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Thirty-Day Readmission After Infrarenal Abdominal Aneurysm Repair: Indications, Risk Factors and Outcomes
Hanaa Dakour Aridi, MD, Satinderjit Locham, MD, Besma Nejim, MBChB, MPH, Nasr S. Ghajar, MS, Husain Alshaikh, MD, Mahmoud B. Malas, MD, MHS.
Johns Hopkins School of Medicine, Baltimore, MD, USA.

Objective(s): Reducing readmissions is an important target fori mproving patient care and enhancing healthcare quality and cost effectiveness. The aim of this study is to assess risk factors, rates and indications of 30-day readmission after open (OAR) and endovascular (EVAR) infrarenal abdominal aortic aneurysm (AAA) repair.
Methods: A retrospective analysis of the Premier Research Database 2009-2015 was performed. Indications for readmission after the index procedure, risk factors and outcomes of the index and rehospitalization were evaluated. Multivariate models were used to assess the association between 30-day readmission and different patient and hospital factors.
Results: A total of 33,332 AAA repair procedures were identified: 27,483 EVAR and 5,849 (17.5%) OAR. The overall rate of 30-day readmission was 8.10 % and was greater after OAR (12.9%vs.7.1% in EVAR; p<0.001).The most common indication for readmission was non-specific (24.9%), followed by infectious (16.1%), respiratory and cardiac complications (11.8% and 11.3%, respectively).After multivariate adjustment, no difference in 30-day readmission between endovascular and open procedures was noted. Other factors significantly associated with 30-day readmission included female gender, insurance type, emergency procedures, certain patient comorbidities (dyslipidemia, CHF, history of TIA, COPD, CKD, PAD, and history of malignancy) and hemorrhage/shock/bleeding occurring during the index admission as well as non-home discharge(Table). The strongest predictor of readmission was discharge to general hospital with 4.6 increase in the odds of readmission compared to home discharge (aOR:4.6;95%CI:3.9-5.5;p<0.001).Patients readmitted after OAR had similar overall in-hospital mortality as those readmitted after EVAR (3.60 vs. 3.61, p=0.99). However, they had a longer hospital stay (6 vs.4 days, p<0.001) and paid a higher re-hospitalization cost ($8,776 vs. $7,757, p<0.001) as compared to patients readmitted after EVAR.
Conclusions: We have shown in this large nationally representative study focusing on AAA repair that 30-days readmission is not procedure specific but rather related to patients gender, comorbidities, insurance type and discharge destination. Efforts should focus on preventable causes for readmission as well as on discharge planning and post-discharge coordination of care for high-risk patients. Avoiding discharge to general hospital is an important modifiable risk with large impact on reducing readmission.
Table - Association between Different Baseline Characteristics and 30-day Readmission

