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Original Investigation
November 16, 2016

Hospital Factors Associated With Care Discontinuity Following Emergency General Surgery

Author Affiliations
  • 1Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women’s Hospital, Boston, Massachusetts
  • 2Center for Surgery and Public Health, Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
  • 3Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Surg. Published online November 16, 2016. doi:10.1001/jamasurg.2016.4078
Key Points

Question  What hospital factors are associated with readmission to a nonindex hospital following emergency general surgery?

Findings  In an analysis of the 100% Medicare inpatient claims file from January 1, 2008, to November 30, 2011, patients who underwent emergency general surgery and were subsequently readmitted to a nonindex hospital were significantly more likely to have had their index surgery at a large, teaching, safety-net hospital.

Meaning  With the adverse outcomes associated with care discontinuity, there is a need for sustained efforts in increasing continuity of care among these hospitals.

Abstract

Importance  Although there is evidence that changes in clinicians during the continuum of care (care discontinuity) are associated with higher mortality and complications among surgical patients, little is known regarding the drivers of care discontinuity among emergency general surgery (EGS) patients.

Objective  To identify hospital factors associated with care discontinuity among EGS patients.

Design, Setting, and Participants  We performed a retrospective analysis of the 100% Medicare inpatient claims file, from January 1, 2008, to November 30, 2011, and matched patient details to hospital information in the 2011 American Hospital Association Annual Survey database. We selected patients aged 65 years and older who had the most common procedures associated with the previously defined American Association for the Surgery of Trauma EGS diagnosis categories and survived to hospital discharge across the United States. The current analysis was conducted from February 1, 2016, to March 24, 2016.

Main Outcomes and Measures  Care discontinuity defined as readmission within 30 days to nonindex hospitals.

Results  There were 109 443 EGS patients readmitted within 30 days of discharge and 20 396 (18.6%) were readmitted to nonindex hospitals. Of the readmitted patients, 61 340 (56%) were female. Care discontinuity was higher among patients who were male (19.5% vs 18.0%), those younger than 85 years old (19.0% vs 16.6%), and those who lived 12.8 km (8 miles) or more away from the index hospitals (23.7% vs 14.8%) (all P < .001). Care discontinuity was independently associated with mortality (adjusted odds ratio [aOR], 1.16; 95% CI, 1.08-1.25). Hospital factors associated with care discontinuity included bed size of 200 or more (aOR, 1.45; 95% CI, 1.36-1.54), safety-net status (aOR, 1.35; 95% CI, 1.27-1.43), and teaching status (aOR, 1.18; 95% CI, 1.09-1.28). Care discontinuity was significantly lower among designated trauma centers (aOR, 0.89; 95% CI, 0.83-0.94) and highest among hospitals in the Midwest (aOR, 1.15; 95% CI, 1.05-1.26).

Conclusions and Relevance  Nearly 1 in 5 older EGS patients is readmitted to a hospital other than where their original procedure was performed. This care discontinuity is independently associated with mortality and is highest among EGS patients who are treated at large, teaching, safety-net hospitals. These data underscore the need for sustained efforts in increasing continuity of care among these hospitals and highlight the importance of accounting for these factors in risk-adjusted hospital comparisons.

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