Exploring Trajectories of Health Care Utilization Before and After Surgery

Background: Long-term trajectories of health care utilization in the context of surgery have not been well characterized. The objective of this study was to examine health care utilization trajectories among surgical patients and identify factors associated with high utilization that could possibly be mitigated after surgical admissions.

Study design: Hospital medical and surgical admissions within 2 years of an index inpatient surgery in the Veterans Health Administration (October 1, 2007 to September 30, 2014) were identified. Group-based trajectory analysis identified 5 distinct trajectories of inpatient admissions around surgery. Characteristics of trajectories of utilization were compared across groups using bivariate statistics and multivariate logistic regression.

Results: Of 280,681 surgery inpatients, most underwent orthopaedic (29.2%), general (28.4%), or peripheral vascular procedures (12.2%). Five trajectories of health care utilization were identified, with 5.2% of patients among consistently high inpatient users accounting for 34.0% of inpatient days. Male (95.4% vs 93.5%, p < 0.01), African-American (21.6% vs 17.3%, p < 0.01), or unmarried patients (61.6% vs 52.5%, p < 0.01) were more likely to be high health care users as compared with other trajectories. High users also had a higher comorbidity burden and a strikingly higher burden of mental health diagnoses (depression: 30.3% vs 16.3%; bipolar disorder: 5.3% vs 2.1%, p < 0.01), social/behavioral risk factors (smoker: 41.1% vs 33.6%, p < 0.01; alcohol use disorder: 28.9% vs 12.9%, p < 0.01), and chronic pain (6.4% vs 2.8%, p < 0.01).

Conclusions: Mental health, social/behavioral, and pain-related factors are independently associated with high pre- and postoperative health care utilization in surgical patients. Connecting patients to social workers and mental health care coordinators around the time of surgery may mitigate the risk of postoperative readmissions related to these factors.