Index versus Non-index Readmission After Hepato-Pancreato-Biliary Surgery: Where Do Patients Go to Be Readmitted?

Predictors of care discontinuity in geriatric trauma patients

BACKGROUND

Readmission to a non-index hospital, or care discontinuity, has been shown to have worse outcomes among surgical patients. Little is known about its effect on geriatric trauma patients. Our goal was to determine predictors of care discontinuity and to evaluate its effect on mortality in this geriatric population.

METHODS

This was a retrospective analysis of Medicare inpatient claims (2014-2015) of geriatric trauma patients. Care discontinuity was defined as readmission within 30 days to a non-index hospital. Demographic and clinical characteristics (including readmission diagnosis category) were collected. Multivariate logistic regression analysis was performed to identify predictors of care discontinuity and to assess its association with mortality.

RESULTS

We included 754,313 geriatric trauma patients. Mean age was 82.13 years (SD, 0.50 years), 68% were male and 91% were White. There were 21,615 (2.87%) readmitted within 30 days of discharge. Of these, 34% were readmitted to a non-index hospital. Overall 30-day mortality after readmission was 25%. In unadjusted analysis, readmission to index hospitals was more likely to be due to surgical infection, GI complaints, or cardiac/vascular complaints. After adjusted analysis, predictors of care discontinuity included readmission diagnoses, patient- and hospital-level factors. Care discontinuity was not associated with mortality (OR, 0.93; 95% confidence interval, 0.86-1.01).

CONCLUSION

More than a third of geriatric trauma patients are readmitted to a non-index hospital, which is driven by readmission diagnosis, travel time and hospital characteristics. However, unlike other surgical settings, this care discontinuity is not associated with increased mortality. Further work is needed to understand the reasons for this and to determine which standardized processes of care can benefit this population.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Impact of Social Determinants of Health on Outcomes Following Resection for Hepatocellular Carcinoma

BACKGROUND

We sought to determine the impact of social determinants of health (SDoH) on outcomes of patients undergoing resection for hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

Patients with HCC in the National Cancer Database who underwent resection from 2009 to 2018 were identified. SDoH associated with length of stay (LOS), 30-day readmission, and 30-day mortality were analyzed using regression analyses adjusted for confounding variables.

RESULTS

Among 9235 patients, the median age (range) was 65.0 (18-90) years, 72.1% were male, and 57.9% were White. A total of 3% were uninsured, 11.1% had Medicaid, 21% resided in regions with a median household income within the lowest quartile of the US population, and 27.0% resided in regions within the lowest quartile of education level. The odds for having longer LOS were lower among patients with the highest regional education level compared with those with the lowest level [odds ratio (OR) 0.86, 95% confidence interval (CI) 0.77-0.97]. The risk of readmission was lower among patients with Medicare (OR 0.52; 95% CI 0.33-0.81), Medicaid (OR 0.52; 95% CI 0.31-0.87), or private insurance (OR 0.56; 95% CI 0.35-0.88) compared with uninsured patients. Thirty-day overall mortality was less likely among patients with Medicare (OR 0.45; 95% CI 0.27-0.75), Medicaid (OR 0.53; 95% CI 0.30-0.93), or private insurance (OR 0.40; 95% CI 0.24-0.66), and among patients with high regional income (OR 0.58; 95% CI 0.44-0.77).

CONCLUSIONS

Adjusted regression analyses identified SDoH that were associated with HCC outcomes. Increased awareness of how SDoH relate to outcomes may inform strategies that attempt to account for these associations and improve patient outcomes.

Predictors and Cost Comparison of Subsequent Urinary Stone Care at Index versus Non-Index Hospitals

OBJECTIVE

To examine the effects of care fragmentation, or the engagement of different health care systems along the continuum of care, on patients with urinary stone disease.

METHODS

All-payer data from the 2016 Healthcare Cost and Utilization Project (HCUP) State Databases from Florida (FL) and New York (NY) were used to identify a cohort of adult patients with an emergency department visit for a diagnosis of urolithiasis, who subsequently re-presented to an index or non-index hospital for renal colic and/or urological intervention. Patient demographics, regional data, and procedural information were collected and 30-day episode-based costs were calculated. Multivariable logistic and gamma generalized linear regression were utilized to identify predictors of receiving subsequent care at an index hospital and associated costs, respectively.

