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A systematic review and meta-analysis of risk factors for and incidence of 30-day readmission after revascularization for peripheral artery disease

      Abstract

      Objective

      Readmission to the hospital after revascularization for peripheral artery disease (PAD) is frequently reported. No consensus exists as to the exact frequency and risk factors for readmission. This review aimed to determine the incidence of and risk factors for 30-day readmission after revascularization for PAD.

      Methods

      PubMed/Medline (Ovid), Scopus, Web of Science, the Cochrane Library, and CINAHL were searched systematically from inception until May 20, 2018. Studies were eligible for inclusion if they included patients with diagnosed PAD undergoing revascularization and reported the readmission rate and a statistical evaluation of the association of at least one risk factor with readmission. Studies were excluded if data for other procedures could not be distinguished from revascularization. Two authors undertook study selection independently with the final inclusion decision resolved through consensus. The PRISMA and Meta-analyses of Observational Studies in Epidemiology guidelines were followed regarding data extraction and quality assessment, which was performed by two authors independently. Data were pooled using a random effects model.

      Results

      The primary outcome was readmission within 30 days of revascularization. Fourteen publications reporting the outcomes of 526,008 patients were included. Reported readmission rates ranged from 10.9% to 30.0% with a mean of 16.4% (95% confidence interval [CI], 15.1%-17.9%). Meta-analyses suggested the following risk factors had a significant association with readmission: female sex (odds ratio [OR], 1.13; 95% CI, 1.05-1.21), black race (OR, 1.36; 95% CI, 1.28-1.46), dependent functional status (OR, 1.72; 95% CI, 1.43-2.06), critical limb ischemia (OR, 2.12; 95% CI, 1.72-2.62), emergency admission (OR, 1.75; 95% CI, 1.43-2.15), hypertension (OR, 1.39; 95% CI, 1.26-1.54), heart failure (OR, 1.82; 95% CI, 1.50-2.20), chronic pulmonary disease (OR, 1.19; 95% CI, 1.08-1.32), diabetes (OR, 1.47; 95% CI, 1.32-1.63), chronic kidney disease (OR, 1.93; 95% CI, 1.62-2.31), dialysis dependence (OR, 2.08; 95% CI, 1.75-2.48), smoking (OR, 0.83; 95% CI, 0.78-0.89), postoperative bleeding (OR, 1.70; 95% CI, 1.23-2.35), and postoperative sepsis (OR, 4.13; 95% CI, 2.02-8.47).

      Conclusions

      Approximately one in six patients undergoing revascularization for PAD are readmitted within 30 days of their procedure. This review identified multiple risk factors predisposing to readmission, which could potentially serve as a way to target interventions to reduce readmissions.

      Keywords

      Peripheral artery disease (PAD) describes atherosclerosis-associated occlusion or stenosis of the arteries supplying blood to the lower limbs.
      • Golledge J.
      Lower-limb arterial disease.
      Common presentations of PAD include intermittent claudication (IC), as well as rest pain, arterial ulceration, and gangrene (collectively known as critical limb ischemia [CLI]).
      • Leng G.C.
      • Lee A.J.
      • Fowkes F.G.
      • Whiteman M.
      • Dunbar J.
      • Housley E.
      • et al.
      Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population.
      PAD affects 10% to 20% of the general population, and its prevalence is increasing associated with an aging population and the rising prevalence of diabetes.
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      • Cambou J.P.
      • Kownator S.
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      • Branchereau A.
      • et al.
      Prevalence of peripheral arterial disease in high-risk patients using ankle-brachial index in general practice: a cross-sectional study.
      • Criqui M.H.
      • Aboyans V.
      Epidemiology of peripheral artery disease.
      • Criqui M.H.
      • Fronek A.
      • Barrett-Connor E.
      • Klauber M.R.
      • Gabriel S.
      • Goodman D.
      The prevalence of peripheral arterial disease in a defined population.
      • Fowkes F.G.
      • Rudan D.
      • Rudan I.
      • Aboyans V.
      • Denenberg J.O.
      • McDermott M.M.
      • et al.
      Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis.
      PAD is commonly treated by endovascular or open revascularization. These treatments have significant risks of complications. Some of these complications, such as wound and hospital-acquired infections, false aneurysm, hematoma, and postoperative cardiovascular events, require readmission to hospital.
      • Kadner A.
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      • et al.
      Complications associated with the arterial puncture closure device--Angio-Seal.
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      • Mills J.L.
      • et al.
      Regional variation in outcomes for lower extremity vascular disease in the Vascular Quality Initiative.
      Among surgical patients, those undergoing lower limb revascularization have some of the highest rates of readmission.
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      • Guzman A.M.
      • Fernandes-Taylor S.
      • Engelbert T.L.
      • Saunders R.S.
      • Kent K.C.
      General and vascular surgery readmissions: a systematic review.
      Readmissions for PAD have been associated with serious complications, including deaths and high costs to health systems.
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      • Brook O.R.
      • Weinstein J.L.
      • Rosen M.P.
      • et al.
      The relevance of readmissions after common IR procedures: readmission rates and association with early mortality.
      • Secemsky E.A.
      • Schermerhorn M.
      • Carroll B.J.
      • Kennedy K.F.
      • Shen C.
      • Valsdottir L.R.
      • et al.
      Readmissions after revascularization procedures for peripheral arterial disease: a nationwide cohort study.
      Each readmission after PAD revascularization has been estimated to cost US$10,000 and, in Australia, one-third of all costs related to atherothrombotic disease (including stroke, coronary artery disease, and PAD) are believed to be attributable to readmissions.
      • Atkins E.R.
      • Geelhoed E.A.
      • Knuiman M.
      • Briffa T.G.
      One third of hospital costs for atherothrombotic disease are attributable to readmissions: a linked data analysis.
      • Orr N.T.
      • El-Maraghi S.
      • Korosec R.L.
      • Davenport D.L.
      • Xenos E.S.
      Cost analysis of vascular readmissions after common vascular procedures.
      • Sachs T.
      • Pomposelli F.
      • Hamdan A.
      • Wyers M.
      • Schermerhorn M.
      Trends in the national outcomes and costs for claudication and limb threatening ischemia: angioplasty vs bypass graft.
      Despite the potential benefits in reducing readmissions in patients with PAD, little is known about which factors predispose patients to readmission, what the indications for readmission are, or in what ways readmission could be reduced. Findings from previous studies have been inconsistent with reported readmission rates ranging from 11% to 30%.
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      As a starting point to decrease PAD-related treatment morbidity and cost, it is important to identify the reported incidence and risk factors for readmission after peripheral revascularization. The aim of this study was to systematically review the reported rates of readmission after revascularization procedures for PAD and identify the risk factors associated with readmission.

      Methods

      This systematic review was undertaken in accordance with the recommendations of the PRISMA and Meta-analyses of Observational Studies in Epidemiology guidelines.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      • Group P.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      • Stroup D.F.
      • Berlin J.A.
      • Morton S.C.
      • Olkin I.
      • Williamson G.D.
      • Rennie D.
      • et al.
      Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group.
      The review protocol was developed before literature searching and made publicly available on the PROSPERO database.
      Risk factors for 30-day readmission after lower limb revascularisation for peripheral artery disease: a systematic review.

       Literature search

      To identify eligible studies, a literature review was performed using Medline/PubMed (1946) Scopus (1970), the Cochrane Library (1951), Web of Science (1965), and CINAHL (1981) databases from database inception until October 2017 without language or geographic restrictions. A second search was undertaken on May 20, 2018. Search terms were developed with the assistance of a specialist medical librarian and individualized for databases. The following search terms were used: (“Peripheral artery* disease” OR “peripheral vascular disease” OR “PVD” OR “arterial occlusive disease” OR “PAOD” OR “intermittent claudication” OR “critical limb ischaemia” OR “vascular surgical procedures “OR “lower limb revascularisation”) AND (“readmission” OR “rehospitalisation”). Titles and abstracts were screened to identify relevant articles, and potentially relevant articles had their full text examined to assess relevance and eligibility using predefined inclusion and exclusion criteria. Duplicate removal was undertaken using EndNote X8. Authors of potentially relevant abstracts were contacted for completed articles. These database searches were supplemented by hand searching reference lists of included studies. Two authors undertook these searches (S.S. and E.M.) on separate occasions and a consensus meeting was held during which any discrepancies were resolved.

