Impact of In-Network Versus Out-of-Network Fragmentation of Care on Long-Term Outcomes After Trauma

Fragmentation of care (FoC), i.e., readmission to a facility different from the index hospital, disproportionately affects trauma patients. However, its effects on long-term outcomes (LTOs) and the impact of shared electronic medical records (EMRs) on these effects are understudied. We aimed to understand the predictors of FoC and its effects on LTOs across out-of-network (ON-FoC; no shared EMR) and in-network (IN-FoC; shared EMR) hospitals.

We conducted a prospective, multi-institutional cohort study including patients of ≥18 y with an Injury Severity Score of ≥9 and self-reported injury-related readmission. Patients were contacted between 6 and 12 mo postinjury to assess long-term outcomes. We classified patients into no FoC, ON-FoC, and IN-FoC groups via chart review. Stepwise regression was performed to identify predictors of FoC, and logistic regression was used to estimate the impact of FoC on LTOs.

Among 400 included patients, 177 (44%) had ON-FoC FoC and 20 (5%) had IN-FoC. A higher level of education, living farther from the index hospital, and severe head injury were predictors of FoC. ON-FoC, but not IN-FoC, was associated with worse limitations in leisure activities and 12-item Short Form survey physical component scores versus no FoC. On the other hand, patients with IN-FoC, but not ON-FoC, reported worse daily pain and 12-item Short Form survey mental scores versus those without FoC.

FoC is associated with poorer LTOs after trauma, but its effects may be modified by shared EMRs. Compared to patients without FoC, ON-FoC was associated with worse long-term functional outcomes, while those with IN-FoC had worse mental health and pain.