Predictors of early mortality and readmissions among dialysis patients undergoing lower extremity amputation

LaTonya Hickson, Andrew D Rule, Bjoerg (Bjorg) Thorsteinsdottir, Raymond C. Shields, Ivan Porter, Mark D. Fleming, Daniel S. Ubl, Cynthia Crowson, Kristine T. Hanson, Bassem T. Elhassan, Rajnish Mehrotra, Shipra Arya, Robert C. Albright, Amy W. Williams, Elizabeth B Habermann

Research output: Contribution to journalArticle

Abstract

Objective: Patients receiving dialysis are at increased risk for lower extremity amputations (LEAs) and postoperative morbidity. Limited studies have examined differences in 30-day outcomes of mortality and health care use after amputation or the preoperative factors that relate to worsened outcomes in dialysis patients. Our objective was to examine dialysis dependency and other preoperative factors associated with readmission or death after LEA. Methods: A retrospective cohort study was conducted of dialysis-dependent and nondialysis patients undergoing major LEA in the 2012 to 2013 American College of Surgeons National Surgical Quality Improvement Program. Primary outcomes included death and hospital readmission within 30 days of amputation. Results: Of 6468 patients, 1166 (18%) were dialysis dependent. The dialysis cohort had more blacks (39% vs 23%), diabetes (76% vs 58%), below-knee amputations (62% vs 55%), and in-hospital deaths (8% vs 3%; all P < .001). The 30-day postoperative death rates (15% vs 7%) and readmission rates (35% vs 20% per 30 person-days; both P < .001) were higher in dialysis patients. Among the live discharges, the rate of any readmission or death within 30 days from amputation was highest in those aged ≥50 years (40% per 30 person-days). Multivariable analyses in the dialysis cohort revealed increased age, above-knee amputation, decreased physical status, heart failure, high preoperative white blood cell count, and low platelet count to be associated with death (P < .05; C statistic, 0.75). The only preoperative factor associated with readmission in dialysis patients was race (P = .04; C statistic, 0.58). Conclusions: Readmission or death after amputation is increased among dialysis patients. Predicting which dialysis patients are at highest risk for death is feasible, whereas predicting which will require readmission is less so. Risk factor identification may improve risk stratification, inform reimbursement policies, and allow targeted interventions to improve outcomes.

Original languageEnglish (US)
JournalJournal of Vascular Surgery
DOIs
StateAccepted/In press - Jan 1 2018

Fingerprint

Amputation
Dialysis
Lower Extremity
Mortality
Knee
Patient Readmission
Quality Improvement
Platelet Count
Leukocyte Count
Cohort Studies
Heart Failure
Retrospective Studies
Morbidity
Delivery of Health Care

Keywords

  • Age
  • Cardiovascular disease
  • Diabetes
  • Hemodialysis
  • Hospitalization
  • Survival analysis

ASJC Scopus subject areas

  • Surgery
  • Cardiology and Cardiovascular Medicine

Cite this

Predictors of early mortality and readmissions among dialysis patients undergoing lower extremity amputation. / Hickson, LaTonya; Rule, Andrew D; Thorsteinsdottir, Bjoerg (Bjorg); Shields, Raymond C.; Porter, Ivan; Fleming, Mark D.; Ubl, Daniel S.; Crowson, Cynthia; Hanson, Kristine T.; Elhassan, Bassem T.; Mehrotra, Rajnish; Arya, Shipra; Albright, Robert C.; Williams, Amy W.; Habermann, Elizabeth B.

In: Journal of Vascular Surgery, 01.01.2018.

Research output: Contribution to journalArticle

Hickson, LaTonya ; Rule, Andrew D ; Thorsteinsdottir, Bjoerg (Bjorg) ; Shields, Raymond C. ; Porter, Ivan ; Fleming, Mark D. ; Ubl, Daniel S. ; Crowson, Cynthia ; Hanson, Kristine T. ; Elhassan, Bassem T. ; Mehrotra, Rajnish ; Arya, Shipra ; Albright, Robert C. ; Williams, Amy W. ; Habermann, Elizabeth B. / Predictors of early mortality and readmissions among dialysis patients undergoing lower extremity amputation. In: Journal of Vascular Surgery. 2018.
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abstract = "Objective: Patients receiving dialysis are at increased risk for lower extremity amputations (LEAs) and postoperative morbidity. Limited studies have examined differences in 30-day outcomes of mortality and health care use after amputation or the preoperative factors that relate to worsened outcomes in dialysis patients. Our objective was to examine dialysis dependency and other preoperative factors associated with readmission or death after LEA. Methods: A retrospective cohort study was conducted of dialysis-dependent and nondialysis patients undergoing major LEA in the 2012 to 2013 American College of Surgeons National Surgical Quality Improvement Program. Primary outcomes included death and hospital readmission within 30 days of amputation. Results: Of 6468 patients, 1166 (18{\%}) were dialysis dependent. The dialysis cohort had more blacks (39{\%} vs 23{\%}), diabetes (76{\%} vs 58{\%}), below-knee amputations (62{\%} vs 55{\%}), and in-hospital deaths (8{\%} vs 3{\%}; all P < .001). The 30-day postoperative death rates (15{\%} vs 7{\%}) and readmission rates (35{\%} vs 20{\%} per 30 person-days; both P < .001) were higher in dialysis patients. Among the live discharges, the rate of any readmission or death within 30 days from amputation was highest in those aged ≥50 years (40{\%} per 30 person-days). Multivariable analyses in the dialysis cohort revealed increased age, above-knee amputation, decreased physical status, heart failure, high preoperative white blood cell count, and low platelet count to be associated with death (P < .05; C statistic, 0.75). The only preoperative factor associated with readmission in dialysis patients was race (P = .04; C statistic, 0.58). Conclusions: Readmission or death after amputation is increased among dialysis patients. Predicting which dialysis patients are at highest risk for death is feasible, whereas predicting which will require readmission is less so. Risk factor identification may improve risk stratification, inform reimbursement policies, and allow targeted interventions to improve outcomes.",
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author = "LaTonya Hickson and Rule, {Andrew D} and Thorsteinsdottir, {Bjoerg (Bjorg)} and Shields, {Raymond C.} and Ivan Porter and Fleming, {Mark D.} and Ubl, {Daniel S.} and Cynthia Crowson and Hanson, {Kristine T.} and Elhassan, {Bassem T.} and Rajnish Mehrotra and Shipra Arya and Albright, {Robert C.} and Williams, {Amy W.} and Habermann, {Elizabeth B}",
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T1 - Predictors of early mortality and readmissions among dialysis patients undergoing lower extremity amputation

