Division of General Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City.
Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City.
JAMA Surg. 2020 Sep 1;155(9):841-848. doi: 10.1001/jamasurg.2020.2348.
Care fragmentation at time of readmission after emergency general surgery (EGS) is associated with high mortality; however, the factors underlying this finding remain unclear.
To identify patient and hospital factors associated with increased mortality among patients after EGS readmitted within 30 days of discharge to a nonindex hospital.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study using the 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database. Participants were all adult patients (18 years or older) who underwent 1 of the 15 most common EGS procedures in the United States from January 1 to November 30, 2014, and survived to discharge. The dates of analysis were October through December 2019.
Thirty-day readmission to a hospital other than that of the index surgical procedure. The study examined the association of interventions during readmission, change in hospital resource level, and severity of patient illness during readmission.
Ninety-day inpatient mortality.
In total, 71 944 patients who underwent EGS (mean [SD] age, 59.0 [18.3] years; 53.5% [38 487 of 71 944] female) were readmitted within 30 days of discharge, of whom 10 495 (14.6%) were readmitted to a nonindex hospital. Compared with patients readmitted to index hospitals, patients readmitted to nonindex hospitals were more likely to be readmitted to hospitals with low annual EGS volume (33.5% vs 25.6%, P < .001) and be in the top half of illness severity profile (37.2% vs 31.2%, P < .001). Overall 90-day mortality was higher in the patients readmitted to nonindex hospitals (6.1% vs 4.3%, P < .001). When adjusted for baseline patient and hospital characteristics, care fragmentation was independently associated with increased mortality (adjusted odds ratio [aOR], 1.36; 95% CI, 1.17-1.58; P < .001). After adjustment for interventions performed during readmission, change in EGS hospital volume level, and severity of patient illness, care fragmentation was no longer independently associated with mortality (aOR, 1.05; 95% CI, 0.88-1.26; P = .58). In this complete model, severity of illness was the strongest risk factor of mortality during readmission.
In this cohort study of adult patients who require rehospitalization after EGS, 14.6% are readmitted to a hospital other than where the index procedure was performed. Although the overall mortality rate is higher for this population, the excess mortality appears to be primarily associated with severity of patient illness at time of readmission. These data underscore the need to develop systems of care to rapidly triage patients to hospitals best equipped to manage their condition.
急诊普通外科（EGS）后再入院时的护理碎片化与死亡率较高有关；然而，这一发现的根本原因仍不清楚。
确定与 EGS 后 30 天内出院至非索引医院再入院的患者死亡率增加相关的患者和医院因素。
设计、地点和参与者：使用 2014 年医疗保健成本和利用项目全国再入院数据库进行回顾性队列研究。参与者均为在美国接受 15 种最常见 EGS 手术之一的成年患者（18 岁或以上），并存活至出院。分析日期为 2019 年 10 月至 12 月。
30 天内再入院至索引手术以外的医院。该研究检查了再入院期间的干预、医院资源水平变化和再入院时患者病情严重程度的相关性。
90 天住院患者死亡率。
共有 71944 名接受 EGS 的患者（平均[SD]年龄，59.0[18.3]岁；53.5%[38487/71944]为女性）在出院后 30 天内再次入院，其中 10495 名（14.6%）被再入院至非索引医院。与再入院至索引医院的患者相比，再入院至非索引医院的患者更有可能被再入院至年度 EGS 量较低的医院（33.5%比 25.6%，P<0.001），并且处于疾病严重程度分布的前半部分（37.2%比 31.2%，P<0.001）。非索引医院再入院患者的总体 90 天死亡率较高（6.1%比 4.3%，P<0.001）。在调整了基线患者和医院特征后，护理碎片化与死亡率升高独立相关（调整后的优势比[OR]，1.36；95%CI，1.17-1.58；P<0.001）。在调整了再入院期间进行的干预、EGS 医院容量水平变化和患者病情严重程度后，护理碎片化与死亡率不再独立相关（调整后的 OR，1.05；95%CI，0.88-1.26；P=0.58）。在这个完整的模型中，疾病严重程度是再入院期间死亡的最强危险因素。
在这项对需要接受 EGS 后再次住院的成年患者进行的队列研究中，有 14.6%的患者被再入院至非索引手术的医院。尽管该人群的总体死亡率较高，但过高的死亡率似乎主要与再入院时患者病情严重程度有关。这些数据强调需要开发护理系统，以便迅速将患者分诊至最能治疗其病情的医院。
