Impact of fragmented care on outcomes in the management of uncomplicated type B aortic dissection

Abstract

Objective: Fragmentation of care (FOC) is referred to as receipt of care across multiple unaffiliated health systems (HS). We evaluated whether FOC was associated with outcomes in patients with uncomplicated type B aortic dissection (uTBAD).

Methods: The Healthcare Cost and Utilization Project State Inpatient Databases for California (2018-2021), New York, Maryland, and Florida (2016-2020) were queried using International Classification of Disease-10th edition, to identify patients who underwent medical management for uTBAD. Patient's hospital affiliation and its linkage to a HS during follow-up were verified using the American Hospital Association data. FOC was defined as receipt of care across multiple unaffiliated, American Hospital Association-defined HS; care delivered among transitions within the same HS was not classified as FOC. Univariate analyses were conducted to compare outcomes between patients with and without FOC, using the χ² or Fisher's exact tests as appropriate. Multivariable logistic regression models were constructed to investigate associations between FOC and outcomes. Model validation was performed using the Hosmer-Lemeshow test and receiver operating characteristic curve analysis.

Results: Among 5476 patients included in the analysis, FOC was observed in 3046 (55.6%). Baseline characteristics between those with and without FOC differed significantly. During follow-up, although mortality rates were similar between groups, the FOC group had significantly more computed tomography scans, higher rates of aortic interventions, and higher complication rates. Furthermore, total costs were markedly higher with FOC. Multivariable analysis also showed that FOC was associated with increased aortic interventions (thoracic endovascular aortic repair: odds ratio [OR], 1.47; 95% confidence interval [CI], 1.26-1.74) and complication rates (renal failure [OR, 1.3; 95% CI, 1.17-1.50], paraplegia [OR, 1.60; 95% CI, 1.07-2.42], and stroke [OR, 1.31; 95% CI, 1.09-1.58]) during follow-up. Total costs were 31% higher in the FOC group (P < .001).

Conclusions: FOC in uTBAD patients is associated with an increased likelihood of intervention with higher postprocedural complication rates and increased health care costs. Coordinated care within a single HS should be prioritized to improve outcomes and decrease health care costs.

Keywords: Complications; Fragmentation of care; Health care costs; Open aortic surgery; SCVS; Thoracic endovascular aortic repair; Transitions of care; Uncomplicated type B aortic dissection.