Topped all conditions included in CMS monitoring program
by Charles Bankhead
Senior Associate Editor, MedPage Today January 24, 2017

HONOLULU — Sepsis accounted for more unplanned hospital readmissions than any of the four conditions included in a national quality monitoring program, according to a review of 14 million hospitalizations.
Of more than 1 million hospitalizations associated with unplanned readmission, 12.2% of the readmissions involved sepsis. Among the four conditions included in the Centers for Medicare and Medicaid Services (CMS) monitoring program, heart failure accounted for the most readmissions (6.7%).
Unplanned readmissions associated with sepsis also had the longest and most costly hospitalizations, Florian Mayr, MD, of the University of Pittsburgh Medical Center, reported here at the Society of Critical Care Medicine meeting.
The study was published simultaneously online in the Journal of the American Medical Association.
“For physicians and patients, I think the most important implication of this study is that sepsis is an acute illness with long-term consequences,” co-author Sachin Yende, MD, also of the University of Pittsburgh, told MedPage Today. “Most people think that once you get better from sepsis and are discharged from the hospital, you don’t have to worry about any consequences. What this study shows is that many of the patients are likely to come back into the hospital within 30 days.”
CMS uses 30-day readmission rates as a measure of quality of care and to provide pay-for-performance guidance. The agency has identified four medical conditions associated with high rates of unplanned readmission and included them in the Hospital Readmissions Reduction Program (HRRP). In addition to heart failure, the conditions are acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), and pneumonia.
HRRP allows CMS to impose financial penalties on hospitals that fail to meet the monitoring system’s goals for readmission. Although the program has been criticized as unfair, insofar as not all readmissions are genuinely preventable, several studies have indicated that it has reduced readmission rates.
More than 1 million patients develop sepsis each year in the United States. The frequency and cost of unplanned readmissions related to sepsis has remained unclear. However, Mayr and colleagues hypothesized that sepsis results in a higher proportion of unplanned readmissions than any of the four conditions included in the CMS monitoring program.
To investigate the association of sepsis with unplanned readmission, investigators searched the 2013 Nationwide Readmissions Database, which maintains data on acute care hospitalizations from 21 states, representing inpatient use by 49% of the U.S. population. The query sought adults who had admissions that were followed by unplanned readmission within 30 days of discharge. The analysis included patients who had more than one admission-readmission episode.
Investigators determined the proportion of admissions related to sepsis, AMI, COPD, heart failure, and pneumonia. Because patients with any of the four CMS-monitored conditions might also have sepsis, investigators determined the proportion of sepsis cases that overlapped with other conditions.
Beginning with 14,325,172 hospitalizations, the analysis identified 1,187,697 associated with unplanned readmission within 30 days. The proportion of unplanned readmissions attributable to the five conditions of interest were:
• Sepsis: 147,084 (12.2%)
• Heart failure: 79,480 (6.7%)
• Pneumonia: 59,378 (5.0%)
• COPD: 54,396 (4.8%)
• AMI: 15,001 (1.3%)
Among patients initially hospitalized because of sepsis, medical records revealed diagnostic codes associated with AMI in 0.7% of cases, COPD in 3.3%, heart failure in 3.4%, and pneumonia in 7.5%.
Unplanned readmissions involving sepsis had a mean length of stay of 7.4 days, followed by pneumonia (6.9), heart failure (6.5), COPD (6.3), and AMI (6.0). The estimated mean cost per readmission was $10,070 for sepsis, $9,533 for pneumonia, $9,424 for AMI, $9,051 for heart failure, and $8,417 for COPD. Pairwise comparisons showed that the cost of sepsis-associated unplanned readmission was significantly higher than any of the four CMS conditions (P<0.005).
Given that the annual healthcare costs associated with sepsis are approximately $3-$4 billion, the results have clear implications for policymakers, said Yende.
“If sepsis is a leading cause of readmissions, policymakers need to look into whether sepsis should be added to the Hospital Readmissions Reduction Program,” he said.
Mayr, Yende and colleagues acknowledged several limitations of the study: use of state-specific data that does not permit tracking patients across state lines (potential for underestimation of readmission rates) and imprecision in readmission cost estimates because of possible variation in definition of sepsis.