Abstract
Acute mesenteric ischemia (AMI) remains a vascular emergency. Our aim was to explore readmission for AMI. We identified all patients admitted for AMI from the state of California through the Healthcare and Utilization Project from 2005 to 2011. Our primary end point was the rate and etiology for readmission. Our secondary end points were the length of hospitalization and in-hospital mortality. Cox proportional hazard regression was utilized to assess risk of 30-day readmission. There were 534 (9.9%) readmissions at 30 days. The mean age was 67 ± 17 years and 209 (39.1%) were male. The five most common etiologies for readmission were AMI (7.6%), cardiac events (5.3%), severe sepsis (1.2%), dehydration (1.1%), and acute kidney failure (1.1%). Once readmitted, these patients were most likely to experience cardiac catheterizations (25.4%), red blood cell transfusions (23.6%), intubation and mechanical ventilation (17.6%), biopsy of the large intestine (13.9%), reoperation for small bowel resection (10.9%), administration of total parenteral nutrition (10.5%), and transfusion of other blood products (6.9%). This hospitalization was 8.8 ± 12.7 days long. In-hospital mortality was 36 patients (6.7%). On multivariable Cox-regression analysis, severe (hazard ratio [HR]: 2.1 [1.4–3.2], p = 0.0005) and moderate (HR: 1.5 [1.03–2.13], p = 0.04) Elixhauser Comorbidity Group, complications (HR: 1.5 [1.2–1.9], p = 0.0007), and longer index hospitalization (HR: 1.02 [1.01–1.02], p < 0.0001) were predictors of readmission. Conclusion AMI remains a vascular emergency. Readmissions have a significant rate of morbid invasive procedures and can lead to an in-hospital mortality of 6.7%. The adoption of guidelines similar to the European Society for Trauma and Emergency Surgery should be considered.
Keywords: mesenteric ischemia, acute mesenteric ischemia, readmission, guidelines, mortality, treatment, length of hospitalization
Acute mesenteric ischemia (AMI) is caused by a sudden interruption of blood flow into the mesenteric arteries ( Fig. 1 ), with an overall mortality rate of up to 80%, 1 2 3 4 and its incidence/prevalence has not decreased in the last few decades. 5 6 7 The development of endovascular techniques has significantly affected the management of patients presenting with AMI, which has not only provided an excellent alternative of management but also decreased overall mortality and improved surgical outcomes. 8 9 However, there is little data regarding the management of patients with AMI once discharged from index hospitalization. Our study sought to investigate whether the patients, who initially survive this devastating event, present to medical facilities for readmission, as well as to explore the course and etiologies of these readmissions.
Fig. 1.
Normal mesenteric arterial circulation and mesenteric ischemia (used with permission of Mayo Foundation for Medical Education and Research. All rights reserved).
In the United States, there are no guidelines for the management of AMI; the European Society for Trauma and Emergency Surgery (ESTES), however, released in 2016 recommendations for the management of patients with AMI. 10
Methods
We utilized the Healthcare Cost and Utilization Project (HCUP) California State Inpatient Database (SID) to identify patients who were admitted for AMI between 2005 and 2011. The reason for choosing the California SID is twofold; first, it is the largest state in the United States in regard to population and second, it is one of the SIDs that focuses in the collection of readmission data in this country. The HCUP SID is a population-based dataset encompassing all hospital discharge records from the state of California. All investigators with access to the data have completed online training and certified data use agreements with HCUP. This study includes completely deidentified data and was approved as exempt from review by the Mayo Clinic Institutional Review Board Committee (IRB#18–010907). Therefore, informed consent was not obtained from participants.
Patients were selected by having a primary diagnosis code for AMI (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] 557.0X) between the years 2005 and 2011. We queried for all those patients with AMI, who were readmitted after dismissal from the index admission within 30 days. Further, only those patients discharged at the index admission alive were accounted for in the readmission data. Discharges were excluded if they had a diagnosis code for aortic aneurysm or dissection (ICD-9-CM 441.X), if patients were younger than 18 years and if information was missing on sex, discharge, or in-hospital death. To account for the impact of the patient's comorbidity, the Elixhauser Comorbidity Index was used to group patients into four comorbidity classes: none (0), mild (1–2), moderate (3–5), and severe (>5). Comorbidities were identified by querying discharges for a predefined set of ICD-9-CM diagnosis codes. 11 Our primary end point was to determine the rate and etiology for readmission after AMI. Our secondary end points included the length of stay (LOS) for this readmission and in-hospital mortality.
