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JAMA. Author manuscript; available in PMC 2016 March 10.
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Published in final edited form as:

JAMA. 2015 March 10; 313(10): 1055–1057. doi:10.1001/jama.2015.1410.

Readmission Diagnoses after Severe Sepsis and Other Acute

Medical Conditions
Hallie C. Prescott, MD, MSc1, Kenneth M. Langa, MD, PhD1, and Theodore J. Iwashyna, MD,
PhD2
1 University of Michigan, Department of Medicine, Ann Arbor, MI, USA
2VA Center for Clinical Management Research, HSR&D Center of Innovation, Ann Arbor, MI,
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USA

To the Editor
Patients are frequently re-hospitalized in the 90 days after severe sepsis1. Little is known,
however, about the reasons for this utilization and whether it can be reduced. We sought to
determine the most common readmission diagnoses after severe sepsis, the extent to which
readmissions may be potentially preventable by post-hospitalization ambulatory care, and
whether the pattern of readmission diagnoses differs compared to that of other acute medical
conditions.

Methods
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We studied participants in the nationally representative U.S. Health and Retirement Study, a
multistage probability sample of households with adults ages 50 years and older, linked to
Medicare claims (1998-2010)2. We identified hospitalizations with severe sepsis using a
validated approach that requires ICD-9-CM codes for both infection and acute organ
dysfunction3,4. We matched hospitalizations for severe sepsis to hospitalizations for 15
common acute medical conditions (Table 1 legend) one-to-one by age, gender, post-
discharge comorbidity burden (Charlson Comorbidity Index), pre-hospitalization functional
disability (limitations of activities and instrumental activities of daily living), and length of
hospitalization using coarsened exact matching5.

We measured the rate and 95%CI of 90-day readmissions. Using Healthcare Cost &
Utilization Project's Clinical Classification Software, we determined the most common
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readmission diagnoses. To gauge what proportion of re-hospitalizations may be potentially

preventable, we measured ambulatory care sensitive conditions (ACSCs)—diagnoses for
which effective outpatient care can reduce hospitalization rates6. We used ACSCs identified

Corresponding Author: Hallie C. Prescott, MD, MSc, 2800 Plymouth Rd., North Campus Research Center, Bldg. 16, 200N-08, Ann
Arbor, MI 48109-2800, Phone: (734) 936-5047, Fax: (734) 764-4556, hprescot@med.umich.edu.
Author Contributions: HCP designed the study, analyzed the data, interpreted the data, and drafted the manuscript. KML acquired
the data, interpreted the data, and revised the manuscript critically for intellectual content. TJI interpreted the data and revised the
manuscript critically for intellectual content.
Declarations: The authors received funding from the National Institutes of Health and the Department of Veterans Affairs. The
authors have no other conflicts of interest.
 Prescott et al. Page 2

by Agency for Healthcare Quality & Research6, and an expanded definition also including
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sepsis, skin/soft tissue infection, acute renal failure, and aspiration pneumonitis, all of which
could plausibly be prevented or treated early to avoid re-hospitalization.

We compared readmission rates using McNemar chi-squared tests with significance at

p<0.001 (two-sided) given multiple comparisons. The University of Michigan IRB approved
this study; patients provided oral informed consent at enrollment and for Medicare linkage.

Results
We identified 3,494 severe sepsis hospitalizations, of which 2,843(81.4%) survived to
discharge. Of these, 2,617(92.1%) were matched to hospitalizations for other acute medical
conditions. The cohort's mean age was 78.9±8.9 years, 57.3% were female, and they had
some pre-existing functional disability [median=1 limitation (IQR:0-4)]. At discharge,
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patients had moderate comorbidity burden [median Charlson Index=6 (IQR:3-8)].

Median(IQR) hospitalization length was 7(4-11) days. Age, gender, comorbidity burden,
functional status, and hospitalization length did not differ between severe sepsis and
matched acute medical conditions, p>0.05 for each.

1,115(42.7%) severe sepsis survivors were re-hospitalized within 90 days. The 10 most
common readmission diagnoses following severe sepsis included several ACSCs: heart
failure, pneumonia, COPD exacerbation, and urinary infection (Table 1). Collectively,
ACSCs accounted for 22.2%(95%CI: 20.3%-24.5%) of 90-day readmissions. Using the
expanded definition, ACSCs accounted for 41.6%(95%CI: 39.1%-44.1%) of 90-day
readmissions after severe sepsis.

Patterns of readmission differed between survivors of severe sepsis and matched acute
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medical conditions (Table 1, Figure 1); rates of readmission for sepsis and renal failure
were higher and accounted for a greater proportion of the total readmissions after severe
sepsis. Readmissions for a primary diagnosis of infection (sepsis, pneumonia, urinary tract,
and skin/soft tissue infection) occurred in 11.9%(95%CI: 10.6%-13.1%) of severe sepsis
survivors, compared to 8.0%(95%CI: 7.0%-9.1%) of matched acute medical conditions,
p<0.001. Readmissions for ACSCs were more common after severe sepsis versus matched
acute conditions [21.6%(95%CI: 20.0%-23.2%) versus 19.1% (95%CI: 17.7%-20.7%),
p=0.022] and accounted for a greater proportion of all 90-day readmissions after severe
sepsis [41.6% (95%CI: 39.2%-44.1%) versus 37.1%(95%CI: 34.8%-39.5%) of
readmissions, p=0.009].

