AT WSA 2016

CORONADO, CALIF. (FRONTLINE MEDICAL NEWS)Postdischarge surgical care fragmentation significantly increases the risk of both 30-day mortality and subsequent readmission in the first year following orthotopic liver transplantation, results from a study of national data showed.

“In an era of regionalization and centers of excellence, the likelihood for postdischarge fragmentation, defined as readmission to any hospital other than the hospital at which the surgery was performed, is an increasing reality,” Anai N. Kothari, MD, said at the annual meeting of the Western Surgical Association. “In many different surgical subspecialties – major vascular operations, bariatric surgery, oncologic resections – it’s known to be a risk factor for adverse events and poor quality. Postdischarge fragmentation is common, [and related to] as often as one in four readmissions. It increases the risk for short- and long-term morbidity and mortality, decreases survival, and increases cost.”

Dr. Kothari of the department of surgery at Loyola University Medical Center, Chicago, said liver transplant patients are susceptible to postdischarge care fragmentation because they have high acuity at baseline and they’re at risk for postoperative complications. “Because of the nature of the postoperative period, there is significant need for care coordination,” he added. “There is an element of travel to a center in order to receive the transplant itself.” In an effort to assess the impact of fragmented readmissions within the first year following orthotopic liver transplant, and to identify factors that might necessitate transfer to the index transplant center, Dr. Kothari and his associates analyzed data from the Healthcare Cost and Utilization Project State Inpatient Databases for Florida and California between 2006 and 2011 to identify patients who underwent orthotopic liver transplant. This information was linked to the American Hospital Association’s Annual Survey Database. They excluded patients younger than 18 years of age, those who died during the index admission, those who had a liver and kidney transplant, those who underwent multiple liver transplants, and those who did not have a hospital readmission. Postdischarge fragmentation was defined as any readmission to a nonindex hospital, including readmitted patients ultimately transferred to the index hospital after 24 hours. Nonfragmented readmission was defined as any patient who went back to the index transplant center or were transferred within 24 hours to the index center.

Dr. Kothari reported results from 2,996 patients with 7,485 readmission encounters at 299 hospitals. Of the 7,485 readmissions, 6,249 (83.5%) were nonfragmented, and 1,236 (16.5%) were fragmented. The mean age of patients was 55 years. There were no significant differences in baseline characteristics between patients with nonfragmented and fragmented admissions in terms of patient age, sex, preoperative and postoperative length of stay, Charlson comorbidity index, and comorbidities, with the exception of renal failure, which was more common among patients in the fragmented admission group.

Compared with the patients in the nonfragmented admission group, those in the fragmented admission group had a greater number of average readmissions per patient (3.3 vs. 2.5, respectively; P less than .0001) and a greater number of average days to readmission (168 vs. 105; P less than .0001). Reasons for readmission differed among the two groups. Patients readmitted to the index transplant center were more likely to have a biliary, hematologic, or neurologic complication, while those in the fragmented admissions group were more likely to be readmitted for things like electrolyte disturbances, respiratory issues, gastrointestinal issues, or hematologic-related issues. There was no difference in overall cost of care between the two groups (an average of $11,621.68 vs. $11.585.39, respectively).

After the investigators adjusted for age, sex, reason for readmission, cost of the index liver transplant, readmission length of stay, number of previous readmissions, and time from transplant, postdischarge fragmentation increased the odds of both 30-day mortality (OR, 1.75) and 30-day readmission (OR, 2.14). “It looks like just having a fragmented readmission is an independent predictor for an adverse event,” Dr. Kothari said.

Significant predictors of adverse events following a fragmented readmission included an increased number of previous readmissions (OR, 1.07) and readmission within 90 days of orthotopic liver transplant (OR, 2.19). “These two factors may be important for guiding providers to say, ‘If you have these things, this patient should likely come back to their index transplant center,’” Dr. Kothari said.

He reported having no relevant financial disclosures.