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Sepsis Survivors Admitted to Skilled Nursing Facilities: Cognitive Impairment, Activities of Daily Living Dependence, and Survival.

ABSTRACT: OBJECTIVE:Severe sepsis survivors frequently experience cognitive and physical functional impairment. The degree of impairment and its association with mortality is understudied, particularly among those discharged to a skilled nursing facility. Our objective was to quantify the cognitive and physical impairment among severe sepsis survivors discharged to a skilled nursing facility and to investigate the relationship between impairment and long-term mortality. DESIGN:Retrospective cohort study. SETTING:United States. SUBJECTS:Random 5% sample of Medicare patients discharged following severe sepsis hospitalization, 2005-2009 (n = 135,370). MEASUREMENT AND MAIN RESULTS:Medicare data were linked with the Minimum Data Set; Minimum Data Set-Cognition Scale was used to assess cognitive function, and the Minimum Data Set activities of daily living hierarchical scale was used to assess functional dependence. Associations were evaluated using multivariable logistic regression, Kaplan-Meier curves, and Cox proportional hazards regression. Of 66,540 beneficiaries admitted to a skilled nursing facility following severe sepsis, 34% had severe or very severe cognitive impairment, and 72.5% had maximal, dependence, or total dependence in activities of daily living. Median survival was 19.4 months for those discharged to a skilled nursing facility without having been in a skilled nursing facility in the preceding 1 year and 10.4 months for those discharged to a skilled nursing facility who had spent time in a skilled nursing facility in the prior year. The adjusted hazard ratio for death was 3.1 for those with very severe cognitive impairment relative to those who were cognitively intact (95% CI, 2.9-3.2; p < 0.001) and 4.3 for those with "total dependence" in activities of daily livings relative to those who were independent (95% CI, 3.8-5.0; p < 0.001). CONCLUSIONS:Discharge to a skilled nursing facility following severe sepsis hospitalization among Medicare beneficiaries was associated with shorter survival, and cognitive impairment and activities of daily living dependence were each strongly associated with shortened survival. These findings can inform decision-making by patients and physicians and underscores high palliative care needs among sepsis survivors discharged to skilled nursing facility.

SUBMITTER: Ehlenbach WJ

PROVIDER: S-EPMC5858875 | biostudies-literature | 2018 Jan

REPOSITORIES: biostudies-literature

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Sepsis Survivors Admitted to Skilled Nursing Facilities: Cognitive Impairment, Activities of Daily Living Dependence, and Survival.

Ehlenbach William J WJ Gilmore-Bykovskyi Andrea A Repplinger Michael D MD Westergaard Ryan P RP Jacobs Elizabeth A EA Kind Amy J H AJH Smith Maureen M

Critical care medicine 20180101 1

<h4>Objective</h4>Severe sepsis survivors frequently experience cognitive and physical functional impairment. The degree of impairment and its association with mortality is understudied, particularly among those discharged to a skilled nursing facility. Our objective was to quantify the cognitive and physical impairment among severe sepsis survivors discharged to a skilled nursing facility and to investigate the relationship between impairment and long-term mortality.<h4>Design</h4>Retrospective ...[more]

PMID: 28991827

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Project description:BackgroundPneumonia and sepsis are among the most common causes of hospitalization in the United States and often result in discharges to a skilled nursing facility (SNF) for rehabilitation. We described the timing and most common causes of 30-day unplanned hospital readmission following an index hospitalization for pneumonia or sepsis.Methods and findingsThis national retrospective cohort study included adults ≥65 years who were hospitalized for pneumonia or sepsis and were discharged to a SNF between July 1, 2012 and July 4, 2015. We quantified the ten most common 30-day unplanned readmission diagnoses and estimated the daily risk of first unplanned rehospitalization for four causes of readmission (circulatory, infectious, respiratory, and genitourinary). The index hospitalization was pneumonia for 92,153 SNF stays and sepsis for 452,254 SNF stays. Of these SNF stays, 20.9% and 25.9%, respectively, resulted in a 30-day unplanned readmission. Overall, septicemia was the single most common readmission diagnosis for residents with an index hospitalization for pneumonia (16.7% of 30-day readmissions) and sepsis (22.4% of 30-day readmissions). The mean time to unplanned readmission was approximately 14 days overall. Respiratory causes displayed the highest daily risk of rehospitalization following index hospitalizations for pneumonia, while circulatory and infectious causes had the highest daily risk of rehospitalization following index hospitalizations for sepsis. The day of highest risk for readmission occurred within two weeks of the index hospitalization discharge, but the readmission risk persisted across the 30-day follow-up.ConclusionAmong older adults discharged to SNFs following a hospitalization for pneumonia or sepsis, hospital readmissions for infectious, circulatory, respiratory, and genitourinary causes occurred frequently throughout the 30-day post-discharge period. Our data suggests further study is needed, perhaps on the value of closer monitoring in SNFs post-hospital discharge and improved communication between hospitals and SNFs, to reduce the risk of potentially preventable hospital readmissions.

Project description:OBJECTIVES:Prior studies have reported mixed findings about the existence of racial disparities in readmission rates among Medicare Advantage beneficiaries, but these studies used data from one state, focused on black-white disparities, and did not focus on patients discharged to skilled nursing facilities (SNFs). The objective of the study was to characterize racial and ethnic disparities in rates of 30-day rehospitalization directly from SNFs among fee-for-service and Medicare Advantage patients. DESIGN:A cross-sectional study of admissions to SNFs in 2015 was conducted. SETTING:SNFs across the United States. PARTICIPANTS:The sample included 1 500 334 white, 213 848 African American, and 99 781 Hispanic Medicare patients who were admitted to 13 375 SNFs. MEASUREMENTS:The main outcome of interest was readmission, identified as patients sent back to any hospital directly from the SNF within 30?days of admission, as indicated on the Minimum Data Set discharge assessment. RESULTS:Overall readmission rates for fee-for-service patients were 16.7% (95% confidence interval [CI] = 16.7%-16.8%) for whites, 18.8% (95% CI =?18.7%-19.0%) for African Americans, and 17.4% (95% CI =?17.1%-17.7%) for Hispanics. Readmission rates in Medicare Advantage were 14.7% (95% CI =?14.5%-14.8%) for whites, 16.8% (95% CI =?16.6%-17.1%) for African Americans, and 15.3% (95% CI =?14.9%-15.6%) for Hispanics. We also found that African Americans had about 1% higher readmission rates than whites, even when they received care within the same SNF. No statistically significant differences were found in the magnitude of within-SNF racial disparities in Medicare Advantage compared with Medicare fee-for-service. CONCLUSION:We found racial disparities in readmission rates even within the same facility for both Medicare Advantage and fee-for-service beneficiaries. Intervention to reduce disparities in readmission rates, as well as more comprehensive quality measures that incorporate outcomes for Medicare Advantage enrollees, are needed. J Am Geriatr Soc 67:1672-1679, 2019.

Dataset Information

Sepsis Survivors Admitted to Skilled Nursing Facilities: Cognitive Impairment, Activities of Daily Living Dependence, and Survival.

Publications

Sepsis Survivors Admitted to Skilled Nursing Facilities: Cognitive Impairment, Activities of Daily Living Dependence, and Survival.

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