T. C. Tsai1,2, E. J. Orav3,4, A. K. Jha2,3 1Brigham And Women’s Hospital,Surgery,Boston, MA, USA 2Harvard School Of Public Health,Health Policy And Management,Boston, MA, USA 3Brigham And Women’s Hospital,Medicine,Boston, MA, USA 4Harvard School Of Public Health,Biostatistics,Boston, MA, USA
Introduction: Despite policies aimed incentivizing clinical integration, little data exist on whether fragmentation of care is associated with worse outcomes for elderly patients undergoing major surgery. We assessed the state-level variation in post-discharge surgical care fragmentation; whether post-discharge surgical care fragmentation was associated with worse outcomes; and whether accounting for distances between hospitals may explain differences in outcomes for those who are readmitted to a different hospital than the original hospital where the index procedure was performed.
Methods: We used the 100% inpatient file for Medicare claims from 2009 through 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 graft, pulmonary lobectomy, endovascular abdominal aortic aneurysm repair, open abdominal aortic aneurysm repair, colectomy, and hip replacement.
Results: There were 93,062 patients that underwent the surgical procedures of interest who were subsequently readmitted within 30-days of discharge; 23,278 of these patients (25%) 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 miles vs. 7.4 miles, p<0.001). 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 (OR 1.48, 95% CI 1.24-1.78, p<0.001) than patients who were admitted to the index hospital.
Conclusion: 1 in 4 older Americans undergoing major surgery are readmitted to a hospital different than the one where the initial operation was performed. Even taking distance traveled into account, post-surgical care fragmentation is associated with a substantially higher risk of death. Focusing on clinical integration may improve outcomes for older Americans undergoing complex surgery.