Care fragmentation is associated with increased short-term mortality during postoperative readmissions: A systematic review and meta-analysis

Hospital Quality Mediates Impact of Care Fragmentation Following Elective Colectomy

BACKGROUND

Readmission at a non-index hospital, or care fragmentation (CF), has been previously linked to greater morbidity and resource utilization. However, a contemporary evaluation of the impact of CF on readmission outcomes following elective colectomy is lacking. We additionally sought to evaluate the role of hospital quality in mediating the effect of CF.

METHODS

All records for adults undergoing elective colectomy were tabulated from the 2016 to 2020 Nationwide Readmissions Database. Patients readmitted non-electively within 30 days to a non-index center comprised the CF cohort (others: Non-CF). Hierarchical mixed-effects models were constructed to ascertain risk-adjusted rates of major adverse events (MAEs, a composite of in-hospital mortality and any complication) attributable to center-level effects. Hospitals with risk-adjusted MAE rates ≥50th percentile were considered Low-Quality Hospitals (LQHs) (others: High-Quality Hospitals [HQHs]).

RESULTS

Of 68,185 patients readmitted non-electively within 30 days, 8968 (13.2%) were categorized as CF. On average, CF was older, of greater comorbidity burden, and more often underwent colectomy for cancer, relative to Non-CF. Following risk adjustment, CF remained independently associated with greater likelihood of MAE (adjusted odds ratio [AOR] 1.16, 95% Confidence Interval [CI] 1.05-1.27) and per-patient expenditures (β+$2,280, CI +$1080-3490). Further, readmission to non-index LQH was linked with significantly increased odds of MAE, following initial care at HQH (AOR 1.43, CI 1.03-1.99) and LQH (AOR 1.72, CI 1.30-2.28; Reference: Non-CF).

CONCLUSIONS

Care fragmentation was associated with greater morbidity and resource utilization at readmission following elective colectomy. Further, rehospitalization at non-index LQH conferred significantly inferior outcomes. Novel efforts are needed to improve continuity of care.

Emergency general surgery in older adult patients: Factors associated with fragmented care

BACKGROUND

Care fragmentation has been shown to lead to increased morbidity and mortality. We aimed to explore the factors related to care fragmentation after hospital discharge in geriatric emergency general surgery patients, as well as examine the association between care fragmentation and mortality.

METHODS

We designed a retrospective study of the Nationwide Readmissions Database 2019. We included patients ≥65 years old admitted with an emergency general surgery diagnosis who were discharged alive from the index admission. The primary outcome was 90-day care fragmentation, defined as an unplanned readmission to a non-index hospital. Multivariable logistic regression was performed, adjusting for patient and hospital characteristics.

RESULTS

A total of 447,027 older adult emergency general surgery patients were included; the main diagnostic category was colorectal (22.6%), and 78.2% of patients underwent non-operative management during the index hospitalization. By 90 days post-discharge, 189,622 (24.3%) patients had an unplanned readmission. Of those readmitted, 20.8% had care fragmentation. The median age of patients with care fragmentation was 76 years, and 53.2% were of female sex. Predictors of care fragmentation were living in rural counties (odds ratio 1.76, 95% confidence interval: 1.57-1.97), living in a low-income ZIP Code, discharge to intermediate care facility (odds ratio 1.28, 95% confidence interval: 1.22-1.33), initial non-operative management (odds ratio 1.17, 95% confidence interval: 1.12-1.23), leaving against medical advice (odds ratio 2.60, 95% confidence interval: 2.29-2.96), and discharge from private investor-owned hospitals (odds ratio 1.18, 95% confidence interval: 1.10-1.27). Care fragmentation was significantly associated with higher mortality.

CONCLUSION

The burden of unplanned readmissions in older adult patients who survive an emergency general surgery admission is underestimated, and these patients frequently experience care fragmentation. Future directions should prioritize evaluating the impact of initiatives aimed at alleviating the incidence and complications of care fragmentation in geriatric emergency general surgery patients.

Short and long-term readmission after major emergency abdominal surgery: a prospective Danish study

PURPOSE

Major emergency abdominal surgery is associated with severe in-hospital complications and loss of performance. After discharge, a substantial fraction of patients are readmitted emergently; however, limited knowledge exists of the long-term consequences. The aim of this study was to examine the risks and causes of short-term (30-day) and long-term (180-day) readmission among patients undergoing major emergency abdominal surgery.

