Are Readmits After Critical Limb Ischemia a 'Necessary Evil'?

Readmissions were so common after hospitalization for critical limb ischemia (CLI) in a large retrospective study that, it is now suggested, maybe they are par for the course -- and therefore unsuitable as a quality metric for hospitals.

Rates of all-cause readmission were 27.1% at 30 days and 56.6% at 6 months in a study that linked state inpatient databases from Florida, New York, and California to a directory from the American Hospital Association. The vast majority of these readmissions were unplanned, according to a report from Shikhar Agarwal, MD, MPH, of Geisinger Medical Center in Danville, Pa., and colleagues in the April 18 issue of the Journal of the American College of Cardiology.

The study included 212,241 patients. Their admissions totaled 695,782, of which 41% were primary CLI admissions.

Predictors of unplanned readmissions at 6 months included age, female sex, black/Hispanic race, prior amputation, higher Charlson comorbidity index, and need for home health care or rehabilitation upon discharge.

Miscellaneous causes constituted the second-most cited reason for readmission, followed by post-procedural complications, septicemia, and diabetes.

"Our study, along with several others, reinstates the need for rational clinical pathways where the focus should be on treating underlying medical comorbidities, improving access to medical care, and intensifying outpatient management of wound care and pain control," the authors wrote.

"Although 30-day readmissions have been traditionally used as a quality metric on which the U.S. Centers of Medicare and Medicaid Services bases reimbursement for percutaneous coronary intervention, adoption of a similar policy for CLI requires some deliberation and caution. This is because most readmissions in CLI are not for procedural complications, and most of these are for noncardiovascular or chronic wound-care–related or infectious issues."

Buyers of private insurance were less likely to be readmitted compared with the Medicaid/Medicare/uninsured populations. Any revascularization was also tied to fewer unplanned readmissions over follow-up, as was a greater travel time to the hospital.

The latter has been described in other contexts including coronary artery bypass grafting and other surgical admissions; this is the first time it's been found with CLI, Agarwal's group commented.

"Patients may travel further as they may have a stronger will to live or a better understanding of differences between hospital types, and hence choose to be treated at a 'center of excellence' and experience better outcomes. In contrast, patients traveling further to seek better hospitals may just be sicker and thus experience adverse clinical outcomes," they suggested.

Additionally, the (log-transformed) length of stay during index hospitalization was also associated with readmission (OR 2.39, 99% CI 2.31-2.47).

What can be done about all these CLI readmissions?

Besides revascularization, improving CLI team communication may improve readmission rates, particularly with the use of telemedicine, proposed Mehdi H. Shishehbor, DO, MPH, PhD, of Cleveland Clinic, and Herbert D. Aronow, MD, MPH, of Brown University in Providence, R.I.

"Nevertheless, for the foreseeable future, CLI treatment will remain complex and we must better understand all involved issues before assigning and publicly reporting readmission as a quality metric or basing reimbursement decisions on associated readmission rates," the duo wrote in an accompanying editorial.

"In short, we must decide whether CLI readmission is a necessary or unnecessary evil in the care continuum of the CLI patient."