Non-Readmitted
(n=30,631)
Readmitted
(n=2,701)
p-valueUnadjusted OR (95% CI)p-valueAdjusted (95% CI)p-value
Procedure, n (%)
Open5,097 (16.6)752 (27.8)<0.001Ref.Ref.
Endovascular25,534 (83.4)752 (27.8)0.52 (0.47-0.57)<0.0010.9 (0.8-1.1)0.29
Ruptured, n (%)1,359 (4.6)268 (10.8)<0.0012.5 (2.2-2.9)<0.0011.0 (0.9-1.2)0.89
Age, mean (SD)73.2 (8.2)74.3 (8.4)<0.0011.02 (1.01-1.02)<0.0011.0 (0.99-1.01)0.38
Gender, n (%)<0.001
Male24,505 (80.0)1,976 (73.2)Ref.Ref.
Female6,124 (20.0)725 (26.8)1.5 (1.3-1.6)<0.0011.1 (1.01-1.2)0.03
Race, n (%)<0.001
White25,041 (81.7)2,172 (80.4)Ref.Ref.
Black1,341 (4.4)173 (6.4)1.5 (1.3-1.8)<0.0011.2 (0.96-1.4)0.12
Other4,249 (13.9)356 (13.2)0.97 (0.9-1.1)0.560.9 (0.7-0.97)0.01
Insurance type, n (%)<0.001
Medicare24,392 (80.2)2,263 (84.3)Ref.Ref.
Medicaid568 (1.9)67 (2.5)1.3 (1.0-1.6)0.071.4 (1.0-1.8)0.03
Private Insurance4,761 (15.7)296 (11.0)0.7 (0.6-0.8)<0.0010.8 (0.7-0.9)0.004
Other690 (2.3)59 (2.2)0.9 (0.7-1.2)0.550.9 (0.7-1.3)0.62
Admission Type, n (%)<0.001
Elective24,505 (80.0)1,735 (64.2)Ref.Ref.
Emergency3,560 (11.6)666 (24.7)2.6 (2.4-2.9)<0.0011.5 (1.3-1.7)<0.001
Urgent2,373 (7.8)278 (10.3)1.7 (1.4-1.9)<0.0011.1 (0.99-1.3)0.07
Others193 (0.6)22 (0.8)1.6 (1.0-2.5)0.041.3 (0.8-2.2)0.25
Discharge Destination<0.001
Home24,152 (78.9)1,410 (52.2)Ref.Ref.
Home under HHO3,616 (11.8)461 (17.1)2.2 (2.0-2.4)<0.0011.7 (1.5-1.9)<0.001
General Hospital720 (2.3)337 (12.5)8.0 (7.0-9.2)<0.0014.6 (3.9-5.5)<0.001
Skilled Nursing Facility1,865 (6.1)435 (16.1)4.0 (3.6-4.5)<0.0012.4 (2.1-2.8)<0.001
Others /Unknown278 (0.9)58 (2.1)3.6 (2.7-4.8)<0.0012.5 (1.8-3.5)<0.001
Comorbidities, n (%)
Diabetes5,905 (19.3)565 (20.9)0.041.1 (1.0-1.2)0.041.0 (0.9-1.1)0.63
Hypertension23,956 (78.2)2,152 (79.7)0.081.1 (0.99-1.2)0.081.0 (0.8-1.1)0.44
Dyslipidemia17,811 (58.2)1,460 (54.0)<0.0010.8 (0.8-0.9)<0.0010.9 (0.8-0.96)0.003
History of TIA2,480 (8.1)297 (11.0)<0.0011.4 (1.2-1.6)<0.0011.3 (1.1-1.4)0.001
Congestive Heart Failure2,256 (7.4)405 (15.0)<0.0012.2 (2.0-2.5)<0.0011.5 (1.3-1.7)<0.001
Old Myocardial Infarction4,436 (14.5)405 (15.0)0.471.0 (0.9-1.2)0.471.1 (0.97-1.2)0.17
Previous Cardiac Surgery4,041 (13.2)542 (20.1)<0.0011.7 (1.5-1.8)<0.0011.1 (0.98-1.2)0.09
Chronic Kidney Disease4,169 (13.6)637 (23.6)<0.0012.0 (1.8-2.2)<0.0011.3 (1.2-1.5)<0.001
Dialysis398 (1.3)112 (4.2)<0.0013.3 (2.7-4.1)<0.0011.3 (1.0-1.7)0.05
COPD 8,654 (28.3)952 (35.3)<0.0011.4 (1.3-1.5)<0.0011.2 (1.1-1.4)<0.001
Asthma1,154 (3.8)125 (4.6)0.031.2 (1.0-1.5)0.031.3 (1.03-1.5)0.03
Peripheral Vascular Disease6,892 (22.5)743 (27.5)<0.0011.3 (1.2-1.4)<0.0011.2 (1.01-1.3)<0.001
Cancer1,481 (4.8)194 (7.2)<0.0011.5 (1.3-1.8)<0.0011.4 (1.2-1.6)<0.001
Obesity3,424 (11.2)336 (12.4)0.051.1 (1.0-1.3)0.050.99 (0.9-1.1)0.86
Alcohol265 (0.9)30 (1.1)0.191.3 (0.9-1.9)0.190.99 (0.7-1.5)0.95
Smoking17,152 (56.0)1,445 (53.5)0.010.9 (0.8-0.98)0.010.9 (0.8-1.0)0.1
Concomitant Palliative Care45 (0.15)12 (0.4)<0.0013.0 (1.6-5.7)0.0010.7 (0.3-1.5)0.39
LOS (days), median (IQR)2 (1,5)5 (2,9)<0.0011.1 (1.09-1.11)<0.001--
In-hospital Complications
Hemorrhage/Shock/Bleeding3,648 (11.9)605 (22.4)<0.0012.1 (1.9-2.4)<0.0011.2 (1.1-1.4)<0.001
Vascular/Graft Related411 (1.3)51 (1.9)0.021.4 (1.1-1.9)0.021.2 (0.86-1.6)0.29
Renal2,167 (7.1)456 (16.9)<0.0012.7 (2.4-3.0)<0.0011.1 (1.0-1.3)0.19
Cardiac2,225 (7.3)374 (13.9)<0.0012.1 (1.8-2.3)<0.0011.1 (0.9-1.2)0.5
Respiratory1,328 (4.3)301 (11.1)<0.0012.8 (2.4-3.2)<0.0011.1 (0.9-1.3)0.21
Infectious275 (0.9)75 (2.8)<0.0013.2 (2.4-4.1)<0.0011.0 (0.7-1.4)0.98
Neurological130 (0.4)55 (2.0)<0.0014.9 (3.5-6.7)<0.0011.2 (0.8-1.9)0.36
Venous Thromboembolic76 (0.3)27 (1.0)<0.0014.1 (2.6-6.3)<0.0011.3 (0.8-2.2)0.29


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