By Betty Tran, MD, MSc
Dr. Tran reports no financial relationships relevant to this field of study.
SYNOPSIS: In this retrospective cohort study, multiple factors were identified during initial hospitalization, including sepsis and shock, that were associated with a hospital readmission within 30 days resulting in death or transition to hospice. Infection was a frequent cause for readmissions that ended in death.
SOURCE: Dietz BW, Jones TK, Small DS, et al. The relationship between index hospitalizations, sepsis, and death or transition to hospice care during 30-day hospital readmissions. Med Care 2017;55:362-370.
Recently, nationwide efforts have focused on reducing hospital readmissions in hopes of reducing costs, morbidity, and mortality, as well as improving quality of care. Identifying risk factors present during an index hospitalization that are associated with 30-day readmissions that result in death or transition to hospice may inform the development of strategies that potentially could reduce readmission rates and/or facilitate transitions to hospice care outside the acute care setting.
In this retrospective cohort study, Dietz et al from the University of Pennsylvania Health system evaluated 17,716 readmissions occurring within 30 days of discharge.
After adjustment for potential confounders, factors during the index hospitalization that were associated with in-hospital death or transition to hospice care during 30-day readmission included: age, insurance status, comorbidities as measured by the Charlson Comorbidity Index (especially a diagnosis of malignancy), number of hospitalizations in the prior year, non-elective admission type, outside hospital transfer, low-discharge hemoglobin and sodium, high-discharge red blood cell distribution width, and disposition to home with home health services or to skilled care facilities.
In addition, sepsis and shock during the index hospitalization were associated with increased in-hospital mortality or transition to hospice during 30-day hospital readmission with an odds ratio of 1.33 (95% confidence interval [CI], 1.02-1.72; P = 0.03) and 1.78 (95% CI, 1.22-2.58; P = 0.002), respectively.
Among 30-day readmissions resulting in death, compared to index non-sepsis hospitalizations, infection was more likely to be the primary cause for readmission among those with an index sepsis hospitalization (51.6% vs. 28.6%; P = 0.009).
Among the 125 cases that resulted in death during a 30-day hospital readmission, 90.4% were admitted to the ICU and 78.4% received mechanical ventilation. Among 30-day hospital readmissions after an index hospitalization for sepsis, factors that were present during the index hospitalization associated with death or transition to hospice during readmission included age, malignancy, more than five hospitalizations in the prior year, and discharge to a long-term acute care facility.
COMMENTARY
This study highlights factors that are associated with an increased risk of hospital readmission within 30 days and adds to the growing body of literature on healthcare use after a hospitalization for sepsis.
Many of the risk factors found, such as age, comorbidities, and high number of hospitalizations, are not surprising, while others, such as discharge hemoglobin and sodium, may track with age and/or comorbidities.
The finding that sepsis and shock were associated with increased risk of 30-day hospital readmission resulting in death or transition to hospice, with infection identified as a frequent primary cause for readmission, also is consistent with findings previously reported.
However, the challenge lies in using these findings in meaningful ways. To what extent hospital readmissions can be prevented is unclear, as these risk factors may identify patients who are on an inevitable downhill trajectory of health leading up to single or multiple hospital readmissions. Theoretically, this at-risk population could be targeted for improved post-discharge coordination of care, including timely and accurate discharge summaries, enhanced communication between acute care and post-discharge health providers, and early and intensive nursing and physician follow-up.
In addition, for many of these patients, palliative care consultation during the index hospitalization could provide not only additional support but also a strategy that could explore patient goals and values and potentially lead to earlier hospice referrals and discharge to home or inpatient hospice units rather than hospital readmission.
Future studies exploring whether these interventions produce an effect on hospital readmission rates will be critical.