       Eligibility criteria

      Studies were eligible for inclusion in this review if they met the following criteria: (1) used an accepted means of diagnosing PAD (ankle-brachial pressure index of <0.9, angiography, duplex ultrasound examination, or physician diagnosis); (2) included only patients undergoing revascularisation to treat PAD (by endovascular, open surgery, or both); (3) examined patients with a range of PAD presentations, including both IC and CLI; (4) statistically evaluated the association of at least one risk factor with 30-day readmission incidence; and (5) reported either the overall readmission rate or the readmission rate for subgroups and the number readmitted for each group so an overall rate could be calculated. Only studies written in English were included. Reports were excluded if (1) they were a case report, editorial, or letter; (2) results from other procedures were not separated from the results for PAD revascularization; or (3) data could not be extracted.

       Data extraction

      Data were extracted from the included studies by two authors (S.S. and E.M.). This review focused on risk factors that were evaluated and reported in five or more studies owing to the large number and heterogeneity of reported risk factors. Preoperative data extracted included age, sex, race, smoking history, obesity, diabetes, congestive heart failure (CHF), hypertension (HTN), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), preoperative functional status, presentation with IC or CLI, and whether an admission was urgent. Operative and postoperative factors collected included revascularization method, postoperative bleeding or sepsis, and length of stay (LOS). The following additional data were also extracted from included studies: sample size, method of statistical analysis and variables adjusted for, overall readmission rate, other risk factors for readmission, reasons for readmission, and the adjusted and unadjusted measures of association with readmission. Readmission was defined as hospital admission within 30 days of the index procedure or discharge from the index admission. Readmission rates were reported as percentage of the total cohort. A quality assessment tool was developed using components of the standard quality assessment criteria for evaluating primary research papers (Supplementary Table I, online only).
      • Kmet L.M.
      • Cook L.S.
      Standard quality assessment criteria for evaluating primary research papers from a variety of fields.
      A score of 15 or greater out of 20 was considered indicative of good study quality. Modifications were made to better suit the population of interest and included adding the type of procedure, defining PAD severity, and describing the indication for readmission. A consensus meeting was held to resolve any discrepancies in the extracted data. One study author was contacted for further information, which was provided.
      • Secemsky E.A.
      • Schermerhorn M.
      • Carroll B.J.
      • Kennedy K.F.
      • Shen C.
      • Valsdottir L.R.
      • et al.
      Readmissions after revascularization procedures for peripheral arterial disease: a nationwide cohort study.

       Statistical analysis

      Statistical analyses were undertaken to estimate the overall rate of readmission and to quantify the association of individual risk factors with readmission. Overall readmission rates were calculated by pooling weighted means across studies and reported with 95% confidence intervals (CIs). To be included in the meta-analysis the association of an individual risk factor with readmission had to be reported in a consistent manner in at least five of the included studies. Odds ratios (ORs) and 95% CIs were calculated from extracted data before data pooling. Summary associations were calculated using random effects Mantel-Haenszel models and represented using forest plots. Studies that were not comparable owing to heterogeneity of outcomes were described in a qualitative manner. The I2 index was used to assess interstudy heterogeneity. An I2 value of 50% or greater was considered to indicate heterogeneity.
      • Higgins J.P.
      • Thompson S.G.
      • Deeks J.J.
      • Altman D.G.
      Measuring inconsistency in meta-analyses.
      Publication bias was assessed using funnel plots of the logarithm of effect size vs standard error.
      • Harbord R.M.
      • Egger M.
      • Sterne J.A.
      A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints.
      All statistical tests were considered significant if the two-sided P value was .05 or less. Computations were undertaken using Comprehensive Meta Analysis 3 (Biostat) and Review Manager 5.3 (The Cochrane Collaboration).

      Results

       Search results

      Initial searches identified 894 studies after the removal of duplicates (Supplementary Fig 1, online only). Eight hundred fourteen abstracts were excluded. Full-text evaluation was undertaken for 80 publications, from which 66 were excluded. The most common reason for exclusion was failure to report a risk factor association with readmission. A total of 14 studies were ultimately included in this review.
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      • Aziz F.
      • Lehman E.B.
      • Reed A.B.
      Unplanned return to operating room after lower extremity arterial bypass is an independent predictor for hospital readmission.
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      • Gonzalez A.A.
      • Cruz C.G.
      • Dev S.
      • Osborne N.H.
      Indication for lower extremity revascularization and hospital profiling of readmissions.
      • Han S.M.
      • Wu B.
      • Eichler C.M.
      • Reilly L.M.
      • Vartanian S.M.
      • Conte M.S.
      • et al.
      Risk factors for 30-day hospital readmission in patients undergoing treatment for peripheral artery disease.
      • Jones C.E.
      • Richman J.S.
      • Chu D.I.
      • Gullick A.A.
      • Pearce B.J.
      • Morris M.S.
      Readmission rates after lower extremity bypass vary significantly by surgical indication.
      • McPhee J.T.
      • Barshes N.R.
      • Ho K.J.
      • Madenci A.
      • Ozaki C.K.
      • Nguyen L.L.
      • et al.
      Predictive factors of 30-day unplanned readmission after lower extremity bypass.
      • Najafian A.
      • Selvarajah S.
      • Schneider E.B.
      • Malas M.B.
      • Ehlert B.A.
      • Orion K.C.
      • et al.
      Thirty-day readmission after lower extremity bypass in diabetic patients.
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.

