Association between interhospital care fragmentation, readmission diagnosis, and outcomes

Turbow, Sara; Sudharsanan, Nikkil; Rask, Kimberly J.; Ali, Mohammed K.

doi:10.37765/ajmc.2021.88639

Cited by 9 publications

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“…In a study of Canadian heart failure patients with fragmented readmissions, ambulance use was associated with a 20% greater odds of a readmission to a different hospital [ 19 ]. A patient’s desire to receive care at a different hospital than they were previously admitted to may also play a role: in previous work, we showed that patients who left their index admission against medical advice, i.e., patients who were likely dissatisfied with the care they received, were twice as likely to be readmitted at a different hospital than were patients who did not leave their index admission against medical advice [ 7 ]. Relatedly, receiving care at a different hospital may be beneficial to patients who require a higher level or specialty care.…”

Section: Discussionmentioning

confidence: 99%

“…Interhospital care fragmentation, when a patient has a readmission to a different hospital than they were previously discharged from, has negative impacts on both patients and the health system, including higher rates of in-hospital mortality [ 1 – 5 ], longer lengths-of-stay [ 1 , 2 ], higher costs per readmission [ 6 – 8 ], as well as increased risk of subsequent readmissions [ 9 – 11 ]. Previous work has shown that up to 25% of readmissions are fragmented [ 7 ], but these readmissions are likely not distributed evenly across patients and hospitals. Understanding what patient characteristics, clinical situations, and hospital or healthcare system structures increase the likelihood of a fragmented readmission is essential to minimize fragmented care where possible, and where to focus care coordination resources to mitigate the negative effects of fragmented readmissions when they do occur.…”

Section: Introductionmentioning

confidence: 99%

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Association of distance between hospitals and volume of shared admissions

Turbow

Uppal

Chang

et al. 2022

BMC Health Serv Res

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Background To assess whether decreasing distance between hospitals was associated with the number of shared patients (patients with an admission to one hospital and a readmission to another). Methods Data were from the Healthcare Cost and Utilization Project’s State Inpatient Databases (Florida, Georgia, Maryland, Utah [2017], New York, Vermont [2016]) and the American Hospital Association Annual Survey (2016 & 2017). This was a cross-sectional analysis of patients who had an index admission and subsequent readmission at different hospitals within the same year. We used unadjusted and adjusted linear regression to evaluate the association between the number of shared patients and the distance between admission-readmission hospital pairs. Results There were 691 hospitals in the sample (247 in Florida, 151 in Georgia, 50 in Maryland, 172 in New York, 58 in Utah, and 13 in Vermont), accounting for a total of 596,772 admission-readmission pairs. 32.6% of the admission-readmission pairs were shared between two hospitals. On average, a one-mile decrease in distance between two hospitals was associated with of 3.05 (95% CI, 3.02, 3.07) more shared admissions. However, variability between states was wide, with Utah having 0.37 (95% CI 0.35, 0.39) more shared admissions between hospitals per one-mile shorter distance, and Maryland having 4.98 (95% CI 4.87, 5.08) more. Conclusions We found that proximity between hospitals is associated with higher volumes of shared admissions.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Association of distance between hospitals and volume of shared admissions

Turbow

Uppal

Chang

et al. 2022

BMC Health Serv Res

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“…When a patient is readmitted to a different hospital than they were previously discharged from, interhospital fragmentation of care occurs. These fragmented readmissions account for around 25% of all 30-day readmissions [ 1 – 3 ] and are associated with a range of negative patient and health system outcomes, including an estimated 20% higher odds of dying during the readmission [ 1 – 5 ], over 75% greater odds of duplicate radiology procedures [ 6 , 7 ], longer lengths-of-stay (LOS) [ 1 , 5 , 8 ], and over two times the odds of subsequent readmissions [ 9 – 12 ].…”

Section: Introductionmentioning

confidence: 99%

“…The effect of fragmented readmissions and the COVID-19 pandemic on patient outcomes may be negatively synergistic. Many of the risk factors for COVID-19 mortality, such as older age, multiple chronic conditions, and lower socioeconomic status are more common in patients with fragmented readmissions [ 1 , 5 ]. However, while there have been numerous studies examining patient and hospital characteristics associated with readmissions, mortality, and LOS in COVID-19 admissions [ 16 , 19 – 22 ], the impact of care fragmentation has gone almost entirely unexamined.…”

Section: Introductionmentioning

confidence: 99%

Care fragmentation and readmission mortality and length of stay before and during the COVID-19 pandemic: data from the National Readmissions Database, 2018–2020

