Implementation of Transitional Care Planning is Associated with Reduced Readmission Rates in Patients Undergoing Lower Extremity Bypass Surgery for Peripheral Arterial Disease

Published:March 07, 2022DOI:


      Patients undergoing lower extremity bypasses (LEB) are at a high risk of developing post-discharge complications requiring readmission. Health systems have developed several strategies to mitigate this risk. One such measure is developing comprehensive Transitional Care Program (TCP), which includes phone calls to patients after being discharged from the hospital. Our study aimed to assess short-term readmission, mortality, and amputation rates of patients who participated in TCP by completing at least one post-discharge follow-up phone call after undergoing LEB for revascularization of peripheral arterial disease (PAD).


      A retrospective review was completed for patients who underwent LEB surgery between January 2010 and January 2020 to treat PAD at Penn State Hershey Medical Center. Immediate discharge follow-up was done via telephone calls using a standardized script. Patients were then divided into two groups, those who did not have a successful follow-up call (Group I) and those who had at least one successful follow-up call within seven days after discharge (Group II). Univariate analysis was used to compare preoperative demographics, intraoperative variables, and postoperative outcomes. The probability of readmission and risk factors contributing to it were computed using multiple stepwise forward regression analyses. Epidemiological analysis was done to evaluate the risk of readmission in the group receiving post-discharge follow-up calls.


      A total of 457 patients underwent LEB from 2010 to 2020 and qualified for inclusion in the study. Among these patients, 126 (27.6%) did not have a successful post-discharge follow-up call (Group I), whereas, 331 (72.4%) patients did complete a successful call (Group II). The mean age of patients was 66.7 years. There were no significant differences in preoperative baseline patient characteristics or intraoperative factors. Patients who completed a successful call had lower readmission rates within thirty days of the operation (8.8 vs. 17.5%, P = 0.008), and this was sustained in multivariate analysis (adjusted odds ratio AOR: 0.18, [confidence interval CI: 0.05–0.66], P = 0.009). However, no differences were observed for thirty-day mortality (Group-I: 3.2% versus Group-II: 1.2%, P = 0.152) or amputation (Group-I: 9.6% versus Group II 5.9%, P = 0.162). Among those who had a successful call, patients with a history of smoking (AOR: 4.05 [CI: 1.21, 17.12] P = 0.025), diabetes mellitus (AOR: 3.42 [CI: 1.35, 8.7] P = 0.01) and myocardial infarction (AOR: 7.15 [CI: 1.76, 20.1] P = 0.006) had a much higher chances of readmission. Risk analysis using epidemiological methods showed that by receiving a call, the risk of readmission could be dropped to half (RR: 0.50 [CI: 0.30, 0.84]), with an attributable risk reduction of −8.7% (CI: −15.9%, −1.4%).


