title: Readmission destination and risk of mortality after major surgery: an observational cohort study.
abstract: BACKGROUND
  Hospital readmissions are common after major surgery, although it is unknown whether patients achieve improved outcomes when they are readmitted to, and receive care at, the index hospital where their surgical procedure was done. We examined the association between readmission destination and mortality risk in the USA in Medicare beneficiaries after a range of common operations.
  
  
  METHODS
  By use of claims data from Medicare beneficiaries in the USA between Jan 1, 2001, and Nov 15, 2011, we assessed patients who needed hospital readmission within 30 days after open abdominal aortic aneurysm repair, infrainguinal arterial bypass, aortobifemoral bypass, coronary artery bypass surgery, oesophagectomy, colectomy, pancreatectomy, cholecystectomy, ventral hernia repair, craniotomy, hip replacement, or knee replacement. We used logistic regression models incorporating inverse probability weighting and instrumental variable analysis to measure associations between readmission destination (index vs non-index hospital) and risk of 90 day mortality for patients who underwent surgery who needed hospital readmission.
  
  
  RESULTS
  9,440,503 patients underwent one of 12 major operations, and the number of patients readmitted or transferred back to the index hospital where their operation was done varied from 186,336 (65·8%) of 283,131 patients who were readmitted after coronary artery bypass grafting, to 142,142 (83·2%) of 170,789 patients who were readmitted after colectomy. Readmission was more likely to be to the index hospital than to a non-index hospital if the readmission was for a surgical complication (189,384 [23%] of 834,070 patients readmitted to index hospital vs 36,792 [13%] of 276,976 patients readmitted non-index hospital, p<0·0001). Readmission to the index hospital was associated with a 26% lower risk of 90 day mortality than was readmission to a non-index hospital, with inverse probability weighting used to control for selection bias (odds ratio [OR] 0·74, 95% CI 0·66-0·83). This effect was significant (p<0·0001) for all procedures in inverse probability-weighted models, and was largest for patients who were readmitted after pancreatectomy (OR 0·56, 95% CI 0·45-0·69) and aortobifemoral bypass (OR 0·69, 95% CI 0·61-0·77). By use of hospital-level variation among regional index hospital readmission rates as an instrument, instrumental variable analysis showed that the patients with the highest probability of returning to the index hospital had 8% lower risk of mortality (OR 0·92 95% CI 0·91-0·94) than did patients who were less likely to be readmitted to the index hospital.
  
  
  CONCLUSIONS
  In the USA, patients who are readmitted to hospital after various major operations consistently achieve improved survival if they return to the hospital where their surgery took place. These findings might have important implications for cost-effectiveness-driven regional centralisation of surgical care.
  
  
  BACKGROUND
  None.
authors.affiliation: Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA; IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA. Electronic address: benjamin.brooke@hsc.utah.edu.
authors.forename: Benjamin S
authors.initials: BS
authors.lastname: Brooke
authors.affiliation: Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
authors.affiliation: Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA.
authors.forename: Larry W
authors.initials: LW
authors.lastname: Kraiss
authors.affiliation: The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH, USA.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Gottlieb
authors.affiliation: Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA; IDEAS Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
authors.forename: Matthew H
authors.initials: MH
authors.lastname: Samore
authors.affiliation: Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT, USA.
authors.forename: Samuel R G
authors.initials: SR
authors.lastname: Finlayson
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003266:Continuity of Patient Care / Q000706:statistics & numerical data; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000401:mortality; D019637:Orthopedic Procedures / Q000401:mortality; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000401:mortality*; D018570:Risk Assessment; D012959:Socioeconomic Factors; D019616:Thoracic Surgical Procedures / Q000401:mortality; D014481:United States / Q000453:epidemiology; D014656:Vascular Surgical Procedures / Q000401:mortality