Hospital Factors Associated with Fragmentation of Care in Emergency General Surgery: Less Continuity, Higher Mortality.

Background: Fragmentation of Care (FOC) is defined as re-admission to a non-index hospital and may be associated with worse outcomes among Emergency General Surgery (EGS) patients. This study assesses hospital characteristics associated with patterns of FOC in EGS patients and the effect of interfacility transfer after FOC on mortality.

Methods: Using the Nationwide Readmissions Database 2019, we included patients ≥ 18 years old who were admitted to an index hospital with an EGS diagnosis managed operatively, and had an emergency readmission within 90 days. Patients were classified into four patterns of fragmentation: no FOC, FOC, de-fragmented care (readmitted to a non-index hospital, then transferred back), and hyper-fragmented care (readmitted to a non-index hospital, then transferred to another non-index hospital). Patient severity of illness was defined using All Patient Refined Diagnosis Related Groups (APR-DRG) severity of illness categories. Multivariable logistic regression analyses were used to identify hospital characteristics associated with FOC and the effect of FOC on 90-day mortality.

Results: Out of 26,100 patients included, 82.5% had no FOC, 16.4% had FOC, 0.3% had de-fragmented care, and 0.9% had hyper-fragmented care. Index hospital characteristics associated with FOC were small size (by number of beds), private investor or government-owned, and low EGS volumes. Controlling for hospital and patient characteristics, FOC (OR 1.22; 95% CI 1.01-1.47; p=0.045) was significantly associated with increased 90-day mortality, driven by those with major or extreme APR-DRG severity of illness (OR 1.36; 95% CI 1.13-1.64; p=0.001).

Conclusion: FOC is associated with worse outcomes in EGS patients. This study highlights the impact of FOC and the hospital characteristics associated with FOC, highlighting the need for further investigation into EGS systems of care.