METHODS

This study included 504 patients who underwent major emergency abdominal surgery at the Zealand University Hospital between March 1, 2017, and February 28, 2019. The population was followed from 0 to 180 days after discharge, and detailed readmission information was registered. A Cox proportional hazards model was used to examine the independent risk factors for readmission within 30 and 180 days.

RESULTS

From 0 to 30 days after discharge, 161 (31.9%) patients were readmitted emergently, accumulating to 241 (47.8%) patients within 180 days after discharge. The main reasons for short-term readmission were related to the gastrointestinal tract and surgical wounds, whereas long-term readmissions were due to infections, cardiovascular complications, and abdominal pain. Stomal placement was an independent risk factor for short-term readmission, whereas an ASA score of 3 was a risk factor for both short-term and long-term readmission.

CONCLUSION

Close to 50% of all patients who underwent major emergency abdominal surgery had one or more emergency readmission within 180 days of discharge, and these data points towards the risk factors involved.

Care Fragmentation Following Hospitalization for Atrial Fibrillation in the United States

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.

Fragmentation of Care and Its Association With Survival and Costs for Patients With Breast Cancer in Colombia

PURPOSE

Breast cancer care requires a multimodal approach and a multidisciplinary team who must work together to obtain good clinical results. The fragmentation of care can affect the breast cancer care; however, it has not been measured in a low-resource setting. The aim of this study was to identify fragmentation of care, the geographic variation of this and its association with 4-year overall survival (OS), and costs of care for patients with breast cancer enrolled in Colombia's contributory health care system.

MATERIALS AND METHODS

A retrospective cohort study was conducted using administrative databases. Women with breast cancer who were treated from January 1, 2013, to December 31, 2015, were included. Fragmentation of care was the exposure, which was measured by the number of different health care provider institutions (HCPIs) that treated a patient during the first year after diagnosis. Crude mortality rates were estimated, survival functions were calculated using the nonparametric Kaplan-Meier approach, and adjusted hazard ratios (HRs) were estimated using multivariate Cox regression model to identify the association of fragmentation with 4-year OS. The association between fragmentation and costs of care was assessed using a multivariate linear regression model.

RESULTS

A total of 10,999 patients with breast cancer were identified, and 1,332 deaths were observed. The 4-year crude mortality rate was 31.97 (95% CI, 30.25 to 33.69) per 1,000 person-years for the whole cohort, and the highest rate was in the cohort defined for the fourth quartile of the fragmentation measurement (eight or more HCPIs), 40.94 (95% CI, 36.49 to 45.39). The adjusted HR for 4-year OS was 1.04 (95% CI, 1.01 to 1.07) for each HCPI additional. The cost of care is increased for each additional HCPIs (cost ratio, 1.25; 95% CI, 1.23 to 1.26).

CONCLUSION

Fragmentation of care decreases overall 4-year OS and increases the costs of care in women with breast cancer for Colombia.

Care Fragmentation After Hospitalization for Acute Myocardial Infarction

Care fragmentation (CF), or readmission at a nonindex hospital, has been linked to inferior clinical and financial outcomes for patients. However, its impact on patients with acute myocardial infarction (AMI) is unclear. This study investigated the prevalence and impact of CF on the outcomes of patients with AMI. All US adult (≥18 years) hospitalizations for AMI from January 2010 to November 2019 were identified using the Nationwide Readmissions Database. Patients were stratified by readmission at an index or nonindex center. Multivariable models were developed to evaluate factors associated with CF, and independent associations with mortality, complications, and resource utilization. A total of 413,819 patients with AMI requiring nonelective readmission within 30 days of discharge were included for analysis. Of these, 25.4% (n = 104,966) experienced CF. The incidence of CF increased from 2010 to 2019 (nptrend <0.001). After adjustment, patients insured by Medicaid faced higher odds of nonindex readmission. CF was associated with in-hospital mortality (adjusted odds ratio [AOR] 1.09, 95% confidence interval [CI] 1.01 to 1.18), and cardiac (AOR 1.12, 95% CI 1.03 to 1.22), respiratory (AOR 1.14, 95% CI 1.12 to 1.26), and infectious complications (AOR 1.14, 95% CI 1.07 to 1.22). Further, CF was linked to increased odds of nonhome discharge (AOR 1.18, 95% CI 1.11 to 1.24) and an additional ∼$5,000 in per-patient hospitalization costs (95% CI 4,260 to 5,100). Approximately 25% of AMI patients experienced CF, which was independently associated with excess mortality, complications, and expenditures. Given the growing national burden of cardiovascular disease, new efforts are needed to mitigate the significant clinical and financial implications of nonindex readmissions and improve value-based healthcare.

