Transitions of Care and Long-Term Surveillance After Vascular Surgery

Abstract

Quality care of vascular surgery patients extends to the post-operative coordination of care and the long-term surveillance, including the medical management of vascular disease. This is particularly highlighted in contemporary modern vascular surgery practice as tremendous focus is being placed on post-operative adverse events and hospital readmissions. The purpose of this review is to provide a contemporary perspective of transitions of care at discharge and long-term surveillance recommendations after vascular surgery interventions.

Introduction

Effective coordination of medical care is a hallmark of quality and is thought to have significant influence on patient outcomes. It is expected that high quality coordination of care transitions will contribute to improved patient care and reduced cost. In this way, care coordination is an important contributor to achieving the “triple aim” of better care, better health and reduced cost outlined by Berwick, et al in 2008.[1] The Patient Protection and Affordable Care Act (ACA) is built upon these principals and contains multiple elements that facilitate communication and coordination of medical care.[2] This includes broad adoption of electronic medical records (EMR) and, among other elements, aligning incentives through shared savings models and delivery integration. It is widely accepted that care coordination is complex, multifaceted and is extremely important throughout the care continuum. In particular, coordination of the care transition from inpatient to outpatient is critical and likely has significant bearing on patient medication adherence, patient satisfaction and unplanned readmission.[3]

Hospital readmission has garnered particular attention in clinical care, health policy and in research. Unplanned readmission is a significant burden to patients, their families and their healthcare providers. It is also a high associated monetary cost with an estimated $15 billon in excess healthcare spending per year.[4] The Centers for Medicare and Medicaid (CMS) use readmission as a hospital quality metric. As an incentive for quality improvement, CMS has initiated penalties for unplanned readmissions in a series of disease-specific states including pneumonia, heart failure, and myocardial infarction.[4–6] It is expected that, in the coming years, these penalties will expand to include post-operative unplanned readmissions for a broad spectrum of procedures starting with orthopedic hip and knee replacement and moving to include coronary bypass surgery. [2, 6] It is anticipated that vascular surgery procedures will be included in the penalty program as early as 2017.[2] It is important to acknowledge, however, that controversy exists regarding the suitability of readmission as a target for financial penalties in surgical care. There is a demonstrated correlation between post-operative complications and mortality, metrics with an accepted relationship to quality of care.[7, 8] However, separating quality care in surgery from non-modifiable patient and environmental factors may be difficult.[9, 10]

The connection between readmission and Medicare reimbursement is particularly relevant in vascular surgery given the high proportion of vascular surgery patients that are Medicare beneficiaries and in light of higher rates of readmission for vascular surgery patients compared to other specialties. A 2009 study demonstrated that vascular surgery patients had the third highest readmission rate, 24%, amongst all Medicare beneficiaries.[4] Another contemporary study that evaluated postsurgical readmission rates, found that in 2012 the overall 30-day readmission rate after surgery was 5.7%, however patients undergoing lower extremity bypass had the highest readmission rate of 15%.[11] Outside of vascular surgery, a growing body of literature focused on this issue has identified discharge planning and coordinating transitions of care as fundamental area to reduce unplanned readmissions and improve outpatient continuity of care.[12] Taken together, effective management of care transitions and their potential effect on readmission is an important opportunity in vascular surgery.

In this review we will focus on two critical care transitions in the care of vascular surgery patients: (1) the early post-operative transition from inpatient to outpatient care and (2) the long term continuity and surveillance for vascular surgery patients We will discuss the existing literature surrounding these intervals, ongoing broad-based initiatives that emphasize these care transitions and outline futures steps that can be taken to better understand care transitions in the vascular surgery population.

2. Postoperative care transitions

There is very limited data related to care transitions specific to patients undergoing vascular surgery. Existing studies on post-operative hospital discharge focus largely on predictors of readmission and determining patients at high risk for readmission.[11, 13] Based on the National Surgical Quality Improvement program (NSQIP), a nomogram for high readmission risk was created with ten variables comprised of patient comorbidities (ASA class, steroid use, dialysis dependence, diabetes, cancer) and procedure related variables (wound class, operative time, urgent surgery, inpatient procedure, discharge destination). This nomogram was effective at predicting unplanned readmission with a C statistic of 0.70.[13] These factors were likely a function of disease comorbidity as multiple studies have shown that early readmission is strongly associated with post-operative complications.[8, 11, 14]