RESULTS

Of the 33,863 patients who experienced a subsequent encounter related to nephrolithiasis, 9,593 (28.3%) received care at a non-index hospital. Receiving subsequent care at the index hospital was associated with fewer acute care encounters prior to surgery (2.5 vs. 2.7; p <0.001) and less days to surgery (29 vs. 42; p < 0.001). Total episode-based costs were higher in the non-index setting, with a mean difference of $783 (Non-index: $13,672, 95% CI $13,292 - $14,053; Index: $12,889, 95% CI $12,677 - $13,102; p < 0.001).

CONCLUSIONS

Re-presentation to a unique healthcare facility following an initial diagnosis of urolithiasis is associated with a greater number of episode-related health encounters, longer time to definitive surgery, and increased costs.

Emergency Department Utilization Following Hepatopancreatic Surgery Among Medicare Beneficiaries

BACKGROUND

Care delivered in hospital-based emergency departments (ED) is a target for cost savings. ED utilization following hepatopancreatic surgery remains poorly defined. We sought to define the rate of ED utilization following liver and pancreatic resection, as well as to identify factors associated with ED visits post-discharge.

METHODS

The Medicare 100% Standard Analytic Files were used to identify Medicare beneficiaries who underwent hepatectomy or pancreatectomy between 2013 and 2017. Claims associated with ED services were identified using the relevant Revenue Center Codes. Patient characteristics and postoperative outcomes associated with ED care within 30 days of discharge were investigated.

RESULTS

Among 37,707 patients who underwent hepatopancreatic surgery, 10,323 (27.4%) had at least one ED visit within 30 days of discharge. Patients presenting to the ED were more likely to be male (OR 1.13, 95%CI 1.07-1.18). Patients undergoing a pancreatectomy (OR 1.39, 95%CI 1.32-1.47), as well as patients who had a perioperative complication (OR 1.16, 95%CI 1.10-1.23) and patients not discharged home (OR 1.41, 95%CI 1.33-1.49), were more likely to require ED care. In contrast, patients undergoing resection for cancer or surgery for an elective basis were less likely to present to the ED postoperatively (OR 0.92, 95%CI 0.87-0.97 and OR 0.22, 95%CI 0.20-0.23, respectively). Patients often had multiple ED visits within 30 days of discharge as 37.2% of patients presented to the ED with at least 2 visits. Visits were also most common in the immediate postoperative period, with 30.9% of ED visits taking place in the first 2 days from discharge. Among patients requiring postoperative ED care, 53.9% were readmitted within 30 days.

CONCLUSION

More than 1 in 4 patients undergoing hepatopancreatic surgery presented to the ED within 30 days of discharge, with most patients returning to the ED within the first week of discharge. A subset of patients had multiple ED visits. Future efforts should target patients most likely to be high ED utilizers to avoid the need for early post-discharge ED use.

Implications of intensive care unit admissions among medicare beneficiaries following resection of pancreatic cancer

BACKGROUND

Intensive care unit (ICU) use has increased among patients with cancer. We sought to define factors associated with ICU admissions among patients with pancreatic cancer and characterize trends in mortality among hospital survivors.

METHODS

The Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database was used to identify patients with pancreatic cancer who underwent resection. Multivariable analyses were conducted to identify factors associated with ICU admission and mortality among hospital survivors.

RESULTS

Among 6422 Medicare beneficiaries who underwent resection of pancreatic cancer, 2386 (37.1%) had an ICU admission. Patients with ICU admissions were more likely to be younger (10-year increase odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.77-0.89), male (OR: 1.17, 95% CI 1.05-1.30) and undergo resection at a teaching hospital (OR: 1.19, 95% CI: 1.05-1.36). While the majority of patients survived to hospital discharge (n = 2106; 88.3%), a majority of patients (n = 1296; 54.3%) died within 6 months. Among patients who had subsequent ICU admissions, 1- and 5-year survival was only 31.8% and 11.0%, respectively.

CONCLUSIONS

Over one-third of patients with pancreatic cancer had an ICU admission. While most patients survived hospitalization, more than one-half of patients died within 6 months of discharge and two-thirds died within 1 year. These data should serve to guide patient-provider discussions around prognosis relative to ICU utilization.

Hepatopancreatobiliary readmission score out performs administrative LACE+ index as a predictive tool of readmission

BACKGROUND

This study aims to compare the LACE + readmission index to a novel hepatopancreatobiliary readmission risk score (HRRS) in predicting post-operative hepatopancreatobiliary (HPB) cancer patient readmissions.