Definitions
The Elixhauser Comorbidity Index is based on 31 individual conditions identified from diagnoses in hospital and physician data. 11 The higher the index, the higher the number of comorbid conditions and the stronger the correlation with higher morbidity and mortality during any specific hospitalization. To facilitate the stratification and comparison of our patient population according to their comorbidities, patients were grouped according to four comorbidity classes: none (0), mild (1–2), moderate (3–5), and severe (>5). 12 13 14
Complications were defined as any episode of the following during hospitalization including hemorrhage, acute kidney injury, cerebrovascular accident, blood transfusion, transfusion related lung injury, pulmonary embolism, pneumonia, ventilator associated pneumonia, tracheostomy, anesthesia reactions,, cardiogenic and septic shock, urinary tract infection, disruption of bowel anastomosis, enterocutaneous fistula, nonhealing wound, wound dehiscence, and wound infection. Cardiac events were defined as any hypertensive emergency, acute onset of atrial fibrillation, and/or any coronary event/intervention
Statistical Analysis
Percentages and means were used to describe the data. Pearson Х 2 was used to compare categorical variables, while Kruskal–Wallis tests were used to compare continuous variables. To assess risk of 30-day readmission, a multivariable Cox-proportional hazard regression model was used to calculate HRs. Models were adjusted using patient age, sex, Elixhauser group, LOS at index admission, patient insurance payer, patient race, and presence of a complication during index admission. All tests of significance were two-sided, and HRs, 95% confidence intervals, and p -values were reported. Statistical significance was set at p -value < 0.05. Analyses were performed using SAS version 9.4 (SAS Institute Inc, Cary, North, Carolina USA).
Results
There were 534 (9.9%) readmissions at 30 days during the study period from a total of 5,505 patients previously admitted for AMI. Patient demographic data are presented in Table 1 . The mean age of this patient population was 67 ± 17 years. Furthermore, the majority of readmitted patients, 325 (60.9%), were female, which was statistically significant compared with the number of male patients readmitted ( p = 0.0058). According to Elixhauser comorbidity class, the number of patients with no comorbidities was 39 (7.3%), mild comorbidities was 157 (29.4%), moderate comorbidities was 256 (47.9%), and severe comorbidities was 82 (15.4%), respectively. The higher the comorbidity class, the greater the chance for readmission ( p = 0.0001).
Table 1. Patient demographics.
| Descriptive statistics by 30-day readmission | ||||
|---|---|---|---|---|
| No | Yes | Total | p -Value | |
| ( N = 4,971) | ( N = 534) | ( N = 5,505) | ||
| Age (y) | ||||
| N | 4,952 | 534 | 5,486 | 0.1004 |
| Mean (SD) | 66.0 (17.5) | 67.1 (17.4) | 66.1 (17.5) | |
| Median | 68.0 | 71.0 | 69.0 | |
| Q1, Q3 | 56.0, 80.0 | 58.0, 80.0 | 56.0, 80.0 | |
| Range | (0.0–100.0) | (0.0–95.0) | (0.0–100.0) | |
| Sex | ||||
| Male | 1,622 (33.2%) | 209 (39.1%) | 1,831 (33.8%) | 0.0058 |
| Female | 3,264 (66.8%) | 325 (60.9%) | 3,589 (66.2%) | |
| Elixhauser Group | ||||
| None | 619 (12.5%) | 39 (7.3%) | 658 (12.0%) | <0.0001 |
| 1–2 | 2,046 (41.2%) | 157 (29.4%) | 2,203 (40.0%) | |
| 3–5 | 1,951 (39.2%) | 256 (47.9%) | 2,207 (40.1%) | |
| Greater than 5 | 355 (7.1%) | 82 (15.4%) | 437 (7.9%) | |
| LOS | ||||
| N | 4,971 | 534 | 5,505 | <0.0001 |
| Mean (SD) | 7.1 (9.8) | 13.9 (18.6) | 7.8 (11.2) | |
| Median | 4.0 | 8.0 | 5.0 | |
| Q1, Q3 | 2.0, 8.0 | 5.0, 16.0 | 2.0, 9.0 | |
| Range | (0.0–182.0) | (0.0–235.0) | (0.0–235.0) | |
| Patient insurance payer | ||||
| Medicare | 2,807 (56.5%) | 309 (57.9%) | 3,116 (56.6%) | 0.2590 |
| Medicaid | 318 (6.4%) | 43 (8.1%) | 361 (6.6%) | |
| Private Insurance | 1,573 (31.6%) | 151 (28.3%) | 1,724 (31.3%) | |
| Other | 272 (5.5%) | 31 (5.8%) | 303 (5.5%) | |
| Race | ||||
| White | 3,421 (73.3%) | 373 (71.5%) | 3,794 (73.1%) | 0.0788 |
| Black | 166 (3.6%) | 24 (4.6%) | 190 (3.7%) | |
| Hispanic | 623 (13.3%) | 85 (16.3%) | 708 (13.6%) | |
| Other | 457 (9.8%) | 40 (7.7%) | 497 (9.6%) | |
| Complications in index hospitalization | ||||
| No | 4,405 (88.6%) | 402 (75.3%) | 4,807 (87.3%) | <0.0001 |
| Yes | 566 (11.4%) | 132 (24.7%) | 698 (12.7%) | |
| Bowel resection in index hospitalization | ||||
| No | 4,895 (98.5%) | 520 (97.4%) | 5,415 (98.4%) | 0.0584 |
| Yes | 76 (1.5%) | 14 (2.6%) | 90 (1.6%) | |
| Mortality of readmitted patients (%) | 36 (6.7%) | |||
| LOS of readmitted patients (days) | 8.8 ± 12.7 | |||
Abbreviations: LOS, length of stay; SD, standard deviation.