       Study characteristics

      The characteristics of the included studies and participants are shown in Tables I and II and Supplementary Tables II to IV (online only). All included studies were retrospective cohort investigations performed in the United States between 2013 and 2018. A total of 526,008 patients were investigated. Sample sizes ranged from 174 to 479,047 with a median size of 4096. Both open and endovascular procedures were represented. Seven studies included patients undergoing open revascularization alone,
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      • Aziz F.
      • Lehman E.B.
      • Reed A.B.
      Unplanned return to operating room after lower extremity arterial bypass is an independent predictor for hospital readmission.
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      • Jones C.E.
      • Richman J.S.
      • Chu D.I.
      • Gullick A.A.
      • Pearce B.J.
      • Morris M.S.
      Readmission rates after lower extremity bypass vary significantly by surgical indication.
      • McPhee J.T.
      • Barshes N.R.
      • Ho K.J.
      • Madenci A.
      • Ozaki C.K.
      • Nguyen L.L.
      • et al.
      Predictive factors of 30-day unplanned readmission after lower extremity bypass.
      • Najafian A.
      • Selvarajah S.
      • Schneider E.B.
      • Malas M.B.
      • Ehlert B.A.
      • Orion K.C.
      • et al.
      Thirty-day readmission after lower extremity bypass in diabetic patients.
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      two investigated endovascular revascularization alone,
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      and the remaining five studies included patients having both revascularization methods.
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      • Gonzalez A.A.
      • Cruz C.G.
      • Dev S.
      • Osborne N.H.
      Indication for lower extremity revascularization and hospital profiling of readmissions.
      • Han S.M.
      • Wu B.
      • Eichler C.M.
      • Reilly L.M.
      • Vartanian S.M.
      • Conte M.S.
      • et al.
      Risk factors for 30-day hospital readmission in patients undergoing treatment for peripheral artery disease.
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      Inclusion and exclusion criteria were variable between studies (Supplementary Table II, online only). Most studies excluded patients who died in hospital and those that were inpatients for 30 or more days (Supplementary Table II, online only). Ten of the 14 studies only included patients undergoing revascularization for infrainguinal artery disease,
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      • Aziz F.
      • Lehman E.B.
      • Reed A.B.
      Unplanned return to operating room after lower extremity arterial bypass is an independent predictor for hospital readmission.
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      • Jones C.E.
      • Richman J.S.
      • Chu D.I.
      • Gullick A.A.
      • Pearce B.J.
      • Morris M.S.
      Readmission rates after lower extremity bypass vary significantly by surgical indication.
      • McPhee J.T.
      • Barshes N.R.
      • Ho K.J.
      • Madenci A.
      • Ozaki C.K.
      • Nguyen L.L.
      • et al.
      Predictive factors of 30-day unplanned readmission after lower extremity bypass.
      • Najafian A.
      • Selvarajah S.
      • Schneider E.B.
      • Malas M.B.
      • Ehlert B.A.
      • Orion K.C.
      • et al.
      Thirty-day readmission after lower extremity bypass in diabetic patients.
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      although one investigation reported on patients undergoing revascularization of either suprainguinal and infrainguinal artery disease.
      • Han S.M.
      • Wu B.
      • Eichler C.M.
      • Reilly L.M.
      • Vartanian S.M.
      • Conte M.S.
      • et al.
      Risk factors for 30-day hospital readmission in patients undergoing treatment for peripheral artery disease.
      Three studies did not provide any comment on the artery disease location (Supplementary Table III, online only).
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      • Gonzalez A.A.
      • Cruz C.G.
      • Dev S.
      • Osborne N.H.
      Indication for lower extremity revascularization and hospital profiling of readmissions.
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      Follow-up time ranged from 30 days to 5 years, with three studies reporting readmission past 30 days.
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      • McPhee J.T.
      • Barshes N.R.
      • Ho K.J.
      • Madenci A.
      • Ozaki C.K.
      • Nguyen L.L.
      • et al.
      Predictive factors of 30-day unplanned readmission after lower extremity bypass.
      All studies included 30-day readmission as a primary outcome; however, this factor was inconsistently defined. Nine studies defined the 30-day period as beginning from the index operation,
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      • Aziz F.
      • Lehman E.B.
      • Reed A.B.
      Unplanned return to operating room after lower extremity arterial bypass is an independent predictor for hospital readmission.
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      • Gonzalez A.A.
      • Cruz C.G.
      • Dev S.
      • Osborne N.H.
      Indication for lower extremity revascularization and hospital profiling of readmissions.
      • Jones C.E.
      • Richman J.S.
      • Chu D.I.
      • Gullick A.A.
      • Pearce B.J.
      • Morris M.S.
      Readmission rates after lower extremity bypass vary significantly by surgical indication.
      • Najafian A.
      • Selvarajah S.
      • Schneider E.B.
      • Malas M.B.
      • Ehlert B.A.
      • Orion K.C.
      • et al.
      Thirty-day readmission after lower extremity bypass in diabetic patients.
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      whereas five defined this period as beginning after discharge from the index admission.
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      • Han S.M.
      • Wu B.
      • Eichler C.M.
      • Reilly L.M.
      • Vartanian S.M.
      • Conte M.S.
      • et al.
      Risk factors for 30-day hospital readmission in patients undergoing treatment for peripheral artery disease.
      • McPhee J.T.
      • Barshes N.R.
      • Ho K.J.
      • Madenci A.
      • Ozaki C.K.
      • Nguyen L.L.
      • et al.
      Predictive factors of 30-day unplanned readmission after lower extremity bypass.
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      Four studies did not distinguish between planned and unplanned admissions
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      • Gonzalez A.A.
      • Cruz C.G.
      • Dev S.
      • Osborne N.H.
      Indication for lower extremity revascularization and hospital profiling of readmissions.
      • Han S.M.
      • Wu B.
      • Eichler C.M.
      • Reilly L.M.
      • Vartanian S.M.
      • Conte M.S.
      • et al.
      Risk factors for 30-day hospital readmission in patients undergoing treatment for peripheral artery disease.
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      ; however, planned readmissions typically made up less than 5% of readmissions in these studies and so was unlikely to impact results. Four studies also reported postoperative complications, including 30-day mortality, 30-day morbidity, and limb outcomes (such as major amputation or graft failure), as secondary outcomes.
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      • Jones C.E.
      • Richman J.S.
      • Chu D.I.
      • Gullick A.A.
      • Pearce B.J.
      • Morris M.S.
      Readmission rates after lower extremity bypass vary significantly by surgical indication.
      • McPhee J.T.
      • Barshes N.R.
      • Ho K.J.
      • Madenci A.
      • Ozaki C.K.
      • Nguyen L.L.
      • et al.
      Predictive factors of 30-day unplanned readmission after lower extremity bypass.
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      Table ISummary of included studies
      Study characteristic
      All data directly transcribed from original studies unless otherwise noted. Patients that were missing peripheral artery disease (PAD) severity data in Ali et al, Aziz et al, and Krafcik et al were added to the asymptomatic/other column.
      Readmissions separated by indication
      AuthorYearSample sizeICCLI
      CLI of any severity as indication for revascularisation.
      Asymptomatic/otherRevascularisation methodFollow-UpIC
      Reported as number readmitted (percentage readmission rate) for that indication in respective study.
      CLI
      CLI of any severity as indication for revascularisation.
      Reported as number readmitted (percentage readmission rate) for that indication in respective study.
      Total
      Ali et al
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      20171096434 (40)589 (54)73 (7)Endovascular30 Days32 (7)104 (18)147 (13)
      Aziz et al
      • Aziz F.
      • Lehman E.B.
      • Reed A.B.
      Unplanned return to operating room after lower extremity arterial bypass is an independent predictor for hospital readmission.
      20162646684 (26)1876 (71)86 (3)Open30 Days72 (11)348 (19)425 (16)
      Aziz et al
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      201837421118 (30)2465 (66)159 (4)Both30 Days104 (9)452 (18)572 (15)
      Bodewes et al
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      201744491647 (37)2802 (63)0 (0)Endovascular30 Days107 (6)447 (16)554 (12)
      Damrauer et al
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      201563072394 (38)3913 (62)0 (0)Open1 Year282 (12)1009 (26)1291 (20)
      Gonzalez et al
      • Gonzalez A.A.
      • Cruz C.G.
      • Dev S.
      • Osborne N.H.
      Indication for lower extremity revascularization and hospital profiling of readmissions.
      2016479,047130,841 (27)171,251 (36)176,955 (37)Both30 Days9551 (7)
      Calculated from original study data.
      33,394 (20)
      Calculated from original study data.
      71,857 (15)
      Calculated from original study data.
      Han et al
      • Han S.M.
      • Wu B.
      • Eichler C.M.
      • Reilly L.M.
      • Vartanian S.M.
      • Conte M.S.
      • et al.
      Risk factors for 30-day hospital readmission in patients undergoing treatment for peripheral artery disease.
      201517439 (22)112 (64)23 (13)Both30 DaysNRNR37 (21)
      Jones et al
      • Jones C.E.
      • Richman J.S.
      • Chu D.I.
      • Gullick A.A.
      • Pearce B.J.
      • Morris M.S.
      Readmission rates after lower extremity bypass vary significantly by surgical indication.
      201661121907 (31)3962 (65)243 (4)Open30 Days180 (9)704 (18)904 (15)
      Krafcik et al
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      201735088 (25)256 (73)6 (2)Open1 Year19 (22)84 (33)105 (30)
      McPhee et al
      • McPhee J.T.
      • Barshes N.R.
      • Ho K.J.
      • Madenci A.
      • Ozaki C.K.
      • Nguyen L.L.
      • et al.
      Predictive factors of 30-day unplanned readmission after lower extremity bypass.
      20131516239 (16)1277 (84)0 (0)Open5 Years33 (14)316 (25)349 (23)
      Najafian et al
      • Najafian A.
      • Selvarajah S.
      • Schneider E.B.
      • Malas M.B.
      • Ehlert B.A.
      • Orion K.C.
      • et al.
      Thirty-day readmission after lower extremity bypass in diabetic patients.
      201692075396 (59)3811 (41)0 (0)Open30 Days749 (14)699 (18)1448 (16)
      Vogel et al
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      20131458505 (35)595 (41)358 (25)Both30 Days54 (11)109 (18)212 (15)
      Vogel et al
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      201853921574 (29)2214 (41)1604 (30)Both30 Days111 (7)304 (14)586 (11)
      Zhang et al
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      201445122420 (54)2092 (46)0 (0)Open30 Days364 (15)467 (22)831 (18)
      Total526,008149,286 (28)197,215 (37)179,507 (34)10% (8-13)20% (18-21)16% (15-18)
      CLI, Critical limb ischemia; IC, intermittent claudication; NR, not reported.
      Data presented as number (%). Readmission totals are presented as pooled mean readmission rate as percent (95% confidence interval).
      a All data directly transcribed from original studies unless otherwise noted. Patients that were missing peripheral artery disease (PAD) severity data in Ali et al, Aziz et al, and Krafcik et al were added to the asymptomatic/other column.
      b CLI of any severity as indication for revascularisation.
      c Reported as number readmitted (percentage readmission rate) for that indication in respective study.
      d Calculated from original study data.
      Table IICharacteristics of included participants
      StudyAverage age, yearsMaleBlack raceObese
      Defined as a body mass index of ≥30.
      Smoking
      Current smoker (within last 12 months).
      HTNCHFCOPDDMCKD
      Includes renal failure, renal insufficiency, estimated glomerular filtration rate of <90, CKD I-V.
      Ali et al
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      (2017)
      70 ± 12671 (61)156 (14)342 (31)362 (33)949 (87)19 (2)114 (10)535 (49)NR
      Aziz et al
      • Aziz F.
      • Lehman E.B.
      • Reed A.B.
      Unplanned return to operating room after lower extremity arterial bypass is an independent predictor for hospital readmission.
      (2016)
      68 ± 111713 (65)454 (17)820 (31)1086 (41)2200 (83)72 (3)350 (13)1174 (44)NR
      Aziz et al
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      (2018)
      NR2384 (64)
      Uses number of males from odds ratio portion of study.
      610 (16)1162 (32)1448 (39)3149 (84)91 (2)464 (12)1709 (46)NR
      Bodewes et al
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      (2017)
      NR2604 (59)782 (18)1381 (31)1362 (31)3787 (85)153 (3)460 (10)2416 (54)1186 (27)
      Damrauer et al
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      (2015)
      72 (IQR, 63-79)3772 (60)585 (9)NRNR4990 (79)234 (4)1658 (26)2532 (40)1133 (18)
      Gonzalez et al
      • Gonzalez A.A.
      • Cruz C.G.
      • Dev S.
      • Osborne N.H.
      Indication for lower extremity revascularization and hospital profiling of readmissions.
      (2016)
      NRNRNRNRNRNRNRNRNRNR
      Han et al
      • Han S.M.
      • Wu B.
      • Eichler C.M.
      • Reilly L.M.
      • Vartanian S.M.
      • Conte M.S.
      • et al.
      Risk factors for 30-day hospital readmission in patients undergoing treatment for peripheral artery disease.
      (2015)
      69 ± 12111 (64)17 (10)NR113 (65)146 (84)20 (11)31 (18)82 (47)34 (20)
      Jones et al
      • Jones C.E.
      • Richman J.S.
      • Chu D.I.
      • Gullick A.A.
      • Pearce B.J.
      • Morris M.S.
      Readmission rates after lower extremity bypass vary significantly by surgical indication.
      (2016)
      67 ± 114021 (66)1019 (17)1861 (30)NR5005 (82)147 (2)797 (13)2654 (43)NR
      Krafcik et al
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      (2017)
      NR215 (61)137 (39)104 (30)142 (41)306 (87)59 (17)48 (14)206 (59)60 (17)
      McPhee et al
      • McPhee J.T.
      • Barshes N.R.
      • Ho K.J.
      • Madenci A.
      • Ozaki C.K.
      • Nguyen L.L.
      • et al.
      Predictive factors of 30-day unplanned readmission after lower extremity bypass.
      (2013)
      69 ± 11929 (61)299 (20)NR443 (29)1074 (71)255 (17)192 (12)824 (54)NR
      Najafian et al
      • Najafian A.
      • Selvarajah S.
      • Schneider E.B.
      • Malas M.B.
      • Ehlert B.A.
      • Orion K.C.
      • et al.
      Thirty-day readmission after lower extremity bypass in diabetic patients.
      (2016)
      NR5950 (65)1527 (17)2815 (31)3882 (42)7771 (84)224 (2)1166 (13)4052 (44)NR
      Vogel et al
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      (2013)
      68 [67-69]848 (58)285 (20)NRNRNR150 (10)260 (18)589 (40)216 (15)
      Vogel et al
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      (2018)
      68 [67-68]3219 (60)1162 (22)NRNR3650 (68)621 (12)968 (18)2332 (43)1063 (20)
      Zhang et al
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      (2014)
      67 ± 122921 (65)772 (17)1243 (28)1911 (42)NRNR572 (13)1976 (44)NR
      CHF, Congestive heart failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; HTN, hypertension; NR, not reported.
      Data are presented as mean ± standard deviation, number (%), or mean [95% confidence interval], unless stated otherwise.
      a Defined as a body mass index of ≥30.
      b Current smoker (within last 12 months).
      c Includes renal failure, renal insufficiency, estimated glomerular filtration rate of <90, CKD I-V.
      d Uses number of males from odds ratio portion of study.