METHODS

A retrospective review of 104 postoperative HPB cancer patients from January 2017 to July of 2019 was performed. Univariable and multivariable analyses were utilized.

RESULTS

The LACE + index did not predict 30-day (OR 1.01, 95% CI, 0.97-1.05, p = 0.81, c-statistic = 0.52) or 90-day (OR 1.02, 95% CI, 0.98-1.05, p = 0.43) readmission. Patients readmitted within 30 days had significantly increased HRRS scores compared to those who were not (0 vs 34, p < 0.001). A single unit increase in HRRS corresponded to a 6.5% increased risk of readmission; (OR 1.065, 95% CI, 1.038-1.094, p < 0.0001). HRRS independently predicted 30-day (OR 1.07, 95% CI, 1.04-1.11, p < 0.0001) and 90-day postoperative readmission (OR 1.05, 95% CI 1.03-1.08, p < 0.0001).

CONCLUSIONS

HRRS better predicts postoperative readmissions for HPB surgical patients compared to LACE+. Accurate assessment of postoperative readmission must include readmission scores focused on clinically relevant perioperative parameters.

Social vulnerability and fragmentation of postoperative surgical care among patients undergoing hepatopancreatic surgery

BACKGROUND

Regionalization of hepatopancreatic surgery to high-volume hospitals has been associated with fragmentation of postoperative care and, in turn, inferior outcomes after surgery. The objective of this study was to examine the association of social vulnerability with the likelihood of experiencing fragmentation of postoperative care (FPC) after hepatopancreatic surgery.

METHODS

Patients who underwent hepatopancreatic surgery and had at least 1 readmission within 90 days were identified using Medicare 100% Standard Analytical Files between 2013 and 2017. Fragmentation of postoperative care was defined as readmission at a hospital other than the index institution where the initial surgery was performed. The association of social vulnerability index and its components with fragmentation of postoperative care was examined.

RESULTS

Among 11,142 patients, 8,053 (72.3%) underwent pancreatectomy, and 3,089 (27.7%) underwent hepatectomy. The overall incidence of fragmentation of postoperative care was 32.9% (n = 3,667). Patients who experienced fragmentation of postoperative care were older (73 years [interquartile range: 69-77]_FPC vs 72 years [interquartile range: 68-77]_non-FPC) and had a higher Charlson comorbidity score (4 [interquartile range: 2-8]_FPC vs 3 [interquartile range: 2-8]_non-FPC) (both P < .001). Median overall social vulnerability index was higher among patients who experienced fragmentation of postoperative care (52.5 [interquartile range: 29.3-70.4]_FPC vs 51.3 [interquartile range: 27.9-69.4]_non-FPC, P = .02). On multivariable analysis, the odds of experiencing fragmentation of postoperative care was higher with increasing overall social vulnerability index (odds ratio: 1.14; 95% confidence interval 1.01-1.30). Additionally, the odds of experiencing fragmentation of postoperative care were higher among patients with high vulnerability owing to their socioeconomic status (odds ratio: 1.28; 95% confidence interval 1.12-1.45) or their household composition and disability (odds ratio: 1.35; 95% confidence interval 1.19-1.54), whereas high vulnerability owing to minority status and language was inversely associated with fragmentation of postoperative care (odds ratio: 0.73; 95% confidence interval 0.64-0.84).

CONCLUSION

Social vulnerability was strongly associated with the odds of experiencing fragmented postoperative care after hepatopancreatic surgery.

Care Fragmentation and Mortality in Readmission after Surgery for Hepatopancreatobiliary and Gastric Cancer: A Patient-Level and Hospital-Level Analysis of the Healthcare Cost and Utilization Project Administrative Database

BACKGROUND

Hepatopancreatobiliary (HPB) and gastric oncologic operations are frequently performed at referral centers. Postoperatively, many patients experience care fragmentation, including readmission to "outside hospitals" (OSH), which is associated with increased mortality. Little is known about patient-level and hospital-level variables associated with this mortality difference.

STUDY DESIGN

Patients undergoing HPB or gastric oncologic surgery were identified from select states within the Healthcare Cost and Utilization Project database (2006-2014). Follow-up was 90 days after discharge. Analyses used Kruskal-Wallis test, Youden index, and multilevel modeling at the hospital level.

