Original Article

CME Article: Frequency of Care Fragmentation and Its Impact on Outcomes in Acute and Chronic Pancreatitis in a Nationally Representative Sample

Authors: Emad Qayed, MD, MPH, Ramzi Mulki, MD


Objectives: Hospitalized patients with acute and chronic pancreatitis (AP and CP) are prone to frequent readmissions to different hospitals. The rate of care fragmentation and its impact on important outcomes are unknown. The aims of this study were to evaluate the rate and predictors of care fragmentation in patients hospitalized with AP and CP using a nationally representative sample, and to analyze the impact of care fragmentation on mortality, cost, and hospital readmissions.

Methods: We identified all adult hospitalizations with a primary diagnosis of AP or CP in the 2010–2014 National Readmissions Database, which captures statewide readmissions. We calculated 30- and 90-day readmission and care fragmentation rates. Readmission to a nonindex hospital was considered care fragmentation. Logistic regression was used to determine hospital and patient factors independently associated with 30-day care fragmentation. Patients readmitted within 30 days were followed for 60 days postdischarge from the first readmission. Mortality during the first readmission, hospitalization costs, and rates of 60-day readmission were compared between those with and without care fragmentation.

Results: There were 479,427 admissions with AP and 25,513 with CP. The rates of 30- and 90-day readmissions were 13.5% and 22.9% for AP and 26.9% and 44.7%% for CP. The rates of 30- and 90-day care fragmentation were 28% and 32% for AP and 33% and 38% for CP. Younger age (younger than 45 y), male patients, length of stay <5 days, ≥4 Elixhauser comorbidities, and self-pay or Medicaid insurance were associated with increased risk of 30-day care fragmentation. Large hospital size, routine discharge, and metropolitan location were associated with lower risk. Patients who had the first readmission to a nonindex hospital had a higher mortality (2% vs 1.6%, P = 0.005), length of stay (6.5 vs 5.6 days, P < 0.0001), mean hospitalization cost ($16,731 vs $13,368, P < 0.0001), and 60-day readmission (48.4% vs 42.9%) compared with those readmitted to the index hospital.

Conclusions: In patients with AP and CP, one-third of 90-day readmissions occur at a nonindex hospital. Care fragmentation is associated with increased mortality, readmissions, and cost of care.

Posted in: Gastroenterology16

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1. Peery AF, Dellon ES, Lund J, et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 2012;143:1179-1187.e3.
2. Garg SK, Campbell JP, Anugwom C, et al. Incidence and predictors of readmissions in acute pancreatitis: a nationwide analysis. Pancreas 2018;47:46-54.
3. Krishna SG, Kamboj AK, Hart PA, et al. The changing epidemiology of acute pancreatitis hospitalizations: a decade of trends and the impact of chronic pancreatitis. Pancreas 2017;46:482-488.
4. Kozak LJ, Owings MF, Hall MJ. National Hospital Discharge Survey: 2002 annual summary with detailed diagnosis and procedure data. Vital Health Stat 13 2005;(158):1-199.
5. Shah R, Haydek C, Mulki R, et al. Incidence and predictors of 30-day readmissions in patients hospitalized with chronic pancreatitis: a nationwide analysis. Pancreatology 2018;18:386-393.
6. Centers for Medicare & Medicaid Services. Hospital Readmissions Reduction Program. https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Accessed March 6, 2020.
7. Chappidi MR, Kates M, Stimson CJ, et al. Quantifying nonindex hospital readmissions and care fragmentation after major urological oncology surgeries in a nationally representative sample. J Urol 2017;197:235-240.
8. Okafor PN, Nnadi AK, Okoli O, et al. Same- vs different-hospital readmissions in patients with cirrhosis after hospital discharge. Am J Gastroenterol 2019;114:464-471.
9. McAlister FA, Youngson E, Kaul P. Patients with heart failure readmitted to the original hospital have better outcomes than those readmitted elsewhere. J Am Heart Assoc 2017;6:e004892.
10. Qayed E, Muftah M. Frequency of hospital readmission and care fragmentation in gastroparesis: a nationwide analysis. World J Gastrointest Endosc 2018;10:200-209.
11. Healthcare Cost and Utilization Project. NRD description of data elements. https://www.hcup-us.ahrq.gov/db/nation/nrd/nrddde.jsp. Accessed July 17, 2019.
12. US Bureau of Labor Statistics. Consumer price index. http://www.bls.gov/cpi. Accessed August 10, 2017.
13. Flaks-Manov N, Shadmi E, Hoshen M, et al. Health information exchange systems and length of stay in readmissions to a different hospital. J Hosp Med 2016;11:401-406.
14. Lahewala S, Arora S, Tripathi B, et al. Heart failure: same-hospital vs. different-hospital readmission outcomes. Int J Cardiol 2019;278:186-191.
15. Rattan R, Parreco J, Lindenmaier LB, et al. Underestimation of unplanned readmission after colorectal surgery: a national analysis. J Am Coll Surg 2018;226:382-390.
16. Qayed E, Shah R, Haddad YK. Endoscopic retrograde cholangiopancreatography decreases all-cause and pancreatitis readmissions in patients with acute gallstone pancreatitis who do not undergo cholecystectomy: a nationwide 5-year analysis. Pancreas 2018;47:425-435.
17. Tsai TC, Orav EJ, Jha AK. Care fragmentation in the postdischarge period: surgical readmissions, distance of travel, and postoperative mortality. JAMA Surg 2015;150:59-64.
18. Brooke BS, Goodney PP, Kraiss LW, et al. Readmission destination and risk of mortality after major surgery: an observational cohort study. Lancet 2015;386:884-895.
19. Hussain T, Chang HY, Veenstra CM, et al. Fragmentation in specialist care and stage III colon cancer. Cancer 2015;121:3316-3324.