Impact of Post-Hospital Syndrome on Outcomes of Elective Endovascular Repair of Abdominal Aortic Aneurysm

Abstract

Post-hospital syndrome (PHS) is an acquired, transient period of health vulnerability that follows hospital admission for acute illness. It is characterized by physiologic deconditioning secondary to stressors from disruption in circadian rhythm, depletion of nutritional reserve, and pain or discomfort associated with hospitalization. PHS is reported as an independent risk factor for readmission and adverse postoperative outcomes. The aim of this study was to investigate whether PHS affects outcomes of elective endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm. The Healthcare Cost and Utilization Project State Inpatient Database for California (2009-2011) was queried using International Classification of Diseases, Ninth Revision codes 441.4 (abdominal aneurysm without mention of rupture), 397.1 (EVAR with graft), and 397.8 (EVAR with branching or fenestrated graft). PHS exposure is defined as any inpatient admission ≤30 days before elective EVAR. Primary outcomes are mortality and postoperative complications. Secondary outcomes include length of stay (LOS), 30-day readmission, and hospital charge. A total of 6155 patients were identified, of whom 327 (5.6%) patients had more than one episode of hospital admission ≤30 days before elective EVAR. In-hospital mortality was comparable (P = .09). However, PHS exposure was associated with increased 30-day readmission (9.5% vs 18.4%; P < .001), LOS (3.0 vs 4.5 days; P < .001), and overall complications (14.8% vs 24.5%; P < .001). Risk adjustment was made on the basis of age, sex, race, comorbidities, and reason for preoperative admission. Multivariate regression analysis demonstrated PHS to be a predictor for longer LOS (odds ratio [OR], 2.5; confidence interval [CI], 2.0-3.2; P < .001), 30-day readmission (OR, 2.0; CI 1.4-2.6; P < .001), and overall complications (OR, 1.7; CI, 1.3-2.2; P < .001; Table). Additional cost associated with increased readmission attributable to PHS exposure was estimated at $448,302 per 100 cases (Fig). PHS is an independent predictor for increased LOS, 30-day readmission, and overall complications after elective EVAR. Recent hospital admission should be carefully assessed before elective EVAR. Medical optimization with an attempt to delay elective surgery up to 30 days may help improve outcomes and decrease unnecessary health care expenditure. This could be a potential quality improvement target.TableAdjusted odds ratio (OR) of post-hospital syndrome (PHS) exposure of type of adverse eventsAdjusted OR95% CIP valueHematoma/hemorrhage1.51.1-2.1.022Acute kidney injury1.51.0-2.4.062Any complication1.71.3-2.2<.001Within 30-day readmission2.01.4-2.6<.001Length of hospital stay >3 days2.52.0-3.2<.001CI, Confidence interval.Adjustment made with age, sex, race, comorbid disease severity (Charlson Comorbidity Index), and reason for preoperative admission. Open table in a new tab