Care fragmentation in the postdischarge period: surgical readmissions, distance of travel, and postoperative mortality.

IMPORTANCE Despite policies aimed at incentivizing clinical integration, few data exist on whether fragmentation of care is associated with worse outcomes for elderly patients undergoing major surgery. OBJECTIVE To determine whether postdischarge surgical care fragmentation is associated with worse outcomes and whether distances between hospitals explain differences in patient outcomes. DESIGN, SETTING, AND PARTICIPANTS We used the 100% Medicare inpatient file for claims from January 1, 2009, through November 30, 2011. Data on hospital structural features, including zip code of location, were obtained from the 2011 American Hospital Association Annual Survey. We identified patients who underwent coronary artery bypass grafting, pulmonary lobectomy, endovascular abdominal aortic aneurysm repair, open abdominal aortic aneurysm repair, colectomy, and hip replacement. MAIN OUTCOMES AND MEASURES Thirty-day surgical mortality. RESULTS A total of 93 062 patients who underwent the surgical procedures of interest were subsequently readmitted within 30 days of discharge; 23 278 of these patients (25.0%) were readmitted to a hospital other than the one where their procedure was performed. Patients who were readmitted to a different hospital generally lived farther from the index hospital than those who were readmitted to the index hospital (20.7 vs 7.4 miles, P < .001). We found large state-level variations in the proportion of surgical patients who were readmitted elsewhere. Patients readmitted to a different hospital that was the same distance from their home as the index hospital had 48% higher odds of mortality (odds ratio, 1.48; 95% CI, 1.24-1.78; P < .001) than patients who were admitted to the index hospital. CONCLUSIONS AND RELEVANCE Of older US patients undergoing major surgery, 1 in 4 is readmitted to a hospital other than the one where the initial operation was performed. Even taking distance traveled into account, postsurgical care fragmentation is associated with a substantially higher risk of death. Focusing on clinical integration may improve outcomes for older US patients undergoing complex surgery.

[1]  Carl van Walraven,et al.  The association between continuity of care and outcomes: a systematic and critical review. , 2010, Journal of evaluation in clinical practice.

[2]  Muhammad Mamdani,et al.  Continuity of care and patient outcomes after hospital discharge , 2004, Journal of General Internal Medicine.

[3]  E. Elkin,et al.  Fragmentation of Care for Frequently Hospitalized Urban Residents , 2006, Medical care.

[4]  C. Steiner,et al.  Comorbidity measures for use with administrative data. , 1998, Medical care.

[5]  Michael E Chernew,et al.  Outpatient care patterns and organizational accountability in Medicare. , 2014, JAMA internal medicine.

[6]  Joshua S Richman,et al.  The relationship between timing of surgical complications and hospital readmission. , 2014, JAMA surgery.

[7]  Julia Adler-Milstein,et al.  Health information exchange among US hospitals. , 2011, The American journal of managed care.

[8]  C. van Walraven,et al.  Impact of physician continuity on death or urgent readmission after discharge among patients with heart failure , 2013, Canadian Medical Association Journal.

[9]  C. Ko,et al.  Continuity of care: Readmission to the same hospital following gastric cancer resection , 2009 .

[10]  C. Adair,et al.  Continuity of care: a multidisciplinary review , 2003, BMJ : British Medical Journal.

[11]  Susan L Ettner,et al.  Association Between Occurrence of a Postoperative Complication and Readmission: Implications for Quality Improvement and Cost Savings , 2013, Annals of surgery.

[12]  J. Donohue,et al.  Distance Bias and Surgical Outcomes , 2013, Medical care.

[13]  E John Orav,et al.  Variation in surgical-readmission rates and quality of hospital care. , 2013, The New England journal of medicine.

[14]  T. Osler,et al.  Hospital readmission after noncardiac surgery: the role of major complications. , 2014, JAMA surgery.

[15]  M. Taljaard,et al.  The independent association of provider and information continuity on outcomes after hospital discharge: implications for hospitalists. , 2010, Journal of hospital medicine.