Conceptually, identification of patients at high risk for readmission could trigger to additional attention to discharge care coordination that could prevent unplanned readmission, including closer clinical follow-up, post hospitalization telephone contact and other interventions aimed at increasing patient contact with clinicians. The potential benefit of earlier post-operative follow-up for patients at high risk for readmission is supported by a retrospective review by Saunders et al, who noted that in many cases outpatient follow-up did not occur early enough in the post-operative period to detect complications.[15] Beyond surgery, a prospective evaluation of early follow-up and comprehensive discharge planning resulted in lower readmission rates compared to patients that did not receive intervention (10.6% vs 21.1%, p<0.001).[16] However, other work has demonstrated that post-discharge telephone calls alone after medical admission demonstrated variable results with efficacy potentially limited by lack of access to the highest risk patients. [17, 18] Importantly, in a systematic review that evaluated multiple domains of a care transition framework, the monitoring and management of symptoms, had the strongest association with readmission reduction in a variety of disease states.[19] In this respect, early follow-up, which is a specific opportunity to manage post-op symptoms, may be an effective opportunity for reduction of unplanned readmissions.

It is a multipronged approach to post-operative care transitions that will likely be most effective at reducing readmission rates.[20] This includes a multidisciplinary approach that depends on clinicians to identify outpatient needs, define therapeutic goals of care, gaps in the patient’s support network, and collaboration between primary care and subspecialty providers.[21] The engagement of multiple providers in post-operative care transitions is supported by a retrospective study demonstrating that early primary care provider follow-up in patients undergoing major vascular surgery (thoracic aortic aneurysm repair) had lower rates of readmission than those that did not have early follow-up with their primary care provider.[22]

The impact of a care coordination protocol has been well studied in chronic medical conditions outside of vascular surgery, most notably in heart failure. Heart failure is associated with high-rates of readmission (estimated 25%) and challenges with outpatient medical management. [23, 24] A 2004 systematic review of strategies to improve outcomes in heart failure, found that in-person multidisciplinary follow-up interventions were the most effective strategy to reduce all-cause readmissions (RR 0.81), heart failure-related readmissions (RR 0.74) and mortality (RR 0.75) in recently hospitalized patients.[23] These follow-up interventions included early follow-up in multidisciplinary heart failure clinic, nurseled patient education, self-management guidelines for patients, protocol-driven medication changes, dietary consultation services, psychosocial support, telephone follow-up, and in-home visits. Importantly, as similarly demonstrated in surgical patients, these interventions are supported by the ability to determine characteristics of heart failure patients at high risk for readmission.[25]

Multiple resources and programs have been developed to specifically address inpatient to outpatient care transitions. Some of these are direct results of the ACA including the Community-Based Care Transition Program (CCTP), Independence At Home Program (IAHP), Hospital Readmission Reduction Program (HRRP), National Pilot Program on Payment Bundling (NPPPB), Medicare Shared Savings Program, and the Pioneer ACO Program. In general, these programs were initiated to integrate the healthcare infrastructure to improve communication between providers and align incentives for healthcare delivery around effective coordination of care. Beyond the ACA, a spectrum of care coordination programs have been developed by other entities. These include the National Transitions of Care Coalition, The Care Transitions Program (CTP), Project BOOST, Project RED, and Post-Acute Care Transitions (PACT) Toolkit.[12, 26–29] These resources are specifically geared towards improving the safety of discharge transitions by providing tools and step-by-step instructions for navigating care transitions. While efficacy data is limited for many of these programs, they do have good face validity and evaluation of each of these tools is ongoing. [Table I]

The implementation of coordinated discharge planning is not without significant hurdles at the institutional and point of care levels. As an example, our institution, has developed a pathway for scheduling the first follow-up visit prior to hospital discharge from their vascular procedure. The coordination and scheduling of clinic and testing appointments required involvement of EMR programmers (to build templates), scheduling services (with specific training for scheduling vascular-related testing and appointments), radiology, vascular lab and the inpatient and outpatient vascular surgery personnel. All together, this seemingly straightforward endeavor, which covers only a fraction of the coordination required for discharge planning, took a great deal of effort to implement. However, our early feedback from this quality improvement initiative has demonstrated improved post-procedure follow-up, decreased time to scheduling follow-up appointments and decreased time investment on the part of clinic personnel contacting patients and arranging follow-up after they have left the hospital.

