Published research has shown that hospital readmissions are commonly needed to treat complications after patients undergo major surgery. Few studies have explored if patients have better outcomes when they are readmitted to and cared for at the hospital where they initially received surgery when compared with going to another hospital for care of these complications.
To investigate this correlation further, Benjamin S. Brooke, MD, PhD, and colleagues conducted a study to examine the association between readmission destination and mortality risk. Published in the Lancet, the researchers analyzed data from Medicare beneficiaries who had a complication after undergoing a common operation. “Using Medicare data helps us track episodes of care and captures billing codes, allowing us to follow where older patients receive care after undergoing surgery,” says Dr. Brooke.
Data were available on more than 9.4 million Medicare patients who were readmitted within 30 days after undergoing one of 12 major surgeries over a 10-year period. These operations included open abdominal aortic aneurysm repair, infrainguinal arterial bypass, aortobifemoral bypass, CABG surgery, oesophagectomy, colectomy, pancreatectomy, cholecystectomy, ventral hernia repair, craniotomy, hip replacement, or knee replacement. The authors used logistic regression models with propensity weighting to measure associations between readmission destination (index vs non-index hospital) and the risk of mortality within 90 days for patients who underwent surgery and required hospital readmission.
Results of the study showed that 65.8% to 83.2% of patients who had complications were readmitted to the same hospital. Readmissions were more likely to be back to the index hospital than to a non-index hospital if they were for a surgical complication (Table). “But importantly, we observed a survival benefit when patients returned to the site where the original operation was done for both surgical and medical complications,” says Dr. Brooke.
Statistical analyses demonstrated that patients were more likely to survive 90 days after readmission when returning to their index hospital than those receiving postoperative care at a different hospital. Patients had even better survival when they were treated by the same surgical team who performed the operation. Survival trends were consistent across all surgeries assessed in the study, ranging from a 44% reduced risk of death for those receiving pancreatectomy to a 13% lower mortality rate for CABG surgery.
“These survival data are important considering the large number of patients who are readmitted after common surgical procedures,” says Dr. Brooke. “The trends remained consistent regardless of whether surgery was performed at a large teaching hospital or at a smaller community hospital.” The results add to mounting evidence that continuity of care leads to better outcomes for a variety of acute and chronic medical conditions.
Findings of the study may have important implications for efforts to provide surgical care that is cost-effective and regionally centralized. “Returning to index hospitals after a surgical complication may be more important than other measures of healthcare quality,” Dr. Brooke says. This includes receipt of treatment at large medical centers that perform high volumes of specific procedures.
Throughout the United States, patients are sometimes encouraged to travel to larger medical centers for complex elective surgical procedures, a phenomenon that has been dubbed “domestic medical tourism.” In some cases, patients are forced by their healthcare plans to travel long distances to get surgery at premier hospitals that are considered regionally close to where patients reside. This is often done in an effort to save costs. In these cases, it can be difficult for patients to return to their index hospital if they experience complications after surgery.
To overcome this hurdle, Dr. Brooke recommends that patients have surgery performed close to their home whenever possible. “When discussing surgical treatment options, physicians should keep travel distance in mind,” he says. “If patients need to travel to a destination hospital, plans should be made to have them stay in the area for a while during the recovery period. And if patients are readmitted to an outside hospital, it’s important to make every effort to transfer them back to their index hospital within 24 hours of their procedure for postoperative management.”
More to Come
Results from the analysis are observational in nature, and the study authors point out that a randomized trial would be needed to prove a causal link. Dr. Brooke adds that future studies should examine the implications of traveling far distances for surgery among both older and younger patients. “We need to determine why outcomes appear to be better when patients return to the index hospital,” he says. “This information may change the way perioperative care is delivered. While it may behoove patients to travel further to get surgery at a particular hospital, doing so may ultimately reduce their access to optimal care in the event of serious complications after discharge.”
Brooke BS, Goodney PP, Kraiss LW, Gottlieb DJ, Samore MH, Finlayson SRG. Readmission destination and risk of mortality after major surgery: an observational cohort study. Lancet. 2015 Jun 17 [Epub ahead of print]. Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60087-3/fulltext.
Dimick JB, Miller DC. Hospital readmission after surgery: no place like home. Lancet. 2015 Jun 17 [Epub ahead of print].
Tsai TC, Orav EJ, Jha AK. Care fragmentation in the postdischarge period: surgical readmissions, distance of travel, and postoperative mortality. JAMA Surg. 2015;150:59-64.
Hollenbeck BK, Miller DC, Wei JT, Montie JE. Regionalization of care: centralizing complex surgical procedures. Nat Clin Pract Urol. 2005;2:461.