       Study quality

      All studies reported clear research questions, participant selection and revascularization methods, and had sample sizes of greater than 100. Overall, study quality was good with 13 of the 14 studies scoring 15 or greater out of 20 for quality assessment. No studies reported a rationale for the sample size included. The quality assessment scoring is shown in detail in Supplementary Table V (online only).

       Readmission rate and reasons for readmission

      The overall readmission frequency in the included studies varied from 10.9% to 30.0%, with an overall pooled mean of 16.4% (95% CI, 15.1%-17.9%). A leave one out sensitivity analysis was performed excluding the largest study (authored by Gonzalez et al),
      • Gonzalez A.A.
      • Cruz C.G.
      • Dev S.
      • Osborne N.H.
      Indication for lower extremity revascularization and hospital profiling of readmissions.
      which showed similar findings (readmission rate without study, 16.7%; 95% CI, 14.8%-18.8%). Most readmissions were related to the index procedure, with operative site complications responsible for 40% to 80% of readmissions.
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      • Han S.M.
      • Wu B.
      • Eichler C.M.
      • Reilly L.M.
      • Vartanian S.M.
      • Conte M.S.
      • et al.
      Risk factors for 30-day hospital readmission in patients undergoing treatment for peripheral artery disease.
      • Jones C.E.
      • Richman J.S.
      • Chu D.I.
      • Gullick A.A.
      • Pearce B.J.
      • Morris M.S.
      Readmission rates after lower extremity bypass vary significantly by surgical indication.
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      Operative site complications included deep and superficial surgical site infections and wound dehiscence. Recurrent PAD symptoms, sepsis, and cardiovascular complications were also consistently reported as indications for readmission. Indications for readmission were generally poorly described, with one study unable to account for 95% of readmission indications and five studies not reporting the reasons for readmission.
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      • Najafian A.
      • Selvarajah S.
      • Schneider E.B.
      • Malas M.B.
      • Ehlert B.A.
      • Orion K.C.
      • et al.
      Thirty-day readmission after lower extremity bypass in diabetic patients.
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.

       Preoperative risk factors for readmission

      Preoperative risk factors meeting criteria for meta-analysis included female sex, black race, indication for revascularization, smoking, obesity, functional status, HTN, CHF, COPD, diabetes, CKD, dialysis dependence, and emergency admission. These risk factors were examined in between 6 and 13 studies each (Fig 1, Fig 2, Fig 3, Fig 4). A meta-analysis was not performed for old age owing to the heterogeneity with which age was defined. On meta-analysis, a significant positive association with readmission was noted for: female sex (OR, 1.13; 95% CI, 1.05-1.21), black race (OR, 1.36; 95% CI, 1.28-1.46), dependent functional status (OR, 1.72; 95% CI, 1.43-2.06), emergency admission (OR, 1.75; 95% CI, 1.43-2.15), HTN (OR, 1.39; 95% CI, 1.26-1.54), CHF (OR, 1.82; 95% CI, 1.50-2.20), COPD (OR, 1.19; 95% CI, 1.08-1.32), diabetes (OR, 1.47; 95% CI, 1.32-1.63), CKD (OR, 1.93; 95% CI, 1.62-2.31), and dialysis dependence (OR, 2.08; 95% CI, 1.75-2.48; Fig 1, Fig 2, Fig 3). The association of obesity with readmission was not significant (OR, 1.12; 95% CI, 0.97-1.31); Supplementary Fig 2, online only) and current smoking had a negative association with readmission (OR, 0.83; 95% CI, 0.78-0.89). CLI, whether defined by rest pain or tissue loss, was associated with an increased risk of readmission and this risk was correlated with increasing disease severity (Fig 4; Supplementary Table IV, online only).
      Figure thumbnail gr1
      Fig 1Association of selected characteristics and readmission. Forest plot of odds ratios (ORs) for readmission with and without selected demographic risk factors. M-H random, Mantel-Haenszel random effects model.
      Figure thumbnail gr2
      Fig 2Association of selected characteristics and readmission. Forest plot of odds ratios (ORs) for readmission with and without selected comorbid risk factors. M-H random, Mantel-Haenszel random effects model.
      Figure thumbnail gr3
      Fig 3Association of selected characteristics and readmission. Forest plot of odds ratios (ORs) for readmission with and without selected risk factors. M-H random, Mantel-Haenszel random effects model.
      Figure thumbnail gr4
      Fig 4Association of peripheral arterial disease (PAD) severity and readmission. Forest plot of odds ratios (ORs) for readmission with differing severities of PAD compared with intermittent claudication (IC). M-H random, Mantel-Haenszel random effects model.

