Fragmentation of Care after Surgical Discharge: Non-Index Readmission after Major Cancer Surgery

Abstract

BACKGROUND Despite national emphasis on care coordination, little is known about how fragmentation affects cancer surgery outcomes. Our study examines a specific form of fragmentation in post-discharge care—readmission to a hospital different from the location of the operation—and evaluates its causes and consequences among patients readmitted after major cancer surgery. STUDY DESIGN We used the State Inpatient Database of California (2004 to 2011) to identify patients who had major cancer surgery and their subsequent readmissions. Logistic models were used to examine correlates of non-index readmissions and to assess associations between location of readmission and outcomes, measured by in-hospital mortality and repeated readmission. RESULTS Of 9,233 readmissions within 30 days of discharge after major cancer surgery, 20.0% occurred in non-index hospitals. Non-index readmissions were associated with emergency readmission (odds ratio [OR] = 2.63; 95% CI, 2.26–3.06), rural residence (OR = 1.81; 95% CI, 1.61–2.04), and extensive procedures (eg hepatectomy vs proctectomy; OR = 2.77; CI, 2.08–3.70). Mortality was higher during non-index readmissions than index readmissions independent of patient, procedure, and hospital factors (OR = 1.31; 95% CI, 1.03–1.66), but was mitigated by adjusting for conditions present at readmission (OR = 1.24; 95% CI, 0.98–1.58). Non-index readmission predicted higher odds of repeated readmission within 60 days of discharge from the first readmission (OR = 1.16; 95% CI, 1.02–1.32), independent of all covariates. CONCLUSIONS Non-index readmissions constitute a substantial proportion of all readmissions after major cancer surgery. They are associated with more repeated readmissions and can be caused by severe surgical complications and increased travel burden. Overcoming disadvantages of non-index readmissions represents an opportunity to improve outcomes for patients having major cancer surgery.

Multivariable analysis of predictors of unplanned hospital readmission after pancreaticoduodenectomy: development of a validated risk score

“…9 In the majority of patients, readmission after major surgery is precipitated by a post-operative complication, which was either undiagnosed or under-treated during the index admission. 10 Post-operative pancreatic fistula (POPF), delayed gastric emptying (DGE) and surgical site infections (SSI) are important determinants of morbidity and Preliminary partial results of this paper were presented as an oral presentation in the 12th Biennial E-AHPBA Congress 2017. readmission after PD. 11,12 Identification of patients at risk of readmission after PD has several potential advantages.…”

Quantifying Nonindex Hospital Readmissions and Care Fragmentation after Major Urological Oncology Surgeries in a Nationally Representative Sample

“…These studies have reported 19-33% of readmitted patients are readmitted to a non-index hospital. 5-8 …”

Why Do Long-Distance Travelers Have Improved Pancreatectomy Outcomes?

“…5 Therefore, regionalization and travel burden also caused concern about equity of healthcare delivery, among other unintended consequences. 6–11 …”