Factors associated with Ninety-day Reintervention following Lower Extremity Revascularization

Objective Peripheral artery disease (PAD) represents a high volume, high-cost burden on the healthcare system. The Centers for Medicare and Medicaid Services (CMS) has developed the Bundled Payments for Care Improvement-Advanced program, in which a single payment is provided for all services administered in a postsurgical 90-day episode of care. Factors associated with 30- and 90-day reinterventions after PAD interventions would represent useful data for both payors and stake holders. Methods We conducted a national cohort study of adults 65 years and older in the Vascular Quality Initiative and CMS linked dataset who underwent an open, endovascular, or hybrid revascularization procedure for PAD between January 1, 2010 to December 31, 2018. Procedures for acute limb ischemia and aneurysms were excluded. The primary outcome was 90-day reintervention. Reintervention at 30-days was a secondary outcome. Covariates of interest included demographic, comorbidities, and patient- and facility-level characteristics. Multivariable Cox regression was used to determine the association between patient- and facility-level characteristics and the risk of 30- and 90-day reinterventions. Results Among 42,429 patients (71.3% endovascular, 23.3% open, and 5.4% hybrid), median [IQR] age was 74 [69-80], 57.9% were male, and 84.3% were White. Chronic limb threatening ischemia (CLTI) was the operative indication in 40.4% of the procedures. Overall, 42.8% were completed in the outpatient setting (40.3% outpatient, 2.5% office-based lab). Over 70% of procedures for CLTI were completed as inpatient while 60% of the claudication interventions were done as outpatient. The 90-day reintervention rate was 14.5% and the 30-day reintervention rate was 5.5%. Compared to inpatient procedures, PAD interventions completed in the outpatient or office-based lab setting had significantly higher 90- and 30--day reintervention rates (ref – inpatient; outpatient 90d reintervention [HR 1.41 (95% CI 1.25-1.60)]; outpatient 30d reintervention [HR 1.90 (95% CI 1.62-2.24)]; office-based lab 90d reintervention [HR 2.09 (95% CI 1.82-2.41)]; office-based lab 30d reintervention [HR 3.54 (95% CI 3.17-3.94)]). Open and hybrid approaches demonstrated lower risk of reintervention compared to endovascular procedures at 30 and 90 days and, compared to aortoiliac disease, all other anatomic segments of disease were associated with higher 90-day reintervention but no difference was noted at 30 days. Conclusions While outpatient PAD interventions may be convenient for patients and providers, the outpatient setting is associated with a significant risk of subsequent reintervention. Additional work is needed to understand how to improve the longevity of outpatient PAD interventions.