Care fragmentation and readmission mortality and length of stay before and during the COVID-19 pandemic: data from the National Readmissions Database, 2018–2020

Abstract

Importance: A quarter of all 30-day readmissions involve fragmented care, where patients return to a different hospital than their original admission; these readmissions are associated with increased in-hospital mortality and longer lengths-of-stay (LOS). The stress on healthcare systems at the beginning of the COVID-19 pandemic could worsen care fragmentation and related outcomes. Objective: To compare fragmented readmissions in 2020 versus 2018–2019 and assess whether mortality and LOS in fragmented readmissions differed in the two time periods. Design: Observational study Setting: National Readmissions Database (NRD), 2018–2020 Participants: All adults (> 18 y/o) with 30-day readmissions Main outcomes and measures: We examined the percentage of fragmented readmissions over 2018–2020. Using unadjusted and adjusted logistic and linear regressions, we estimated the associations between fragmented readmissions and in-hospital mortality and LOS. Results: 24.0–25.7% of readmissions in 2018–2020 and 27.3%-31.0% of readmissions for COVID-19 were fragmented. 2018–2019 fragmented readmissions were associated with 18–20% higher odds of in-hospital mortality compared to nonfragmented readmissions. Fragmented readmissions for COVID-19 were associated with an 18% increase in in-hospital mortality (AOR 1.18, 95% CI 1.12, 1.24). The LOS of fragmented readmissions in March-November 2018–2019 were on average 0.81 days longer, while fragmented readmissions between March-November of 2020 were associated with a 0.88–1.03 day longer LOS. Conclusions and relevance: A key limitation is that the NRD does not contain information on several patient/hospital-level factors that may be associated with the outcomes of interest. We observed increased fragmentation during COVID-19, but its impact on in-hospital mortality and LOS remained consistent with previous years.