Readmissions Following Necrotizing Fasciitis, Both Common and Costly

Author(s):
Addison May; Victor B Talisa; David Wilfret; Andrew Bernard; Wayne Dankner; Eileen Bulger; Sachin Yende

Background:

Improvements in hospital-related mortality following necrotizing soft tissue infections (NSTI) have increased the number of survivors at risk for long-term sequelae.

Hypothesis:

To determine the burden of readmissions and associated healthcare spending in patients who survived admission for necrotizing fasciitis, a common form of NSTI.

Methods:

Retrospective analysis of the 2014 Nationwide Readmissions Database (NRD), a unique database designed to support analyses of national readmissions rates that includes insured and uninsured patients, was undertaken.  We identified index admissions for NF using ICD-9 CM codes in 10 discharge diagnoses fields. To ascertain readmissions, we identified a sub-cohort of patients>18 years, alive during the index admission, not discharged against medical advice, hospitalized before October1st, and with complete patient-level data. We examined patient clinical characteristics and outcomes (readmissions and costs). We conducted sensitivity analyses using alternate criteria to identify NF (limiting ICD-9 codes to either 3 or 5 fields and using DRG codes) and compared 90 day readmission rate for NF to common medical conditions.

Results:

There were 3739 admissions that met the sub-cohort definitions. Average age was 52 years, 60% were men, and 90% had one or more comorbidities. Approximately 10% had shock and 22% met criteria for acute kidney injury. The median length of stay was 10 days (interquartile range (IQR):6-19 days). The 30, 60, and 90 day readmission risk was 17% (n=650), 25% (n=931), and 29% (n=1083), respectively. Most readmissions (89%) were not for planned procedures and 65% had an ICD-9 infection code. Of the readmitted patients (n=1083), 70% (n=759) were readmitted once, 22% (n=237) twice, and 5% (n=58) more than twice in 90 days. In comparison, 90 day readmissions were similar for common medical conditions: burns (17%), acute MI (23%) and pneumonia (28%). The median cost/readmission was $10,577(IQR: $5,935-$20,228). The risks of readmissions and median costs were similar in sensitivity analyses using more stringent criteria to identify NF.

Conclusions:

Readmission are common after NF and similar to other publicly available quality measures. They occur in over 1 in 4 survivors over 90 days and are associated with high healthcare spending. Comorbidity was high and may contribute to subsequent infection and readmission.