Patients with depression are less likely to go home after critical limb revascularization

Although often overlooked during the preoperative evaluation, recent evidence has suggested that depression in patients with peripheral artery disease is associated with increased postoperative complications, including decreased primary and secondary patency after revascularization and an increased risk of major amputation and mortality. Postoperative nonhome discharge (NHD) is an important outcome for patients and has also been associated with other adverse outcomes; however, the effect that depression has on NHD after vascular surgery has remained unexplored. We hypothesized that depression would be associated with an increased risk of NHD after revascularization for chronic limb threatening ischemia (CLTI).

Endovascular, open, and hybrid (combined open and endovascular) cases of revascularization for CLTI were identified from the 2012 to 2014 National (Nationwide) Inpatient Sample. CLTI, diagnoses of depression, and medical comorbidities were defined using the corresponding International Classification of Diseases, Ninth Revision, Clinical Modification codes. A hierarchical multivariable binary logistic regression controlling for hospital level variation and for confounders meeting P <.01 on bivariate analysis was used to examine the association between depression and NHD. A sensitivity analysis after coarsened exact matching for baseline characteristics that differed between the two groups was performed to reduce any imbalance.

A total of 64,817 cases were identified, of which 5472 (8.4%) included a diagnosis of depression and 16,524 (25.5%) NHD. The patients with depression were younger and more likely to be women and white, have multiple comorbidities and a nonelective admission, and experience a postoperative complication (P <.05). On unadjusted analyses, patients with depression had an 8% absolute increased risk of requiring NHD (32.1% vs 24.9%; P <.001). On multivariable analysis, patients with depression had an increased odds for NHD (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.40-1.61; c-statistic, 0.81) compared with those without depression. After stratification by operative approach, depression had a larger effect estimate in endovascular revascularization (OR, 1.57; 95% CI, 1.42-1.74) compared with open (OR, 1.45; 95% CI, 1.30-1.62). A test for interaction between depression and gender identified that men with depression had greater odds of NHD compared with women with depression (OR, 1.68; 95% CI, 1.51-1.88; vs OR, 1.37; 95% CI, 1.25-1.51; interaction P <.01). A sensitivity analysis after coarsened exact matching confirmed these findings.

To the best of our knowledge, the present study is the first to identify an association between depression and NHD after revascularization for CLTI. These results provide further evidence of the negative effects that comorbid depression has on patients undergoing revascularization for CLTI. Future studies should examine whether treating depression can improve the outcomes in this patient population.