Discussion
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Hospitalizations in the 90 days after severe sepsis are common, and 42% occurred for
diagnoses that could potentially be prevented or treated early to avoid hospitalization
compared to 37% after matched acute medical conditions. A limitation of the present study
is that we inferred potential preventability of re-hospitalizations by measuring readmissions
for ACSCs. Nonetheless, the high prevalence and great concentration of specific diagnoses
during this early post-discharge period suggests that further study is warranted of the

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feasibility and potential benefit of post-discharge interventions tailored to patients’

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personalized risk for a limited number of common conditions.

Acknowledgements
The Health and Retirement Study is funded by the National Institute on Aging and performed at the Institute for
Social Research, University of Michigan. We appreciate the expert programming of Ryan McCammon, MS, and
Vanessa Dickerman, MS, at the University of Michigan. They were not compensated for their contributions besides
salary. Dr. Prescott has had full access to all the data in the study and takes responsibility for the integrity of the
data and the accuracy of the data analysis.

Funding: This work was supported by grants T32 HL007749, R01 AG0030155, R21 AG044752, and U01
AG09740 from the National Institutes of Health and IIR 11-109 from the Department of Veterans Affairs Health
Services Research & Development Service. The views expressed in this article are those of the authors and do not
necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

Role of Funders: The funders had no role in the design and conduct of the study; collection, management, analysis,
and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the
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manuscript for publication.

References
1. Prescott HC, Langa KM, Liu V, Escobar GJ, Iwashyna TJ. Increased 1-year healthcare use in
survivors of severe sepsis. Am. J. Respir. Crit. Care Med. Jul 1; 2014 190(1):62–69. [PubMed:
24872085]
2. Sonnega A, Faul JD, Ofstedal MB, Langa KM, Phillips JWR, Weir DR. Cohort Profile: the Health
and Retirement Study (HRS). Int. J. Epidemiol. 2014
3. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of
severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit.
Care Med. Jul; 2001 29(7):1303–1310. [PubMed: 11445675]
4. Iwashyna TJ, Odden A, Rohde J, et al. Identifying patients with severe sepsis using administrative
claims: patient-level validation of the angus implementation of the international consensus
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conference definition of severe sepsis. Med. Care. Jun; 2014 52(6):e39–43. [PubMed: 23001437]
5. Blackwell, Matthew; Iacus, Stefano; King, Gary; Porro, Giuseppe. cem: Coarsened Exact Mzatching
in Stata. The Stata Journal. 2009; 9(4):524–546.
6. Agency for Healthcare Research and Quality. [September 30, 2014] Guide to Prevention Quality
Indicators. Updated March, 2007. Available at: http://www.qualityindicators.ahrq.gov/Downloads/
Modules/PQI/V31/pqi_guide_v31.pdf.
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Figure 1. Total and Potentially Preventable 90-Day Readmissions among Survivors of Severe
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Sepsis and Matched Hospitalizations for Acute Medical Conditions

Potentially preventable readmission diagnoses include pneumonia, hypertension,
dehydration, asthma, urinary tract infection, chronic obstructive pulmonary disease
exacerbation, perforated appendix, diabetes, angina, congestive heart failure, sepsis, acute
renal failure, skin/soft tissue infection, and aspiration pneumonitis. 95% CI for readmission
proportions are depicted in the shaded areas.

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Table 1

Top 10 Readmission Diagnoses After Severe Sepsis Hospitalization

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N (%) (95%CI) of Survivors with a 90-Day Readmission for this Diagnosis

Rank Diagnosis Severe Sepsis Survivors (N=2,617) Survivors of Matched Hospitalizations McNemar P
for Other Acute Medical Conditions
(N=2,617)
1 Sepsis 167 (6.4%) (5.4%-7.3%) 73 (2.8%) (2.2%-3.4%) <0.001

2 Congestive Heart Failure 144 (5.5%) (4.6%-6.4%) 204 (7.8%) (6.8%-8.8%) 0.001

3 Pneumonia 92 (3.5%) (2.8%-4.2%) 85 (3.3%) (2.6%-3.9%) 0.58

4 Acute Renal Failure 87 (3.3%) (2.6%-4.0%) 30 (1.2%) (0.7%-1.6%) <0.001

5 Rehabilitation 74 (2.8%) (2.2%-3.5%) 120 (4.6%) (3.8%-5.4%) 0.001

6 Respiratory Failure 65 (2.5%) (1.9%-3.1%) 38 (1.5%) (1.0%-1.9%) 0.007

7 Complication of Device, 52 (2.0%) (1.5%-2.5%) 59 (2.3%) (1.7%-2.8%) 0.50

Implant, or Graft
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8 COPD Exacerbation 49 (1.9%) (1.4%-2.4%) 41 (1.6%) (1.1%-2.0%) 0.40

9 Aspiration Pneumonitis 47 (1.8%) (1.3%-2.3%) 31 (1.2%) (0.8%-1.6%) 0.06

10 Urinary Tract Infection 44 (1.7%) (1.2%-2.2%) 47 (1.8%) (1.3%-2.3%) 0.75

The top 10 readmission diagnoses accounted for 51.5% of all readmissions in the 90 days after severe sepsis hospitalization. Principal diagnoses for
the matched hospitalizations for other acute medical conditions were the 15 most common acute hospitalization non-sepsis diagnoses in our cohort:
heart failure; pneumonia; cardiac arrhythmia; COPD exacerbation; acute myocardial infarction; acute cerebrovascular disease; complication of a
device, implant, or graft; chest pain; fluid or electrolyte disorder; urinary tract infection; hip fracture; gastrointestinal hemorrhage; complication or
surgical or medical care; syncope; and diabetes with complication.
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JAMA. Author manuscript; available in PMC 2016 March 10.