RESULTS

There were 7,536 patients readmitted within 90 days of HPB or gastric oncologic surgery to 636 hospitals; 28% of readmissions (n = 2,123) were to an OSH, where 90-day readmission mortality was significantly higher: 8.0% vs 5.4% (p < 0.01). Patients readmitted to an OSH lived farther from the index surgical hospital (median 24 miles vs 10 miles; p < 0.01) and were readmitted later (median 25 days after discharge vs 12; p < 0.01). These variables were not associated with readmission mortality. Surgical complications managed at an OSH were associated with greater readmission mortality: 8.4% vs 5.7% (p < 0.01). Hospitals with <100 annual HPB and gastric operations for benign or malignant indications had higher readmission mortality (6.4% vs 4.7%, p = 0.01), although this was not significant after risk-adjustment (p = 0.226).

CONCLUSIONS

For readmissions after HPB and gastric oncologic surgery, travel distance and timing are major determinants of care fragmentation. However, these variables are not associated with mortality, nor is annual hospital surgical volume after risk-adjustment. This information could be used to determine safe sites of care for readmissions after HPB and gastric surgery. Further analysis is needed to explore the relationship between complications, the site of care, and readmission mortality.

Postoperative care fragmentation in bariatric surgery and risk of mortality: a nationwide study

BACKGROUND

Readmission after bariatric surgery may to lead to fragmentation of care if readmission occurs at a facility other than the index hospital. The effect of readmission to a nonindex hospital on postoperative mortality remains unclear for bariatric surgery.

OBJECTIVES

To determine postoperative mortality rates according to readmission destinations.

SETTING

Nationwide analysis of all surgical facilities in France.

METHODS

Multicenter, nationwide study of adult patients undergoing bariatric surgery from January 1, 2013, through December 31, 2018. Data from all surgical facilities in France were extracted from a national hospital discharge database.

RESULTS

In a cohort of 278,600 patients who received bariatric surgery, 12,760 (4.6%) were readmitted within 30 days. In cases of readmission, 23% of patients were admitted to a nonindex hospital. Patients readmitted to a nonindex facility had different characteristics regarding sex (men, 23.6% versus 18.2%, respectively; P < .001), co-morbidities (Charlson Co-morbidity Index, .74 versus .53, respectively; P < .001), and travel distance (38.3 km versus 26.9 km, respectively; P < .001) than patients readmitted to the index facility. The main reasons for readmission were leak/peritonitis and abdominal pain. The overall mortality rate after readmission was .56%. The adjusted odds ratio (OR) of mortality for the nonindex group was 4.96 (95% confidence interval [CI], 3.1-8.1; P < .001). In the subgroups of patients with a gastric leak, the mortality rate was 1.5% and the OR was 8.26 (95% CI, 3.7-19.6; P < .001).

CONCLUSION

Readmissions to a nonindex hospital are associated with a 5-fold greater mortality rate. The management of readmission for complications after bariatric surgery should be considered as a major issue to reduce potentially preventable deaths.

Quality performance indicators for hepato-pancreatico-biliary procedures: a systematic review

BACKGROUND

This systematic review was undertaken to define and summarize existing, proposed quality performance indicators (QPI) for hepato-pancreatico-biliary (HPB) procedures.

METHODS

A systematic literature review identified studies reporting on quality indicators for cholecystectomy, hepatectomy, pancreatectomy and complex biliary surgical procedures. The databases searched were MEDLINE, EMBASE, PubMed, and SCOPUS, with all literature available until the search date of 1 May 2020 included. The reference lists of all included papers, as well as related review articles, were manually searched to identify further relevant studies.

RESULTS

Forty-five publications report quality indicators for pancreatectomy (n = 22), hepatectomy (n = 7), HPB resections in general (n = 12), and cholecystectomy (n = 6). No publications proposed QPI for complex biliary surgery. The 45 papers used national audit (n = 18), consensus methodology (n = 5), state-wide audit (n = 3), unit audit (n = 9), review methodology (n = 9), and survey methodology (n = 1). Sixty-one QPI were reported for pancreatectomy, 22 reported for hepatectomy, and 14 reported for HPB resections in general, in domains of infrastructure, provider, and documentation. Fourteen infrastructure and provider-based QPI were reported for cholecystectomy.

CONCLUSIONS

There are few internationally agreed QPI for HPB procedures that allow global comparison of provider performance and that set aspirational goals for patient care and experience.

How Safe Are Safety-Net Hospitals? Opportunities to Improve Outcomes for Vulnerable Patients Undergoing Hepatopancreaticobiliary Surgery

INTRODUCTION

Safety-net hospitals are critical to the US health system as they provide care to vulnerable patients. The effect of hospital safety-net burden on patient outcomes in hepatopancreaticobiliary (HPB) surgery was examined.

