Hospital-Based Acute Care Use in Survivors of Septic Shock*

Abstract

Objective Septic shock is associated with increased long-term morbidity and mortality. However, little is known about the use of hospital-based acute care in survivors after hospital discharge. The objectives of the study were to examine the frequency, timing, causes, and risk factors associated with Emergency Department (ED) visits and hospital readmissions within 30 days of discharge. Design Retrospective cohort study. Setting Tertiary, academic hospital in the United States. Patients Patients admitted with septic shock (serum lactate ≥ 4 mmol/L or refractory hypotension) and discharged alive to a non-hospice setting between 2007 and 2010. Interventions None. Measurements and Main Results The co-primary outcomes were all-cause hospital readmission and ED visits (treat-and-release encounters) within 30 days to any of the three health system hospitals. Of 269 at-risk survivors, 63 (23.4%, 95% confidence interval (CI): 18.2, 28.5) were readmitted within 30 days of discharge and another 12 (4.5%, 95% CI: 2.3, 7.7) returned to the ED for a treat-and-release visit. Readmissions occurred within 15 days of discharge in 75% of cases and were more likely in oncology patients (p=0.001) and patients with a longer hospital length of stay (p=0.04). Readmissions were frequently due to another life-threatening condition and resulted in death or discharge to hospice in 16% of cases. The reasons for readmission were deemed potentially related to the index septic shock hospitalization in 78% (49/63) of cases. The most common cause was infection-related, accounting for 46% of all 30-day readmissions, followed by cardiovascular or thromboembolic events (18%). Conclusions The use of hospital-based acute care appeared to be common in septic shock survivors. Encounters often led to readmission within 15 days of discharge, were frequently due to another acute condition, and appeared to result in substantial morbidity and mortality. Given the potential public health implications of these findings, validation studies are needed.

Post–Acute Care Use and Hospital Readmission after Sepsis

“…We confirmed that postdischarge readmission risk is high after sepsis, in line with rates reported in recent studies focused on severe sepsis and septic shock (16,17). In the single study in which researchers compared health care utilization after severe sepsis with subjects' own health care use presepsis and with matched nonsepsis controls, Prescott and coworkers found a substantial increase in resource utilization, including a 30-day hospital readmission rate of 26.5% (16).…”

“…In the final models, we additionally controlled for center and presepsis characteristics, factors present prior to the index hospitalization that are known to be, or potentially to be, associated with readmission risk (13,17,(21)(22)(23)(24)(25). We examined the following presepsis characteristics: age, sex, race, marital status, insurance status, comorbid conditions (using the Charlson Comorbidity Index score (25) and a history of malignancy specifically), and number of admissions over the prior year.…”

“…Last, we used mixedeffects multivariable logistic regression models (with random intercepts for patients) to examine risk factors associated with 30-day readmission after sepsis hospitalizations. In addition to variables included in readmission prediction scores (13,17,(21)(22)(23)(24), we examined four hospitalization factors: acute dialysis, acute neurologic dysfunction, the use of mechanical ventilation, and presence of shock. We identified these conditions using validated claims-based approaches and included them in models based on the hypothesis that these factors, which reflect illness severity and have been related to long-term cognitive and/or physical impairment after critical illness (10,(27)(28)(29), would be associated with readmission.…”

“…Recent data suggest that health care utilization increases after sepsis (14)(15)(16)(17). As these studies were largely restricted to the elderly (15,16) or the most severely ill (14,16,17), and because all but one lacked a comparison group (14,15,17), essential questions remain unanswered.…”

“…As these studies were largely restricted to the elderly (15,16) or the most severely ill (14,16,17), and because all but one lacked a comparison group (14,15,17), essential questions remain unanswered. In our present multicenter study, we set out to examine four questions.…”