• Thomas C Tsai, E John Orav, and Ashish K Jha.
• Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts2Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
• JAMA Surg. 2015 Jan 1;150(1):59-64.

ImportanceDespite policies aimed at incentivizing clinical integration, few data exist on whether fragmentation of care is associated with worse outcomes for elderly patients undergoing major surgery.ObjectiveTo determine whether postdischarge surgical care fragmentation is associated with worse outcomes and whether distances between hospitals explain differences in patient outcomes.Design, Setting, And ParticipantsWe used the 100% Medicare inpatient file for claims from January 1, 2009, through November 30, 2011. Data on hospital structural features, including zip code of location, were obtained from the 2011 American Hospital Association Annual Survey. We identified patients who underwent coronary artery bypass grafting, pulmonary lobectomy, endovascular abdominal aortic aneurysm repair, open abdominal aortic aneurysm repair, colectomy, and hip replacement.Main Outcomes And MeasuresThirty-day surgical mortality.ResultsA total of 93 062 patients who underwent the surgical procedures of interest were subsequently readmitted within 30 days of discharge; 23 278 of these patients (25.0%) were readmitted to a hospital other than the one where their procedure was performed. Patients who were readmitted to a different hospital generally lived farther from the index hospital than those who were readmitted to the index hospital (20.7 vs 7.4 miles, P < .001). We found large state-level variations in the proportion of surgical patients who were readmitted elsewhere. Patients readmitted to a different hospital that was the same distance from their home as the index hospital had 48% higher odds of mortality (odds ratio, 1.48; 95% CI, 1.24-1.78; P < .001) than patients who were admitted to the index hospital.Conclusions And RelevanceOf older US patients undergoing major surgery, 1 in 4 is readmitted to a hospital other than the one where the initial operation was performed. Even taking distance traveled into account, postsurgical care fragmentation is associated with a substantially higher risk of death. Focusing on clinical integration may improve outcomes for older US patients undergoing complex surgery.

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