1
|
Kim S, Hadaya J, Joachim K, Ali K, Mallick S, Cho NY, Benharash P, Lee H. Care fragmentation is associated with increased mortality after ileostomy creation. Surgery 2024; 175:1000-1006. [PMID: 38161087 DOI: 10.1016/j.surg.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/06/2023] [Accepted: 11/17/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Ileostomy is the mainstay treatment option for various gastrointestinal conditions. Given the increased risk of post-discharge complications and high readmission rates that can be further aggravated by receiving care at different facilities (care fragmentation), further examination is necessary. We thus used a national cohort to explore the associations of care fragmentation among ileostomy patients experiencing adverse outcomes and increased hospitalization expenditures. METHODS All adult hospitalizations for ileostomy were tabulated from the 2016 to 2020 Nationwide Readmissions Database. Those readmitted within 90 days after discharge were included for analysis. Patients treated at a different facility than the original location where the index ileostomy was performed were categorized into the care-fragmented cohort. Multivariable regressions were developed to characterize the association of the care-fragmented cohort with postoperative outcomes, readmissions, and expenditures. RESULTS Of 52,254 patients with ileostomy creation hospitalizations with 90-day nonelective readmission, 9,045 (17.3%) experienced care fragmentation. Following risk adjustment, those experiencing care fragmentation faced increased odds of mortality (adjusted odds ratio 1.81, 95% confidence interval 1.54-2.12), cardiac (adjusted odds ratio 1.63, 95% confidence interval 1.42-1.85), respiratory (adjusted odds ratio 1.71, 95% confidence interval 1.53-1.91), infectious (adjusted odds ratio 1.33, 95% confidence interval 1.23-1.43), and thromboembolic (adjusted odds ratio 1.28, 95% confidence interval 1.13-1.45) complications. Furthermore, patients experiencing care fragmentation were more likely to have increased hospitalization costs ($1,700, 95% confidence interval 0.8-2.5). CONCLUSION Care fragmentation in ileostomy patients demonstrated an increased risk for mortality, postoperative complications, and increased hospitalization expenses. To mitigate risks for adverse outcomes, future studies should evaluate the impacts of inter-hospital communication with the goal of improving care continuity and optimizing healthcare delivery for care-fragmented populations.
Collapse
Affiliation(s)
- Shineui Kim
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, CA. https://twitter.com/shineeshink
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, CA; Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, CA
| | - Kole Joachim
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, CA
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, CA
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, CA
| | - Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, CA. https://twitter.com/NamYong_Cho
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California Los Angeles, CA; Department of Surgery, David Geffen School of Medicine at UCLA, University of California Los Angeles, CA
| | - Hanjoo Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA.
| |
Collapse
|
2
|
Verma A, Madrigal J, Coaston T, Ascandar N, Williamson C, Benharash P. Care Fragmentation Following Hospitalization for Atrial Fibrillation in the United States. JACC. ADVANCES 2023; 2:100375. [PMID: 38938260 PMCID: PMC11198211 DOI: 10.1016/j.jacadv.2023.100375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 02/15/2023] [Accepted: 03/10/2023] [Indexed: 06/29/2024]
Abstract
Background Despite the high prevalence of atrial fibrillation (AF), the incidence and impact of care fragmentation (CF) following hospitalization for this condition remain unstudied. Objectives The present study used a national database to determine the incidence of and risk factors associated with CF. Outcomes following CF were also examined. Methods All adults who were discharged alive following hospitalization for AF (index facility) were identified within the 2016 to 2019 Nationwide Readmissions Database. Patients requiring nonelective rehospitalization within 30 days of discharge were categorized into 2 groups. The CF cohort included those readmitted to a nonindex facility, while others were classified as noncare fragmentation. Multivariable regression was used to evaluate factors associated with CF, as well as its impact on in-hospital mortality, length of stay, and costs at rehospitalization. Results Of an estimated 686,942 patients who met study criteria and survived to discharge, 13.6% (n = 93,376) experienced unplanned readmission within 30 days. Among those readmitted, 21.3% (n = 19,906) were readmitted to a nonindex facility. Patients who experienced CF were younger, more commonly male and less frequently readmitted for AF. Upon multivariable adjustment, male sex, Medicaid insurance (ref: private), and transfer status were associated with increased odds of CF. Upon readmission, CF was associated with a 18% increment in relative odds of in-hospital mortality, a 0.3-day increment in length of stay, and an additional $1,500 in hospitalization costs. Conclusions CF was associated with significant clinical and financial burden. Further studies are needed to address factors which contribute to increased mortality and resource use following CF.
