Study: Patients with depression less likely to go home after critical limb revascularisation

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Lead author James C Iannuzzi

A recent analysis by finds an association between depression and non-home discharge after revascularisation for chronic limb-threatening ischaemia (CLTI). Authors Joel L Ramirez, James C Iannuzzi (University of California, San Francisco, San Francisco, USA) and colleagues write in an online Journal of Vascular Surgery (JVS) article that these results “provide further evidence of the negative impact that comorbid depression has on patients undergoing revascularisation for CLTI,” and propose that future studies should examine whether treating depression can improve outcomes in this patient population.

“Recent evidence suggests that depression in patients with peripheral arterial disease (PAD) is associated with increased postoperative complications,” the authors begin, noting that problems can include decreased primary and secondary patency after revascularisation and increased risk of major amputation and mortality.

Ramirez et al note that the impact of depression on non-home discharge after vascular surgery remains unexplored, despite this being “an important outcome” for patients. They hypothesised that depression would be associated with an increased risk for non-home discharge following revascularisation for CLTI.

The investigators identified endovascular, open, and hybrid cases of revascularisation for CLTI from the 2012–2014 National (Nationwide) Inpatient Sample, which they explain is “a patient-level administrative claims database that is published annually by the Agency for Healthcare Research and Quality and represents approximately 20% of discharges from US hospitals”.

They write that a hierarchical multivariable binary logistic regression controlling for hospital level variation examined the association between depression and non-home discharge and controlled for confounders meeting p<0.01 on bivariate analysis.

Ramirez and colleagues identified 64,817 cases, of which 5,472 (8.4%) were diagnosed with depression, and 16,524 (25.5%) required non-home discharge. They relay that patients with depression were younger, more likely to be women, white, have multiple comorbidities, a non-elective admission, and experience a postoperative complication (p<0.05).

The authors report that, on unadjusted analyses, patients with depression had a 7% absolute increased risk of requiring non-hospital discharge (32.1% vs. 24.9%, p<0.001). On multivariable analysis, they found that patients with depression had an adjusted 50% increased odds for non-hospital discharge (odds ratio [OR]=1.5; 95% confidence interval [CI]=1.4–1.61; c-statistic, 0.81) compared to those without depression.

After stratification by operative approach, Ramirez et al identified that depression had a larger effect estimate in endovascular revascularisation (OR=1.57; CI=1.42–1.74) compared to open (OR=1.45; 95% CI=1.3–1.62).

Finally, the authors write in JVS that a test for interaction between depression and gender showed that men with depression had higher odds of non-hospital discharge compared to women with depression (OR=1.68; 95% CI=1.51–1.88 vs. OR=1.37; 95% CI=1.25–1.51; interaction p<0.01).

In the discussion of their findings, Ramirez and colleagues recognise that the present study is limited by certain factors. For example, they note that their investigation was based on a large national administrative database, in which all diagnoses are determined based upon billing codes. They acknowledge that use of this particular source “may introduce bias and be susceptible to under-reporting of certain comorbidities”.

The authors summarise that this study found a novel association between depression and non-hospital discharge after revascularisation for CLTI. Considering the wider impact of their findings, they write: “These results provide further evidence that an increased awareness about mental health is fundamental to care for vascular surgery patients and to understand postoperative pathways.”


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