Potential ways to improve survival for cancer patients who receive fragmented care

Key takeaways

• Pancreatic, liver, bile duct, and stomach cancer operations are inherently complex and initially often take place at large cancer centers where surgical teams perform a large volume of procedures.
• Readmission to a different hospital from where patients had these operations initially performed markedly increases death risk.
• There are ways to address care fragmentation with newly identified risk factors for readmission; cancer hospitals should seek to determine safe sites of care for readmissions after these types of operations.

CHICAGO: New research reveals that 28 percent of patients who are readmitted to the hospital with complications after surgical removal of pancreatic, liver, or stomach cancer go to a different hospital for follow-up care. This fragmentation of health care is associated with a 50 percent increased odds of dying, according to a study published online by the Journal of the American College of Surgeons ahead of print.

The researchers from Washington University School of Medicine, St. Louis, sought to identify patient and hospital characteristics that raise the death risk during readmission to an outside hospital--one other than the original hospital where the operation was performed, referred to as the index hospital. Using the state inpatient databases from the federal Healthcare Cost and Utilization Project, the investigators evaluated data from adults undergoing surgical removal of liver, pancreatic, bile duct, and gastric cancers beginning in 2006. Patients lived in California, Florida, or New York.

A total of 31,256 patients were discharged from the hospital postoperatively, and 7,536, or 24 percent, were readmitted to any hospital in the first three months after discharge. Among readmitted patients, 28 percent, or 2,123, went to an outside hospital. As in prior research,¹ the study findings showed a higher death rate for those patients versus patients returning to the index hospital: 8 percent versus 5.4 percent.

Centralized cancer care not always aligned with readmissions

Most operations to remove liver, pancreatic, bile duct or stomach cancers take place at regional medical centers where surgical teams perform a large volume of these complex procedures.² These operations have high rates of complications and readmissions, and large surgical volume is associated with improved outcomes.

"This centralization of cancer surgical care means many patients travel great distances to undergo their operations and therefore may need to present instead to a hospital closer to home if they experience complications. That hospital may not have access to the patient's surgical records or even the specialists to care for patients with such complex medical problems," said the study's lead investigator, David G. Brauer, MD, MPHS. "Patients who experience this type of care fragmentation die more often than patients who don't experience care fragmentation. Convenience of care should not come at the expense of getting the appropriate care."

Readmission risk factors

The researchers identified the following risk factors for readmission to an outside hospital:

• Longer time since the first discharge: a median, or middle value, of 25 days versus 12 days for patients readmitted to the index hospital
• Living much farther from the index hospital than other readmitted patients: 24 miles versus 10 miles
• Living in a rural area, older age, and white race*

(*The reason for a racial disparity will be the subject of future study but could be because white patients make up a larger proportion of rural populations compared with more metropolitan populations in the states studied.)

Ways to address fragmented care

Based on identified risk factors from this study, Dr. Brauer recommended the following ways to reduce care fragmentation for these patients:

• Index hospitals should identify patients who have the "clear" risk factors found in this study, such as living far away and older age, and should determine safe sites of care for hospital readmission.
• Surgeons might consider more frequent follow-up and telehealth visits with at-risk patients.
• At-risk patients should ask their surgeons where they should go if they have a complication.
• When patients choose an outside hospital for readmission, they should ask the treating physicians to communicate with their surgeons.
• If there is any concern regarding the patient, the readmission hospital should divert care back to the surgeon or another higher-acuity hospital.

Care fragmentation is complex

The investigators noted finding characteristics of readmission hospitals that resulted in fewer in-hospital deaths, even at outside hospitals. These factors included teaching hospitals and hospitals that performed at least 100 of these cancer operations annually. However, Dr. Brauer said multivariable statistical analyses found no significant mortality association with these hospital characteristics, indicating the reasons for care fragmentation are complex.

In addition, Dr. Brauer noted geographical distance was a barrier to care access. However, neither greater distance from the index hospital nor longer time between discharge and readmission had an association with more deaths, suggesting other factors contributed to the mortality difference at outside hospitals. "Our analysis shows that returning to the original surgeon and hospital to manage complications, while preferable, may not always be an absolute necessity," Dr. Brauer said.

He concluded: "There is a suggestion that certain hospital-level characteristics, such as high surgical volume, may make an outside facility safer for postoperative readmission care. It also depends on the specifics of the patient and severity of postoperative complication, barriers to access care, and the treating physicians, including their familiarity with the patient's cancer operation."

Dr. Brauer led the research team while a surgical resident at Washington University School of Medicine, St. Louis. He is now a clinical fellow in surgical oncology at Memorial Sloan-Kettering Cancer Center, New York City. Other study authors are Ningying Wu, PhD; Matthew R. Keller, MS; Sarah A. Humble, MS; Ryan C. Fields, MD, FACS; Chet W. Hammill, MD, MCR, FACS; William G. Hawkins, MD, FACS; Graham A. Colditz, MD, DrPH; and Dominic E. Sanford, MD, MPHS, all from Washington University School of Medicine, St. Louis.

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This research received funding from the National Cancer Institute (Grant number T32CA009621), National Institutes of Health (NIH). Dr. Brauer was supported partly by a grant from the National Center for Advancing Translational Sciences of the NIH (UL1TR002345) and a grant through the Agency for Healthcare Research and Quality (R24HS19455).

The authors report no relevant disclosures.

"FACS" designates that a surgeon is a Fellow of the American College of Surgeons.

This study was presented March 7, 2020, at the annual meeting of the Americas Hepato-Pancreato-Biliary Association in Miami.

Citation: Care Fragmentation and Mortality in Readmission after Surgery for Hepatopancreatobiliary and Gastric Cancer: A Patient-Level and Hospital-Level Analysis of the Healthcare Cost and Utilization Project Administrative Database. Journal of the American College of Surgeons. DOI: 10.1016/j.jamcollsurg.2021.03.017.

1: Beal EW, Bagante F, Paredes A, et al. Index versus non-index readmission after hepato-pancreato-biliary surgery: where do patients go to be readmitted? J Gastrointest Surg. 2019;23(4):702-711.

2: Colavita PD, Tsirline VB, Belyansky I, et al. Regionalization and outcomes of hepato-pancreato-biliary cancer surgery in USA. J Gastrointest Surg. 2014 Mar;18(3):532-541.

About the American College of Surgeons

The American College of Surgeons is a scientific and educational organization of surgeons that was founded in 1913 to raise the standards of surgical practice and improve the quality of care for surgical patients. The College is dedicated to the ethical and competent practice of surgery. Its achievements have significantly influenced the course of scientific surgery in America and have established it as an important advocate for all surgical patients. The College has more than 82,000 members and is the largest organization of surgeons in the world. For more information, visit http://www.facs.org.

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