Temporal variability of readmission determinants in postoperative vascular surgery patients.

INTRODUCTION: Clinical information continues to be limited regarding changes in the temporal risk profile for readmissions during the initial postoperative year in vascular surgery patients. We set out to describe the associations between demographics, clinical outcomes, comorbidity indices, and hospital readmissions in a sample of patients undergoing common extremity revascularization or dialysis access (ERDA) procedures. We hypothesized that factors independently associated with readmission will evolve from "short-term" to "long-term" determinants at 30-, 180-, and 360-day postoperative cutoff points. METHODS: Following IRB approval, medical records of patients who underwent ERDA at two institutions were retrospectively reviewed between 2008 and 2014. Abstracted data included patient demographics, procedural characteristics, the American Society of Anesthesiologists score, Goldman Criteria for perioperative cardiac assessment, the Charlson comorbidity index, morbidity, mortality, and readmission (at 30-, 180-, and 360-days). Univariate analyses were performed for readmissions at each specified time point. Variables reaching statistical significance of P< 0.20 were included in multivariate analyses for factors independently associated with readmission. RESULTS: A total of 450 of 744 patients who underwent ERDA with complete medical records were included. Patients underwent either an extremity revascularization (e.g. bypass or endarterectomy, 406/450) or a noncatheter dialysis access procedure (44/450). Sample characteristics included 262 (58.2%) females, mean age 61.4 ± 12.9 years, 63 (14%) emergent procedures, and median operative time 164 min. Median hospital length of stay (index admission) was 4 days. Cumulative readmission rates at 30-, 180-, and 360-day were 12%, 27%, and 35%, respectively. Corresponding mortality rates were 3%, 7%, and 9%. Key factors independently associated with 30-, 180-, and 360-day readmissions evolved over the study period from comorbidity and morbidity-related issues in the short-term to cardiovascular and graft patency issues in the long-term. Any earlier readmission elevated the risk of subsequent readmission. CONCLUSIONS: We noted important patterns in the temporal behavior of hospital readmission risk in patients undergoing ERDA. Although factors independently associated with readmission were not surprising (e.g. comorbidity profile, cardiovascular status, and graft patency), the knowledge of temporal trends described in this study may help determine clinical risk profiles for individual patients and guide readmission reduction strategies. These considerations will be increasingly important in the evolving paradigm of value-based healthcare.

Cardiovascular adjustments and perceived exertion during exercise on the BAPS board.

The Biomechanical Ankle Platform System (BAPS) is widely used in medical rehabilitation; however, the cardiovascular demand and subjective acceptability of the BAPS rehabilitation exercise are presently not documented. The purpose of this study was to evaluate the pattern and magnitude of the cardiovascular adjustments and rating of perceived exertion (RPE) during an acute bout of exercise on the wobble board. Twenty healthy (mean age 24.2 +/- 2.9 years old) subjects exercised for 10 min each on the BAPS board on two different occasions. One test was performed using the small hemisphere board while the other test was performed with the large hemisphere board. The subjects' heart rate (HR), blood pressure (BP), cutaneous blood flow (BF), skin temperature (ST) at the ankle joint, local and overall RPE responses were monitored at specific time periods. Micro-circulation, skin temperature and heart rate were monitored with the LaserFlo Blood Perfusion Monitor, the Physitherm thermocouple and the Cardiotach recorder, respectively. The subjects' rating of perceived effort during exercise was obtained with a 15-point category scale. The result showed significant perturbation of the cardiovascular system during the BAPS exercise. Similarly, both local and overall RPE increased as the duration of exercise increased. The BF and RPE during the large hemisphere exercise session were significantly higher than the small hemisphere session. The subjects' subjective report following the exercise suggests the need for caution in the use of the BAPS board exercise for frail patients and also patients with lower extremity joint pathologies.