demographics, comorbidities, procedural, and postoperative characteristics. Variables significant on univariate screen (P < 0.2) were evaluated with logistic regression to identify independent determinants. Results: Of 9,847 infrainguinal bypass patients, 5,842 (59%) patients were identified with 30-day data, and 907 (16%) were readmitted within 30 days. Of readmissions, 675 (85%) were unplanned. Potentially modifiable independent determinants of any 30-day readmission included 30-day surgical site infection (SSI) (odds ratio [OR]: 10, 95% confidence interval [CI]: 8.2-12, P < 0.0001), postoperative acute kidney injury (OR: 1.7, 95% CI: 1.2-2.5, P = 0.002), and discharge anticoagulation (OR: 1.2, 95% CI: 1.04-1.5; P = 0.02). Predictors of unplanned 30-day readmission were very similar but identified in-hospital major amputation as an additional independent predictor (OR: 2.8, 95% CI: 1.6-4.9, P = 0.0002). Conclusions: This study demonstrates the interest in, and value of, 30-day data collection in VSGNE/VQI and documents the frequency of readmission after infrainguinal bypass. Readmission within 30 days is strongly associated with SSI, stressing the importance of efforts to decrease this complication. Given that many other predictors are unmodifiable, 30-day readmission is only appropriate as a quality metric if it is risk adjusted using large, real-world datasets such as VQI. Lessons learned from this analysis can be used to select optimal 30-day data elements.