title: Adverse Effect of Post-Discharge Care Fragmentation on Outcomes after Readmissions after Liver Transplantation.
abstract: BACKGROUND
  Post-discharge surgical care fragmentation is defined as readmission to any hospital other than the hospital at which surgery was performed. The objective of this study was to assess the impact of fragmented readmissions within the first year after orthotopic liver transplantation (OLT).
  
  
  METHODS
  The Healthcare Cost and Utilization Project State Inpatient Databases for Florida and California from 2006 to 2011 were used to identify OLT patients. Post-discharge fragmentation was defined as any readmission to a non-index hospital, including readmitted patients transferred to the index hospital after 24 hours. Outcomes included adverse events, defined as 30-day mortality and 30-day readmission after a fragmented readmission. All statistical analyses considered a hierarchical data structure and were performed with multilevel, mixed-effects models.
  
  
  RESULTS
  We analyzed 2,996 patients with 7,485 readmission encounters at 299 hospitals; 1,236 (16.5%) readmissions were fragmented. After adjustment for age, sex, readmission reason, index liver transplantation cost, readmission length of stay, number of previous readmissions, and time from transplantation, post-discharge fragmentation increased the odds of both 30-day mortality (odds ratio [OR] = 1.75; 95% CI 1.16 to 2.65) and 30-day readmission (OR = 2.14; 95% CI 1.83 to 2.49). Predictors of adverse events after a fragmented readmission included increased number of previous readmissions (OR = 1.07; 95% CI 1.01 to 1.14) and readmission within 90 days of OLT (OR = 2.19; 95% CI 1.61 to 2.98).
  
  
  CONCLUSIONS
  Post-discharge fragmentation significantly increases the risk of both 30-day mortality and subsequent readmission after a readmission in the first year after OLT. More inpatient visits before a readmission and less time elapsed from index surgery increase the odds of an adverse event after discharge from a fragmented readmission. These parameters could guide transfer decisions for patients with post-discharge fragmentation.
authors.affiliation: Department of Surgery, Loyola University Medical Center, Maywood, IL One:MAP Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, IL Department of Medicine, Section of Hepatology, Loyola University Medical Center, Maywood, IL.
authors.forename: Anai N
authors.initials: AN
authors.lastname: Kothari
authors.forename: Veronica M
authors.initials: VM
authors.lastname: Loy
authors.forename: Sarah A
authors.initials: SA
authors.lastname: Brownlee
authors.forename: Yoshiki
authors.initials: Y
authors.lastname: Ezure
authors.forename: Colleen
authors.initials: C
authors.lastname: Schaidle-Blackburn
authors.forename: Scott J
authors.initials: SJ
authors.lastname: Cotler
authors.forename: Diego
authors.initials: D
authors.lastname: di Sabato
authors.forename: Paul C
authors.initials: PC
authors.lastname: Kuo
authors.forename: Amy D
authors.initials: AD
authors.lastname: Lu
mesh_terms: D002140:California; D003430:Cross-Sectional Studies; D005260:Female; D005431:Florida; D017052:Hospital Mortality; D006801:Humans; D016031:Liver Transplantation / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000401:mortality* / Q000628:therapy*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors