Care Fragmentation and Mortality in Readmission after Surgery for Hepatopancreatobiliary and Gastric Cancer: A Patient-Level and Hospital-Level Analysis of the Healthcare Cost and Utilization Project Administrative Database

Abstract

BACKGROUND: Hepatopancreatobiliary (HPB) and gastric oncologic operations are frequently performed at referral centers. Postoperatively, many patients experience care fragmentation, including readmission to “outside hospitals” (OSH), which is associated with increased mortality. Little is known about patient-level and hospital-level variables associated with this mortality difference. STUDY DESIGN: Patients undergoing HPB or gastric oncologic surgery were identified from select states within the Healthcare Cost and Utilization Project database (2006–2014). Follow-up was 90 days after discharge. Analyses used Kruskal-Wallis test, Youden index, and multilevel modeling at the hospital level. RESULTS: There were 7,536 patients readmitted within 90 days of HPB or gastric oncologic surgery to 636 hospitals; 28% of readmissions (n = 2,123) were to an OSH, where 90-day readmission mortality was significantly higher: 8.0% vs 5.4% (p < 0.01). Patients readmitted to an OSH lived farther from the index surgical hospital (median 24 miles vs 10 miles; p < 0.01) and were readmitted later (median 25 days after discharge vs 12; p < 0.01). These variables were not associated with readmission mortality. Surgical complications managed at an OSH were associated with greater readmission mortality: 8.4% vs 5.7% (p < 0.01). Hospitals with <100 annual HPB and gastric operations for benign or malignant indications had higher readmission mortality (6.4% vs 4.7%, p = 0.01), although this was not significant after risk-adjustment (p = 0.226). CONCLUSIONS: For readmissions after HPB and gastric oncologic surgery, travel distance and timing are major determinants of care fragmentation. However, these variables are not associated with mortality, nor is annual hospital surgical volume after risk-adjustment. This information could be used to determine safe sites of care for readmissions after HPB and gastric surgery. Further analysis is needed to explore the relationship between complications, the site of care, and readmission mortality.

Establishing Regionalized Acute Care Across a Health Care System to Decentralize Postoperative Care After Oncologic Surgery

“…16 We also examined several clinical outcomes including 90day postoperative mortality, which was selected as it is likely a downstream consequence applicable across all surgical specialties if a patient were to experience inadequate care, triage, or failure to rescue on the basis of the initial site of acute care presentation. 11 Chi-square or Wilcoxon Mann-Whitney tests were used for between-group differences. Hierarchical modeling with random effects at the level of each geographic region was used to account for possible unmeasured patient and facility differences between the geographic regions.…”

“…Patients often receive oncologic surgery at centralized facilities because of well-established relationships between volume and outcomes, [4][5][6][7][8][9][10] but an extensive body of literature has shown that a high percentage of surgical patients are evaluated, readmitted, and cared for at local facilities other than where the site of their initial operation and that this form of fragmented care is associated with worse shortand long-term outcomes. [11][12][13][14] Innovative models of care delivery are needed to address the gap between centralized oncologic surgeries and decentralized fragmented postoperative acute care.…”

The effect of fragmented cancer care and change in nurse staffing grade on cancer patient mortality

“…However, other studies did not find an effect on mortality despite the association of fragmented care with treatment delay (Abelson et al, 2021). Moreover, fragmented care‐related factors, including distance for travel, were not significantly associated with increased patient readmission‐associated mortality (Brauer et al, 2021). Although a relationship between fragmented care and patient outcomes has not been observed, fragmented care may cause treatment delays in patients with cancer (Abelson et al, 2021).…”

Association of healthcare fragmentation and the survival of patients with colorectal cancer in Colombia

“…The present study used propensity score matching to control for confounding (49). Matching algorithms were selected through an iterative process that made it possible to select the algorithm that produced the best balance of the baseline variables.…”