Assessment of short readmissions following elective pulmonary lobectomy

BACKGROUND

Reducing readmissions is critical for improving patient care and lowering costs. Despite this, few studies have assessed length of readmission following pulmonary lobectomy.

METHODS

Using the Healthcare Cost and Utilization Project New York State Inpatient Database, we identified adult patients undergoing elective pulmonary lobectomy (2007-2015) and assessed readmission within 30 days of hospital discharge. We analyzed the relationship between length of readmission and post-operative morbidity and mortality as well as primary diagnoses at readmission.

RESULTS

Of 19947 included patients, 2173 (10.9%) were readmitted within 30 days. The median (IQR) length of readmission was 5 (2-8) days. Longer length of readmission was associated with significantly higher likelihood of major complication (for every 1-day increase, aOR = 1.14, 95% CI = 1.12-1.17, p < 0.001) and mortality (aOR = 1.03, 95% CI = 1.02-1.04, p < 0.001) within 90 days. Primary diagnosis codes at readmission differed significantly with length of readmission.

CONCLUSIONS

Interventions that target short readmissions may help to prevent a proportion of readmissions following elective lung resection.

Failure to Rescue in Emergency General Surgery: Impact of Fragmentation of Care

OBJECTIVE

Compare EGS patient outcomes after index and nonindex hospital readmissions, and explore predictive factors for nonindex readmission.

BACKGROUND

Readmission to a different hospital leads to fragmentation of care. The impact of nonindex readmission on patient outcomes after EGS is not well established.

METHODS

The Nationwide Readmissions Database (2017) was queried for adult patients readmitted after an EGS procedure. Patients were stratified and propensity-matched according to readmission destination: index versus nonindex hospital. Outcomes were failure to rescue (FTR), mortality, number of subsequent readmissions, overall hospital length of stay, and total costs. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors.

RESULTS

A total of 471,570 EGS patients were identified, of which 79,127 (16.8%) were readmitted within 30 days: index hospital (61,472; 77.7%) versus nonindex hospital (17,655; 22.3%). After 1:1 propensity matching, patients with nonindex readmission had higher rates of FTR (5.6% vs 4.3%; P < 0.001), mortality (2.7% vs 2.1%; P < 0.001), and overall hospital costs [in $1000; 37 (27-64) vs 28 (21-48); P < 0.001]. Nonindex readmission was independently associated with higher odds of FTR [adjusted odds ratio 1.18 (1.03-1.36); P < 0.001]. Predictors of nonindex readmission included top quartile for zip code median household income [1.35 (1.08-1.69); P < 0.001], fringe county residence [1.08 (1.01-1.16); P = 0.049], discharge to a skilled nursing facility [1.28 (1.20-1.36); P < 0.001], and leaving against medical advice [2.32 (1.81-2.98); P < 0.001].

CONCLUSION

One in 5 readmissions after EGS occur at a different hospital. Nonindex readmission carries a heightened risk of FTR.

LEVEL OF EVIDENCE

Level III Prognostic.

STUDY TYPE

Prognostic.

Re-Admission in Patients with Necrotizing Soft Tissue Infections: Continuity of Care Matters

Background: Necrotizing soft tissue infections (NSTIs) are rapidly progressive infections with high mortality and complication rates. The incidence of NSTIs has been increasing steadily whereas mortality has decreased; survivors have a high risk of re-hospitalization. We hypothesized that re-admission to the index hospital where the first admission occurred would be associated with better clinical outcomes compared with re-admission to a non-index hospital. Patients and Methods: We identified patients from the 2017 Nationwide Readmissions Database with an index admission for NSTIs and examined all-cause re-admissions within 90 days of discharge. We noted whether re-admission occurred at the index or a non-index hospital. Survey-weighted logistic regression identified factors associated with death at the first re-admission and re-admission to index hospital. We also compared patient outcomes between patients admitted to index versus non-index hospitals. Results: We identified 27,051 NSTI survivors, of whom 6,954 (25.7%) had an unplanned re-admission within 90 days. A large proportion of re-admission occurred at non-index hospitals (28.3%; n = 1,966). Factors associated with non-index re-admission included prolonged index length of stay, discharge to short-term hospital, and leaving against medical advice. Patients re-admitted to index hospitals had a lower mortality rate (4.7% vs. 6.7%; p = 0.003), lower admission costs (in $1000; 45 [23-88] vs. 50 [24-104]; p = 0.004) and higher discharge rate to home (55.7% vs. 48.6%; p < 0.001). Conclusions: More than one-quarter of re-admissions among NSTI survivors were to non-index hospitals. Continuity of care is important because re-admission to the index hospital was associated with better patient outcomes.

