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Sakowitz S, Bakhtiyar SS, Mallick S, Cho NY, Kim S, Le NK, Lee H, Benharash P. Hospital Quality Mediates Impact of Care Fragmentation Following Elective Colectomy. Am Surg 2024:31348241248795. [PMID: 38659168 DOI: 10.1177/00031348241248795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
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.
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Affiliation(s)
- Sara Sakowitz
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Syed Shahyan Bakhtiyar
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
- Department of Surgery, University of Colorado, Denver, CO, USA
| | - Saad Mallick
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Nam Yong Cho
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Shineui Kim
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Nguyen K Le
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
| | - Hanjoo Lee
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
- Division of Colorectal Surgery, Department of Surgery, Harbor-UCLA Medical Center, Torrence, CA, USA
| | - Peyman Benharash
- CORELAB, Department of Surgery, University of California, Los Angeles, CA, USA
- Department of Surgery, University of California, Los Angeles, CA, USA
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Kushniruk A, Morken IM, Storm M, Husebø AML. Designing a Future eHealth Service for Posthospitalization Self-management Support in Long-term Illness: Qualitative Interview Study. JMIR Hum Factors 2023; 10:e39391. [PMID: 36745492 PMCID: PMC9941902 DOI: 10.2196/39391] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 09/09/2022] [Accepted: 11/14/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND For patients with noncommunicable diseases (NCDs; eg, heart failure [HF] and colorectal cancer [CRC]), eHealth interventions could meet their posthospital discharge needs and strengthen their ability to self-manage. However, inconclusive evidence exists regarding how to design eHealth services to meet the complex needs of patients. To foster patient acceptability and ensure the successful development and implementation of eHealth solutions, it is beneficial to include different stakeholders (ie, patients and health care professionals) in the design and development phase of such services. The involvement of different stakeholders could contribute to ensuring feasible, acceptable, and usable solutions and that eHealth services are developed in response to users' supportive care needs when transitioning to home after hospitalization. This study is the first step of a larger complex intervention study aimed at meeting the postdischarge needs of 2 NCD populations. OBJECTIVE This study aimed to explore the perspectives of patients with HF and CRC and health care professionals on patient self-management needs following hospital discharge and investigate how a future nurse-assisted eHealth service could be best designed to foster patient acceptability, support self-management, and smooth the transition from hospital to home. METHODS A qualitative, explorative, and descriptive approach was used. We conducted 38 semistructured interviews with 10 patients with HF, 9 patients surgically treated for CRC with curative intent, 6 registered nurses recruited as nurse navigators of a planned eHealth service, and 13 general practitioners experienced in HF and CRC treatment and follow-up care. Patients were recruited conveniently from HF and CRC outpatient clinics, and the nurses were recruited from the cardiology and gastro-surgical departments at a university hospital in the southwest of Norway. The general practitioners were recruited from primary care in surrounding municipalities. Semistructured interview guides were used for data collection, and the data were analyzed using thematic analysis. RESULTS In total, 3 main themes were derived from the data analysis: expecting information, reassurance, and guidance when using eHealth for HF and CRC self-management; expecting eHealth to be comprehensible, supportive, and knowledge promoting; and recognizing both the advantages and disadvantages of eHealth for HF and CRC self-management. The data generated from this interview study depicted the diverse needs for self-management support of patients with CRC and HF after hospital discharge. In addition, valuable suggestions were identified regarding the design and content of the eHealth service. However, participants described both possible advantages and disadvantages of a remote eHealth service. CONCLUSIONS This study is the first step in the development of an eHealth service for posthospitalization self-management support for long-term illnesses. It concerns patients' supportive care needs and user requirements of an eHealth service. The findings of this study may add value to the planning and development of eHealth interventions for patients with NCDs.
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Affiliation(s)
| | - Ingvild Margreta Morken
- Department of Quality and Health Technologies, University of Stavanger, Stavanger, Norway.,Research Group for Health and Nursing Sciences, Stavanger University Hospital, Stavanger, Norway
| | - Marianne Storm
- Faculty of Health Sciences and Social Care, Molde University College, Molde, Norway
| | - Anne Marie Lunde Husebø
- Department of Public Health, University of Stavanger, Faculty of Health Sciences, Stavanger, Norway.,Research Group for Health and Nursing Sciences, Stavanger University Hospital, Stavanger, Norway
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Snow K, Galaviz K, Turbow S. Patient Outcomes Following Interhospital Care Fragmentation: A Systematic Review. J Gen Intern Med 2020; 35:1550-1558. [PMID: 31625038 PMCID: PMC7210367 DOI: 10.1007/s11606-019-05366-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 08/14/2019] [Accepted: 09/12/2019] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Interhospital fragmentation of care occurs when patients are admitted to different, disconnected hospitals. It has been hypothesized that this type of care fragmentation decreases the quality of care received and increases hospital costs and healthcare utilization. This systematic review aims to synthesize the existing literature exploring the association between interhospital fragmentation of care and patient outcomes. METHODS MEDLINE, the Cochrane Library, EMBASE, and the Science Citation Index were systematically searched for studies published up to April 30, 2018 reporting the association between interhospital fragmentation of care and patient outcomes. We included peer-reviewed observational studies conducted in adults that reported measures of association between interhospital care fragmentation and one or more of the following patient outcomes: mortality, hospital length of stay, cost, and subsequent hospital readmission. RESULTS Seventy-nine full texts were reviewed and 22 met inclusion criteria. Nearly all studies defined fragmentation of care as a readmission to a different hospital than the patient was previously discharged from. The strongest association reported was that between a fragmented readmission and in-hospital or short-term mortality (adjusted odds ratio range 0.95-3.62). Over half of the studies reporting length-of-stay showed longer length of stay in fragmented readmissions. All three studies that investigated healthcare utilization suggested an association between fragmented care and odds of subsequent readmission. The study populations and exposures were too heterogenous to perform a meta-analysis. DISCUSSION Our review suggests that fragmented hospital readmissions contribute to increased mortality, longer length-of-stay, and increased risk of readmission to the hospital.
