S. Zafar1, A. A. Shah1, H. Channa2, L. L. Wilson4, N. Wasif3 1Howard University College Of Medicine,General Surgery,Washington, DC, USA 2Purdue University,Agricultural Economics,West Lafayette, IN, USA 3Mayo Clinic In Arizona,Surgical Oncology,Phoenix, AZ, USA 4Howard University College Of Medicine,Surgical Oncology,Washington, DC, USA
Introduction:
Hospital readmissions after major cancer surgery pose a major healthcare burden and are associated with increased costs and worse outcomes. Increasing regionalization of cancer surgery has the inadvertent potential to lead to fragmentation of care if readmissions occur at a different hospital from the index facility. Using a national dataset we aim to quantify rates of readmission to non-index hospitals after major cancer surgery and to compare outcomes between index and non-index hospital readmissions.
Methods:
We used the National Readmissions Dataset (2013) as our data source. All adult patients undergoing a major cancer operation (defined as esophagectomies/gastrectomies, hepatico-biliary resections, pancreatectomies, colorectal resections, and cystectomies) within the first 9 months of the year were selected. Readmission characteristics including timing, cost, morbidity and mortality were analyzed. Discharge weights were used to calculate national estimates. Adjusting for clustering by facility, we used multivariate logistic regression to identify factors associated with non-index vs. index readmissions and also to identify differences in mortality, major complications and subsequent readmissions. Generalized linear modeling was used to test for differences in length of stay (LOS) and hospital costs between the two groups.
Results:
A total of 57,362 patients with 86,362 hospital admissions were analyzed. Overall, the 90 day readmission rate was 23.1% and median time to readmission was 42 days (IQR 20-70 days). Weighted analysis revealed the total national cost for 90 day readmissions to be $682 million. Of the 17,020 readmissions, 22.0% were to a non-index hospital. Independent factors associated with 90 day readmission to a non-index hospital included younger age, male gender, type of procedure, more comorbidities, Medicaid insurance, longer LOS, in-hospital complications, discharge to a nursing facility, and index surgery at a teaching hospital (p<0.05). Following risk adjustment, patients readmitted to non-index hospitals had 32% higher odds of mortality (OR 1.32, 95% CI: 1.03-1.70) and 26% higher odds of having a major complication (OR 1.26, 95% CI: 1.10-1.43). Subsequent readmissions and hospital costs were not significantly different between the two groups.
Conclusion:
The 90 day readmission rate following major cancer surgery in the United States is 23.1%, of which a further 22% are to a non-index hospital. When compared to patients readmitted to the index hospital, readmission to a non-index hospital is associated with higher mortality and morbidity. Targeted interventions to reduce non-index readmissions may mitigate fragmentation of postoperative care and result in improved outcomes.