A study conducted by a team of Cleveland Clinic investigators has found readmissions after sepsis hospitalizations to be common and costly, and most often associated with infectious etiologies. Study findings, published in the 2019 issue of Chest, has shed new light on the epidemiology and predictors of 30-day readmission in patients with sepsis.
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“There are limited number of studies specifically looking at the causes behind sepsis-related readmission, although sepsis is one of the most common reasons for admission to the intensive care unit (ICU),” says Shruti K. Gadre, MD, Cleveland Clinic critical care physician and lead author of the study. “This study aimed to assess the healthcare burden attributable to sepsis and sepsis-related readmissions.”
One in five patients readmitted within 30 days of sepsis discharge
Study cohort included a total of 898,257 patients admitted with sepsis from 2013 and 2014 who survived to discharge and whose information was included in the Healthcare Cost and Utilization Project’s Nationwide Readmission Data. Mean patient age was 66.8 ± 17.4 years with 60% of the study cohort ≥65 years. The primary outcome was 30-day readmission, and the causes for readmission were identified using the codes outlined in the International Classification of Diseases, Ninth Revision, Clinical Modification.
Of 898,257 patients, a total of 157,235 (17.5%) had a 30-day readmission, with a median time to readmission of 11 days. The most common cause for readmission was infectious etiology (42.16%, of which 22.86% due to sepsis), followed by gastrointestinal (9.6%), cardiovascular (8.73%), pulmonary (7.82%) and renal problems (4.99%).
“One of the most striking findings was that readmissions within the 30 days after a sepsis discharge were quite common and affected approximately one in five patients, which is a significant portion of the study cohort,” says Dr. Gadre.
Predictors of readmission
The other interesting aspect was that patients who had a lot of comorbidities at the initial index admission were at an increased risk for 30-day readmission.
“We found that a lot of the patients were readmitted for comorbid conditions, such as heart failure or acute kidney injury, that could potentially be addressed in the outpatient setting,” she says.
The study also identified several predictors associated with increased 30-day readmission, such as diabetes, chronic kidney disease and congestive heart failure.
“Longer lengths of hospital stay at index admission were also associated with a higher risk for readmission, as was the discharge to either a long-term or short-term care facility and a Charlson comorbidity index ≥2,” notes Dr. Gadre.
The cost of readmission
In assessing readmission costs, the study found the mean cost per readmission to be $16,852, which amounts to approximately $3.5 billion in annual costs within the United States. Putting things into context, Dr. Gadre says that the annual economic burden due to conditions for which the Hospital Readmissions Reduction Program monitors readmissions is close to $7 billion. These conditions include heart failure, chronic obstructive pulmonary disease, pneumonia and acute myocardial infarction.
“So, sepsis readmissions account for half of that amount on an annual basis, which is a significant cost to the healthcare system,” says Dr. Gadre, adding that several approaches could be explored as potential solutions to this problem.
Areas for improvement
“The most common cause of readmission was infectious disease, so thinking about antibiotic stewardship is really important,” she says. “This means using the right antibiotics for the right duration for the right patient, as well as completing the courses of antibiotics and not just stopping them at discharge.”
The other potential area of improvement, Dr. Gadre notes, is in facilitating a smooth transition of care from the ICU to the regular nursing floor to a skilled nursing facility.
“Lastly, some of these comorbidities and reasons for readmission are potential factors that we can address in the outpatient setting. We should think about post-ICU discharge clinics where we could look at these conditions and treat them earlier rather than their leading to readmission,” she says.
In continuation of their research, Dr. Gadre and her collaborators are planning to look at the epidemiology of readmission for patients with acute respiratory distress syndrome (ARDS).