Increased 1-year healthcare use in survivors of severe sepsis

Abstract

Rationale: Hospitalizations for severe sepsis are common, and a growing number of patients survive to hospital discharge. Nonetheless, little is known about survivors' post-discharge healthcare use.

Objectives: To measure inpatient healthcare use of severe sepsis survivors compared with patients' own presepsis resource use and the resource use of survivors of otherwise similar nonsepsis hospitalizations.

Methods: This is an observational cohort study of survivors of severe sepsis and nonsepsis hospitalizations identified from participants in the Health and Retirement Study with linked Medicare claims, 1998-2005. We matched severe sepsis and nonsepsis hospitalizations by demographics, comorbidity burden, premorbid disability, hospitalization length, and intensive care use.

Measurements and main results: Using Medicare claims, we measured patients' use of inpatient facilities (hospitals, long-term acute care hospitals, and skilled nursing facilities) in the 2 years surrounding hospitalization. Severe sepsis survivors spent more days (median, 16 [interquartile range, 3-45] vs. 7 [0-29]; P < 0.001) and a higher proportion of days alive (median, 9.6% [interquartile range, 1.4-33.8%] vs. 1.9% [0.0-7.9%]; P < 0.001) admitted to facilities in the year after hospitalization, compared with the year prior. The increase in facility-days was similar for nonsepsis hospitalizations. However, the severe sepsis cohort experienced greater post-discharge mortality (44.2% [95% confidence interval, 41.3-47.2%] vs. 31.4% [95% confidence interval, 28.6-34.2%] at 1 year), a steeper decline in days spent at home (difference-in-differences, -38.6 d [95% confidence interval, -50.9 to 26.3]; P < 0.001), and a greater increase in the proportion of days alive spent in a facility (difference-in-differences, 5.4% [95% confidence interval, 2.8-8.1%]; P < 0.001).

Conclusions: Healthcare use is markedly elevated after severe sepsis, and post-discharge management may be an opportunity to reduce resource use.

Keywords: healthcare facilities; hospitalization; patient outcomes assessment; patient readmission; skilled nursing facility.

Figure 1.

Identification and matching of severe sepsis and nonsepsis cohorts. We measured premorbid disability as the number of limitations in activities and instrumental activities of daily living. HRS = Health and Retirement Study.

Figure 2.

Use and mortality for 1,083 matched survivors in the 2 years surrounding severe sepsis and nonsepsis hospitalizations. This figure displays the daily location of 1,083 matched survivors of severe sepsis and nonsepsis hospitalizations in the 1 year before (A and C) and 1 year after hospitalization (B and D). The index admission is not included. The year prior ends at the day before hospitalization; the year after begins the day after hospital discharge. Patients are depicted as being at home (blue), admitted to a healthcare facility (red), or dead (black).

Figure 3.

Difference-in-differences analysis of healthcare use in the severe sepsis and nonsepsis cohorts. The difference-in-differences between the severe sepsis and nonsepsis cohorts was (A) −38.6 days spent at home (95% confidence interval [CI], −50.9 to −26.3 d; P < 0.001), and (B) +5.4% of days alive spent in an inpatient healthcare facility (95% CI, +2.8 to +8,1%; P < 0.001). The difference-in-differences for days spent in a healthcare facility was not significant (−4.2 d; 95% CI, −9.0 to +0.7 d; P = 0.09).