title: Surgical readmissions: results of integrating pre-, peri- and postsurgical care.
abstract: To explore the feasibility of recruiting surgical oncology patients and implementing a surgical integrated discharge (SID) programme led by advanced practice providers (APP).
  
  
  
  Burden of illness and complexity of treatment regimen makes it challenging for surgical oncology patients to participate in research. Surgical oncology nurses may have the necessary expertise to overcome this problem.
  
  
  
  Controlled longitudinal prospective observational study.
  
  
  
  The SID programme included multidisciplinary care coordination, regular communication among APPs and proactive postdischarge follow-up. Administrative databases were used to identify matching historical controls (n= 113) and evaluate programme outcomes.
  
  
  
  Patient enrolment was 84%. The main challenges for the programme implementation included incompatible health information systems among care settings, variation in care processes among hospital units and need for provider behaviour change.
  
  
  
  Most surgical oncology patients are willing to participate in outcomes programmes when contacted by familiar clinical personnel but programme implementation requires leadership support, communication among care teams and training and infrastructure.
authors.affiliation: Surgical Health Outcomes & Research Enterprise (SHORE) Rochester New York USA; Department of Surgery University of Rochester Medical Center Rochester New York USA.
authors.forename: Katia
authors.initials: K
authors.lastname: Noyes
authors.affiliation: Department of Urology University of Rochester Medical Center Rochester New York USA.
authors.forename: Janet
authors.initials: J
authors.lastname: Baack-Kukreja
authors.affiliation: Department of Urology University of Rochester Medical Center Rochester New York USA.
authors.forename: Edward M
authors.initials: EM
authors.lastname: Messing
authors.affiliation: Department of Surgery University of Rochester Medical Center Rochester New York USA.
authors.forename: Luke
authors.initials: L
authors.lastname: Schoeniger
authors.affiliation: Department of Surgery University of Rochester Medical Center Rochester New York USA.
authors.forename: Eva
authors.initials: E
authors.lastname: Galka
authors.affiliation: Surgical Health Outcomes & Research Enterprise (SHORE) Rochester New York USA.
authors.forename: Wei
authors.initials: W
authors.lastname: Pan
authors.affiliation: Department of Biostatics and Computational Biology University of Rochester Medical Center Rochester New York USA.
authors.forename: Cai
authors.initials: C
authors.lastname: Xueya
authors.affiliation: Surgical Health Outcomes & Research Enterprise (SHORE) Rochester New York USA; Department of Surgery University of Rochester Medical Center Rochester New York USA.
authors.forename: Fergal J
authors.initials: FJ
authors.lastname: Fleming
authors.affiliation: Surgical Health Outcomes & Research Enterprise (SHORE) Rochester New York USA; Department of Surgery University of Rochester Medical Center Rochester New York USA.
authors.forename: John Rt
authors.initials: JR
authors.lastname: Monson
authors.affiliation: Department of Medicine, Hematology/Oncology Wilmot Cancer Institute University of Rochester Medical Center Rochester New York USA.
authors.forename: Supriya G
authors.initials: SG
authors.lastname: Mohile
authors.affiliation: Lahey Hospital & Medical Center Burlington Massachusetts USA.
authors.forename: Todd
authors.initials: T
authors.lastname: Francone
keywords: Discharge process; integrated care; multidisciplinary care; readmission; surgical outcomes