Failure to Rescue in Emergency General Surgery: Impact of Fragmentation of Care

OBJECTIVE:Compare emergency general surgery (EGS) patient outcomes following index and non-index hospital readmissions, and explore predictive factors for non-index readmission. BACKGROUND:Readmission to a different hospital leads to fragmentation of care. The impact of non-index readmsision on patient outcomes following EGS is not well established. METHODS:The Nationwide Readmissions Database (2017) was queried for adult patients readmitted following an EGS procedure. Patients were stratified and propensity-matched according to readmission destinationindex vs. non-index hospital. Outcomes were failure to rescue (FTR), mortality, number of subsequent readmissions, overall hospital LOS, and total costs. Hierarchical logistic regression was performed to account for clustering effect within hospitals and adjusting for patient- and hospital-level potential confounding factors. RESULTS:A total of 471,570 EGS patients were identified, of which 79,127 (16.8%) were readmitted within 30 daysindex hospital (61,472; 77.7%) vs. non-index hospital (17,655; 22.3%). Following 1:1 propensity matching, patients with non-index readmission had higher rates of FTR (5.6% vs. 4.3%; p < 0.001), mortality (2.7% vs. 2.1%; p < 0.001), and overall hospital costs (in $1000; 37 [27–64] vs. 28 [21–48]; p < 0.001). Non-index readmission was independently associated with higher odds of FTR (aOR 1.18 [1.03–1.36]; p < 0.001). Predictors of non-index readmission included top quartile for zip code median household income (1.35 [1.08–1.69]; p < 0.001), fringe county residence (1.08 [1.01–1.16]; p = 0.049), discharge to a skilled nursing facility (1.28 [1.20–1.36]; p < 0.001), and leaving AMA (2.32 [1.81–2.98]; p < 0.001). CONCLUSION:One in five readmissions after EGS occur at a different hospital. Non-index readmission carries a heightened risk of FTR. LEVEL OF EVIDENCE:Level III Prognostic STUDY TYPE:Prognostic