       Operative and postoperative risk factors for readmission

      Operative and postoperative risk factors meeting criteria for meta-analysis included postoperative bleeding and sepsis, and postoperative increased LOS. Increased LOS was studied in six studies,
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      • Jones C.E.
      • Richman J.S.
      • Chu D.I.
      • Gullick A.A.
      • Pearce B.J.
      • Morris M.S.
      Readmission rates after lower extremity bypass vary significantly by surgical indication.
      • Najafian A.
      • Selvarajah S.
      • Schneider E.B.
      • Malas M.B.
      • Ehlert B.A.
      • Orion K.C.
      • et al.
      Thirty-day readmission after lower extremity bypass in diabetic patients.
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      postoperative sepsis in seven,
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      • Najafian A.
      • Selvarajah S.
      • Schneider E.B.
      • Malas M.B.
      • Ehlert B.A.
      • Orion K.C.
      • et al.
      Thirty-day readmission after lower extremity bypass in diabetic patients.
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      and postoperative bleeding was studied in nine.
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      • Aziz F.
      • Lehman E.B.
      • Reed A.B.
      Unplanned return to operating room after lower extremity arterial bypass is an independent predictor for hospital readmission.
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      • McPhee J.T.
      • Barshes N.R.
      • Ho K.J.
      • Madenci A.
      • Ozaki C.K.
      • Nguyen L.L.
      • et al.
      Predictive factors of 30-day unplanned readmission after lower extremity bypass.
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      A meta-analysis for LOS was not performed owing to the heterogeneity with which it was defined. Postoperative bleeding (OR, 1.70; 95% CI, 1.23-2.35) and postoperative sepsis (OR, 4.13; 95% CI, 2.02-8.47) were both significantly associated with readmission (Fig 3). Marked interstudy heterogeneity was noted for postoperative bleeding or sepsis, as well as CLI (Figs 3 and 4). The association of revascularization method (open or endovascular) with readmission was only investigated in four studies and thus was not formally meta-analyzed.
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      • Gonzalez A.A.
      • Cruz C.G.
      • Dev S.
      • Osborne N.H.
      Indication for lower extremity revascularization and hospital profiling of readmissions.
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      There was a higher mean pooled readmission rate after open procedures than endovascular revascularization (open: 18.7%, 95% CI, 13.3%-25.8%; endovascular: 15.3%, 95% CI, 11.0%-20.8%; Supplementary Table VI, online only).

      Discussion

      This systematic review suggests that readmission following peripheral revascularization is common, affecting approximately one in six patients. The review also identified important preoperative and postoperative risk factors for readmission, including emergency admission, CLI, CKD, CHF, dependent functional status, and postoperative bleeding and sepsis. These risk factors were individually associated with an approximate two- to four-fold higher rate of readmission. Patients frequently have more than one of these risk factors and, therefore, the use of predictive models incorporating multiple risk factors may allow for the identification of those at particularly high risk at the time of admission or before discharge.
      A number of previous studies have attempted to develop predictive models for readmission of patients with PAD. Ali et al
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      conducted an analysis of 1096 patients undergoing endovascular procedures and used significant risk factors identified through multivariate analyses to create a risk prediction model. Included factors were body mass index of 30 or greater, smoking status, diabetes, dyspnea, dependent functional status, emergency procedure, and unplanned return to the operating room. The presence of all these risk factors resulted in a predicted risk of readmission of almost 100%. Another study by the same group in patients undergoing open bypass used postoperative bleeding, long operative time, amputation, renal insufficiency, reoperation, wound infection, and being physiologically high risk (a risk score utilising patient factors such as age >80, New York Heart Association functional class III or greater, ejection fraction of <30%, or unstable angina) in a predictive model.
      • Aziz F.
      • Lehman E.B.
      • Reed A.B.
      Unplanned return to operating room after lower extremity arterial bypass is an independent predictor for hospital readmission.
      The presence of all risk factors was associated with an approximately 100% chance of readmission. Neither of these models have, however, been validated in an independent cohort. Several of the risk factors used in these predictive models could not be included in this meta-analysis because of limited reporting or the inconsistent definitions used in different studies. Findings from this systematic review confirm the association of some but not all of the factors with readmission. Based on this review, it may be possible to develop a more robust predictive model given the number of studies included. This, however, remains to be confirmed and would require testing in a prospective cohort study.
      The findings from this systematic review suggest it is possible to identify patients at high risk of readmission. These patients could theoretically be selected for interventions to decrease readmission.
      • McPhee J.T.
      • Nguyen L.L.
      • Ho K.J.
      • Ozaki C.K.
      • Conte M.S.
      • Belkin M.
      Risk prediction of 30-day readmission after infrainguinal bypass for critical limb ischemia.
      • Brooke B.S.
      • De Martino R.R.
      • Girotti M.
      • Dimick J.B.
      • Goodney P.P.
      Developing strategies for predicting and preventing readmissions in vascular surgery.
      It is possible that interventions targeted at risk factors identified in this review, such as improving functional status, could be used to reduce readmission after elective admission. This approach has been successfully used in previous studies for preventing readmission in other patient groups. For example, a previous randomised controlled trial of hospitalized older patients at risk of readmission reported that an intervention consisting of physiotherapy assessment and tailored exercise programs halved hospital readmissions (22% intervention vs 47% control; P = .007).
      • Courtney M.
      • Edwards H.
      • Chang A.
      • Parker A.
      • Finlayson K.
      • Hamilton K.
      Fewer emergency readmissions and better quality of life for older adults at risk of hospital readmission: a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone follow-up program.
      The value of this approach in patients with PAD is unknown. Other possible methods that have been suggested include better patient education, improved discharge planning, predischarge scheduling of follow-up appointments, follow-up phone calls, patient hot lines, and postdischarge home visits.
      • Hansen L.O.
      • Young R.S.
      • Hinami K.
      • Leung A.
      • Williams M.V.
      Interventions to reduce 30-day rehospitalization: a systematic review.
      These have been investigated in a previous systematic review reporting outcomes of a range of programs aimed at reducing readmissions.
      • Nuckols T.K.
      • Keeler E.
      • Morton S.
      • Anderson L.
      • Doyle B.J.
      • Pevnick J.
      • et al.
      Economic evaluation of quality improvement interventions designed to prevent hospital readmission: a systematic review and meta-analysis.
      Quality improvement programs investigated ranged from primarily communication-based interventions, such as predischarge patient or caregiver engagement, to more intensive follow-up, for example telemonitoring of patient physiological data after discharge. Quality improvement interventions reduced readmissions for CHF by an average of 12.1% and by 6.3% for general hospital populations. Interventions to reduce readmission were also associated with a significant decrease in net costs owing to readmission. Although these interventions were not targeted toward patients with PAD, these findings show the potential to successfully reduce readmission.
      This study had several limitations. There was substantial heterogeneity in the methods of reporting in the included studies. Most studies reported unplanned 30-day readmission from the index operation; however, this factor was not universal, with some studies beginning the 30-day period from discharge and others including planned readmission. Similar heterogeneity was noted in terms of the reporting of risk factors. Because of the difference in reporting of old age and LOS in different studies, these risk factors could not be included in the meta-analysis; thus, their true effect on readmission remains unclear. Similarly, a lack of detailed reporting of subgroups prevented stratification of risk factors by certain key variables. Stratification of risk factors by presentation and revascularization method has been shown to influence findings in previous studies. Bodewes et al
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      reported that longer procedure time was only associated with increased readmission rate in patients with IC, not those with CLI. Similarly, some studies have found differences in risk factors for readmission in patients undergoing endovascular vs open revascularization procedures.
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      Owing to a lack of reporting, it was not possible to perform subgroup analyses examining risk factors for readmission specific to presentation group or procedure type. This focus is important for future studies, because having these data would be useful in determining a particular patient's readmission risk. It also was not possible to report the relationship between risk factor control, such as blood pressure or hemoglobin A1c, and readmission. Such data would be important in identifying whether it is likely that better control of such risk factors preoperatively might decrease the incidence of readmission. Further research is needed to assess this finding. Because of the lack of consistent multivariable analysis methods, adjusted models could not be pooled in the meta-analyses. This factor leaves open the possibility of confounding between covariates. Interestingly, smoking was consistently negatively associated with readmission across several studies, and on overall meta-analysis.
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      • Aziz F.
      • Lehman E.B.
      • Reed A.B.
      Unplanned return to operating room after lower extremity arterial bypass is an independent predictor for hospital readmission.
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      • Han S.M.
      • Wu B.
      • Eichler C.M.
      • Reilly L.M.
      • Vartanian S.M.
      • Conte M.S.
      • et al.
      Risk factors for 30-day hospital readmission in patients undergoing treatment for peripheral artery disease.
      • McPhee J.T.
      • Barshes N.R.
      • Ho K.J.
      • Madenci A.
      • Ozaki C.K.
      • Nguyen L.L.
      • et al.
      Predictive factors of 30-day unplanned readmission after lower extremity bypass.
      • Najafian A.
      • Selvarajah S.
      • Schneider E.B.
      • Malas M.B.
      • Ehlert B.A.
      • Orion K.C.
      • et al.
      Thirty-day readmission after lower extremity bypass in diabetic patients.
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      Owing to the counterintuitive nature of this association, Ali et al
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      investigated possible confounding, and found that a large proportion of nonsmokers were of dependent functional status, which was associated with readmission. They hypothesized that former smokers had become functionally dependent at the time of analysis, and their functional status and the fact they were now classed as nonsmokers confounded the relationship. Another important limitation of the included studies was they were all based on retrospective analysis of data from the US healthcare system. It is, therefore, unclear as to how these results relate to patients in other settings. Another limitation was that most studies only reported readmission within 30 days of discharge when it is established that patients commonly represent at a later time.
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.

