title: Fragmentation of Care after Surgical Discharge: Non-Index Readmission after Major Cancer Surgery.
abstract: Despite national emphasis on care coordination, little is known about how fragmentation affects cancer surgery outcomes. Our study examines a specific form of fragmentation in post-discharge care-readmission to a hospital different from the location of the operation-and evaluates its causes and consequences among patients readmitted after major cancer surgery.
  
  
  
  We used the State Inpatient Database of California (2004 to 2011) to identify patients who had major cancer surgery and their subsequent readmissions. Logistic models were used to examine correlates of non-index readmissions and to assess associations between location of readmission and outcomes, measured by in-hospital mortality and repeated readmission.
  
  
  
  Of 9,233 readmissions within 30 days of discharge after major cancer surgery, 20.0% occurred in non-index hospitals. Non-index readmissions were associated with emergency readmission (odds ratio [OR] = 2.63; 95% CI, 2.26-3.06), rural residence (OR = 1.81; 95% CI, 1.61-2.04), and extensive procedures (eg hepatectomy vs proctectomy; OR = 2.77; CI, 2.08-3.70). Mortality was higher during non-index readmissions than index readmissions independent of patient, procedure, and hospital factors (OR = 1.31; 95% CI, 1.03-1.66), but was mitigated by adjusting for conditions present at readmission (OR = 1.24; 95% CI, 0.98-1.58). Non-index readmission predicted higher odds of repeated readmission within 60 days of discharge from the first readmission (OR = 1.16; 95% CI, 1.02-1.32), independent of all covariates.
  
  
  
  Non-index readmissions constitute a substantial proportion of all readmissions after major cancer surgery. They are associated with more repeated readmissions and can be caused by severe surgical complications and increased travel burden. Overcoming disadvantages of non-index readmissions represents an opportunity to improve outcomes for patients having major cancer surgery.
authors.affiliation: Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC.
authors.forename: Chaoyi
authors.initials: C
authors.lastname: Zheng
authors.affiliation: Division of Health Care Research and Policy and Robert D and Patricia E Kern Center for the Science of HealthCare Delivery, Mayo Clinic, Rochester, MN.
authors.forename: Elizabeth B
authors.initials: EB
authors.lastname: Habermann
authors.affiliation: MedStar Health Research Institute, Washington, DC; Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC.
authors.forename: Nawar M
authors.initials: NM
authors.lastname: Shara
authors.affiliation: Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC.
authors.forename: Russell C
authors.initials: RC
authors.lastname: Langan
authors.affiliation: Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC.
authors.forename: Young
authors.initials: Y
authors.lastname: Hong
authors.affiliation: Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC.
authors.forename: Lynt B
authors.initials: LB
authors.lastname: Johnson
authors.affiliation: MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC; MedStar Health Research Institute, Washington, DC; Department of Surgery, MedStar-Georgetown University Hospital, Washington, DC. Electronic address: wba6@georgetown.edu.
authors.forename: Waddah B
authors.initials: WB
authors.lastname: Al-Refaie
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002140:California / Q000453:epidemiology; D013505:Digestive System Surgical Procedures / Q000009:adverse effects; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000453:epidemiology / Q000601:surgery*; D010351:Patient Discharge / Q000706:statistics & numerical data; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011013:Pneumonectomy / Q000009:adverse effects; D011183:Postoperative Complications; D011468:Prostatectomy / Q000009:adverse effects; D018570:Risk Assessment; D013997:Time Factors; D055815:Young Adult