Patient Outcomes Following Interhospital Care Fragmentation: A Systematic Review

  • Katelin Snow
  • Karla Galaviz
  • Sara TurbowEmail author
Review Article



Interhospital fragmentation of care occurs when patients are admitted to different, disconnected hospitals. It has been hypothesized that this type of care fragmentation decreases the quality of care received and increases hospital costs and healthcare utilization. This systematic review aims to synthesize the existing literature exploring the association between interhospital fragmentation of care and patient outcomes.


MEDLINE, the Cochrane Library, EMBASE, and the Science Citation Index were systematically searched for studies published up to April 30, 2018 reporting the association between interhospital fragmentation of care and patient outcomes. We included peer-reviewed observational studies conducted in adults that reported measures of association between interhospital care fragmentation and one or more of the following patient outcomes: mortality, hospital length of stay, cost, and subsequent hospital readmission.


Seventy-nine full texts were reviewed and 22 met inclusion criteria. Nearly all studies defined fragmentation of care as a readmission to a different hospital than the patient was previously discharged from. The strongest association reported was that between a fragmented readmission and in-hospital or short-term mortality (adjusted odds ratio range 0.95–3.62). Over half of the studies reporting length-of-stay showed longer length of stay in fragmented readmissions. All three studies that investigated healthcare utilization suggested an association between fragmented care and odds of subsequent readmission. The study populations and exposures were too heterogenous to perform a meta-analysis.


Our review suggests that fragmented hospital readmissions contribute to increased mortality, longer length-of-stay, and increased risk of readmission to the hospital.


readmission continuity of care fragmentation of care patient outcomes systematic review 


Author’s Contribution

No one contributed to the article who is not listed as an author.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2019_5366_MOESM1_ESM.docx (98 kb)
ESM 1 (DOCX 13 kb)
11606_2019_5366_MOESM2_ESM.docx (98 kb)
ESM 2 (DOCX 14 kb)
11606_2019_5366_MOESM3_ESM.doc (98 kb)
ESM 3 (DOC 63 kb)


