After Complex Cancer Surgery, Readmission to Different Hospital Tied to Increased Risk of Death

By Scott Baltic

April 30, 2021

NEW YORK (Reuters Health) - Patients who have postoperative complications after being discharged following complex oncologic surgery are less likely to die if they are readmitted to the hospital where the surgery was performed, than if they are admitted to a different hospital, according to a new study.

The fragmentation of care that happens when a patient is readmitted to an outside hospital (OSH) is more likely if a patient lives farther from the index hospital or if they present later after the index discharge. But these two factors were not associated with increased mortality, researchers report in the Journal of the American College of Surgeons.

Further, although hospitals performing fewer than 100 complex surgeries of this type annually saw higher rates of mortality following readmission than those performing 100 or more, the difference was not significant after adjustment. Nor was the size of the hospital, by bed count, significantly associated with 90-day readmission mortality.

Overall, the authors concluded, "mortality remains associated with variables largely inherent to the patient's baseline performance status and the details of their initial surgical hospitalization."

Lead author Dr. David G. Brauer, now at Memorial Sloan Kettering Cancer Center, in New York City, told Reuters Health by email, "The results can be a bit confusing and may have led to more questions than answers, but we think this is a good advancement in the field."

Dr. Brauer, who worked on the study while at Washington University School of Medicine in St. Louis, Missouri, said this was the first study in surgical patients to examine the relationship between surgical volume or hospital bed count in care fragmentation in readmissions.

Using data from the Healthcare Cost and Utilization Project, he and his colleagues identified 7,536 patients (mean age, 66) in California, Florida or New York who had undergone surgery for hepatopancreatobiliary or gastric cancer between 2006 and 2014 and been re-hospitalized within 90 days.

Of these, 2,123 (28%) were readmitted to an OSH. Mortality was significantly higher among this group than those readmitted to the index hospital (8.0% vs. 5.4%; odds ratio, 1.5; P<0.001).

In addition, patients in the OSH subgroup presented significantly later than did the patients readmitted to the index hospital (median, 25 days vs. 12 days).

Greater distance between a patient's residence and the index hospital significantly increased the likelihood of readmission to an OSH, especially for patients living more than 100 miles from the index hospital.

Patients experiencing any surgical complication, such as wound infections, sepsis, or bowel obstructions, who were readmitted at an OSH were at significantly higher risk of mortality than those who went back to the index hospital (8.4% vs. 5.7%).

Dr. Brauer noted that there is "a large body of literature identifying care fragmentation in readmissions as a problem due to increased mortality" and said the his team wanted to examine what hospital- and patient-level factors could be causing this increased mortality.

"Ultimately, we intended to find if specific symptoms like abdominal pain or specific diagnoses like a wound infection would suggest that a patient absolutely should be transferred back to the index hospital," he explained. "I think an answer like that is still possible, but will require a much more granular approach to this data."

Based on this study's findings, Dr. Brauer said, "demographic variables pale in comparison to clinical variables," such as comorbidities and length of stay during the initial hospitalization.

"As a clinician, I would worry about both care fragmentation and mortality if I discharged an older patient who lives farther away, has multiple medical comorbidities, and was in the hospital for an extended period of time immediately after their surgery. That person has several risk factors for a bad outcome and probably should be closely followed as an outpatient," he concluded.

Dr. Thomas C. Tsai, of Harvard Medical School and Harvard T.H. Chan School of Public Health, in Boston, told Reuters Health by email the new findings are "consistent with the growing body of data suggesting fragmentation of follow-up care after major surgical procedures is associated with a higher rate of mortality."

Factors that might contribute to this increased mortality, he continued, include an outside hospital lacking a multidisciplinary care team experienced at managing high-acuity surgical complications and "inappropriate triage and transfers that delay timely treatment needed to prevent an isolated non-life-threatening complication from cascading into a life-threatening condition," also known as "failure to rescue."

"Mortality has been shown to be highest when patients are readmitted to a hospital of lower quality than where they underwent an operation," he concluded.

Dr. Michael E. Lidsky, of the Division of Surgical Oncology at Duke University Medical Center, in Durham, North Carolina, said the decision to go to a local hospital versus travel farther to the index hospital is often based on multiple factors.

"It is conceivable that critically ill patients with increased severity of complications were unable to travel to the index hospital, thus landing themselves in a smaller, less-experienced, less-resource equipped medical center, but also in critical condition and extremis," he told Reuters Health by email.

Neither Dr. Tsai nor Dr. Lidsky was involved with the study.

SOURCE: Journal of the American College of Surgeons, online April 15, 2021.