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. 2018 Nov;68(5):1505-1516.
doi: 10.1016/j.jvs.2018.03.408. Epub 2018 Jun 28.

Predictors of early mortality and readmissions among dialysis patients undergoing lower extremity amputation

LaTonya J Hickson  1 , Andrew D Rule  2 , Bjorg Thorsteinsdottir  3 , Raymond C Shields  4 , Ivan E Porter  5 , Mark D Fleming  6 , Daniel S Ubl  7 , Cynthia S Crowson  8 , Kristine T Hanson  7 , Bassem T Elhassan  9 , Rajnish Mehrotra  10 , Shipra Arya  11 , Robert C Albright  2 , Amy W Williams  2 , Elizabeth B Habermann  7
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Predictors of early mortality and readmissions among dialysis patients undergoing lower extremity amputation

LaTonya J Hickson et al. J Vasc Surg. 2018 Nov.

Abstract

Objective: Patients receiving dialysis are at increased risk for lower extremity amputations (LEAs) and postoperative morbidity. Limited studies have examined differences in 30-day outcomes of mortality and health care use after amputation or the preoperative factors that relate to worsened outcomes in dialysis patients. Our objective was to examine dialysis dependency and other preoperative factors associated with readmission or death after LEA.

Methods: A retrospective cohort study was conducted of dialysis-dependent and nondialysis patients undergoing major LEA in the 2012 to 2013 American College of Surgeons National Surgical Quality Improvement Program. Primary outcomes included death and hospital readmission within 30 days of amputation.

Results: Of 6468 patients, 1166 (18%) were dialysis dependent. The dialysis cohort had more blacks (39% vs 23%), diabetes (76% vs 58%), below-knee amputations (62% vs 55%), and in-hospital deaths (8% vs 3%; all P < .001). The 30-day postoperative death rates (15% vs 7%) and readmission rates (35% vs 20% per 30 person-days; both P < .001) were higher in dialysis patients. Among the live discharges, the rate of any readmission or death within 30 days from amputation was highest in those aged ≥50 years (40% per 30 person-days). Multivariable analyses in the dialysis cohort revealed increased age, above-knee amputation, decreased physical status, heart failure, high preoperative white blood cell count, and low platelet count to be associated with death (P < .05; C statistic, 0.75). The only preoperative factor associated with readmission in dialysis patients was race (P = .04; C statistic, 0.58).

Conclusions: Readmission or death after amputation is increased among dialysis patients. Predicting which dialysis patients are at highest risk for death is feasible, whereas predicting which will require readmission is less so. Risk factor identification may improve risk stratification, inform reimbursement policies, and allow targeted interventions to improve outcomes.

Keywords: Age; Cardiovascular disease; Diabetes; Hemodialysis; Hospitalization; Survival analysis.

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Conflict of interest statement

CONFLICT OF INTEREST

The authors have no financial disclosures.

The results presented in this paper have not been published previously in whole or part, except in abstract format.

Figures

Figure 1
Figure 1
Figure 1a. Death rates by days from Lower Extremity Amputation among National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients (solid line) with 95% confidence intervals (dashed line) compared to non-dialysis patients (bold line). Numbers of patients listed below the plot refer to dialysis-dependent patients under observation at each time point. Figure 1b. 30-day death rates by age among National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients undergoing Lower Extremity Amputation (solid line) with 95% confidence intervals (dashed line) compared to non-dialysis patients (bold line). Numbers of patients listed below the plot refer to dialysis-dependent patients under observation at each time point. Figure 1c. Comparison of 30-day death rates by age and Lower Extremity Amputation operation type (above knee amputation is solid line and below knee amputation is dashed line) among National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients.
Figure 1
Figure 1
Figure 1a. Death rates by days from Lower Extremity Amputation among National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients (solid line) with 95% confidence intervals (dashed line) compared to non-dialysis patients (bold line). Numbers of patients listed below the plot refer to dialysis-dependent patients under observation at each time point. Figure 1b. 30-day death rates by age among National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients undergoing Lower Extremity Amputation (solid line) with 95% confidence intervals (dashed line) compared to non-dialysis patients (bold line). Numbers of patients listed below the plot refer to dialysis-dependent patients under observation at each time point. Figure 1c. Comparison of 30-day death rates by age and Lower Extremity Amputation operation type (above knee amputation is solid line and below knee amputation is dashed line) among National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients.
Figure 1
Figure 1
Figure 1a. Death rates by days from Lower Extremity Amputation among National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients (solid line) with 95% confidence intervals (dashed line) compared to non-dialysis patients (bold line). Numbers of patients listed below the plot refer to dialysis-dependent patients under observation at each time point. Figure 1b. 30-day death rates by age among National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients undergoing Lower Extremity Amputation (solid line) with 95% confidence intervals (dashed line) compared to non-dialysis patients (bold line). Numbers of patients listed below the plot refer to dialysis-dependent patients under observation at each time point. Figure 1c. Comparison of 30-day death rates by age and Lower Extremity Amputation operation type (above knee amputation is solid line and below knee amputation is dashed line) among National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients.
Figure 2
Figure 2
Figure 2a. Readmission rates (solid line) with 95% confidence intervals (dashed lines) according to days from discharge following Lower Extremity Amputation among National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients compared to non-dialysis patients (bold line). Numbers of patients listed below the plot refer to dialysis-dependent patients under observation at each time point. Figure 2b. 30-day readmission rates by age among National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients undergoing Lower Extremity Amputation (solid line) compared to non-dialysis patients (dashed line). Figure 2c. Readmission or death within 30 days among patients with live discharge after Lower Extremity Amputation by age in National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients. Deaths without readmissions (dotted line) cumulated with deaths preceded by readmissions (dashed line) and readmissions without death (solid line).
Figure 2
Figure 2
Figure 2a. Readmission rates (solid line) with 95% confidence intervals (dashed lines) according to days from discharge following Lower Extremity Amputation among National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients compared to non-dialysis patients (bold line). Numbers of patients listed below the plot refer to dialysis-dependent patients under observation at each time point. Figure 2b. 30-day readmission rates by age among National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients undergoing Lower Extremity Amputation (solid line) compared to non-dialysis patients (dashed line). Figure 2c. Readmission or death within 30 days among patients with live discharge after Lower Extremity Amputation by age in National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients. Deaths without readmissions (dotted line) cumulated with deaths preceded by readmissions (dashed line) and readmissions without death (solid line).
Figure 2
Figure 2
Figure 2a. Readmission rates (solid line) with 95% confidence intervals (dashed lines) according to days from discharge following Lower Extremity Amputation among National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients compared to non-dialysis patients (bold line). Numbers of patients listed below the plot refer to dialysis-dependent patients under observation at each time point. Figure 2b. 30-day readmission rates by age among National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients undergoing Lower Extremity Amputation (solid line) compared to non-dialysis patients (dashed line). Figure 2c. Readmission or death within 30 days among patients with live discharge after Lower Extremity Amputation by age in National Surgical Quality Improvement Program 2012–2013 dialysis-dependent patients. Deaths without readmissions (dotted line) cumulated with deaths preceded by readmissions (dashed line) and readmissions without death (solid line).
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