The Unfinished Journey After Major Surgery: Interhospital Transfer and Care Fragmentation

Interhospital transfer (IHTR) is commonly used to access specialized surgical care, yet post-discharge readmission destination among transferred surgical patients remains poorly characterized. Therefore, the association of IHTR and hospital transfer burden with care fragmentation after major surgery was evaluated.

Adults aged ≥ 18 years undergoing major surgery between 2016 and 2020 were identified from the Nationwide Readmissions Database. Procedures included coronary artery bypass grafting, abdominal aortic aneurysm repair, esophagectomy, hepatectomy, rectal resection, pneumonectomy, pancreatectomy, and colectomy. Patients were stratified as IHTR versus non-transfer (NTR). Care fragmentation was defined as 30-day readmission to a hospital different from the index surgical hospital. Multivariable regression evaluated the association of IHTR with postoperative and readmission outcomes. Hospital-level analyses evaluated the association between hospital transfer burden and care fragmentation.

Among 1,831,450 patients, 77,498 (4.2%) were categorized as IHTR and 1,753,952 (95.8%) as NTR. Compared with NTR patients, IHTR patients had higher comorbidity burden (median Elixhauser groups, 6 [IQR, 4-8] vs. 4 [IQR, 2-5]) and more commonly underwent nonelective surgery (n = 67,184 [86.7%] vs. n = 688,802 [39.3%]; both p < 0.001). Thirty-day readmission was modestly higher among IHTR versus NTR patients (n = 12,743 [16.4%] vs. n = 211,311 [12.1%]; adjusted odds ratio [aOR], 1.02; 95% CI, 1.00-1.05), whereas care fragmentation among readmitted patients was substantially more common after IHTR (n = 6424 [50.4%] vs. n = 40,327 [19.1%]; aOR = 3.75; 95% CI, 3.58-3.92). This association was consistent among nonelective (aOR = 4.05; 95% CI, 3.86-4.26) and elective patients (aOR = 3.46; 95% CI, 3.10-3.86). Greater hospital transfer burden was associated with higher care fragmentation odds overall and among NTR readmitted patients (both aOR, 1.08).

IHTR was strongly associated with care fragmentation after major surgery, despite a modest association with 30-day readmission overall. Greater hospital transfer burden was also associated with hospital-level care fragmentation, suggesting that transfer status and hospital transfer burden may help identify patients and hospitals at increased risk for fragmented post-discharge acute care within regionalized surgical systems.