B. H. Jacobson1, J. Zheng2, E. J. Orav3, T. C. Tsai2, 4 1Stanford Medical School, Stanford, CA, USA 2Harvard T.H. Chan School of Public Health, Department Of Health Policy And Management, Boston, MA, USA 3Brigham And Women’s Hospital, Division Of General Internal Medicine And Primary Care, Boston, MA, USA 4Brigham And Women’s Hospital, Department Of Surgery, Boston, MA, USA
Introduction: Fragmentation of post-surgical care has been associated with an increased risk of mortality among surgical patients, but it is unknown how the overall health and vulnerability of patients – such as frailty – influences the potential harm that they face when receiving fragmented post-surgical care. We therefore assessed whether frail patients were especially vulnerable to increased mortality associated with fragmented post-surgical care.
Methods: Using Medicare inpatient claims data from 2005-2016, we examined a cohort of 221,225 surgical patients who underwent hip replacement, knee replacement, colectomy, coronary artery bypass grafting, or pulmonary lobectomy and were then readmitted following surgery. A multivariable logistic regression was used to assess whether higher odds of mortality were associated with frail patients receiving fragmented post-surgical care.
Results: 28% of patients in the sample were frail as defined by a validated claims-based index, and 25% were readmitted to a different hospital from the one where their surgery was performed. 30-day mortality was highest in frail patients with fragmented care (4.1%) and lowest in non-frail patients with unfragmented care (2.1%), and this remained true when examining risk-adjusted 30-day mortality. Fragmentation of care resulted in an equal adverse effect on 30-day mortality across both frail and non-frail patients (0.77% increase in mortality among frail patients, 0.75% increase in mortality among non-frail patients, p = 0.96).
Conclusion: Frail patients receiving fragmented post-surgical care were associated with nearly double the mortality of non-frail patients without fragmented post-surgical care, highlighting the additive effects of fragmentation and frailty on mortality. Given that fragmentation poses an additional burden to frail patients already facing increased post-surgical mortality, frailty pathways for surgical patients and geriatric centers of excellence should aim to reduce fragmented post-surgical care for frail patients in order to improve outcomes for this vulnerable patient population.
