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Title: Treating Peripheral Artery Disease in the Wake of Rising Costs and Protracted Length of Stay.
Author: Wang GJ, Jackson BM, Foley PJ, Damrauer SM, Kalapatapu V, Golden MA, Fairman RM.
Journal: Ann Vasc Surg; 2017 Oct; 44():253-260. PubMed ID: 28479423.
Abstract:
BACKGROUND: There has been growing scrutiny in the treatment of patients with peripheral artery disease due to the utilization of resources to manage this complex patient population. The purpose of this study was to determine the factors associated with prolonged length of stay (LOS > 7 days) following lower extremity bypass using data from the Vascular Quality Initiative as well as to define the additional costs incurred due to prolonged LOS in our health system. METHODS: Summary statistics were performed of patients undergoing lower extremity bypass from 2010 to 2015. Student's t-tests and χ² tests were performed to compare those with and without prolonged LOS. Multivariable logistic regression was then performed to determine the independent predictors for increased LOS. We then compared our institutional LOS with that of representative institutions from the University Health System Consortium and evaluated the impact of prolonged LOS on limb salvage and survival. RESULTS: This study included 334 patients with a mean age of 66.4 ± 12.4 years, 64.7% males, 58.5% of white race, 11.1% on dialysis, 80.5% smokers, and 53.6% with diabetes. The mean LOS was 15.7 ± 12.2 days. Prolonged LOS was associated with transfer (15.4% vs. 2.3%, P = 0.001), diabetes (58.3% vs. 40.2%, P = 0.004), critical limb ischemia (71.3% vs. 49.4%, P < 0.001), preoperative need for ambulatory assistance (44.5% vs. 16.1%, P < 0.001), prior ipsilateral bypass (6.9% vs. 1.1%, P = 0.042), urgent surgery (39.7% vs. 9.8%, P < 0.001), tibial or distal target vessel (52.7% vs. 28.0%, P < 0.001), use of vein (65.4% vs. 46.3%, P = 0.002), return to operating room (42.6% vs. 1.2%, P < 0.001), ambulatory assistance (65.0% vs. 34.1%, P < 0.001) as well as discharge anticoagulant (22.8% vs. 9.8%, P = 0.010). Multivariable logistic regression identified urgency (odds ratio [OR] = 5.09, 95% confidence interval [CI] 2.16-12.02, P < 0.001), critical limb ischemia (OR = 3.12, 95% CI 1.65-5.90, P < 0.001), return to OR (OR = 40.30, 95% CI 5.36-303.20, P < 0.001), use of vein (OR = 2.19, 95% CI 1.18-4.07, P = 0.013), and the need for anticoagulation at discharge (OR = 2.56, 95% CI 1.03-6.33, P = 0.043) as independent predictors of LOS > 7 days. Prolonged hospital stays accounted for an additional $40,561.64 in total cost and $26,028 in direct costs incurred. Despite these increased costs, limb salvage and overall survival were not adversely impacted in the prolonged LOS group in follow-up. CONCLUSIONS: Lower extremity bypass is associated with a longer than expected LOS in our health system, much of which can be attributed to return to the OR for minor amputations and wound issues. This led to added total and direct costs, where the majority of this increase was attributable to prolonged LOS. Limb salvage and overall survival were preserved, however, in this subset of patients in follow-up. These findings suggest that lower extremity bypass patients are a resource-intensive population of patients, but that these costs are worthwhile in the setting of preserved limb salvage and overall survival.

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