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Association of care fragmentation and mortality after curative-intent gastrointestinal cancer surgery
Charalampos M Charalampous1, Rabia Bega1, Selamawit Woldesenbet1
1Department of Surgery, The Ohio State University Wexner Medical Center and The James Comprehensive Cancer Center, Columbus, Ohio, United States.
Background:
Regionalization of complex gastrointestinal (GI) cancer surgery to high-volume centers can increase the risk of unplanned readmission to a different hospital, known as care fragmentation. We sought to assess the association between care fragmentation and 90-day mortality.
Methods:
Patients who underwent curative-intent surgery for hepatopancreatobiliary or colorectal cancer were identified using the Surveillance, Epidemiology, and End Results-Medicare database (2007-2020). Care fragmentation was defined as an unplanned 30-day readmission to a hospital other than the index hospital. Mixed-effects models with sequential adjustment for patient-level, hospital-level, and geographic distance characteristics were used to estimate the association between care fragmentation and 90-day mortality.
Results:
Among 63,908 patients, 13.8% (n = 8805) were readmitted within 30 days; 19.0% (n = 1671) of these individuals experienced fragmented care. Patients with fragmented care more often resided in high Social Vulnerability Index areas (36.9%, n = 617 vs 32.6%, n = 2324) and more frequently underwent surgery at teaching hospitals (63.6%, n = 1062 vs 57.7%, n = 4116) compared with patients readmitted to the index hospital (both P <.001). Interestingly, the distance between residence and index facility was considerably longer among individuals who experienced fragmented care (median, 26.97 km [IQR, 9.98-76.26] vs median, 11.56 km [IQR, 5.05-27.82]; P <.001). After adjustment for patient- and hospital-level factors, as well as distance to the hospital, fragmented care was independently associated with higher odds of 90-day mortality (adjusted odds ratio, 1.40; 95% CI, 1.21-1.61).
Conclusion:
Care fragmentation was associated with substantially higher mortality among older adults who were readmitted after GI cancer surgery. Investment in cross-institutional continuity of care is needed to preserve the survival benefits of centralized surgery upon discharge.