title: Care fragmentation in the postdischarge period: surgical readmissions, distance of travel, and postoperative mortality.
abstract: OBJECTIVE
  Despite policies aimed at incentivizing clinical integration, few data exist on whether fragmentation of care is associated with worse outcomes for elderly patients undergoing major surgery.
  
  
  OBJECTIVE
  To determine whether postdischarge surgical care fragmentation is associated with worse outcomes and whether distances between hospitals explain differences in patient outcomes.
  
  
  METHODS
  We used the 100% Medicare inpatient file for claims from January 1, 2009, through November 30, 2011. Data on hospital structural features, including zip code of location, were obtained from the 2011 American Hospital Association Annual Survey. We identified patients who underwent coronary artery bypass grafting, pulmonary lobectomy, endovascular abdominal aortic aneurysm repair, open abdominal aortic aneurysm repair, colectomy, and hip replacement.
  
  
  METHODS
  Thirty-day surgical mortality.
  
  
  RESULTS
  A total of 93 062 patients who underwent the surgical procedures of interest were subsequently readmitted within 30 days of discharge; 23 278 of these patients (25.0%) were readmitted to a hospital other than the one where their procedure was performed. Patients who were readmitted to a different hospital generally lived farther from the index hospital than those who were readmitted to the index hospital (20.7 vs 7.4 miles, P < .001). We found large state-level variations in the proportion of surgical patients who were readmitted elsewhere. Patients readmitted to a different hospital that was the same distance from their home as the index hospital had 48% higher odds of mortality (odds ratio, 1.48; 95% CI, 1.24-1.78; P < .001) than patients who were admitted to the index hospital.
  
  
  CONCLUSIONS
  Of older US patients undergoing major surgery, 1 in 4 is readmitted to a hospital other than the one where the initial operation was performed. Even taking distance traveled into account, postsurgical care fragmentation is associated with a substantially higher risk of death. Focusing on clinical integration may improve outcomes for older US patients undergoing complex surgery.
authors.affiliation: Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts2Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Thomas C
authors.initials: TC
authors.lastname: Tsai
authors.affiliation: Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts4Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: E John
authors.initials: EJ
authors.lastname: Orav
authors.affiliation: Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts4Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts5Veterans Affairs Boston Healthcare System, Boston, Massachusetts.
authors.forename: Ashish K
authors.initials: AK
authors.lastname: Jha
mesh_terms: D000368:Aged; D015331:Cohort Studies; D003266:Continuity of Patient Care / Q000706:statistics & numerical data*; D016208:Databases, Factual; D005260:Female; D015577:Geriatric Assessment / Q000379:methods; D019538:Health Care Surveys; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D020380:Needs Assessment; D010351:Patient Discharge / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000401:mortality* / Q000503:physiopathology / Q000628:therapy; D011785:Quality Assurance, Health Care; D012189:Retrospective Studies; D018570:Risk Assessment; D013514:Surgical Procedures, Operative / Q000009:adverse effects / Q000379:methods / Q000401:mortality*; D016019:Survival Analysis; D014195:Travel; D014481:United States