Risk Factors for Long-term Mortality and Patterns of End-of-Life Care Among Medicare Sepsis Survivors Discharged to Home Health Care

Abstract

IMPORTANCE Despite a growing recognition of the increased mortality risk among sepsis survivors, little is known about the patterns of end-of-life care among this population. OBJECTIVE To describe patterns of end-of-life care among a national sample of sepsis survivors and identify factors associated with long-term mortality risk and hospice use. DESIGN, SETTING, AND PARTICIPANTS This cohort study assessed sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care using national Medicare administrative, claims, and home health assessment data from 2013 to 2014. The initial and final primary analyses were conducted in July 2017 and from July to August 2019, respectively. EXPOSURES Sepsis hospital discharge and 1 or more home health assessments within 1 week. MAIN OUTCOMES AND MEASURES Outcomes were 1-year mortality among all sepsis survivors and hospitalization in the last 30 days of life, death in an acute care hospital, and hospice use among decedents. Multivariate logistic regression was used to identify factors associated with 1-year mortality and hospice use. RESULTS Among 87 581 sepsis survivors who were Medicare fee-for-service beneficiaries discharged to home health care, 49 323 (56.3%) were aged 75 years or older, 69 499 (79.4%) were non-Hispanic white, and 48 472 (55.3%) were female. Among the total survivors, 24 423 (27.9%) people died within 1 year of discharge, with a median (interquartile range) survival time of 119 (51-220) days. Among these decedents, 16 684 (68.2%) were hospitalized in the last 30 days of life, 6560 (26.8%) died in an acute care hospital, and 12 573 (51.4%) were enrolled in hospice, with 5729 (45.6%) using hospice for 7 or fewer days. Several factors were associated with 1-year mortality, including a cancer diagnosis (odds ratio [OR], 3.66; 95% CI, 3.50-3.83; P < .001), multiple dependencies of activities of daily living or instrumental activities of daily living (OR, 2.80; 95% CI, 2.57-3.05; P < .001), and an overall poor health status (OR, 2.21; 95% CI, 2.01-2.44; P < .001) documented on home health assessment. Among the decedents, cancer was associated with hospice use (OR, 2.25; 95% CI, 2.11-2.41; P < .001), patients aged 85 years or older (OR, 1.49; 95% CI, 1.37-1.61; P < .001), and living in an assisted living setting (OR, 1.93; 95% CI, 1.69-2.19; P < .001). CONCLUSIONS AND RELEVANCE The findings of this study suggest that death within 1 year after sepsis discharge may be common among Medicare beneficiaries discharged to home health care. Although 1 in 2 decedents used hospice, aggressive care near the end of life and late hospice referral were common. Readily identifiable risk factors suggest opportunities to target efforts to improve palliative and end-of-life care among high-risk sepsis survivors.

Characteristics, Outcomes, and Trends of Patients With COVID-19–Related Critical Illness at a Learning Health System in the United States

“…Potential explanations for the low COVID-19 readmission rate include increased use of acute rehabilitation, given the relationship between acute rehabilitation and improved outcomes among sepsis survivors ( 30 ); increased use of home health services, given data suggesting that early and intense home health care is associated with fewer rehospitalizations ( 31 ); unprecedented support at home in the setting of the pandemic; and a new phenotype of sepsis survivors who may have fewer subsequent infections ( 29 ). However, given the rate of persistent lymphopenia observed and known increased risk for 1-year mortality after sepsis ( 32 , 33 ), studies designed to examine the long-term health of COVID-19 survivors are needed. Of note, COVID-19 survivorship and disposition outcomes may be biased because of challenges with post–acute care placement due to infection control concerns.…”

Inpatient hospital performance is associated with post-discharge sepsis mortality

“…Readmissions after discharge are common (21% within 30 days) [ 11 ], and sepsis survivors have increased post-discharge mortality [ 12 – 14 ]. Post-discharge deaths have been associated with premorbid health status and hospital factors [ 15 , 16 ], but it is unclear whether these factors are modifiable, and whether hospital care can alter the post-discharge course.…”

Why Septic Patients Remain Sick After Hospital Discharge?

“…Prescott, Langa ( 17 ), Yende, Kellum ( 22 ), and Courtright, Jordan ( 23 ) conducted cohort studies in septic patients. The authors had the main objective of assessing the mortality rate after one year of hospital discharge.…”

“…Yende, Kellum ( 22 ) demonstrated that in addition to the high mortality rate, survivors showed a persistent increase in the blood levels of inflammation and immunosuppression biomarkers associating these observations with worse long-term outcomes. Courtright, Jordan ( 23 ) also pointed out that 68.2% the patients who died were re-hospitalized in the last 30 days of life.…”