  1. 1.
    Weir DL, McAlister FA, Majumdar SR, Eurich DT. The interplay between continuity of care, multimorbidity, and adverse events in patients with diabetes. Med Care 2016;54(4):386-393. Scholar
  2. 2.
    Van Walraven C, Oake N, Jennings A, Forster AJ. The association between continuity of care and outcomes: a systematic and critical review. J Eval Clin Pract. 2010;16(5):947-956. Scholar
  3. 3.
    Guo J-Y, Chou Y-J, Pu C, Pu C. Effect of continuity of care on drug-drug interactions. Med Care. 2017;55(8):744-751.CrossRefGoogle Scholar
  4. 4.
    Lai Y-R, Yang Y-S, Tsai M-L, et al. Impact of potentially inappropriate medication and continuity of care in a sample of Taiwan elderly patients with diabetes mellitus who have also experienced heart failure. Geriatr Gerontol Int. 2015;16(10):1117-1126. Scholar
  5. 5.
    Bekelis K, Roberts DW, Zhou W, Skinner J. Fragmentation of care and the use of head computed tomography in patients with ischemic stroke. Circ Cardiovasc Qual Outcomes. 2014;7(3):430-436. Scholar
  6. 6.
    Nyweide DJ, Anthony DL, Bynum JP, et al. Continuity of care and the risk of preventable hospitalization in older adults. JAMA Intern Med. 2013;173(20):1879-1885. Scholar
  7. 7.
    Kao Y-H, Wu S-C.STROBE-compliant article: is continuity of care associated with avoidable hospitalization in older asthmatic patients? Medicine. 2016;95(38):e4948–7. Scholar
  8. 8.
    Lin I-P, Wu S-C. Effects of long-term high continuity of care on avoidable hospitalizations of chronic obstructive pulmonary disease patients. Health Policy. 2017;121(9):1001-1007. Scholar
  9. 9.
    Missios S, Bekelis K. Outpatient continuity of care and 30-day readmission after spine surgery. Spine J. 2016;16(11):1309-1314. Scholar
  10. 10.
    Fan VS, Burman M, McDonell MB, Fihn SD. Continuity of care and other determinants of patient satisfaction with primary care. JGIM. 2005;20(3):226-233. Scholar
  11. 11.
    Burke RE, Jones CD, Hosokawa P, Glorioso TJ, Coleman EA, Ginde AA. Influence of nonindex hospital readmission on length of stay and mortality. Med Care. 2018;56(1):85-90. Scholar
  12. 12.
    McAlister FA, Youngson E, Kaul P. Patients with heart ailure readmitted to the original hospital have better outcomes than those readmitted elsewhere. J Am Heart Assoc. 2017;6(5):e004892-e004897. Scholar
  13. 13.
    Flaks-Manov N, Shadmi E, Bitterman H, Balicer R. Readmission to a different hospital—risk factors and impact on length of stay. Value Health. 2014;17(3):A148. Scholar
  14. 14.
    Galanter WL, Applebaum A, Boddipalli V, et al. Migration of patients between five urban teaching hospitals in Chicago. J Med Syst. 2013;37(2):1989–8. Scholar
  15. 15.
    Graboyes EM, Kallogjeri D, Saeed MJ, Olsen MA, Nussenbaum B. Postoperative care fragmentation and thirty-day unplanned readmissions after head and neck cancer surgery. Laryngoscope. 2016;127(4):868-874. Scholar
  16. 16.
    Chappidi MR, Kates M, Stimson CJ, Bivalacqua TJ, Pierorazio PM. Quantifying nonindex hospital readmissions and care fragmentation after major urological oncology surgeries in a nationally representative sample. J Urol. 2017;197(1):235-240. Scholar
  17. 17.
    Parreco J, Buicko J, Cortolillo N, Namias N, Rattan R. Risk factors and costs associated with nationwide nonelective readmission after trauma. J Trauma Acute Care Surg. 2017;83(1):126-134. Scholar
  18. 18.
    Brooke BS, Goodney PP, Kraiss LW, Gottlieb DJ, Samore MH, Finlayson SRG. Readmission destination and risk of mortality after major surgery: an observational cohort study. Lancet. 2015;386(9996):884-895. Scholar
  19. 19.
    Justiniano CF, Xu Z, Becerra AZ, et al.Long-term deleterious impact of surgeon care fragmentation after colorectal surgery on survival. Dis Colon Rectum. 2017;60(11):1147-1154. Scholar
  20. 20.
    Kothari AN, Loy VM, Brownless SA, et al. Adverse effect of post-discharge care fragmentation on outcomes after readmissions after liver transplantation. J Am Coll Surg. 2017;225(1):62-67. Scholar
  21. 21.
    Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010;25(9):603-605. Scholar
  22. 22.
    Wolinsky FD, Miller TR, An H, Brezinski PR, Vaughn TE, Rosenthal GE. Dual use of Medicare and the Veterans Health Administration: are there adverse health outcomes? BMC Health Serv Res. 2006;6(1):651–11. Scholar
  23. 23.
    Jia H, Zheng Y, Reker DM, et al. Multiple system utilization and mortality for veterans with stroke. Stroke. 2007;38(2):355-360. Scholar
  24. 24.
    Hua M, Ng Gong M, Miltiades A, Wunsch H. Outcomes after rehospitalization at the same hospital or a different hospital following critical illness. AJRCCM. 2017;195(11):1486-1493.Google Scholar
  25. 25.
    Zheng C, Habermann EB, Shara NM, et al. Fragmentation of care after surgical discharge: non-index readmission after major cancer surgery. J Am Coll Surgeons. 2016;222(5):780-789.e782. Scholar
  26. 26.
    Saunders RS, Fernandes-Taylor S, Kind AJH, et al. Rehospitalization to primary versus different facilities following abdominal aortic aneurysm repair. J Vasc Surg. 2014;59(6):1502-1510.e1502. Scholar
  27. 27.
    Glebova NO, Hicks CW, Taylor R, et al. Readmissions after complex aneurysm repair are frequent, costly, and primarily at nonindex hospitals. J Vasc Surg. 2014;60(6):1429-1437. Scholar
  28. 28.
    Staples JA, Thiruchelvam D, Redelmeier DA. Site of hospital readmission and mortality: a population-based retrospective cohort study. CMAJ Open. 2014;2(2):E77-E85. Scholar
  29. 29.
    Tsai TC, Orav EJ, Jha AK. Care Fragmentation in the postdischarge period. JAMA Surg. 2015;150(1):59–6. Scholar
  30. 30.
    Pak JS, Lascano D, Kabat DH, et al. Patterns of care for readmission after radical cystectomy in New York State and the effect of care fragmentation. Urol Oncol. 2015;33(10):426.e13-426.e19. Scholar
  31. 31.
    Stitzenberg KB, Chang Y, Smith A, Meyers MO, Nielsen ME. Impact of location of readmission on outcomes after major cancer surgery. Ann Surg Oncol. 2017;24(2):319-329. Scholar
  32. 32.
    Luu N-P, Hussain T, Chang H-Y, Pfoh E, Pollack CE. Readmissions after colon cancer surgery: does it matter where patients are readmitted? JOP. 2016;12(5):e502-e512. Scholar
  33. 33.
    Flaks-Manov N, Shadmi E, Hoshen M, Balicer R. Health information exchange systems and length of stay in readmissions to a different hospital. J Hosp Med. 2016;11(6):401-406.CrossRefGoogle Scholar
  34. 34.
    Axon RN, Gebregziabher M, Everett CJ, Heidenreich P, Hunt K. Dual health care system use is associated with higher rates of hospitalization and hospital readmission among veterans with heart failure. Am Heart J. 2016;174(C):157-163. Scholar
  35. 35.
    Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. Continuity of care: a multidisciplinary review. BMJ. 2003;1219-1221.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  1. 1.Department of MedicineEmory University School of MedicineAtlantaUSA
  2. 2.Hubert Department of Global HealthEmory University Rollins School of Public HealthAtlantaUSA
  3. 3.Division of General Medicine and Geriatrics, Department of MedicineEmory University School of MedicineAtlantaUSA

Personalised recommendations