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Impact Of Fragmented Care On Outcomes In The Management Of Uncomplicated Type B Aortic Dissection
Omkar S. Pawar, MSCE, BDS
1, Hepeel Chang, MD
2, Karan Garg, MD
3, William J. Yoon, MD, PhD
1, Jane Chung, MD
1, Benjamin Colvard, MD
1, Jonathan Kwong, MD
1, Kaitlyn Dunphy, MD
1, Mrinalini Patil, MD
1, Jae S. Cho, MD
1.
1University Hospitals, Cleveland Medical Center, Cleveland, OH, USA,
2Westchester Medical Center, New York, NY, USA,
3New York University Langone Health, New York, NY, USA.
Objective: Fragmentation of care (FOC) refers to health care delivery that occurs among a large number of poorly coordinated providers and/or across different healthcare systems (HS). The study aims to determine the impact of FOC on 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/Florida (2016-2020) were queried using International Classification of Disease-10
th (ICD-10) edition to identify patients who underwent medical management for uTBAD. Patients’ hospital identification and its association with health system (HS) were verified using the American Hospital Association database. FOC was defined as delivery of care across different HS; interfacility transfers within the same HS were not. Univariate analyses were conducted to compare outcomes between patients with and without FOC, employing Chi-square 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 Hosmer-Lemeshow test, and receiver operating characteristic curve analysis.
Results: 18,694 patients presented with acute aortic dissection (ICD-10 Diagnosis codes I7.101 and I7.103). After excluding those with type A dissection and aortic repair for complicated TBAD, 5,476 uTBAD patients were analyzed. FOC was observed in 3,017 patients (55.6%). Baseline characteristics between those with and without FOC differed significantly. During follow-up, while morality rates were similar between groups, FOC group had significantly more computed tomography scans, higher rates of aortic interventions, and elevated complication rates. Furthermore, total healthcare costs were markedly higher with FOC (Table 1). Multivariable analysis also showed that FOC was associated with increased aortic interventions (OR 1.49, 95%CI 1.26-1.77, p<0.000) and complication rates (renal insufficiency [OR 1.30, 95%CI 1.15-1.48, p<0.000], paraplegia [OR 1.60, 95%CI 1.06-2.42, p=0.022], and stroke [OR 1.33, 95%CI 1.11-1.60, p=0.002]) during follow-up.
Conclusions: FOC in uTBAD patients is associated with increased likelihood of intervention with higher post-procedural complications and elevated healthcare costs. Coordinated care within a single HS should be prioritized to improve outcomes and reduce healthcare cost.
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