      Conclusions

      This systematic review identified that readmission after revascularization for PAD is common and has established risk factors. Future research is needed to assess the benefit of novel ways to reduce this complication in at-risk patients.

      Author contributions

      Conception and design: SS, JM, JG
      Analysis and interpretation: SS, EM, JM, JG
      Data collection: SS, EM
      Writing the article: SS, EM, JM, JG
      Critical revision of the article: SS, EM, JM, JG
      Final approval of the article: SS, EM, JM, JG
      Statistical analysis: SS, JM
      Obtained funding: SS, JM, JG
      Overall responsibility: SS
      The authors thank Dr Dylan R. Morris for statistical advice, Dr Eric Secemsky for providing manuscripts still under review, Nilosh Sathiyamoorthi for image preparation, and Sam Rannard for providing database searching expertise.

      Appendix (online only).

      Supplementary Table I (online only)Quality assessment criteria
      • Golledge J.
      Lower-limb arterial disease.
      Quality categoryQuestionsS.S.E.M.
      1Research questionDid the study report clear aims (including all of the following: population, intervention, and outcome of interest)?
      2Was the study setting defined (eg, hospital based; single center or multicenter)?
      3Was the study reported as a prospective study (eg, hypothesis/research question defined before recruitment of patients)
      4Selection criteriaWere the methods for recruitment /sampling detailed in the study?
      5Was the diagnosis of PAD adequately defined (ie, positive diagnosis of PAD by one or several of the following: ABPI of ˂0.9; angiography, physician's examination; other clinical imaging)
      6Type of surgical procedure undergone identified (endovascular, open bypass or both)
      7Were inclusion and exclusion criteria detailed?
      8Participant characteristicsWas PAD severity defined in the cases? (ie, based on symptoms or the Fontaine classification: PAD stage I-IV, or divided into IC, CLI-RP, CLI-TL, CLI-gangrene)
      9Sufficient relevant baseline medical and demographic information characterizing participants was provided (or reference to previously published baseline data provided). Defined as including ≥5 of the following: age, gender, smoking, HTN, cholesterol, ABI, DM, previous AMI/CAD, CLI, renal impairment.
      10Sample sizeWas the sample size >100 participants?
      11Was the basis of sample size/calculation reported in methodology?
      12OutcomeWas the primary outcome defined as readmission to a hospital as an inpatient ≤30 days after surgical intervention for any cause?
      13Was the indication for admission noted
      14Was it reported whether admission was planned or unplanned
      15MethodsProcess by which follow-up was performed to identify outcomes described (eg, ACS-NSQIP dataset, hospital records, etc)
      16Ethical issues (eg, consent, patient confidentiality, ethics approval) addressed
      17AnalysisDid the study exclude or adjust for ≥2 confounders using one or several statistical methods (eg, logistic regression): age, gender, HTN, IHD, ABI, BMI, DM, smoking, dyslipidemia impaired renal function, previous stroke, preoperative wound, ASA classification
      18Measure of association (eg, odds ratio) included for each risk factor
      19Whether the association was statistically significant (eg, P value) included
      20Did the study report findings in the context of the existing literature?
      Individual score (Y)
      Averaged score (%)
      ABI, Ankle-brachial index; ABPI, ankle-brachial pressure index; ACS-NSQIP, American College of Surgeons National Surgical Quality Improvement Program; AMI, acute myocardial infarction; ASA, American Society of Anesthesiologists; BMI, body mass index; CAD, coronary artery disease; CLI, critical limb ischemia; CLI-RP, critical limb ischemia with rest pain only; CLI-TL, critical limb ischemia with tissue loss, including ulcer and gangrene; DM, diabetes mellitus; HTN, hypertension; IHD, ischemic heart disease.
      Supplementary Table II (online only)Characteristics of included studies
      StudyData sourceInclusion criteriaExclusion criteriaOutcomes
      Ali et al
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      (2017)
      ACS-NSQIP (2013)Lower extremity endovascular revascularization for PADBilateral limb revascularization in the same calendar year; planned readmissionPostoperative 30-day readmission
      Aziz et al
      • Aziz F.
      • Lehman E.B.
      • Reed A.B.
      Unplanned return to operating room after lower extremity arterial bypass is an independent predictor for hospital readmission.
      (2016)
      ACS-NSQIP (2013)LEB for PADBilateral limb revascularization in the same calendar year; planned readmissionPostoperative 30-day readmission
      Aziz et al
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      (2018)
      ACS-NSQIP (2013)Lower extremity revascularization for PADPlanned readmission; aortoiliac diseasePostoperative 30-day readmission
      Bodewes et al
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      (2017)
      ACS-NSQIP (2012-2014)Infrainguinal endovascular intervention for PADIn-hospital mortality; hospital stay >30 days; planned readmissionPostoperative 30-day readmission

      Secondary: in-hospital and 30-day mortality, MALE, complications, discharge other than home
      Damrauer et al
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      (2015)
      California State Inpatient Database (2007-2011)LEB for infrainguinal PADIn-hospital mortality; transfer to another in-patient hospital; same day discharge and readmissionPostdischarge 30-day readmission

      Secondary: 1-year readmission
      Gonzalez et al
      • Gonzalez A.A.
      • Cruz C.G.
      • Dev S.
      • Osborne N.H.
      Indication for lower extremity revascularization and hospital profiling of readmissions.
      (2016)
      CMS Medicare Provider Analysis and Review (2005-2009)ICD-9 procedural codes 38.08, 38.18, 38.38, 38.48, 38.88, 39.25, 39.29, 39.35, and 39.90In-hospital mortality; low volume hospitalPostoperative 30-day readmission
      Han et al
      • Han S.M.
      • Wu B.
      • Eichler C.M.
      • Reilly L.M.
      • Vartanian S.M.
      • Conte M.S.
      • et al.
      Risk factors for 30-day hospital readmission in patients undergoing treatment for peripheral artery disease.
      (2015)
      University of California (2011-2012)Lower extremity revascularization or amputation for PADIn-hospital mortality; trauma indication; endovascular procedure for aortic stent graftsPostdischarge 30-day readmission
      Jones et al
      • Jones C.E.
      • Richman J.S.
      • Chu D.I.
      • Gullick A.A.
      • Pearce B.J.
      • Morris M.S.
      Readmission rates after lower extremity bypass vary significantly by surgical indication.
      (2016)
      ACS-NSQIP (2012-2014)LEB for PADEmergent cases; ASA class 5; LOS >10 days; death within 30 days of index operation; amputation during readmission; planned readmissionPostoperative 30-day readmission