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Affiliation(s)
- Katelin Snow
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Karla Galaviz
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Sara Turbow
- Division of General Medicine and Geriatrics, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
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Hekkert K, Borghans I, Cihangir S, Westert GP, Kool RB. What is the impact on the readmission ratio of taking into account readmissions to other hospitals? A cross-sectional study. BMJ Open 2019; 9:e025740. [PMID: 30967406 PMCID: PMC6500251 DOI: 10.1136/bmjopen-2018-025740] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Readmissions are used widespread as an indicator of the quality of care within hospitals. Including readmissions to other hospitals might have consequences for hospitals. The aim of our study is to determine the impact of taking into account readmissions to other hospitals on the readmission ratio. DESIGN AND SETTING We performed a cross-sectional study and used administrative data from 77 Dutch hospitals (2 333 173 admissions) in 2015 and 2016 (97% of all hospitals). We performed logistic regression analyses to calculate 30-day readmission ratios for each hospital (the number of observed admissions divided by the number of expected readmissions based on the case mix of the hospital, multiplied by 100). We then compared two models: one with readmissions only to the same hospital, and another with readmissions to any hospital in the Netherlands. The models were calculated on the hospital level for all in-patients and, in more detail, on the level of medical specialties. MAIN OUTCOME MEASURES Percentage of readmissions to another hospital, readmission ratios same hospital and any hospital and C-statistic of each model in order to determine the discriminative ability. RESULTS The overall percentage of readmissions was 10.3%, of which 91.1% were to the same hospital and 8.9% to another hospital. Patients who went to another hospital were younger, more often men and had fewer comorbidities. The readmission ratios for any hospital versus the same hospital were strongly correlated (r=0.91). There were differences between the medical specialties in percentage of readmissions to another hospital and C-statistic. CONCLUSIONS The overall impact of taking into account readmissions to other hospitals seems to be limited in the Netherlands. However, it does have consequences for some hospitals. It would be interesting to explore what causes this difference for some hospitals and if it is related to the quality of care.
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Affiliation(s)
- Karin Hekkert
- IQ healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Ine Borghans
- Team Risk Detection, Dutch Health and Youth Care Inspectorate (IGJ), Utrecht, The Netherlands
| | - Sezgin Cihangir
- Team Expertise and Support, Dutch Hospital Data, Utrecht, The Netherlands
| | - Gert P Westert
- IQ healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Rudolf B Kool
- IQ healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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Stitzenberg KB, Chang Y, Smith AB, Meyers MO, Nielsen ME. Impact of Location of Readmission on Outcomes After Major Cancer Surgery. Ann Surg Oncol 2016; 24:319-329. [PMID: 27613557 DOI: 10.1245/s10434-016-5528-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The burden of readmissions after major cancer surgery is high. Prior work suggests that one-third of readmitted patients are readmitted to a different hospital than where the surgery was performed. The impact of this location of readmission needs to be more thoroughly understood. METHODS This retrospective cohort study was performed on Surveillance, Epidemiology, and End Results (SEER)-Medicare patients with bladder, esophagus, lung, or pancreas cancer diagnosed from 2001 to 2007 who underwent extirpative surgery and were readmitted within 90 days. Readmission location was classified as 'index' if readmission was at the hospital where surgery was performed, or 'different' if readmission was elsewhere. Outcomes including complications, reoperations, in-hospital mortality, 90-day mortality, and 90-day total costs were compared based on the location of readmission using a propensity score inverse probability treatment weight analysis. RESULTS Overall, 7903 (28 %) patients were readmitted within 90 days of index hospitalization. Thirty-three percent were readmitted to a different hospital (bladder 30 %, esophagus 34 %, lung 34 %, pancreas 34 %). Ninety-day mortality and total costs of care were not significantly different between the readmission location groups (all p > 0.05); however, substantial differences in the types of patients, and timing of and reasons for readmission were observed between the two groups. CONCLUSIONS Patients readmitted to different hospitals after major cancer surgery are a different group of patients than those readmitted to the index hospital. Accounting for this, we did not find significant differences in short-term clinical outcomes or costs of care based on readmission location; however, differences in long-term outcomes were observed that should be further explored in future studies.
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Affiliation(s)
- Karyn B Stitzenberg
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA. .,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
| | - YunKyung Chang
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Angela B Smith
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.,Department of Urology, University of North Carolina, Chapel Hill, NC, USA
| | - Michael O Meyers
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Matthew E Nielsen
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.,Department of Urology, University of North Carolina, Chapel Hill, NC, USA
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