Care Fragmentation: Affecting the Elderly Disproportionately

Fragmentation—a lack of care continuity when disparate healthcare professionals provide care without integrated access to clinical information—is a public health focus. It’s a concern for surgeons when patients undergo complex procedures that require lengthy periods of recovery. Fragmentation is especially troubling when patients are elderly.

Researchers from Harvard, Brigham and Young Women’s Hospital, and the Veterans Administration in Boston, postulated that readmission to a facility other than the one in which a surgery was done could present a unique challenge. They structured a study to answer 3 questions:

• The frequency of elderly surgical patient readmission to hospitals other than the initial hospital where surgery was performed
• The fate of elderly patients readmitted elsewhere compared to those readmitted to the original hospital
• The role of distance to the original and the readmitting hospitals

This study appears in the online version of JAMA Surgery.

The researchers employed a Medicare inpatient file and examined claims filed between January 1, 2009, and November 30, 2011. They used the 2011 American Hospital Association Annual Survey Data on hospital structural features to clarify hospital type. Patients who were included had undergone coronary artery bypass grafting, pulmonary lobectomy, endovascular abdominal aortic aneurysm repair, open abdominal aortic aneurysm repair, colectomy, or hip replacement.

The researchers identified 93,062 patients who underwent these procedures and were readmitted within 30 days of discharge; one-quarter of the patients (n=23,278) received care at a hospital other than the one where their initial procedure was performed. The proportion of surgical patients who were readmitted elsewhere varied significantly by state. Patients in Alaska, Arizona, Georgia, Maine, Hawaii, Maryland, Nevada, New Hampshire, New Jersey, New York, and Texas were significantly more likely to be readmitted to a different hospital if necessary.

Distance between home and nearest hospitals was a concern. Patients readmitted to a different hospital generally lived an average of 14 miles farther from the index hospital than those who returned to the operating hospital. Of note, however, patients who lived in states with similarly rural populations (ie, Maine and Montana, which have similar proportions of populations living in rural areas) were vastly different in their readmission locations.

When the researchers looked at readmission to a different hospital that was the same distance from home as the index hospital, they found that the mortality odds increased. These patients were nearly 50% more likely to die than others.

The researchers suggest hospitals and policy makers adopt 2 strategies to improve outcomes. They could urge patients who develop complications to return to their index hospitals. They could also take steps to improve clinical data exchange and clinical integration.

Elderly surgical patients who have complex medical histories and comorbidities benefit from readmission to their index hospitals in several ways. First, care is rendered quickly because test results are readily available and don’t need to be duplicated. Second, the original care providers recognize complications sooner and can implement appropriate interventions.