      Secondary: 14-day readmission, 30-day postoperative complications
      Krafcik et al
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      (2017)
      Boston Medical Center (2008-2016)LEB for PADEmergent cases; amputationsPostoperative 30-day, 90-day, and 1-year readmission
      McPhee et al
      • McPhee J.T.
      • Barshes N.R.
      • Ho K.J.
      • Madenci A.
      • Ozaki C.K.
      • Nguyen L.L.
      • et al.
      Predictive factors of 30-day unplanned readmission after lower extremity bypass.
      (2013)
      Brigham and Women's Hospital (1995-2011)LEB for PADIn-hospital mortality; trauma or aneurysmal disease as indication; planned readmissionPostdischarge 30-day readmission

      Secondary: postoperative complications, 5-year graft patency and limb salvage
      Najafian et al
      • Najafian A.
      • Selvarajah S.
      • Schneider E.B.
      • Malas M.B.
      • Ehlert B.A.
      • Orion K.C.
      • et al.
      Thirty-day readmission after lower extremity bypass in diabetic patients.
      (2016)
      ACS-NSQIP (2011-2012)Infrainguinal LEB; age >18 yearsConcomitant suprainguinal procedure; postoperative acute limb ischemia; death within 30 days of index operation; hospitalization >30 days; planned readmission; missing demographic or readmission dataPostoperative 30-day readmission
      Vogel et al
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      (2013)
      Health Facts (Cerner) (2008-2010)Elective LEB or endovascular revascularization for PADAge <18 years; diagnosis of pregnancy, complications of pregnancy/childbirth or obstetric procedures; primary care, psychiatric or rehabilitation facility setting; concomitant open/endovascular procedure; planned readmissionsPostdischarge 30-day readmission
      Vogel et al
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      (2018)
      Health Facts (Cerner) (2008-2014)Elective LEB or endovascular revascularization for PADAge <21 years; concomitant open/endovascular procedures; emergent case; hospital stay >30 days; in-hospital mortality; second encounter within 3 hours of discharge or admission; missing laboratory or medication data; hospice discharge destinationPostdischarge 30-day readmission
      Zhang et al
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      (2014)
      ACS-NSQIP (2005-2011)Infrainguinal LEB for PADIn-hospital mortality; hospital stay >30 daysPostoperative 30-day readmission

