Most readmissions for critical limb ischemia are unplanned

At 30 days and six months, the majority of readmissions for critical limb ischemia (CLI) are unplanned, according to an analysis of hospital databases in Florida, New York and California.

The all-cause readmission rates were 27.1 percent at 30 days and 56.6 percent at six months. People were more likely to be readmitted at six months if they were female or black/Hispanic, had no insurance or Medicaid or Medicare, had a prior amputation or needed home healthcare or a rehabilitation facility when discharged from the hospital.

Lead researcher Shikhar Agarwal, MD, MPH, of Geisinger Medical Center in Danville, Pennsylvania, and colleagues published their results online in the Journal of the American College of Cardiology on March 6.

The researchers defined CLI as an advanced stage of peripheral artery disease and noted the condition is associated with considerable morbidity and mortality. They added that during the past decade, fewer patients with CLI have undergone surgical revascularization and had major amputations, but more patients have undergone endovascular revascularization procedures. Still, the annual rate of CLI admissions have remained similar during that time period.

This analysis examined in-hospital admissions in Florida from 2009 to 2013, New York from 2010 to 2013 and California from 2009 to 2011. The researchers obtained the data from the State Inpatient Database, which is sponsored by the Agency for Healthcare Research and Quality. In all, they had information on 212,241 patients and 695,782 hospital admissions, of which 284,189 were primary CLI admissions.

Among the primary CLI admissions, the in-hospital mortality rate was 2.3 percent, the rate of endovascular revascularization alone was 16.6 percent, the rate of surgical revascularization alone was 10.7 percent, the rate of sequential revascularization was 2.9 percent and the rate of major amputation was 11.8 percent. In addition, 36.9 percent of admissions were sent to rehabilitation facilities, 28.1 percent received home healthcare and 33.6 percent were discharged home from the hospital.

The unplanned readmission rates for primary CLI admissions were 23.6 percent at 30 days and 47.7 percent at six months. In-hospital mortality was higher among unplanned readmissions compared with planned readmissions, but the incidence of revascularization procedures and major amputations was higher during planned readmissions.

The researchers also found that a long length of hospital stay during the index admission was associated with a higher incidence of readmission at 30 days and six months, while a longer travel time between a patient’s residence and the hospital was associated with a lower incidence of unplanned readmission.

They cited a few limitations of the study, including its retrospective observational design and its reliance on data from only three states, which could be subject to selection bias. They also mentioned there could have been errors in coding of diseases or procedures. In addition, the database did not have information on the type and invasiveness of the surgical or endovascular therapy and did not capture out of hospital mortality. Further, they estimated travel time based on residential zip codes and hospital zip codes.

“Additional work is needed to develop systems of care for patients with critical limb ischemia that define optimum management earlier in the course that improve both limb-related outcomes and survival while reducing the need for hospital readmission during long-term follow-up,” the researchers wrote.