Turbow,

Walker,

Culler

et al. 2024

BMC Health Serv Res

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Importance A quarter of all 30-day readmissions involve fragmented care, where patients return to a different hospital than their original admission; these readmissions are associated with increased in-hospital mortality and longer lengths-of-stay (LOS). The stress on healthcare systems at the beginning of the COVID-19 pandemic could worsen care fragmentation and related outcomes. Objective To compare fragmented readmissions in 2020 versus 2018–2019 and assess whether mortality and LOS in fragmented readmissions differed in the two time periods. Design Observational study Setting National Readmissions Database (NRD), 2018–2020 Participants All adults (> 18 y/o) with 30-day readmissions Main outcomes and measures We examined the percentage of fragmented readmissions over 2018–2020. Using unadjusted and adjusted logistic and linear regressions, we estimated the associations between fragmented readmissions and in-hospital mortality and LOS. Results 24.0–25.7% of readmissions in 2018–2020 and 27.3%-31.0% of readmissions for COVID-19 were fragmented. 2018–2019 fragmented readmissions were associated with 18–20% higher odds of in-hospital mortality compared to nonfragmented readmissions. Fragmented readmissions for COVID-19 were associated with an 18% increase in in-hospital mortality (AOR 1.18, 95% CI 1.12, 1.24). The LOS of fragmented readmissions in March-November 2018–2019 were on average 0.81 days longer, while fragmented readmissions between March-November of 2020 were associated with a 0.88–1.03 day longer LOS. Conclusions and relevance A key limitation is that the NRD does not contain information on several patient/hospital-level factors that may be associated with the outcomes of interest. We observed increased fragmentation during COVID-19, but its impact on in-hospital mortality and LOS remained consistent with previous years.

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“…Repeated hospitalizations, admissions to postacute care, and readmissions present opportunities for interhospital fragmentation of care, wherein a patient’s admission and readmission are to different hospitals. This type of care fragmentation is associated with higher in-hospital mortality, 9 , 10 , 11 , 12 longer lengths of stay, 13 , 14 and increased risk of subsequent readmissions. 9 , 15 , 16 , 17 Because a patient’s medical history and record of previous hospitalization may not be available during a fragmented readmission, effective transitions of care may be challenging and may lead to higher rates of nonhome discharge than would be observed in a nonfragmented readmission.…”

Section: Introductionmentioning

confidence: 99%

Association of Fragmented Readmissions and Electronic Information Sharing With Discharge Destination Among Older Adults

et al. 2023

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ImportanceWhen an older adult is hospitalized, where they are discharged is of utmost importance. Fragmented readmissions, defined as readmissions to a different hospital than a patient was previously discharged from, may increase the risk of a nonhome discharge for older adults. However, this risk may be mitigated via electronic information exchange between the admission and readmission hospitals.ObjectiveTo determine the association of fragmented hospital readmissions and electronic information sharing with discharge destination among Medicare beneficiaries.Design, Setting, and ParticipantsThis cohort study retrospectively examined data from Medicare beneficiaries hospitalized for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, syncope, urinary tract infection, dehydration, or behavioral issues in 2018 and their 30-day readmission for any reason. The data analysis was completed between November 1, 2021, and October 31, 2022.ExposuresSame hospital vs fragmented readmissions and presence of the same health information exchange (HIE) at the admission and readmission hospitals vs no information shared between the admission and readmission hospitals.Main Outcomes and MeasuresThe main outcome was discharge destination following the readmission, including home, home with home health, skilled nursing facility (SNF), hospice, leaving against medical advice, or dying. Outcomes were examined for beneficiaries with and without Alzheimer disease using logistic regressions.ResultsThe cohort included 275 189 admission-readmission pairs, representing 268 768 unique patients (mean [SD] age, 78.9 [9.0] years; 54.1% female and 45.9% male; 12.2% Black, 82.1% White, and 5.7% other race and ethnicity). Of the 31.6% fragmented readmissions in the cohort, 14.3% occurred at hospitals that shared an HIE with the admission hospital. Beneficiaries with same hospital/nonfragmented readmissions tended to be older (mean [SD] age, 78.9 [9.0] vs 77.9 [8.8] for fragmented with same HIE and 78.3 [8.7] years for fragmented without HIE; P &lt; .001). Fragmented readmissions were associated with 10% higher odds of discharge to an SNF (adjusted odds ratio [AOR], 1.10; 95% CI, 1.07-1.12) and 22% lower odds of discharge home with home health (AOR, 0.78; 95% CI, 0.76-0.80) compared with same hospital/nonfragmented readmissions. When the admission and readmission hospital shared an HIE, beneficiaries had 9% to 15% higher odds of discharge home with home health (patients without Alzheimer disease: AOR, 1.09 [95% CI, 1.04-1.16]; patients with Alzheimer disease: AOR, 1.15 [95% CI, 1.01-1.32]) compared with fragmented readmissions where information sharing was not available.Conclusions and RelevanceIn this cohort study of Medicare beneficiaries with 30-day readmissions, whether a readmission is fragmented was associated with discharge destination. Among fragmented readmissions, shared HIE across admission and readmission hospitals was associated with higher odds of discharge home with home health. Efforts to study the utility of HIE for care coordination for older adults should be pursued.

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Association between interhospital care fragmentation, readmission diagnosis, and outcomes

Cited by 9 publications

References 0 publications

Association of distance between hospitals and volume of shared admissions

Association of distance between hospitals and volume of shared admissions

Care fragmentation and readmission mortality and length of stay before and during the COVID-19 pandemic: data from the National Readmissions Database, 2018–2020

Association of Fragmented Readmissions and Electronic Information Sharing With Discharge Destination Among Older Adults

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