There is a clear opportunity to expand the paucity of data surrounding the role and effect of discharge planning in vascular surgery. Based on the experiences treating other disease states, care transitions done poorly are associated with readmissions and related adverse outcomes. These effects are likely magnified in the vascular surgery patient population due to a large proportion of elderly patients with complex medical problems. The limited information we have in vascular surgery is heavily focused on patient medical comorbidities. However, as demonstrated in other disease states, there are cognitive, social and healthcare-system elements that need to be addressed in the effective management of discharge care transitions. Because of this, the natural next steps in understanding effective care transitions for vascular surgery patients should focus on expanded understanding of the patients at high risks for failed care transition (readmission, low literacy) and the development of management strategies that build on the work of other specialties.

3. Long-term surveillance and follow-up

Vascular surgery patients, unlike many surgical patients, need post-procedure follow-up into the indefinite future. There are two primary goals of this longitudinal care in vascular surgical patients. First, vascular surgery interventions warrant continued monitoring for development of recurrent disease or progression of pathology within areas of prior treatment. Second, vascular disease is a chronic condition that warrants long-term surveillance and optimal management of modifiable risk factors.

Longitudinal follow-up after vascular interventions are associated with improved long-term outcomes. Nowhere is this more apparent than in lower extremity interventions, particularly bypass, for PAD. This was established in the mid 1990’s where intensive follow-up surveillance of vein bypass grafts was noted to markedly improve (primary assisted) patency.[30, 31] Long-term follow-up after common vascular surgery interventions are relatively proscribed with guidelines and recommendations in place for the post-operative surveillance of endovascular aneurysm repair,[32] carotid artery interventions,[33, 34] and lower extremity bypass.[35, 36] These guidelines generally recommend more intensive surveillance in the first year and decreasing frequency (usually to annual visits) over time. In addition, generally speaking, an abnormality detected that does not warrant immediate intervention (e.g. a moderate graft stenosis, a type 2 endoleak) should be monitoring with higher frequency. [Table II]

In spite of relatively straightforward recommendations for surveillance, there is still likely a high rate of non-adherence to recommended follow-up. This has been recently exemplified in two studies evaluating follow-up after endovascular aneurysm repair. The first noted early imaging follow-up was poor with 40% of patients lacking surveillance imaging 2-months after surgery.[37] The second noted a 50% loss to follow-up at 5-years.[38] Unfortunately, but understandably, aside from studies such as these that use non-granular billing data, evidence for the negative impact of non-adherence to follow-up surveillance is likely subject to significant publication bias.

In addition to disease and intervention surveillance, long-term follow-up is also an opportunity for improved outcomes via continued management of modifiable risk factors for vascular disease. All treatment guidelines for vascular disease specifically identify long-term management of modifiable risk factors as an important component of good outcomes after vascular surgical intervention. To again take examples from the AAA literature, results from both the EVAR-2 and UKSAT trials suggest that optimal medical management of patients improved fitness for surgery and long-term survival.[39, 40]

The two areas of medical management with greatest potential impact in follow-up are smoking cessation and medication adherence. The benefits of smoking cessation have been repeatedly demonstrated.[41, 42] It has also been demonstrated that both brief cessation advice by a clinician and frequent patient contact enhance rates of cessation.[43] Importantly, specific to vascular surgery, higher rates of smoking cessation were seen after vascular surgery procedures compared to population estimates for cessation. In addition, patients that were referred for smoking cessation counseling and/or offered nicotine replacement therapy were more likely to remain abstinent from tobacco at 1-year compared to those that were not (48% vs 33%).[44]

Optimal medication treatment of modifiable risk factors is the second area of particular impact on patients after vascular surgery. In most cases, this includes antiplatelet medications and HMG co-A reductase inhibitors (“statins”). Aspirin has been demonstrated to be effective for secondary prevention of cardiovascular events. Similarly, statin medications have sufficiently demonstrated benefit in patients with PAD and PAD risk-factors, that the 2013 AHA/ACC guidelines recommend high- or moderate-intensity statin medications for nearly all patients.[45] The benefit of these medications was supported by the two retrospective cohort studies demonstrating benefit of statins in peri-procedural and long term survival.[46, 47] Importantly, improved medication adherence is associated with frequent contact (including clinic visits) with providers and with the counseling that can occur during a clinical encounter.[48, 49]

A key, and often underemphasized, element in determining appropriate post-procedure surveillance is striking the appropriate balance between sufficient and excessive follow-up. It is important to consider each follow-up interval as having a high likelihood of capturing a clinical event. Follow-up and surveillance studies completed too frequently impose an unnecessary burden on patients in both time and cost. Too infrequent surveillance risks the chance of missing an important clinical event. Follow-up that is too infrequent also limits the opportunities for counseling and assurance of optimal medical management.