The mean LOS of those patients not readmitted was 7.1 ± 9.8 days versus the LOS of those patients, who were readmitted that was 13.9 ± 18.6 days ( p = 0.0001). The patient's insurance payer ( p = 0.25) nor the patient's race ( p = 0.07) was associated with readmission for AMI. The patients with greater number of complications at the index hospitalization were more likely to be readmitted. From the patients who were readmitted, 132 (24.7%) had complications at the index hospitalization, versus 566 (11.4%) patients who were not readmitted ( p < 0.0001).There was a trend of higher readmission rate among those patients, who experienced bowel resection ( n = 14, 2.6%) during the index hospitalization versus those patients without bowel resection ( n = 76, 1.5%), p = 0.0584. Moreover, the likelihood of readmission was greatest during the first 10 to 15 days following discharge from the index hospitalization, which plateaus after that time ( Fig. 2 ). Finally, this second LOS was noted to be 8.8 ± 12.7 days and in-hospital mortality was noted in 36 patients (6.7%).
Fig. 2.
Probability of 30-day readmission.
Multivariable Cox-regression analysis revealed that four variables were predictive of readmission including LOS of index admission (hazard ratio [HR]: 1.02 [1.01–1.02], p < 0.0001), complications during the index hospitalization (HR: 1.48 [1.18–1.86], p = 0.0007), Elixhauser class of moderate, that is, 3 to 5 (HR: 1.5 [1.03–2.13], p = 0.0347), and Elixhauser class of severe, that is, greater than 5 (HR: 2.09 [1.38–3.18], p = 0.0005). This was not the case for Elixhauser comorbidity classes of no comorbidities (0), or Elixhauser class of mild (1–2), age, sex, insurance payer, and race ( Table 2 ). From this patient cohort, who were readmitted for AMI, the five most common etiologies for readmission were AMI in 40 (7.6%) patients , cardiac events in 28 (5.3%) patients, severe sepsis in 7 (1.2%) patients, dehydration in 6 (1.1%) patients, and acute kidney failure in 6 (1.1%) patients, respectively. Once patients were readmitted, they underwent the following treatments including cardiac catheterizations in 136 (25.4%) patients, red blood cell transfusions in 126 (23.6%) patients, intubation and mechanical ventilation in 94 (17.6%) patients, biopsy of the large intestine in 74 (13.9%) patients, reoperation for small bowel resection in 58 (10.9%) patients, administration of total parenteral nutrition in 56 (10.5%) patents, and transfusions of other blood products in 37 (6.9%) patients, respectively ( Table 3 ).
Table 2. Cox-regression analysis for risk of 30-day readmission.
| Cox-regression model for 30-day readmission | ||||
|---|---|---|---|---|
| Parameter | Hazard ratio | Hazard ratio and 95% confidence interval | Pr > ChiSq | |
| Age | 1.004 | 0.997 | 1.011 | 0.2836 |
| Female sex | 0.870 | 0.726 | 1.044 | 0.1345 |
| Elixhauser Group | ||||
| None | 1.000 | N/A | N/A | N/A |
| 1 to 2 | 0.997 | 0.691 | 1.436 | 0.9851 |
| 3 to 5 | 1.479 | 1.029 | 2.126 | 0.0347 |
| Greater than 5 | 2.093 | 1.378 | 3.177 | 0.0005 |
| Length of stay | 1.016 | 1.011 | 1.020 | <.0001 |
| Complication | 1.479 | 1.179 | 1.856 | 0.0007 |
Table 3. The most common etiologies and procedures at time of readmission at 30 days.
