C. Balentine1,2, M. C. Mason3, P. J. Richardson4, P. Kougias3,4, F. Bakaeen5, A. D. Naik4,6, D. H. Berger3,4, D. A. Anaya7 1University Of Alabama At Birmingham,Department Of Surgery,Birmingham, AL, USA 2University Of Alabama At Birmingham,Institute For Cancer Outcomes And Survivorship,Birmingham, AL, USA 3Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 4Houston Veterans Affairs Health Services Research And Development Center For Innovations In Quality, Effectiveness And Safety (IQUEST),Houston, TX, USA 5Cleveland Clinic,Department Of Thoracic And Cardiovascular Surgery,Cleveland, OH, USA 6Baylor College Of Medicine,Alkek Department Of Medicine,Houston, TX, USA 7H. Lee Moffitt Cancer Center & Research Institute,Department Of Gastrointestinal Oncology,Tampa, FL, USA
Introduction: Patients value regaining independence and returning home after surgery, but they are frequently discharged to post-acute care facilities including skilled nursing and inpatient rehabilitation hospitals. Studies of hospital variation in post-acute care use have primarily focused on medical conditions, have been limited to Medicare patients, or have ignored the Veterans Affairs system (the largest healthcare provider in the United States). Consequently, there is no nationally representative data on how rates of discharge to post-acute care facilities differ across hospitals following complex surgery. The purpose of this study is to explore hospital-level variation in post-acute care utilization after cardiovascular and abdominal surgery in public, private and Veterans Affairs hospitals. We hypothesized that there would be significant variation in post-acute care use across hospitals, regardless of the type of health system.
Methods: We performed a retrospective cohort study of 3,487,365 patients from the Nationwide Inpatient Sample and 60,666 from the Veterans Affairs health system who had colorectal surgery, hepatectomy, pancreatectomy, coronary bypass, aortic aneurysm repair, and peripheral vascular bypass between 2008-2011. For Veterans, 32% were age 70 or older, and 98% were men. For non-Veterans, 39% were age 70 or older, and 60% were men. The primary endpoint was hospital-level unadjusted and risk-adjusted observed-to-expected ratios for discharge to post-acute care facilities (skilled nursing or inpatient rehabilitation)
Results: 631,199 (18%) non-Veteran patients and 4,744 (8%) Veterans were discharged to post-acute care facilities. Hospital rates of discharge to post-acute care facilities varied from 1% to 36% for Veterans hospitals and from 1% to 59% for non-Veteran hospitals. Risk-adjusted observed-to-expected ratios ranged from 0.10 to 4.15 in the Veterans Affairs and from 0.11 to 4.3 for non-Veteran hospitals. Variation in post-acute care utilization persisted even among high-volume referral centers. Rates of discharge to post-acute care facilities for high-volume centers ranged from 1-54% and observed-to-expected ratios ranged from 0.13-2.99 for non-Veteran hospitals and 0.13-3.13 for Veterans.
Conclusion:There is substantial variation in post-acute care utilization and rates of home discharge after abdominal and cardiovascular surgery, even among hospitals that specialize in complex surgery. To help more patients achieve their goal of returning home after surgery it will be important to improve postoperative recovery, develop evidence-based guidelines for the use of post-acute care, and better identify patients with post-acute care needs.