Patients with complications after major surgery are 26% more likely to survive if they return to the hospital where they had their operation, researchers find.
Patients with complications after major surgery have better survival odds if they're readmitted to the same hospital where the surgery was performed, throwing into doubt the assumption that traveling long distances to high-volume hospitals necessarily leads to the best outcomes.
"There's a trade-off involved," says lead study author Benjamin Brooke, MD, PhD assistant professor of surgery at the University of Utah and director of the Utah Intervention Quality and Implementation Research (U-INQUIRE) group.
"Sure, you might get better surgical outcomes from going to a high-volume hospital initially," he says. But "our data suggests that there is a potential downside to that."
Benjamin Brooke |
The observational cohort study of more than 9 million Medicare patients, published in The Lancet, found that patients with complications after major surgery are 26% more likely to survive if they return to the hospital where they had their operation compared to those readmitted to a different hospital.
The findings suggest the importance of continuity of care. "Having the familiarity with that patient was more important than the fact that they did a lot of operations," Brooke says.
The researchers used Medicare claims data from between January 1, 2001, and November 15, 2011, to assess patients who needed hospital readmission within 30 days after 12 different procedures:
- Open abdominal aortic aneurysm repair
- Infrainguinal arterial bypass
- Aortobifemoral bypass
- Coronary artery bypass surgery
- Oesophagectomy
- Colectomy
- Pancreatectomy
- Cholecystectomy
- ventral hernia repair
- Craniotomy
- Hip replacement
- Knee replacement
"The perception is [that] when complications occur after a major operation, it doesn't really matter where patients go," Brooke says. Instead the emphasis is placed on where patients have their initial procedure.
Although Brooke says he and his team hypothesized that patients would get better outcomes if they went to the same hospital, "we were fairly surprised that it was the same across all operations at the same level," even after adjusting for hospital volume.
Although the reimbursement trend might be toward centers of excellence and regionalized surgery, it's intuitive that continuity of care would also be a critical factor.
"It makes sense that if you meet a patient, you learn the patient's medical history, you perform the operation, you're very familiar with that patient's anatomy," Brooke says. "You're the same physician who already has all of that in-depth, contextual known of that patient… having that familiarity with that patient is what drives a lot of the mortality benefit in this study."
Continuity of Care
Researchers also found that having the same surgeon taking care of patients for surgery and readmission provided the greatest mortality benefit.
"That really emphasizes this whole concept of continuity of care," Brooke says.
There are a couple of next steps for providers and policy makers, Brooke says. At the local level, the takeaway is implementing a change in how patients are triaged if they have complications during the post-op period.
If a patient is stable, ambulance companies could make efforts to take him back to the index hospital where he had his surgery. Or if a patient shows up in a different ED, the ED team should make every effort to get that patient back to the index hospital. Ideally, there would be an automated system of initiating this transfer process.
"By showing the results of the data that we have, maybe we can influence the decisions," Brooke says.
At the policy level, Brooke says there should be plans in place to keep surgical patients who do travel for surgery near the index hospital for a few weeks post-op, especially since the majority of readmissions occur within the first two weeks after surgery. For instance, a program could provide affordable lodging so patients can have their first post-op visit with their own surgical team.
Brooke says he's not debating the value of high-quality operations, but "if we set up these programs to regionalize major surgery, we to need have a strategy to account for these complications that occur."
Alexandra Wilson Pecci is an editor for HealthLeaders.