Collapse
Affiliation(s)
- Arjun Verma
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Josef Madrigal
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Troy Coaston
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Nameer Ascandar
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Catherine Williamson
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| |
Collapse
|
3
|
McCrum ML, Cannon AR, Allen CM, Presson AP, Huang LC, Brooke BS. Contributors to Increased Mortality Associated With Care Fragmentation After Emergency General Surgery. JAMA Surg 2021; 155:841-848. [PMID: 32697290 DOI: 10.1001/jamasurg.2020.2348] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance Care fragmentation at time of readmission after emergency general surgery (EGS) is associated with high mortality; however, the factors underlying this finding remain unclear. Objective To identify patient and hospital factors associated with increased mortality among patients after EGS readmitted within 30 days of discharge to a nonindex hospital. Design, Setting, and Participants Retrospective cohort study using the 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database. Participants were all adult patients (18 years or older) who underwent 1 of the 15 most common EGS procedures in the United States from January 1 to November 30, 2014, and survived to discharge. The dates of analysis were October through December 2019. Exposures Thirty-day readmission to a hospital other than that of the index surgical procedure. The study examined the association of interventions during readmission, change in hospital resource level, and severity of patient illness during readmission. Main Outcomes and Measures Ninety-day inpatient mortality. Results In total, 71 944 patients who underwent EGS (mean [SD] age, 59.0 [18.3] years; 53.5% [38 487 of 71 944] female) were readmitted within 30 days of discharge, of whom 10 495 (14.6%) were readmitted to a nonindex hospital. Compared with patients readmitted to index hospitals, patients readmitted to nonindex hospitals were more likely to be readmitted to hospitals with low annual EGS volume (33.5% vs 25.6%, P < .001) and be in the top half of illness severity profile (37.2% vs 31.2%, P < .001). Overall 90-day mortality was higher in the patients readmitted to nonindex hospitals (6.1% vs 4.3%, P < .001). When adjusted for baseline patient and hospital characteristics, care fragmentation was independently associated with increased mortality (adjusted odds ratio [aOR], 1.36; 95% CI, 1.17-1.58; P < .001). After adjustment for interventions performed during readmission, change in EGS hospital volume level, and severity of patient illness, care fragmentation was no longer independently associated with mortality (aOR, 1.05; 95% CI, 0.88-1.26; P = .58). In this complete model, severity of illness was the strongest risk factor of mortality during readmission. Conclusions and Relevance In this cohort study of adult patients who require rehospitalization after EGS, 14.6% are readmitted to a hospital other than where the index procedure was performed. Although the overall mortality rate is higher for this population, the excess mortality appears to be primarily associated with severity of patient illness at time of readmission. These data underscore the need to develop systems of care to rapidly triage patients to hospitals best equipped to manage their condition.