The physiology of failure: Identifying risk factors for mortality in emergency general surgery patients using a regional health system integrated electronic medical record

BACKGROUND

Emergency general surgery (EGS) patients have increased mortality risk compared with elective counterparts. Recent studies on risk factors have largely used national data sets limited to administrative data. Our aim was to examine risk factors in an integrated regional health system EGS database, including clinical and administrative data, hypothesizing that this novel process would identify clinical variables as important risk factors for mortality.

METHODS

Our nine-hospital health system's billing data were queried for EGS International Classification of Disease codes between 2013 and 2018. Codes were grouped by diagnosis, and urgent or emergent encounters were included and merged with electronic medical record clinical data. Outcomes assessed were inpatient and 1-year mortality. Standard and multivariable statistics evaluated factors associated with mortality.

RESULTS

There were 253,331 EGS admissions with 3.6% inpatient mortality rate. Patients who suffered inpatient and 1-year mortality were older, more likely to be underweight, and have neutropenia or elevated lactate. On multivariable analysis for inpatient mortality: age (odds ratio [OR], 1.7-6.7), underweight body mass index (OR, 1.6), transfer admission (OR, 1.8), leukopenia (OR, 2.0), elevated lactate (OR, 1.8), and ventilator requirement (OR, 7.1) remained associated with increased risk. Adjusted analysis for 1-year mortality demonstrated similar findings, with highest risk associated with older age (OR, 2.8-14.6), underweight body mass index (OR, 2.3), neutropenia (OR, 2.0), and tachycardia (OR, 1.7).

CONCLUSION

After controlling for patient and disease characteristics available in administrative databases, clinical variables remained significantly associated with mortality. This novel yet simple process allows for easy identification of clinical data points imperative to the study of EGS diagnoses that are critical in understanding factors that impact mortality.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic; Level III.

Center Volume Impacts Readmissions and Mortality after Congenital Cardiac Surgery

OBJECTIVE

To characterize the relationship between surgical volume and postoperative outcomes in congenital heart surgery, we used a national cohort to assess the costs, readmissions, and complications in children undergoing cardiac operations.

STUDY DESIGN

The Nationwide Readmissions Database was used to identify pediatric patients (≤18 years) undergoing congenital cardiac surgery from 2010 to 2017. Hospitals were categorized based on deciles and tertiles of annual caseload with high-volume categorized as the highest tertile of volume. Multivariable regression models adjusting for patient and hospital characteristics were used to study the impact of volume on 30-day nonelective readmission, mortality, home discharge, and resource use.

RESULTS

Of an estimated 69 448 hospitalizations included for analysis, 56 672 (82%) occurred at high-volume centers. After adjustment for key clinical factors, each decile increase in volume was associated with a 25% relative decrease in the odds of mortality, a 14% decrease in the odds of nonhome discharge, and a 4% relative decrease in the likelihood of 30-day nonelective readmission. After risk adjustment, each incremental increase in volume decile was associated with a one-half-day decrease in the hospital length of stay, but did not alter costs of the index hospitalization. However, after including all readmissions within 30 days of the index discharge, high-volume centers were associated with significantly lower costs compared with low-volume hospitals.

CONCLUSIONS

Increased congenital cardiac surgery volume is associated with improved mortality, reduced duration of hospitalization, 30-day readmissions, and resource use. These findings demonstrate the inverse relationship between hospital volume and resource use and may have implications for the centralization of care for congenital cardiac surgery.

The impacts of health systems financing fragmentation in low- and middle-income countries: a systematic review protocol

BACKGROUND

Health systems are often fragmented in low- and middle-income countries (LMICs). This can increase inefficiencies and restrict progress towards universal health coverage. The objective of the systematic review described in this protocol will be to evaluate and synthesize the evidence concerning the impacts of health systems financing fragmentation in LMICs.