| Five most common etiologies of readmission at 30 days | |
| Etiology | Number of patients (%) |
| Acute mesenteric ischemia | 40 (7.6) |
| Cardiac events | 28 (5.3) |
| Severe sepsis | 7 (1.2) |
| Dehydration | 6 (1.1) |
| Acute kidney failure | 6 (1.1) |
| Ten most common procedures at 30-day readmission | |
| Procedure | Number of patients (%) |
| Cardiac catheterizations | 136 (25.4) |
| Transfusion of red blood cells | 126 (23.6) |
| Intubation and mechanical ventilation | 94 (17.6) |
| Biopsy of large intestine | 74 (13.9) |
| Resection of small bowel | 58 (10.9) |
| Total parenteral nutrition | 56 (10.5) |
| Transfusion of other products | 37 (6.9) |
Discussion
AMI is a significant vascular emergency, and although the treatment options and outcomes for this condition have improved, it is still a devastating event with an overall mortality of up to 80%. 5 15 16 In our study, we explored the etiologies for readmission following AMI-related index hospitalization. Furthermore, we were interested in exploring what would happen to this patient population once readmitted including their LOS and procedures that they undergo during this second hospitalization. In a recent report for patients with chronic mesenteric ischemia, it was noted that cardiovascular and cerebrovascular events were the culprit for their readmission. 17 Furthermore, the rate of readmission was comparatively higher in the chronic mesenteric ischemia patient population (19.5 vs. our 9.9% readmission rate for AMI in our present study). This could be possibly explained by the fact that the majority of AMI patients expire during their index hospitalization. 18
When AMI patients are readmitted, the main reasons for readmission were AMI (7.6%) cardiac events (5.3%), and severe sepsis (1.2%), which are all sequelae from the initial inciting event and are predictors of mortality. 19 Furthermore, predictors for readmission were longer LOS and complications at index admission, moderate, and severe Elixhauser class of comorbidities. These variables have been identified as markers/predictors of more complex index admission for AMI. 20 Once these individuals are readmitted, they tend to have a shorter LOS compared with their initial hospitalization and a relatively lower percentage of patients expire (6.7%).
There is paucity of data in the review of causes for AMI readmission. In fact, Fink et al 21 explored the malpractice claims due to late recognition of this disease entity, which is the most significant risk factor predicting mortality in this patient population. 19 Therefore, it is paramount to entertain this diagnosis in patients presenting to urgent facilities with abdominal pain that is out of proportion to physical examination. 22 Once these patients have been identified, understanding the etiology and their main complaints would aid the prompt recognition from the emergency room providers' perspective at the time of re-evaluation. A shift in care occurred once improved outcomes were noted with endovascular techniques. In fact, in recent single-center studies and systematic reviews, the recommendation for endovascular therapy first has been suggested: endovascular interventions improve mortality, lowers length of hospitalization and transfusion requirements, lowers rates of pneumonia and sepsis and decrease cost of care. 8 23 24 25 In Europe, the ESTES guidelines created in 2016 10 aimed to improve outcomes for patients with AMI. Despite a lack of randomized controlled trials for the management of AMI, recommendations regarding diagnosis, treatment, and follow-up are given at various levels of evidence, including the use of contrast-enhanced computed tomography angiography of the abdomen/pelvis, use of broad-spectrum antibiotics, use of endovascular or open embolectomy, use of systemic anticoagulation, and supportive intensive care unit measures.
Limitations
Our study is based on a population-based dataset encompassing all hospital discharge records from the state of California, which limits the granular analysis of the data and its generalization to the overall population. Variables such as laboratory values, imaging studies, patient's vital signs, and details of the operative reports are not available. Additionally, patients who were lost to follow-up and/or have moved out of state could not be accounted for. Therefore, it is difficult to assess the severity of each patient's presentation and hospitalization. Furthermore, we are limited to ICD-9 coding data and a time period from 2005 to 2011, which can certainly affect current practices related to AMI around the United States. Finally, we chose to analyze the readmissions data at 30 days since the difference between the etiologies of readmissions at 60 days was very similar to those patients readmitted at 30 days from their index hospitalization ( Supplementary Table 1 ). Furthermore, this is an exploratory manuscript to understand the reasons for readmission in this devastating vascular entity.
Conclusion
AMI remains a significantly prevalent vascular emergency with a 9.9% rate of readmission, for which the main etiology was a complication related to AMI at 7.6%. This second hospitalization was noted to be 8.8 ± 12.7 days long and is marked with significant morbid invasive procedures/medical interventions and can lead to an in-hospital mortality of 6.7%. The adoption of consensus guidelines similar to the ESTES guidelines for the management of AMI should be considered.
Acknowledgment
This study was supported in part by the Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery.
Footnotes
Conflict of Interest None declared.
Supplementary Material
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