Collapse
Affiliation(s)
- Marta L McCrum
- Division of General Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City
| | - Austin R Cannon
- Division of General Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City
| | - Chelsea M Allen
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Lyen C Huang
- Division of General Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City
| | - Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City
| |
Collapse
|
4
|
Dawson TH, Bhutiani N, Benns MV, Miller KR, Bozeman MC, Kehdy FJ, Motameni AT. Comparing patterns of care and outcomes after operative management of complications after bariatric surgery at MBSAQIP accredited bariatric centers and non-bariatric facilities. Surg Endosc 2020; 35:4719-4724. [PMID: 32909202 DOI: 10.1007/s00464-020-07942-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/25/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Many operations for complications after bariatric surgery are performed by surgeons without bariatric expertise at centers without teams who routinely care for bariatric patients. This study sought to evaluate whether bariatric expertise affects patterns of care and perioperative outcomes among patients undergoing operative intervention for complications after bariatric surgery. METHODS Administrative claims data from the Kentucky Office of Health Policy were queried for inpatients undergoing operative intervention for complications related to bariatric surgery between 2015 and 2018. Patients were stratified with respect to whether or not they underwent surgery at a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accredited bariatric surgery center (BCE) or not (non-BCE). Groups were compared with respect to demographic, procedural, and outcome variables. RESULTS BCE patients were more often Caucasian than non-BCE patients (p < 0.001) and have either private insurance or Medicare coverage (p = 0.02). Regarding operative approach, operations were more likely to be performed laparoscopically in BCE (88.5% BCE vs. 80.9% non-BCE, p = 0.007). Length of stay was significantly shorter for BCE patients (median 2 days BCE vs. 3 days non-BCE, p < 0.001), and BCE patients were more likely to be discharged home (85.4% BCE vs. 78.5% non-BCE, p = 0.02). Inpatient mortality and average total charges per patient did not differ significantly between the two groups CONCLUSIONS: Surgical management of complications after bariatric surgery at BCE is associated with greater utilization of minimally invasive techniques, shorter hospital stay, and increased likelihood of routine home discharge. These findings should prompt a review and standardization of care patterns for patients with complications after bariatric surgery aimed at optimizing outcomes and improving value.
Collapse
Affiliation(s)
- Timothy H Dawson
- Division of Trauma and Acute Care Surgery, University of Louisville Department of Surgery, 550 S. Jackson Street, 2nd Floor Ambulatory Care Building, Louisville, KY, 40202, USA
| | - Neal Bhutiani
- Division of Trauma and Acute Care Surgery, University of Louisville Department of Surgery, 550 S. Jackson Street, 2nd Floor Ambulatory Care Building, Louisville, KY, 40202, USA.
| | - Matthew V Benns
- Division of Trauma and Acute Care Surgery, University of Louisville Department of Surgery, 550 S. Jackson Street, 2nd Floor Ambulatory Care Building, Louisville, KY, 40202, USA
| | - Keith R Miller
- Division of Trauma and Acute Care Surgery, University of Louisville Department of Surgery, 550 S. Jackson Street, 2nd Floor Ambulatory Care Building, Louisville, KY, 40202, USA
| | - Matthew C Bozeman
- Division of Trauma and Acute Care Surgery, University of Louisville Department of Surgery, 550 S. Jackson Street, 2nd Floor Ambulatory Care Building, Louisville, KY, 40202, USA
| | - Farid J Kehdy
- Division of Trauma and Acute Care Surgery, University of Louisville Department of Surgery, 550 S. Jackson Street, 2nd Floor Ambulatory Care Building, Louisville, KY, 40202, USA
| | - Amir T Motameni
- Division of Trauma and Acute Care Surgery, WakeMed Raleigh Department of Surgery, Raleigh, NC, USA
| |
Collapse
|
5
|
Cham S, Wen T, Friedman A, Wright JD. Fragmentation of postoperative care after surgical management of ovarian cancer at 30 days and 90 days. Am J Obstet Gynecol 2020; 222:255.e1-255.e20. [PMID: 31520627 DOI: 10.1016/j.ajog.2019.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/02/2019] [Accepted: 09/05/2019] [Indexed: 12/12/2022]
Abstract
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.
Collapse
|
6
|
Schulman AR, Dolan R, Abougergi MS, Telem D, Cohen-Mekelburg S. Impact of fragmentation on rehospitalization after bariatric surgery. Surg Endosc 2020; 35:291-297. [DOI: 10.1007/s00464-020-07395-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/28/2020] [Indexed: 01/20/2023]
|
7
|
Shkirkova K, Connor M, Lamorie-Foote K, Patel A, Liu Q, Ding L, Amar A, Sanossian N, Attenello F, Mack W. Frequency, predictors, and outcomes of readmission to index versus non-index hospitals after mechanical thrombectomy in patients with ischemic stroke. J Neurointerv Surg 2019; 12:136-141. [DOI: 10.1136/neurintsurg-2019-015085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/02/2019] [Accepted: 07/09/2019] [Indexed: 01/25/2023]
Abstract
BackgroundStroke 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.ObjectiveTo characterize rates and outcomes of readmission to index and non-index hospitals for patients with ischemic stroke who underwent MT.MethodsThis 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.ResultsIn 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).ConclusionOne-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.
Collapse
|