Long-term Deleterious Impact of Surgeon Care Fragmentation After Colorectal Surgery on Survival: Continuity of Care Continues to Count.

Abstract

Surgical care fragmentation at readmission impacts short-term outcomes. However, the long-term impact of surgical care fragmentation is unknown. The purpose was to evaluate the impact of surgical care fragmentation, encompassing both surgeon and hospital care, at readmission after colorectal surgery on 1-year survival. This was a retrospective cohort study. The study included patients undergoing colorectal resection in New York State from 2004 to 2014. Included were 20,016 patients undergoing colorectal resection who were readmitted within 30 days of discharge and categorized by source-of-care fragmentation. Each readmission was classified by the source of fragmentation: readmission to the index hospital and managed by another provider, readmission to another hospital by the index surgeon, and readmission to another hospital by another provider. Patients readmitted to the index hospital and managed by the index surgeon served as controls. One-year overall survival and 1-year colorectal cancer-specific survival were the outcomes measured. After propensity adjustment, surgeon care fragmentation was independently associated with decreased survival. In comparison with patients without surgical care fragmentation (patients readmitted to the index hospital and managed by the index surgeon), patients readmitted to the index hospital and managed by another provider had over a 2-fold risk (HR, 2.33; 95% CI, 2.10-2.60) and patients readmitted to another hospital by another provider had almost a 2-fold risk (HR, 1.91; 95% CI, 1.63-2.25) of 1-year mortality. Among 9545 patients with a colorectal cancer diagnosis, surgical care fragmentation was once again associated with decreased survival with patients readmitted to the index hospital and managed by another provider having a HR of 2.12 (95% CI, 1.76-2.56) and patients readmitted to another hospital by another provider having a HR of 1.57 (95% CI, 1.17-2.11) compared with patients readmitted to the index hospital and managed by the index surgeon. Limitations include possible miscoding of data, retrospective design, and selection bias. After accounting for patient, index hospital, index surgeon, and readmission factors, there is a significant 2-fold decrease in survival associated with surgeon care fragmentation regardless of hospital continuity. See Video Abstract at http://links.lww.com/DCR/A431.