METHODS

Discharge data between 2004 and 2014 from the National Inpatient Sample were utilized. Hospitals with a safety-net burden were divided into tertiles: low (LBH) (< 13.6%), medium (MBH) (13.6-33.3%), and high (HBH) (> 33.3%). The association of hospital safety-net burden with complications, in-hospital mortality, never events, and costs were defined.

RESULTS

Nearly 5% of the analytic cohort (n = 65,032) had surgery at a HBH. Patients treated at HBH were younger (median age, HBH 55 years vs LBH 62 years; p < 0.001), black or Hispanic (HBH 40.5% vs LBH 12.7%; p < 0.001), and of lowest income quartile (HBH 38.4% vs LBH 19.6%; p < 0.001). One-third of patients at HBH experienced a complication compared with only a quarter of patients at LBH (p < 0.001). HBH had higher rates of in-hospital mortality (HBH 6.5% vs. LBH 2.8%; p < 0.001), never events (HBH 5.4% vs. LBH 1.4%; p < 0.001), and a higher cost of surgery (HBH $30,716 vs. LBH $28,054; p < 0.001).

CONCLUSION

Perioperative outcomes were worse at HBH, highlighting that efforts are needed to improve their delivery of care.

Mental illness is associated with increased risk of suicidal ideation among cancer surgical patients

BACKGROUND

Mental illness and depression can be associated with increased risk of suicidal ideation (SI). We sought to determine the association between mental illness and SI among cancer surgical patients.

METHODS

Medicare beneficiaries who underwent resection of lung, esophageal, pancreatic, colon, or rectal cancer were analyzed. Patients were categorized as no mental illness, anxiety and/or depression disorders or bipolar/schizophrenic disorders.

RESULTS

Among 211,092 Medicare beneficiaries who underwent surgery for cancer, the rate of suicidal ideation was 270/100,000 patients. Antecedent mental health diagnosis resulted in a marked increased SI. On multivariable analysis, patients with anxiety alone (OR 1.49, 95%CI 1.04-2.14), depression alone (OR 2.60, 95%CI 1.92-3.38), anxiety + depression (OR 4.50, 95%CI 3.48-5.86), and bipolar/schizophrenia (OR 7.30, 95%CI 5.27-10.30) had increased odds of SI.

CONCLUSIONS

Roughly 1 in 370 Medicare beneficiaries with cancer who underwent a wide range of surgical procedures had SI. An antecedent mental health diagnosis was a strong risk factor for SI.

Hepatopancreatobiliary Surgery: the Role of Clinical Resources and Variation in Performance of Hospitals Located in "Distressed" Communities

INTRODUCTION

The USA has one of the largest known income-based health disparities, with low-income adults being up to five times more likely to report being in poor health. We evaluated the association of hospital zip-code-based distressed communities index (DCI) with post-surgical outcomes following hepatopancreatobiliary (HPB) surgery.

METHODS

Adults undergoing HPB surgery were identified in the National Inpatient Sample. The association between hospital socioeconomic distress and outcomes including complications, mortality, failure to rescue (FTR), and never events were compared between high-distress facilities (HDF) and low-distress facilities (LDF).

RESULTS

A total of 11,119 (37.8%) patients underwent an operation at an HDF. Patients treated at HDF were younger (18-39 years, HDF: n = 1261, 11.3% vs. LDF: n = 966, 9.0%; p < 0.001), Black/Hispanic (HDF: n = 2060, 18.5% vs. LDF: n = 1440, 11.4%; p < 0.001) and in the lowest income quartile (HDF: n = 2825, 25.4% vs. LDF: n = 1116, 10.8%; p < 0.001). While complications were comparable at HDF versus LDF (HDF: n = 2483, 22.3% vs. LDF: n = 2370, 22.0%; p = 0.28), patients treated at HDF had higher odds of in-hospital mortality (OR, 1.31; 95% CI, 1.07-1.59), FTR (OR, 1.24; 95% CI, 1.02-1.52), and a never event (OR, 1.76; 95% CI, 1.29-2.39; all p < 0.001). Hospitals having advanced internal medicine services had reduced odds of mortality (OR, 0.61; 95% CI, 0.47-0.80) whereas high nurse-to-patient ratio was associated with reduced odds of a complication (OR, 0.89; 95% CI, 0.81-0.98).

