Study Evaluates Impact of Travel Distance on Nonindex Readmission After Complex Aortic Surgery

KEY FINDINGS

• Patients traveling further for complex aortic surgery had a higher hazard of nonindex readmission, and nonindex readmission was associated with significantly higher mortality.
• The hazard of nonindex readmission was threefold higher for patients traveling the furthest for the index surgery as compared with those who were closest.
• There was no significant relationship between travel distance quintile and mortality hazard.
• Patients who had a nonindex readmission by 30 days had a 46% greater long-term mortality hazard as compared with index readmission patients.
• There was a dose-response relationship between travel distance and nonindex readmission, with the HR of nonindex readmission steadily increasing from Q3 through Q5.

ENDOVASCULAR TODAY ASKS…

Lead study investigator Zach Feldman, MD, with Massachusetts General Hospital in Boston, Massachusetts, expanded on the findings and the importance of care coordination after complex aortic surgery.

This study found no mortality signal associated with travel distance itself, despite some markers of higher complexity (larger aneurysm diameter, higher rates of prior aortic surgery) at greater distances. What is the significance of this finding? How might this inform future research?

This is a reassuring finding, highlighting the high level of vascular surgical care provided across centers in the VQI, even on the most complex of aortic repairs. Further, this underscores how the breakdown in care delivery may not result in severe complications within the first 30 days per se, but rather, how early care coordination gaps may lead to readmission at local nonindex hospitals. However, we should not just call this a “win” that short-term mortality is avoided and a patient is readmitted—indeed, nonindex readmissions were associated with significant impacts on long-term survival in our cohort.

What should the ideal follow-up protocol include for vulnerable populations at a far travel distance from the index hospital?

We recommend a comprehensive increase in patient engagement throughout the perioperative care episode in patients with complex aortic pathology, even starting with the initial consultation for elective patients. Of course, this may not be possible in patients presenting with acute aortic syndromes, but ideally, increasing the touchpoints with family members, primary care physicians, and local vascular surgeons prior to the index repair may be paramount. Additional preoperative telemedicine or in-person visits may prepare patients and caregivers for the expected range of postoperative courses. Lastly, open lines of communication with local admitting hospitals (and especially with local vascular surgeons) postoperatively may pre-empt escalation of complications after aortic surgery. We would even suggest that the index vascular surgeon’s team connect with a local vascular surgeon for the patients travelling farthest.

From your experience, what factors are patients (or their families) weighing when considering where they will present for urgent or nonurgent issues? What discussions do you have with them about this, postsurgery?

Many patients and caregivers are unfamiliar with the spectrum of possible postoperative complications after complex vascular surgery. They may think that a bout of abdominal pain or a painful, cold extremity is within the expectations of the postoperative recovery period. Many choose to “wait it out” and avoid presenting to care for the first several hours of symptoms. They may also think that many hospitals have the same capabilities to recognize, triage, and escalate aortic issues. The preoperative consent discussions and postoperative discussions with families must heavily re-emphasize alarm symptoms, highlight the degree of suspicion local hospitals should have, and provide modes of contact for the index surgical team available to local hospitals 24/7. We emphasize to patients that when in doubt, they should have a low threshold to connect with our team.  

What measures can be implemented to optimize care coordination and follow-up between aortic centers and community hospitals?

In an ideal world, integrating health systems should ensure that communication channels and especially imaging systems allow wide dissemination of information throughout their own and particularly across other health systems. Aortic centers should also consider establishing system-wide “aortic speed dial” systems to enable quick access to aortic hubs from the community sites for any issue that may arise, especially among the emergency and hospitalist physicians who may first identify patients in trouble. These may even be distributed to rehabilitation hospitals within some health systems. As capacity constraints continue to mount in healthy systems across the country, “e-consults” from aortic centers may enable more seamless cross-system guidance for community sites. The central theme here is reducing barriers to communication.