Better Survival when Postop Problems are Treated at Original Hospital

By Lisa Rapaport

(Reuters Health) - When patients have complications after surgery, it's best to go back to the hospital where the operation was done, a new study suggests.

Patients who go instead to a hospital that didn't do the original operation have a higher risk of death, the researchers found.

"Even when we accounted for how sick patients were, what type of hospital they went to, and how far they traveled for care, we still found that patients had higher mortality rates when they had post-operative care at a different facility," said the study's lead author, Dr. Thomas Tsai of Harvard School of Public Health and Brigham and Women's Hospital in Boston.

Tsai and colleagues examined data on more than 93,000 Medicare patients who were rehospitalized for complications after major surgery from January 2009 through November 2011.

The surgeries covered by the study are common among the elderly: coronary artery bypass grafting, pulmonary lobectomy, abdominal aortic aneurysm repair, colectomy, and hip replacement.

One in four patients got readmitted to a different hospital - not the one where the operation was performed, the study found.

Even when the researchers accounted for how far patients lived from the original hospital, postsurgical care fragmentation was associated with a substantially higher risk of death.

After adjusting for all variables, including type of hospitals involved and the distances to both hospitals, patients were more likely to die within 30 days after surgery if they had complications treated at a different hospital.

Specifically, those readmitted to the original hospital had a mortality rate of 4.1%, compared with 5.8% for those admitted to a different hospital, which translates to a 41% difference.

"The implication is that we need to pay more attention to the post-discharge recovery period," Tsai said in a telephone interview. "We all want to avoid a 2 a.m. ambulance ride to a hospital that may not know our medical history or specialize in our type of care. We have to do more to help patients plan for these contingencies before we send them home from surgery the first time."

Generally, patients readmitted to a different hospital lived farther from the original facility than the one where they went for follow-up care, the researchers wrote online December 3 in JAMA Surgery. And, they were less likely to live in urban areas.

One limitation of the study was the method of measuring the distances that patients traveled for care. The researchers used zip codes for the hospitals and patient homes, and didn`t account for variations in travel times.

Another shortcoming was the use of claims data, which is designed for billing purposes and can exclude many specifics about the care patients receive, the researchers said.

Dr. Stephen F. Jencks, an independent healthcare safety consultant, told Reuters Health by phone, "The real question this new research raises is why people are turning up at a different hospital. Is it because they had a true emergency and they called the surgery department at the hospital that treated them and were told to rush to the nearest emergency room? Or is it because they felt bad after surgery and called 911 because they didn't have a plan in place for who to contact and the ambulance just took them to the nearest hospital?"

The second scenario could be prevented with better planning, said Jencks, who was the lead author on a seminal paper on readmissions published in 2009 in the New England Journal of Medicine (https://bit.ly/1ytG37U).

Patients shouldn't leave the hospital without a follow-up appointment scheduled and clear directions on who to call for help when complications arise, he said.

"The notion of hospital discharge has to change from a hand-off where you lose all responsibility for the patient to a transfer from one physician to another," Jencks said.

SOURCE: https://bit.ly/1vwRuEM

JAMA Surgery 2014.

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