CONCLUSION

Approximately 40% of patients were admitted to HDF. These patients were more likely to be Black/Hispanic and underinsured. Perioperative outcomes were worse at HDF following HPB surgery.

Composite Length of Stay, An Outcome Measure of Postoperative and Readmission Length of Stays in Pancreatoduodenectomy

PURPOSE

Postoperative length of stay (PLOS) and readmission rate are pancreatoduodenectomy (PD) outcome measures, which are reported individually but may be interrelated. The purpose of this study was to evaluate how well a composite length of stay measure (CLOS) that included PLOS and readmission length of stay describes outcomes. To do so, we evaluated how well CLOS correlated to postoperative complications absolutely and compared to PLOS.

METHODS

A total of 668 PDs performed between 2011 and 2018 were evaluated. CLOS was calculated from PLOS and readmission length of stay. Complication severity was judged by the Modified Accordion Grading System (MAGS). Multinomial logistical regression models (MLRM) were used to investigate the relationship between either PLOS or CLOS and complications. Multilevel and pairwise area under curves (AUC) using SAS macro %MultAUC were provided for both models.

RESULTS

A total of 432 of 668 patients (65%) developed complications. One hundred seventy-seven patients (27%) were readmitted. Mean PLOS was 10.2 days (7.1 SD) and mean CLOS was 12.3 days (10.1 SD). PLOS and CLOS both were correlated linearly to MAGS grade. Spearman correlation coefficient for CLOS vs. MAGS of 0.68 was higher than that of 0.49 for PLOS vs. MAGS. Multilevel AUC from MLRM using PLOS was 0.66, but multilevel AUC from MLRM using CLOS was 0.71.

DISCUSSION

CLOS provides an accurate estimate of hospital day utilization per patient for PD, reflecting not only the basal hospital recovery time for PD but the added time needed because of readmissions due to complications. It is tightly correlated to number and severity of postoperative complications.

Emergency department visits after pancreatoduodenectomy: examining a novel quality metric

BACKGROUND

Postoperative emergency department (ED) visits represent fragmented care, are costly, and often evolve into readmission. Readmission rates after pancreatoduodenectomy (PD) are defined, while ED visits following PD are not. We examined the pattern of 30-day post-discharge ED visits for PD patients.

METHODS

A quaternary institutional database analysis of adult patients who underwent PD between 2010-2017 was reviewed for ED utilization within 30 days from discharge.

RESULTS

Of the 1,004 patients who underwent PD, 12% (N = 117) patients sought care in the ED within 30 days from postoperative discharge. The median time to ED presentation was 5 days post-discharge (IQR 3-9). Half of ED visits occurred during nights and weekends (N = 59, 50%). Of ED-utilizing patients, 64% (N = 76) were admitted to the hospital and 29% (N = 34) were discharged from the ED. ED visits were associated with a Clavien-Dindo Classification of 0 in 10.2% (N = 13) of patients, I-II in 62.4% (N = 73), and III-V in 26.5% (N = 31).

DISCUSSION

Post-discharge ED utilization is a novel quality metric and represents a potential target population for reducing hospital readmissions. Over two-thirds (72%) of ED visits were associated with low acuity complications, and promoting institutional strategies addressing postoperative ED visits may improve patient care and efficient utilization of healthcare resources.

Fragmentation of postoperative care after surgical management of ovarian cancer at 30 days and 90 days

BACKGROUND

Fragmentation of care, wherein a patient is discharged from an index hospital and undergoes an unexpected readmission to a nonindex hospital, is associated with increased risk of adverse outcomes. Fragmentation has not been well-characterized in ovarian cancer.

OBJECTIVE

The objective of this study was to assess risk factors and outcomes that are associated with fragmentation of care among women who undergo surgical treatment of ovarian cancer.

STUDY DESIGN

The Nationwide Readmission Database was used to identify all-cause 30-day and 90-day postoperative readmissions after surgical management of ovarian cancer from 2010-2014. Postoperative fragmentation was defined as readmission to a hospital other than the index hospital of the initial surgery. Multivariable regression analyses were used to identify predictors of fragmentation in both 30-day and 90-day readmissions. Similarly, multivariable models were developed to determine the association between fragmentation and death among women who were readmitted.

