National frequency, trends, and healthcare burden of care fragmentation in readmissions for end-stage liver disease in the USA

BACKGROUND: End-stage liver disease (ESLD) patients have frequent readmissions to the same facility or a different hospital (care fragmentation). Care fragmentation results in care delivery from an unfamiliar clinical team or setting, a potential source of suboptimal clinical outcomes. We examined the occurrence, trends, and association between care fragmentation and outcomes during readmissions for ESLD. METHODS: From the Nationwide Readmissions Database (January to September 2010-2014), we followed adult (age ≥18 years) hospitalizations for ESLD who were discharged alive for 90 days. During 30- and 90-day readmissions, we calculated the frequency, determinants, and clinical outcomes of care fragmentation (SAS 9.4). RESULTS: Of the 67,480 ESLD hospitalizations surviving at discharge from 2010-2014, 35% (23,872) and 52% (35,549) were readmitted in 30- and 90-days respectively. During readmissions, the frequencies of care fragmentation were similar (30-day: 25.4% and 90-day: 25.8%) and remained stable from 2010 to 2014 (P trends>0.5). Similarly, factors associated with care fragmentation were consistent across 30- and 90-day readmissions. These included ages: 18-44 years, liver cancer, receipt of liver transplantation, hepatorenal syndrome, prolonged length of stay, and hospitalization in non-teaching facilities. During 30- and 90-day readmissions, care fragmentation was associated with higher risk of mortality (adjusted mean ratio: 1.13[1.03-1.24] and 1.14 [1.06-1.23]; P values<0.0001), prolonged length of stay (4.6-days vs. 4.1-days and 5.2-days vs. 4.6-days; P values<0.0001), and higher hospital charges ($36,884 vs. $28,932 and $37,354 vs. $30,851; P values<0.0001). CONCLUSIONS: Care fragmentation is high among readmissions for ESLD and is associated with poorer outcomes.