In spite of all that is known about long term surveillance and optimal medical management in vascular surgery patients, there are still a number of areas needing further investigation. Most pointedly, understanding the consequences of inadequate surveillance and follow-up in patients that have undergone vascular surgery is still inadequate. These consequences need to be clearly defined if care coordination in general and follow-up in particular are to be credible metrics of quality.

4. Conclusions

The need to improve quality of healthcare, reduce readmission rates, and adhere to a proactive approach for long-term surveillance following vascular interventions is paramount. Review of the current state of vascular surgery in our rapidly evolving healthcare system demonstrates that there are significant gaps in identifying high-risk patients and implementing effective coordination of care protocols. However, initiatives being implemented in medical specialties may have relevance and applicability to the care of vascular surgery patients. It is clear that financial incentives will become a factor in the care coordination of vascular surgery patients and will likely drive innovation.

Table 1.

Implementation and clinical resources for transitions of care

Program	Year	Sponsor	Target Users	Description	Target Population	Outcome Data
Institute for Healthcare Improvement	1991	Institute for Healthcare Improvement	Healthcare systems and providers	General resources for care transitions, quality improvement and patient safety	General	-
Project RED	2003	AHRQ, NHLBI, BCBS, PCORI	Healthcare systems, providers, patients and caregivers	Implementation program	General	Decreased hospital utilization and cost [50–52]
PACT Toolkit	2003	Society of Hospital Medicine	Healthcare systems and providers	Resources for transitions short-term acute hospital stays to skilled nursing facilities	SNF transitions	-
National Transitions of Care Coalition	2006	CMSA	Policy makers, healthcare systems, providers, patients and caregivers	General resources for care transitions	General	-
Care Transitions Program	2007	John A. Hartford Foundation and Robert Wood Johnson Foundation	Healthcare systems, providers, patients and caregivers	Implementation program for System level interventions	Medically complex patients	50% reduction in readmissions, sustained results, lower mean healthcare costs[53–56]
Project BOOST	2008	Society of Hospital Medicine	Healthcare systems, providers, patients and caregivers	Implementation program	Medically complex patients	Reduced 30-day readmission rates by 2%[57]

Abbreviations – RED: Re-Engineered Discharge; AHRQ: Agency for Healthcare Research and Quality; NHLBI: National Heart, Lung, and Blood Institute; BCBS: Blue Cross and Blue Shield Foundation; PCORI: Patient-Centered Outcomes Research Institute; SNF: Skilled Nursing Facility; PACT: Post-Acute Care Transitions; CMSA: Case Management Society of America; BOOST: Better Outcomes through Optimizing Safe Transitions.

Table 2.

Summary of SVS surveillance recommendations following select vascular surgery procedures.

Procedure	Recommendation GRADE, Evidence Level[58]*	Postoperative Imaging	Long-Term Follow up	Modality
Endovascular aneurysm repair [32]	Grade 1, Level A Grade 2, Level C	1 month	6 months (if any abnormality is present at 1 month), annually Annually (if there is no endoleak or sac enlargement present after the first 12 month CT)	CT imaging (Non-contrast CT for renal insufficiency) Duplex ultrasound
Carotid artery interventions [33, 34]	Grade 2, Level C	1 month	6 months, annually	Duplex ultrasound CT or MR (for cases of proximal stenosis or inconclusive duplex ultrasound)
Lower extremity bypass [35, 36]	Grade 2, Level C	1 month	3, 6 months, annually	Duplex ultrasound

GRADE 1 indicates a strong recommendation in which the benefits clearly outweigh risks. GRADE 2 is a weak recommendation, and the balance between risks and benefits are uncertain. The evidence level refers to the quality of research. Levels A, B and C indicate to high, moderate, and low quality evidence, respectively.[58, 59]

Abbreviations - CT, computed tomography; MR, magnetic resonance.