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Original Investigation
July 22, 2020

Contributors to Increased Mortality Associated With Care Fragmentation After Emergency General Surgery

Author Affiliations
  • 1Division of General Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City
  • 2Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
  • 3Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City
JAMA Surg. Published online July 22, 2020. doi:10.1001/jamasurg.2020.2348
Key Points

Question  What factors are responsible for the increased mortality observed in patients readmitted to a nonindex hospital after emergency general surgery?

Findings  In this cohort study of 71 944 patients in the 2014 Nationwide Readmissions Database who underwent emergency general surgery, patients readmitted to a nonindex hospital had a higher overall mortality rate compared with patients readmitted to index hospitals. This excess mortality was primarily explained by severity of patient illness at readmission.

Meaning  Because severity of patient illness is not modifiable, there is a need to develop systems that allow for rapid assessment and triage of patients after emergency general surgery to hospitals best equipped to manage their specific condition.

Abstract

Importance  Care fragmentation at time of readmission after emergency general surgery (EGS) is associated with high mortality; however, the factors underlying this finding remain unclear.

Objective  To identify patient and hospital factors associated with increased mortality among patients after EGS readmitted within 30 days of discharge to a nonindex hospital.

Design, Setting, and Participants  Retrospective cohort study using the 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database. Participants were all adult patients (18 years or older) who underwent 1 of the 15 most common EGS procedures in the United States from January 1 to November 30, 2014, and survived to discharge. The dates of analysis were October through December 2019.

Exposures  Thirty-day readmission to a hospital other than that of the index surgical procedure. The study examined the association of interventions during readmission, change in hospital resource level, and severity of patient illness during readmission.

Main Outcomes and Measures  Ninety-day inpatient mortality.

Results  In total, 71 944 patients who underwent EGS (mean [SD] age, 59.0 [18.3] years; 53.5% [38 487 of 71 944] female) were readmitted within 30 days of discharge, of whom 10 495 (14.6%) were readmitted to a nonindex hospital. Compared with patients readmitted to index hospitals, patients readmitted to nonindex hospitals were more likely to be readmitted to hospitals with low annual EGS volume (33.5% vs 25.6%, P < .001) and be in the top half of illness severity profile (37.2% vs 31.2%, P < .001). Overall 90-day mortality was higher in the patients readmitted to nonindex hospitals (6.1% vs 4.3%, P < .001). When adjusted for baseline patient and hospital characteristics, care fragmentation was independently associated with increased mortality (adjusted odds ratio [aOR], 1.36; 95% CI, 1.17-1.58; P < .001). After adjustment for interventions performed during readmission, change in EGS hospital volume level, and severity of patient illness, care fragmentation was no longer independently associated with mortality (aOR, 1.05; 95% CI, 0.88-1.26; P = .58). In this complete model, severity of illness was the strongest risk factor of mortality during readmission.

Conclusions and Relevance  In this cohort study of adult patients who require rehospitalization after EGS, 14.6% are readmitted to a hospital other than where the index procedure was performed. Although the overall mortality rate is higher for this population, the excess mortality appears to be primarily associated with severity of patient illness at time of readmission. These data underscore the need to develop systems of care to rapidly triage patients to hospitals best equipped to manage their condition.

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