AU - Hickson, LaTonya

AU - Rule, Andrew D

AU - Thorsteinsdottir, Bjoerg (Bjorg)

AU - Shields, Raymond C.

AU - Porter, Ivan

AU - Fleming, Mark D.

AU - Ubl, Daniel S.

AU - Crowson, Cynthia

AU - Hanson, Kristine T.

AU - Elhassan, Bassem T.

AU - Mehrotra, Rajnish

AU - Arya, Shipra

AU - Albright, Robert C.

AU - Williams, Amy W.

AU - Habermann, Elizabeth B

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Objective: Patients receiving dialysis are at increased risk for lower extremity amputations (LEAs) and postoperative morbidity. Limited studies have examined differences in 30-day outcomes of mortality and health care use after amputation or the preoperative factors that relate to worsened outcomes in dialysis patients. Our objective was to examine dialysis dependency and other preoperative factors associated with readmission or death after LEA. Methods: A retrospective cohort study was conducted of dialysis-dependent and nondialysis patients undergoing major LEA in the 2012 to 2013 American College of Surgeons National Surgical Quality Improvement Program. Primary outcomes included death and hospital readmission within 30 days of amputation. Results: Of 6468 patients, 1166 (18%) were dialysis dependent. The dialysis cohort had more blacks (39% vs 23%), diabetes (76% vs 58%), below-knee amputations (62% vs 55%), and in-hospital deaths (8% vs 3%; all P < .001). The 30-day postoperative death rates (15% vs 7%) and readmission rates (35% vs 20% per 30 person-days; both P < .001) were higher in dialysis patients. Among the live discharges, the rate of any readmission or death within 30 days from amputation was highest in those aged ≥50 years (40% per 30 person-days). Multivariable analyses in the dialysis cohort revealed increased age, above-knee amputation, decreased physical status, heart failure, high preoperative white blood cell count, and low platelet count to be associated with death (P < .05; C statistic, 0.75). The only preoperative factor associated with readmission in dialysis patients was race (P = .04; C statistic, 0.58). Conclusions: Readmission or death after amputation is increased among dialysis patients. Predicting which dialysis patients are at highest risk for death is feasible, whereas predicting which will require readmission is less so. Risk factor identification may improve risk stratification, inform reimbursement policies, and allow targeted interventions to improve outcomes.

AB - Objective: Patients receiving dialysis are at increased risk for lower extremity amputations (LEAs) and postoperative morbidity. Limited studies have examined differences in 30-day outcomes of mortality and health care use after amputation or the preoperative factors that relate to worsened outcomes in dialysis patients. Our objective was to examine dialysis dependency and other preoperative factors associated with readmission or death after LEA. Methods: A retrospective cohort study was conducted of dialysis-dependent and nondialysis patients undergoing major LEA in the 2012 to 2013 American College of Surgeons National Surgical Quality Improvement Program. Primary outcomes included death and hospital readmission within 30 days of amputation. Results: Of 6468 patients, 1166 (18%) were dialysis dependent. The dialysis cohort had more blacks (39% vs 23%), diabetes (76% vs 58%), below-knee amputations (62% vs 55%), and in-hospital deaths (8% vs 3%; all P < .001). The 30-day postoperative death rates (15% vs 7%) and readmission rates (35% vs 20% per 30 person-days; both P < .001) were higher in dialysis patients. Among the live discharges, the rate of any readmission or death within 30 days from amputation was highest in those aged ≥50 years (40% per 30 person-days). Multivariable analyses in the dialysis cohort revealed increased age, above-knee amputation, decreased physical status, heart failure, high preoperative white blood cell count, and low platelet count to be associated with death (P < .05; C statistic, 0.75). The only preoperative factor associated with readmission in dialysis patients was race (P = .04; C statistic, 0.58). Conclusions: Readmission or death after amputation is increased among dialysis patients. Predicting which dialysis patients are at highest risk for death is feasible, whereas predicting which will require readmission is less so. Risk factor identification may improve risk stratification, inform reimbursement policies, and allow targeted interventions to improve outcomes.

KW - Age

KW - Cardiovascular disease

KW - Diabetes

KW - Hemodialysis

KW - Hospitalization

KW - Survival analysis

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