Hospital Factors Associated with Fragmentation of Care in Emergency General Surgery: Less Continuity, Higher Mortality.

Abstract

Fragmentation of care (FOC) is defined as readmission to a nonindex hospital and can be associated with worse outcomes among emergency general surgery (EGS) patients. This study assessed hospital characteristics associated with patterns of FOC in EGS patients and the effect of interfacility transfer after FOC on mortality. Using the Nationwide Readmissions Database 2019, we included patients 18 years or older who were admitted to an index hospital with an EGS diagnosis managed operatively and had an emergency readmission within 90 days. Patients were classified into 4 patterns of fragmentation: no FOC, FOC, defragmented care (readmitted to a nonindex hospital, then transferred back), and hyperfragmented care (readmitted to a nonindex hospital, then transferred to another nonindex hospital). Patient severity of illness was defined using severity of illness categories of All Patient-Refined Diagnosis Related Groups (APR-DRG). Multivariable logistic regression analyses were used to identify hospital characteristics associated with FOC and the effect of FOC on 90-day mortality. Of 26,100 patients included, 82.5% had no FOC, 16.4% had FOC, 0.3% had defragmented care, and 0.9% had hyperfragmented care. Index hospital characteristics associated with FOC were small size (by number of beds), private investor or government owned, and low EGS volumes. Controlling for hospital and patient characteristics, FOC (odds ratio 1.22; 95% CI 1.01 to 1.47; p = 0.045) was significantly associated with increased 90-day mortality, driven by those with major or extreme severity of illness of APR-DRGs (odds ratio 1.36; 95% CI 1.13 to 1.64; p = 0.001). FOC is associated with worse outcomes in EGS patients. This study highlights the impact of FOC and the hospital characteristics associated with FOC, highlighting the need for further investigation into EGS systems of care.