Care Fragmentation After Surgery Increases Mortality Risk

Marta McCrum, MD, MPH

Among patients who are hospitalized following emergency general surgery, 14.6% are readmitted to a different hospital than where their index procedure is performed and face higher risk of mortality.

The findings suggested the need to develop systems that allow for the rapid assessment and triage of patients after emergency general surgery to hospitals best equipped to manage their condition.

Marta McCrum, MD, MPH, and colleagues identified patient and hospital factors associated with increased mortality among patients after emergency general surgery readmitted within 30 days of discharge to a different hospital. They found the overall mortality rate was higher for the population of patients readmitted to a different hospital from where their procedure was performed, but excess mortality was primarily associated with the severity of patient illness at the time of readmission.

The investigators used the 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database to conduct the retrospective cohort study. The database contained 15 million unweighted discharges.

McCrum and the team identified all adult patients at least 18 years old with a nonelective index admission who underwent 1 of the 15 most common emergency general surgery procedures and survived to discharge. Procedures included cholecystectomy, appendectomy, incision and drainage, lysis of adhesions, and small-bowel resection.

The team collected demographic data and examined hospital characteristics including ownership, bed size, rural location, and teaching hospital status. They also analyzed the proportion of complex or advanced presentations for 9 common emergency general surgery diseases.

Severity scales were defined by The American Association for the Surgery of Trauma (AAST). A simple disease was AAST class 1 to 3. Complex disease was AAST class 4 to 5.

Overall, 71,944 patients who underwent emergency general surgery (mean age, 59 years old; 53.5% female) were readmitted within 30 days of discharge. Less than 15% (14.6%) were readmitted to a non-index hospital. Patients readmitted to non-index hospitals were more likely to be readmitted to hospitals with low annual emergency general surgery 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) compared to patients readmitted to index hospitals.

The 90-day mortality was higher for those readmitted to different hospitals (6.1% vs 4.3%; P <.001). After the team adjusted for baseline patient and hospital characteristics, care fragmentation was independently associated with increased mortality (aOR, 1.36; 95% CI, 1.17-1.58; P <.001). When adjusted for interventions performed during readmission, change in emergency general surgery hospital volume level, and severity of patient illness, care fragmentation was not independently associated with mortality (aOR, 1.05; 95% CI, .88-1.26; P=.58).

The investigators found when the model was complete, severity of illness was the strongest risk factor of mortality during readmission.

McCrum and the team’s results highlighted the critical role that severity of illness plays in the outcomes of patients following emergency general surgery.

The results suggested the importance of considering patient physiology in emergency general surgery triage, specifically in the case of readmission. If patients experience serious complications, expediting readmission to an optimally resourced center is most appropriate regardless of the discontinuity in surgeon or hospital care.

The study, “Contributors to Increased Mortality Associated With Care Fragmentation After Emergency General Surgery,” was published online on JAMA Surgery.