Introduction: 

Care fragmentation (CF), defined as receipt of care across various hospitals, has been linked with generally worse outcomes. However, its extent and impact on outcomes of proctectomy which encompasses a wide array of pathologies, remains undefined. We examined the association of CF following proctectomy with clinical and financial outcomes of inpatient hospitalizations in a national cohort.

Methods: 

All elective adult (≥18) hospitalizations entailing proctectomy with a readmission within 30 days were identified in the 2016-2021 Nationwide Readmissions database. Care fragmentation was defined as readmission to a facility other than the center performing the operation. Patients were grouped in the CF cohort if they experienced care fragmentation (Others: n-CF). Hospital volume was calculated among the study cohort and divided into tertiles.

The primary outcome of interest was mortality during a readmission. Secondary endpoints included perioperative complications (cardiac, respiratory, infectious), length of stay (LOS), and cumulative hospitalization costs. Multivariable logistic and linear regression models were developed to examine the association between care fragmentation and outcomes of interest. 

Results: 

Of 14,543 patients readmitted following proctectomy, 14.6% experienced care fragmentation. Compared to Others, CF were older (65 [54-74] vs 61 years [50-71], p<0.005) and more commonly insured by Medicare (54.6 vs 40.5%, p<0.005). Additionally, CF were more commonly treated at a large volume hospital (47.6 vs 42.6%, p<0.05). 

Following risk adjustment, advancing age (Adjusted Odds Ratio [AOR] 1.01 per year, 95% Confidence Interval [CI] 1.01-1.02), Medicare Insurance (AOR 1.38, 95% CI 1.15-1.67, Ref: Private), and care at a large volume hospital (AOR 1.34, 95% CI 1.12-1.61) were associated with increased odds of care fragmentation.  

Those experiencing care fragmentation faced increased odds of mortality (AOR 2.19, 95% CI 1.31-3.68). Additionally, care fragmentation was associated with the development of several complications including cardiac (AOR 1.93, 95% CI 1.30-2.89), respiratory (AOR 1.56, 95% CI 1.15-2.12), and acute kidney injury (AOR 1.35, 95% CI 1.15-1.57); Figure). Moreover, care fragmentation was linked with increased initial LOS (β 0.85, 95% CI 0.34-1.36) and 30-day cumulative hospitalization costs (β +$5,300, 95% CI $2,600-8100). 

Conclusion:

In the present study, care fragmentation was associated with increased risk of mortality at readmission, clinical complications, and hospitalization costs. Future studies should evaluate the role of inter-hospital communication for postoperative care with the goal of improving continuity of care, optimizing patient outcomes, and reducing the burden of complications in care fragmented proctectomy patients.