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Post-Surgical Mortality Rates Linked to Readmission Location

Surgery patients 26% more likely to survive if they return to site of original procedure, authors find

Patients with complications after major surgery have better survival odds if they’re readmitted to the same hospital where the surgery was performed, throwing into doubt the assumption that traveling long distances to high-volume hospitals necessarily leads to the best outcomes, according to an article posted on the HealthLeaders Media website.

An observational cohort study of more than 9 million Medicare patients, published in The Lancet, found that patients with complications after major surgery were 26% more likely to survive if they returned to the hospital where they had their operations compared with those readmitted to a different hospital. The findings suggest the importance of continuity of care, according to lead author Benjamin Brooke, MD, PhD, of the University of Utah.

“Having the familiarity with that patient was more important than the fact that they did a lot of operations,” Brooke said.

The researchers used Medicare claims data from between January 1, 2001, and November 15, 2011, to assess approximately 9.5 million patients who needed hospital readmission within 30 days after 12 different procedures, including colectomy, craniotomy, coronary artery bypass surgery, and hip- or knee-replacement surgery.

The number of patients readmitted or transferred back to the index hospital where their procedure was performed varied from 186,336 (65.8%) of 283,131 patients who were readmitted after coronary artery bypass grafting, to 142,142 (83.2%) of 170,789 patients who were readmitted after colectomy. Readmission was more likely to be to the index hospital than to a nonindex hospital if the readmission was for a surgical complication (189,384 [23%] of 834,070 patients readmitted to the index hospital vs. 36,792 [13%] of 276,976 patients readmitted to a non-index hospital; P < 0.0001). Readmission to the index hospital was associated with a 26% lower risk of 90-day mortality compared with readmission to a non-index hospital. This effect was significant (P < 0.0001) for all procedures, and was largest for patients who were readmitted after pancreatectomy (odds ratio [OR], 0.56) or aortobifemoral bypass (OR, 0.69).

Although Brooke and his colleagues hypothesized that patients would have better outcomes if they went to the same hospital, “we were fairly surprised that it was the same across all operations at the same level,” even after adjusting for hospital volume, he said.

Although the reimbursement trend might be toward centers of excellence and regionalized surgery, it’s intuitive that continuity of care would also be a critical factor, Brooke remarked.

“It makes sense that if you meet a patient, you learn the patient’s medical history; you perform the operation; you’re very familiar with that patient’s anatomy,” he said. “You’re the same physician who already has all of that in-depth, contextual knowledge of that patient. Having that familiarity with that patient is what drives a lot of the mortality benefit in this study.”

The researchers also found that having the same surgeon taking care of patients for surgery and readmission provided the greatest mortality benefit.

At the local level, the takeaway is implementing a change in how patients are triaged if they have complications during the post-op period, Brooke said.

If a patient is stable, ambulance companies could make efforts to take him or her back to the index hospital where the surgery took place. Also, if a patient shows up in a different emergency department, the emergency team should make every effort to get that patient back to the index hospital. Ideally, there should be an automated system of initiating this transfer process.

At the policy level, Brooke says there should be plans in place to keep surgical patients who have traveled for surgery near the index hospital for a few weeks post-op, especially since most readmissions occur within the first 2 weeks after surgery. For instance, a program could provide affordable lodging so patients can have their first post-op visit with their own surgical team.

Sources: HealthLeaders Media; June 30, 2015; and The Lancet; June 17, 2015.

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