      This single-institution retrospective study demonstrates the importance of immediate discharge follow-up phone calls in patients who undergo open lower extremity revascularization to reduce thirty-day readmissions. Our analysis showed patients who received immediate follow-up phone calls were less likely to be readmitted to the hospital. The development of reliable and efficient systems to enhance immediate discharge follow-up in vascular surgery patients is pivotal to improving quality of care, preventing readmissions, and reducing healthcare costs.
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        • Dua A.
        • Lee C.J.
        Epidemiology of peripheral arterial disease and critical limb ischemia.
        Tech Vasc Interv Radiol. 2016; 19: 91-95
        • Borza T.
        • Oreline M.K.
        • Skolarus T.A.
        • et al.
        Association of the hospital readmissions reduction program with surgical readmissions.
        JAMA Surg. 2018; 153: 243-250
        • Campia U.
        • Gerhard-Herman M.
        • Piazza G.
        • et al.
        Peripheral artery disease: past, present, and future.
        Am J Med. 2019; 132: 1133-1141
        • Gerhard-Herman M.D.
        • Gornik H.L.
        • Barrett C.
        • et al.
        2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
        Circulation. 2017; 135: e726-e779
        • Forbes T.L.
        • Ricco J.
        Lower extremity bypass versus endovascular therapy for young patients with symptomatic peripheral arterial disease.
        Eur J Vasc Endovasc Surg. 2012; 44: 120
        • Klein A.J.
        • Ross C.B.
        Endovascular treatment of lower extremity peripheral arterial disease.
        Trends Cardiovasc Med. 2016; 26: 495-512
        • Firnhaber J.M.
        • Powell C.S.
        Lower extremity peripheral artery disease: diagnosis and treatment.
        Am Fam Physician. 2019; 99: 362-369
        • Martinez R.A.
        • Shnayder M.
        • Parreco J.
        • et al.
        Nationally representative readmission factors in patients with claudication and critical limb ischemia.
        Ann Vasc Surg. 2018; 52: 96-107
        • Aicher B.O.
        • Hanlon E.
        • Rosenberger S.
        • et al.
        Reduced length of stay and 30-day readmission rate on an inpatient vascular surgery service.
        J Vasc Nurs. 2019; 37: 78-85
        • Gupta P.K.
        • Fernandes-Taylor S.
        • Ramanan B.
        • et al.
        Unplanned readmissions after vascular surgery.
        J Vasc Surg. 2014; 59: 473-482
        • Smith S.L.
        • Matthews E.O.
        • Moxon J.V.
        • et al.
        A systematic review and meta-analysis of risk factors for and incidence of 30-day readmission after revascularization for peripheral artery disease.
        J Vasc Surg. 2019; 70: 996-1006.e7
        • Duwayri Y.
        • Goss J.
        • Knechtle W.
        • et al.
        The readmission event after vascular surgery: causes and costs.
        Ann Vasc Surg. 2016; 36: 7-12
        • Mehtsun W.T.
        • Papanicolas I.
        • Zheng J.
        • et al.
        National trends in readmission following inpatient surgery in the hospital readmissions reduction program era.
        Ann Surg. 2018; 267: 599-605
        • Ibrahim A.M.
        • Nathan H.
        • Thumma J.R.
        • et al.
        Impact of the hospital readmission reduction program on surgical readmissions among Medicare beneficiaries.
        Ann Surg. 2017; 266: 617-624
        • Latz C.A.
        • Wang L.J.
        • Boitano L.
        • et al.
        Unplanned readmissions after endovascular intervention or surgical bypass for critical limb ischemia.
        J Vasc Surg. 2021; 73: 942-949.e1
        • Ochoa Chaar C.I.
        • Gholitabar N.
        • Goodney P.
        • et al.
        One-year readmission after open and endovascular revascularization for critical limb ischemia.
        Ann Vasc Surg. 2019; 61: 25-32.e2
        • Agarwal S.
        • Pitcavage J.M.
        • Sud K.
        • et al.
        Burden of readmissions among patients with critical limb ischemia.
        J Am Coll Cardiol. 2017; 69: 1897-1908
        • Iqbal A.
        • Raza A.
        • Huang E.
        • et al.
        Cost effectiveness of a novel attempt to reduce readmission after ileostomy creation.
        JSLS. 2017; 21 (e2016.00082)
        • Woods C.E.
        • Jones R.
        • O'Shea E.
        • et al.
        Nurse-led postdischarge telephone follow-up calls: a mixed study systematic review.
        J Clin Nurs. 2019; 28: 3386-3399
        • Clari M.
        • Frigerio S.
        • Ricceri F.
        • et al.
        Follow-up telephone calls to patients discharged after undergoing orthopaedic surgery: double-blind, randomised controlled trial of efficacy.
        J Clin Nurs. 2015; 24: 2736-2744
        • BMJ
        How to calculate risk. EBM Toolkit: BMJ Best Practices.
        (Available from:)
        • Porta M.S.
        • Greenland S.
        • Hernán M.
        • et al.
        • International Epidemiological Association
        A Dictionary of Epidemiology.
        6th ed. Oxford University Press, Oxford2014: 223
        • Jencks S.F.
        • Williams M.V.
        • Coleman E.A.
        Rehospitalizations among patients in the Medicare fee-for-service program.
        N Engl J Med. 2009; 360: 1418-1428
        • Hornick J.R.
        • Balderman J.A.
        • Eugea R.
        • et al.
        A telephone call 1 week after hospitalization can identify risk factors for vascular surgery readmission.
        J Vasc Surg. 2016; 64: 719-725
        • Engelbert T.L.
        • Fernandes-Taylor S.
        • Gupta P.K.
        • et al.
        Clinical characteristics associated with readmission among patients undergoing vascular surgery.
        J Vasc Surg. 2014; 59: 1349-1355
        • Gupta A.
        • Fonarow G.C.
        The hospital readmissions reduction program-learning from failure of a healthcare policy.
        Eur J Heart Fail. 2018; 20: 1169-1174
        • Zuckerman R.B.
        • Sheingold S.H.
        • Orav E.J.
        • et al.
        Readmissions, observation, and the hospital readmissions reduction program.
        N Engl J Med. 2016; 374: 1543-1551
        • Kennedy B.
        • Craig J.B.
        • Wetsel M.
        • et al.
        Three nursing interventions' impact on HCAHPS scores.
        J Nurs Care Qual. 2013; 28: 327-334
        • Lee T.L.
        • Bokovoy J.
        Understanding discharge instructions after vascular surgery: an observational study.
        J Vasc Nurs. 2005; 23: 25-29
        • Kronfli A.
        • Boukerche F.
        • Medina D.
        • et al.
        Immediate postoperative hyperglycemia after peripheral arterial bypass is associated with short-term and long-term poor outcomes.
        J Vasc Surg. 2021; 73: 1350-1360
        • Jack B.W.
        • Chetty V.K.
        • Anthony D.
        • et al.
        A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.
        Ann Intern Med. 2009; 150: 178-187
        • Ceppa E.P.
        • Pitt H.A.
        • Nakeeb A.
        • et al.
        Reducing readmissions after pancreatectomy: limiting complications and coordinating the care continuum.
        J Am Coll Surg. 2015; 221: 708-716
        • Mistiaen P.
        • Poot E.
        Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home.
        Cochrane Database Syst Rev. 2006; : CD004510
        • D'Amore J.
        • Murray J.
        • Powers H.
        • et al.
        Does telephone follow-up predict patient satisfaction and readmission?.
        Popul Health Manag. 2011; 14: 249-255