      Secondary: 30-day morbidity, 30-day mortality
      ACS-NSQIP, American College of Surgeons-National Surgical Quality Improvement Program; ASA, American Society of Anesthesiologists; ICD, International Classification of Diseases; LEB, lower extremity bypass; LOS, length of stay; MALE, major adverse limb events; PAD, peripheral artery disease.
      Supplementary Table III (online only)Location of occlusive disease in patients included in the studies
      StudyYearSample sizeAortoiliacFemoropoplitealTibial or pedalNot reported or known
      Ali et al
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      Paper excludes aorto-iliac disease.
      201710960 (0)832 (76)253 (23)11 (1)
      Aziz et al
      • Aziz F.
      • Lehman E.B.
      • Reed A.B.
      Unplanned return to operating room after lower extremity arterial bypass is an independent predictor for hospital readmission.
      Paper excludes aorto-iliac disease.
      201626460 (0)1594 (61)987 (37)65 (2)
      Aziz et al
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      Paper excludes aorto-iliac disease.
      201837420 (0)NRNRNR
      Bodewes et al
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      Paper excludes aorto-iliac disease.
      201744490 (0)3532 (79)917 (21)0 (0)
      Damrauer et al
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      Paper excludes aorto-iliac disease.
      201563070 (0)NRNRNR
      Gonzalez et al
      • Gonzalez A.A.
      • Cruz C.G.
      • Dev S.
      • Osborne N.H.
      Indication for lower extremity revascularization and hospital profiling of readmissions.
      2016479,047NRNRNRNR
      Han et al
      • Han S.M.
      • Wu B.
      • Eichler C.M.
      • Reilly L.M.
      • Vartanian S.M.
      • Conte M.S.
      • et al.
      Risk factors for 30-day hospital readmission in patients undergoing treatment for peripheral artery disease.
      201517428 (16)122 (70)24 (14)
      Jones et al
      • Jones C.E.
      • Richman J.S.
      • Chu D.I.
      • Gullick A.A.
      • Pearce B.J.
      • Morris M.S.
      Readmission rates after lower extremity bypass vary significantly by surgical indication.
      Paper excludes aorto-iliac disease.
      201661120 (0)NRNRNR
      Krafcik et al
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      Paper excludes aorto-iliac disease.
      20173500 (0)184 (53)166 (47)0 (0)
      McPhee et al
      • McPhee J.T.
      • Barshes N.R.
      • Ho K.J.
      • Madenci A.
      • Ozaki C.K.
      • Nguyen L.L.
      • et al.
      Predictive factors of 30-day unplanned readmission after lower extremity bypass.
      Paper excludes aorto-iliac disease.
      201315160 (0)609 (40)907 (60)0 (0)
      Najafian et al
      • Najafian A.
      • Selvarajah S.
      • Schneider E.B.
      • Malas M.B.
      • Ehlert B.A.
      • Orion K.C.
      • et al.
      Thirty-day readmission after lower extremity bypass in diabetic patients.
      Paper excludes aorto-iliac disease.
      201692070 (0)5454 (59)3753 (41)0 (0)
      Vogel et al
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      20131458NRNRNRNR
      Vogel et al
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      20185392NRNRNRNR
      Zhang et al
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      Paper excludes aorto-iliac disease.
      201445120 (0)1888 (42)2624 (58)0 (0)
      NR, Not reported.
      Data presented as number (%).
      a Paper excludes aorto-iliac disease.
      Supplementary Table IV (online only)Thirty-day readmission rates for patients with different presenting symptoms
      AuthorSample sizeIC readmittedCLI-RP readmittedCLI-TL readmittedCLI- Any readmitted
      Reported as percentage of total CLI patients in study.
      Total readmitted
      Total readmitted in original study, including IC, CLI, and asymptomatic patients.
      Ali et al
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      109632 (7)30 (15)74 (19)104 (18)147 (13)
      Aziz et al
      • Aziz F.
      • Lehman E.B.
      • Reed A.B.
      Unplanned return to operating room after lower extremity arterial bypass is an independent predictor for hospital readmission.
      264672 (11)143 (17)205 (20)348 (19)425 (16)
      Aziz et al
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      3742104 (9)173 (17)279 (20)452 (18)572 (15)
      Bodewes et al
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      4449107 (6)131 (14)316 (17)447 (16)554 (12)
      Damrauer et al
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      6307282 (12)261 (19)748 (30)1009 (26)1291 (20)
      Gonzalez et al
      • Gonzalez A.A.
      • Cruz C.G.
      • Dev S.
      • Osborne N.H.
      Indication for lower extremity revascularization and hospital profiling of readmissions.
      Total patient numbers calculated from presented study data.
      479,0479551 (7)NRNR33,394 (20)71,857 (15)
      Han et al
      • Han S.M.
      • Wu B.
      • Eichler C.M.
      • Reilly L.M.
      • Vartanian S.M.
      • Conte M.S.
      • et al.
      Risk factors for 30-day hospital readmission in patients undergoing treatment for peripheral artery disease.
      174NRNRNRNR37 (21)
      Jones et al
      • Jones C.E.
      • Richman J.S.
      • Chu D.I.
      • Gullick A.A.
      • Pearce B.J.
      • Morris M.S.
      Readmission rates after lower extremity bypass vary significantly by surgical indication.
      6112180 (9)294 (17)410 (19)704 (18)904 (15)
      Krafcik et al
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      35019 (22)19 (32)65 (33)84 (33)105 (30)
      McPhee et al
      • McPhee J.T.
      • Barshes N.R.
      • Ho K.J.
      • Madenci A.
      • Ozaki C.K.
      • Nguyen L.L.
      • et al.
      Predictive factors of 30-day unplanned readmission after lower extremity bypass.
      151633 (14)93 (19)223 (28)316 (25)349 (23)
      Najafian et al
      • Najafian A.
      • Selvarajah S.
      • Schneider E.B.
      • Malas M.B.
      • Ehlert B.A.
      • Orion K.C.
      • et al.
      Thirty-day readmission after lower extremity bypass in diabetic patients.
      9207749 (14)NRNR699 (18)1448 (16)
      Vogel et al
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      145854 (11)35 (15)74 (20)109 (18)212 (15)
      Vogel et al
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      5392111 (7)91 (12)213 (15)304 (14)586 (11)
      Zhang et al
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      4512364 (15)NRNR467 (22)831 (18)
      Total
      Total readmission reported as a weighted pooled readmission rate across studies.
      526,00810% (95% CI, 8-13%)17% (95% CI, 15-18%)22% (95% CI, 18-25%)20% (95% CI, 18-21%)16% (95% CI, 15-18%)
      CI, Confidence interval; CLI, critical limb ischemia; CLI-RP, critical limb ischemia with rest pain only; CLI-TL, CLI with tissue loss, including ulcer and gangrene; IC, intermittent claudication, NR, not reported.
      Data are presented as number (%) unless otherwise indicated.
      a Reported as percentage of total CLI patients in study.
      b Total readmitted in original study, including IC, CLI, and asymptomatic patients.
      c Total patient numbers calculated from presented study data.
      d Total readmission reported as a weighted pooled readmission rate across studies.
      Supplementary Table V (online only)Quality assessment of included studies
      CriteriaAli
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      (2017)
      Aziz
      • Aziz F.
      • Lehman E.B.
      • Reed A.B.
      Unplanned return to operating room after lower extremity arterial bypass is an independent predictor for hospital readmission.
      (2016)
      Aziz
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      (2018)
      Bodewes
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      (2017)
      Damrauer
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      (2015)
      Gonzalez
      • Gonzalez A.A.
      • Cruz C.G.
      • Dev S.
      • Osborne N.H.
      Indication for lower extremity revascularization and hospital profiling of readmissions.
      (2016)
      Han
      • Han S.M.
      • Wu B.
      • Eichler C.M.
      • Reilly L.M.
      • Vartanian S.M.
      • Conte M.S.
      • et al.
      Risk factors for 30-day hospital readmission in patients undergoing treatment for peripheral artery disease.
      (2015)
      Jones
      • Jones C.E.
      • Richman J.S.
      • Chu D.I.
      • Gullick A.A.
      • Pearce B.J.
      • Morris M.S.
      Readmission rates after lower extremity bypass vary significantly by surgical indication.
      (2016)
      Krafcik
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      (2017)
      McPhee
      • McPhee J.T.
      • Barshes N.R.
      • Ho K.J.
      • Madenci A.
      • Ozaki C.K.
      • Nguyen L.L.
      • et al.
      Predictive factors of 30-day unplanned readmission after lower extremity bypass.
      (2013)
      Najafian
      • Najafian A.
      • Selvarajah S.
      • Schneider E.B.
      • Malas M.B.
      • Ehlert B.A.
      • Orion K.C.
      • et al.
      Thirty-day readmission after lower extremity bypass in diabetic patients.
      (2016)
      Vogel
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      (2013)
      Vogel
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      (2018)
      Zhang
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      (2014)
      1YYYYYYYYYYYYYY
      2YYYYYYYYYYYYYY
      3NNNNNNNNYNNNNN
      4YYYYYYYYYYYYYY
      5YYNYYYYYNYNYYY
      6YYYYYYNYYYYYYY
      7YYNYYYYYYYYYYY
      8YYYYYYYYYYYYYY
      9YYYYYNYYYYYNYY
      10YYYYYYYYYYYYYY
      11NNNNNNNNNNNNNN
      12YYYYYYYYYYYYNY
      13YYNYYNYYYYNNYY
      14YYYNYYYYNYYNNN
      15YYYYYYYYYYYYYY
      16YYYYYNNYYYYYYY
      17YYYYYNYYNYYYYY
      18YYYYYYYYYYYYYY
      19YYYYYYYYYYYYYY
      20YNYYYNYYYYYYYY
      Total Score (/20)1817151718131618161816151617
      N, No (0 points); Y, yes (scores 1 point).
      Scores shown after consensus meeting of authors.
      Supplementary Table VI (online only)Readmission rates for open versus endovascular procedures
      StudyEndovascular readmission rate (%)
      Reported as percentage of endovascular or open cohorts readmitted.
      Open bypass readmission rate (%)
      Reported as percentage of endovascular or open cohorts readmitted.
      Ali et al
      • Ali T.Z.
      • Lehman E.B.
      • Aziz F.
      Unplanned return to operating room after lower extremity endovascular intervention is an independent predictor for hospital readmission.
      13.4N/A
      Aziz et al
      • Aziz F.
      • Lehman E.B.
      • Reed A.B.
      Unplanned return to operating room after lower extremity arterial bypass is an independent predictor for hospital readmission.
      N/A16.1
      Aziz et al
      • Aziz F.
      • Lehman E.B.
      Pre-existing conditions determine the occurrence of unplanned readmissions after procedures for treatment of peripheral arterial disease.
      13.416.1
      Bodewes et al
      • Bodewes T.C.
      • Soden P.A.
      • Ultee K.H.
      • Zettervall S.L.
      • Pothof A.B.
      • Deery S.E.
      • et al.
      Risk factors for 30-day unplanned readmission following infrainguinal endovascular interventions.
      12.5N/A
      Damrauer et al
      • Damrauer S.M.
      • Gaffey A.C.
      • DeBord Smith A.
      • Fairman R.M.
      • Nguyen L.L.
      Comparison of risk factors for length of stay and readmission following lower extremity bypass surgery.
      N/A20.5
      Gonzalez et al
      • Gonzalez A.A.
      • Cruz C.G.
      • Dev S.
      • Osborne N.H.
      Indication for lower extremity revascularization and hospital profiling of readmissions.
      22.9
      Calculated from original study data.
      35.8
      Calculated from original study data.
      Han et al
      • Han S.M.
      • Wu B.
      • Eichler C.M.
      • Reilly L.M.
      • Vartanian S.M.
      • Conte M.S.
      • et al.
      Risk factors for 30-day hospital readmission in patients undergoing treatment for peripheral artery disease.
      21.721.1
      Jones et al
      • Jones C.E.
      • Richman J.S.
      • Chu D.I.
      • Gullick A.A.
      • Pearce B.J.
      • Morris M.S.
      Readmission rates after lower extremity bypass vary significantly by surgical indication.
      N/A14.8
      Krafcik et al
      • Krafcik B.M.
      • Komshian S.
      • Lu K.
      • Roberts L.
      • Farber A.
      • Kalish J.A.
      • et al.
      Short- and long-term readmission rates after infrainguinal bypass in a safety net hospital are higher than expected.
      N/A30.0
      McPhee et al
      • McPhee J.T.
      • Barshes N.R.
      • Ho K.J.
      • Madenci A.
      • Ozaki C.K.
      • Nguyen L.L.
      • et al.
      Predictive factors of 30-day unplanned readmission after lower extremity bypass.
      N/A23.0
      Najafian et al
      • Najafian A.
      • Selvarajah S.
      • Schneider E.B.
      • Malas M.B.
      • Ehlert B.A.
      • Orion K.C.
      • et al.
      Thirty-day readmission after lower extremity bypass in diabetic patients.
      N/A15.7
      Vogel et al
      • Vogel T.R.
      • Kruse R.L.
      Risk factors for readmission after lower extremity procedures for peripheral artery disease.
      15.313.9
      Vogel et al
      • Vogel T.R.
      • Smith J.B.
      • Kruse R.L.
      Hospital readmissions after elective lower extremity vascular procedures.
      12.39.6
      Zhang et al
      • Zhang J.Q.
      • Curran T.
      • McCallum J.C.
      • Wang L.
      • Wyers M.C.
      • Hamdan A.D.
      • et al.
      Risk factors for readmission after lower extremity bypass in the American College of Surgeons National Surgery Quality Improvement Program.
      N/A18.4
      Total
      Calculated as weighted mean readmission rate using random effects modeling for either endovascular or open procedures. Reported as mean readmission rate (95% confidence interval).
      15.3 (11.0-20.8)18.7 (13.3-25.8)
      N/A, Not applicable.
      a Reported as percentage of endovascular or open cohorts readmitted.
      b Calculated from original study data.
      c Calculated as weighted mean readmission rate using random effects modeling for either endovascular or open procedures. Reported as mean readmission rate (95% confidence interval).
      Figure thumbnail fx1
      Supplementary Fig 1 (online only)PRISMA flow diagram of study selection.
      • Leng G.C.
      • Lee A.J.
      • Fowkes F.G.
      • Whiteman M.
      • Dunbar J.
      • Housley E.
      • et al.
      Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population.
      Figure thumbnail fx2
      Supplementary Fig 2 (online only)Association of obesity and readmission. Forest plot of the association between obesity and readmission. Obesity defined as a body mass index (BMI) greater than or equal to 30 kg/m2. M-H random, Mantel-Haenszel random effects model.

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