RESULTS

A total of 10,445 patients (13.3%) were readmitted at 30 days, and 14,124 patients (18.0%) were readmitted at 90 days. Of these, there was a 20.8% and 25.7% rate of postoperative care fragmentation for 30-day and 90-day readmissions, respectively. Patient risk factors that were associated with fragmented postoperative care included Medicare insurance, lower income quartiles, and nonroutine discharge to facility. Hospital factors that were associated with decreased risk of fragmentation included operation at a metropolitan teaching hospital and performance of extended procedures. Cost and length of stay for the readmission were similar among those who had fragmented and nonfragmented readmissions at both 30 and 90 days. Although there was no association between death and fragmentation for patients who were readmitted within 30 days (odds ratio, 1.19; 95% confidence interval, 0.93-1.51), patients who had a fragmented readmission at 90 days were 22% more likely to die than those who were readmitted at 90 days to their index hospital (odds ratio, 1.22; 95% confidence interval, 1.00-1.49).

CONCLUSION

Fragmentation of care is common in women with ovarian cancer who require postoperative readmission. Fragmented postoperative care is associated with an increased risk of death among women who are readmitted within 90 days of surgery.

Care Discontinuity in Emergency General Surgery: Does Hospital Quality Matter?

BACKGROUND

Changes in care providers and hospitals after emergency general surgery (EGS) (care discontinuity) are associated with increased morbidity and mortality. The cause of these worse outcomes is unknown. Our goal was to determine if hospital quality is associated with mortality after readmissions independent of continuity in care.

STUDY DESIGN

This was a retrospective analysis of Medicare inpatient claims (2007 to 2015). All inpatients older than 65 years of age who underwent 1 of 7 EGS procedures shown to represent 80% of EGS volume, complications, and mortality nationally, were included. Care discontinuity was defined as readmission within 30 days to a nonindex hospital. Hospital quality was determined by hospital-level, risk-adjusted mortality rates by EGS procedure and categorized into high quality (HQ) and low quality (LQ). The primary outcome was overall mortality. Multivariate logistic regression analysis was used to determine the association of discontinuity and mortality.

RESULTS

There were 882,929 EGS patients, 87,232 of whom were readmitted within 30 days of discharge. Care discontinuity was independently associated with mortality (odds ratio [OR] 1.23; 95% CI 1.17 to 1.29). When readmitted patients were stratified by quality of index and readmitting hospital, mortality was associated with the quality of both the index hospital and the readmitting hospital. The highest mortality rate was observed in patients with index admission at low-quality hospitals and readmission to a different low-quality hospital.

CONCLUSIONS

Both care discontinuity and hospital quality are independently associated with mortality in EGS patients. These data support maintaining continuity of care, even at low performing hospitals.

Thirty-Day Nonindex Readmissions and Clinical Outcomes After Cardiac Surgery

BACKGROUND

With increasing emphasis on readmissions as an important quality metric, there is an interest in regionalization of care to high-volume centers. As a result, care of readmitted cardiac surgery patients may be fragmented if readmission occurs at a nonindex hospital. This study characterizes the frequency, risk factors, and outcomes of nonindex hospital readmission after cardiac surgery.

METHODS

In this multicenter, population-based, nationally representative sample, we used weighted 2010-2015 National Readmission Database claims to identify all US adult patients who underwent 2 of the major cardiac surgeries, isolated coronary artery bypass grafting (CABG) or isolated surgical aortic valve replacement (SAVR), during their initial hospitalization. We examined characteristics, predictors, and outcomes after nonindex readmission.

RESULTS

Overall, 1,070,073 procedures were included (844,206 CABG and 225,866 SAVR). Readmission at 30 days was 12.8% for CABG and 14.5% for SAVR. Nonindex readmissions accounted for 23% and 26% at 30 days; these were primarily noncardiac in etiology. The proportion of nonindex readmissions did not change significantly from 2010 to 2015. For CABG and SAVR, in-hospital mortality (adjusted odds ratios of 1.26 and 1.37, respectively) and major complications (odds ratios of 1.17 and 1.25, respectively) were significantly higher during nonindex versus index readmission, even after adjusting for patient risk profile, case mix, and hospital characteristics. Older age, higher income, and increased comorbidity burden were all independent predictors of nonindex readmission.

CONCLUSIONS

A considerable proportion of patients readmitted after cardiac surgery are readmitted to nonindex hospitals. This fragmentation of care may account for worse outcomes associated with nonindex readmissions in this complex population.

