Mar 9, 2017
A new registry-based study suggests nearly one in every four patients with critical limb ischemia (CLI) has an unplanned hospital readmission within 30 days, with that number climbing to almost one in every two patients by 6 months.
Several independent predictors of future readmission were identified, including greater length of stay (LOS) during index admission and the novel finding of a significant, inverse relationship with patient travel time. For patients living <20 minutes, 20 to 40 minutes, 40 to 60 minutes, and >60 minutes from the hospital, 6-month unplanned readmissions reached 50.2%, 46.9%, 43.2%, and 38.1%, respectively (P for trend <0.001).
“These findings have implications for how providers manage patient discharge as well as for policy makers as payment reforms are implemented based on length of stay or readmission,” lead author Dr Shikhar Agarwal (Geisinger Medical Center, Danville, PA) and colleagues write.
The study was published March 6, 2017 in the Journal of the American College of Cardiology.Commenting to heartwire from Medscape, Dr Mehdi Shishehbor (Cleveland Clinic, OH) said the readmission rates are consistent with what is known, citing a study reported last year by his team with a 56% readmission rate among 252 CLI patients at a median of 83 days after endovascular therapy.
The CLI expert also cautioned against the use of 30- or even 90-day CLI readmissions as a publicly reported quality metric or for reimbursement decisions.
“Only a minority, about a third of patients, heal within 90 days, so I think we have to look at CLI differently from other conditions such as bypass surgery, coronary PCI, or acute MI,” he said.
“The focus has been on revascularization and that’s important, but if we’re really trying to reduce hospitalizations and reduce costs, we need to look beyond revascularization. We need to think outside the box.”
In an invited commentary on the study, Shishehbor points out that nearly 9% of the 6-month readmissions in the new study were planned, which might reflect the complex nature of CLI treatment and the need for staged procedures. On the other hand, the US Centers of Medicare and Medicaid Services (CMS) will reimburse hospitals only for the higher of the two diagnosis-related groups (DRG) if, for example, a patient undergoes revascularization followed by a minor amputation.
To counter these competing incentives, Shishehbor told heartwire that CLI reimbursements should be bundled under a single episode that includes wound care and extends beyond the typical 30- or 90-day window to perhaps 6 months.
“Imagine if 9% of patients are coming back for staged procedures and we could eliminate even half of those, that’s a huge financial impact to the system,” he said.
To examine CLI readmission rates and its predictors, Agarwal and colleagues analyzed readmission data from 2009 to 2013 in 212,241 CLI patients (mean age 68.3 years; 58% male) from Florida, New York, and California in the AHRQ state inpatient database.