Objective Although recent studies have shown that 30-day readmissions following sepsis are common, the overall fiscal impact of these rehospitalizations and their variability between hospitals relative to other high-risk conditions, such as congestive heart failure (CHF) and acute myocardial infarction (AMI), are unknown. The objectives of this study were to characterize the frequency, cost, patient-level risk factors and hospital-level variation in 30-day readmissions following sepsis compared to CHF and AMI. Design A retrospective cohort analysis of hospitalizations from 2009 to 2011. Setting All acute-care, non-federal hospitals in California Patients Hospitalizations for sepsis (N=240,198), CHF (N=193,153), and AMI (N=105,684) identified by administrative discharge codes. Measurements and Main Results The primary outcomes were the frequency and cost of all-cause 30-day readmissions following hospitalization for sepsis compared to CHF and AMI. Variability in predicted readmission rates between hospitals was calculated using mixed effects logistic regression analysis. The all-cause 30-day readmission rates were 20.4%, 23.6%, and 17.7% for sepsis, CHF and AMI, respectively. The estimated annual costs of 30-day readmissions in the state of California during the study period were $500 million/year for sepsis, $229 million/year for CHF, and $142 million/year for AMI. The risk and reliability-adjusted readmission rates across hospitals ranged from 11.0% to 39.8% (median 19.9%, IQR 16.1–26.0%) for sepsis, 11.3% to 38.4% (median 22.9%, IQR 19.2–26.6%) for CHF, and 3.6% to 40.8% (median 17.0%, IQR 12.2–20.0%) for AMI. Patient-level factors associated with higher odds of 30-day readmission following sepsis included younger age, male gender, Black or Native-American race, a higher burden of medical co-morbidities, urban residence, and lower income. Conclusion Sepsis is a leading contributor to excess healthcare costs due to hospital readmissions. Interventions at clinical and policy levels should prioritize identifying effective strategies to reduce sepsis readmissions.

IMPORTANCE Maximizing the value of critical care services requires understanding the relationship between intensive care unit (ICU) utilization, clinical outcomes, and costs. OBJECTIVE To examine whether hospitals had consistent patterns of ICU utilization across 4 common medical conditions and the association between higher use of the ICU and hospital costs, use of invasive procedures, and mortality. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of 156 842 hospitalizations in 94 acute-care nonfederal hospitals for diabetic ketoacidosis (DKA), pulmonary embolism (PE), upper gastrointestinal bleeding (UGIB), and congestive heart failure (CHF) in Washington state and Maryland from 2010 to 2012. Hospitalizations for DKA, PE, UGIB, and CHF were identified from the presence of compatible International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Multilevel logistic regression models were used to determine the predicted hospital-level ICU utilization during hospitalizations for the 4 study conditions. For each condition, hospitals were ranked based on the predicted ICU utilization rate to examine the variability in ICU utilization across institutions. MAIN OUTCOMES AND MEASURES The primary outcomes were associations between hospital-level ICU utilization rates and risk-adjusted hospital mortality, use of invasive procedures, and hospital costs. RESULTS The 94 hospitals and 156 842 hospitalizations included in the study represented 4.7% of total hospitalizations in this study. ICU admission rates ranged from 16.3% to 81.2% for DKA, 5.0% to 44.2% for PE, 11.5% to 51.2% for UGIB, and 3.9% to 48.8% for CHF. Spearman rank coefficients between DKA, PE, UGIB, and CHF showed significant correlations in ICU utilization for these 4 medical conditions among hospitals (ρ Ն 0.90 for all comparisons; P < .01 for all). For each condition, hospital-level ICU utilization rate was not associated with hospital mortality. Use of invasive procedures and costs of hospitalization were greater in institutions with higher ICU utilization for all 4 conditions. CONCLUSIONS AND RELEVANCE For medical conditions where ICU care is frequently provided, but may not always be necessary, institutions that utilize ICUs more frequently are more likely to perform invasive procedures and have higher costs but have no improvement in hospital mortality. Hospitals had similar ICU utilization patterns across the 4 medical conditions, suggesting that systematic institutional factors may influence decisions to potentially overutilize ICU care. Interventions that seek to improve the value of critical care services will need to address these factors that lead clinicians to admit patients to higher levels of care when equivalent care can be delivered elsewhere in the hospital.