Increased complication and mortality among non-index hospital readmissions after brain tumor resection is associated with low-volume readmitting hospitals

OBJECTIVE

Fragmentation of care following craniotomy for tumor resection is increasingly common with the regionalization of neurosurgery. Hospital readmission to a hospital (non-index) other than the one from which patients received their original care (index) has been associated with increases in both morbidity and mortality for cancer patients. The impact of non-index readmission after surgical management of brain tumors has not previously been evaluated. The authors set out to determine rates of non-index readmission following craniotomy for tumor resection and evaluated outcomes following index and non-index readmissions.

METHODS

Retrospective analyses of data from cases involving resection of a primary brain tumor were conducted using data from the Nationwide Readmissions Database (NRD) for 2010-2014. Multivariate logistic regression was used to evaluate the independent association of patient and hospital factors with readmission to an index versus non-index hospital. Further analysis evaluated association of non-index versus index hospital readmission with mortality and major complications during readmission. Effects of readmission hospital procedure volume on mortality and morbidity were evaluated in post hoc analysis.

RESULTS

In a total of 17,459 unplanned readmissions, 84.4% patients were readmitted to index hospitals and 15.6% to non-index hospitals. Patient factors associated with increased likelihood of non-index readmission included older age (75+: OR 1.44, 95% CI 1.19-1.75), elective index admission (OR 1.19, 95% CI 1.08-1.30), increased Elixhauser comorbidity score ≥2 (OR 1.18, 95% CI 1.01-1.37), and malignant tumor diagnosis (OR 1.32, 95% CI 1.19-1.45) (all p < 0.04). Readmission to a non-index facility was associated with a 28% increase in major complications (OR 1.28, 95% CI 1.14-1.43, p < 0.001) and 21% increase in mortality (OR 1.21, 95% CI 1.02-1.44, p = 0.032) in initial analysis. Following a second multivariable logistic regression analysis including the readmitting hospital characteristics, low procedure volume of a readmitting facility was significantly associated with non-index readmission (p < 0.001). Readmission to a lower-procedure-volume facility was associated with a 46%-75% increase in mortality (OR 1.46-1.75, p < 0.005) and a 21%-35% increase in major complications (OR 1.21-1.34, p < 0.005). Following adjustment for volume at a readmitting facility, admission to a non-index facility was no longer associated with mortality (OR 0.90, 95% CI 0.71-1.14, p = 0.378) or major complications (OR 1.09, CI 0.94-1.26, p = 0.248).

CONCLUSIONS

Of patient readmissions following brain tumor resection, 15.6% occur at a non-index facility. Low procedure volume is a confounder for non-index analysis and is associated with an increased likelihood of major complications and mortality, as compared to readmission to high-procedure-volume hospitals. Further studies should evaluate interventions targeting factors associated with unplanned readmission.

Frequency, predictors, and outcomes of readmission to index versus non-index hospitals after mechanical thrombectomy in patients with ischemic stroke

Background

Stroke systems of care employ a hub-and-spoke model, with fewer centers performing mechanical thrombectomy (MT) compared with stroke-receiving centers, where a higher number offer high-level, centralized treatment to a large number of patients.

Objective

To characterize rates and outcomes of readmission to index and non-index hospitals for patients with ischemic stroke who underwent MT.

Methods

This study leveraged a population-based, nationally representative sample of patients with stroke undergoing MT from the Nationwide Readmissions Database between 2010 and 2014. Descriptive, logistic regression analyses, and univariate and multivariate logistic regression models were carried out to determine patient- and hospital-level factors, mortality, complications, and subsequent readmissions associated with index and non-index hospitals' 90-day readmissions.

Results

In the study, 2111 patients with a stroke were treated with MT, of whom 534 were readmitted within 90 days. The most common reasons for readmission were: septicemia (5.9%), atrial fibrillation (4.8%), and cerebral artery occlusion with infarct (4.8%). Among readmitted patients, 387 (74%) were readmitted to index and 136 (26%) to non-index hospitals. On multivariable logistic regression analysis, non-index hospital readmission was not independently associated with major complications (p=0.09), mortality (p=0.34), neurological complications (p=0.47), or second readmission (p=0.92).

Conclusion

One-quarter of patients with a stroke treated with MT were readmitted within 90 days, and one quarter of these patients were readmitted to non-index hospitals. Readmission to a non-index hospital was not associated with mortality or increased complication rates. In a hub-and-spoke model it is important that follow-up care for a specialized procedure can be performed effectively at a vast number of non-index hospitals covering a large geographic area.