METHODS

Literature searches will be conducted in multiple electronic databases, from their inception onwards, including MEDLINE, EMBASE, LILACS, CINAHL, Scopus, ScienceDirect, Scielo, Cochrane Library, EconLit, and JSTOR. Gray literature will be also targeted through searching OpenSIGLE, Google Scholar, and institutional websites (e.g., HMIC, The World Bank, WHO, PAHO, OECD). The search strings will include keywords related to LMICs, health system financing fragmentation, and health system goals. Experimental, quasi-experimental, and observational studies conducted in LMICs and examining health financing fragmentation across any relevant metric (e.g., the presence of different health funders/insurers, risk pooling mechanisms, eligibility categories, benefits packages, premiums) will be included. Studies will be eligible if they compare financing fragmentation in alternative settings or at least two-time points. The primary outcomes will be health system-related goals such as health outcomes (e.g., mortality, morbidity, patient-reported outcome measures) and indicators of access, services utilization, equity, and financial risk protection. Additional outcomes will include intermediate health system objectives (e.g., indicators of efficiency and quality). Two reviewers will independently screen all citations, abstract data, and full-text articles. Potential conflicts will be resolved through discussion and, when necessary, resolved by a third reviewer. The methodological quality (or risk of bias) of selected studies will be appraised using established checklists. Data extraction categories will include the studies' objective and design, the fragmentation measurement and domains, and health outcomes linked to the fragmentation. A narrative synthesis will be used to describe the results and characteristics of all included studies and to explore relationships and findings both within and between the studies.

DISCUSSION

Evidence on the impacts of health system fragmentation in LMICs is key for identifying evidence gaps and priority areas for intervention. This knowledge will be valuable to health system policymakers aiming to strengthen health systems in LMICs.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020201467.

Fragmentation of surgery and chemotherapy in the initial phase of ovarian cancer care and its association with overall survival

BACKGROUND

Fragmentation occurs when a patient receives care at more than one hospital, and the long-term effects in ovarian cancer are unknown. We examined the association between fragmentation of primary debulking surgery (PDS) and adjuvant chemotherapy (AC) and overall survival (OS).

METHODS

The National Cancer Database was used to identify women with stage II-IV epithelial ovarian cancer between 2004 and 2016 who underwent PDS followed by AC. Fragmentation was defined as receipt of AC at a different institution than where PDS was performed. After propensity score weighting, proportional hazard models were developed to estimate the association between fragmented care and OS.

RESULTS

Of the 36,300 patients identified, 13,347 (36.8%) had fragmented care. Patient factors associated with fragmentation included older age, higher income, and longer travel distance for PDS; hospital factors included PDS performed at a community center or a facility with lower annual surgical volume (P < 0.05, all). Fragmentation was associated with a 15% risk of 30-day delay to AC (aRR 1.15, 95% CI 1.09-1.22). In a propensity scoring weighted analysis, mortality was reduced when AC was fragmented (HR 0.95, 95% CI 0.92-0.97). Sensitivity analyses indicated fragmentation was associated with improved survival in metropolitan residents. Stratified analyses indicated patients who traveled 50 miles or more with PDS and AC at the same institution had the worst OS.

CONCLUSION

Fragmentation of PDS and AC has no adverse effects on long-term survival. Survival outcomes were worst for those who received care at the same institution 50 miles or more away.

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.

Does multicenter care impact the outcomes of surgical patients with gastrointestinal malignancies requiring complex multimodality therapy?

BACKGROUND

Regionalization of oncologic care has increased, but less is known whether patient outcomes are influenced by receipt of multimodality care through multicenter care (MCC) or single-center care (SCC).

METHODS

Patients from 2004 to 2015 National Cancer Data Base diagnosed with stage II-III esophageal (EA), stage II-III pancreatic (PA), and stage II-IV rectal (RA) adenocarcinoma who underwent resection at a high volume center (HVC) and required radiation and/or chemotherapy were included. MCC (care at 2+ facilities) and SCC patients were propensity-score matched 1:2 and Cox proportional hazards regression used to analyze survival.

RESULTS

On multivariable regression analysis, MCC in RA patients (N = 325/2097, 15.5%) was more associated with residing ≥40 miles from the HVC (odds ratio [OR] = 2.37; P = .044) and receipt of neoadjuvant chemotherapy (1.42, P = .040). In PA patients (N = 75/380, 19.7%), residing ≥40 miles from the HVC (OR = 3.22; P = .001), and in EA patients (N = 88/534, 16.5%), younger patients (<50 years: OR = 2.96; P = .011) were associated with MCC. Following propensity score matching, EA (N = 147), PA (N = 133), and RA (N = 661) patients had no difference in 1-year and 3-year overall survival when comparing MCC to SCC.

CONCLUSIONS

The use of MCC appears safe without a difference in survival and may offer significant advantages in convenience to patients as they undergo their complex oncologic care.

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.