PracticeUpdate Dermatology May 2019

EDITOR’S PICKS 8

Analysis of Readmissions Following Hospitalization for Cellulitis JAMA Dermatology Take-home message

Abstract IMPORTANCE Cellulitis commonly results in hos- pitalization. Limited data on the proportion of cellulitis admissions associated with readmis- sion are available. OBJECTIVE To characterize the US national read- mission rate associated with hospitalization for treatment of cellulitis. DESIGN, SETTING, AND PARTICIPANTS This retro- spective cohort analysis of cellulitis admissions from the nationally representative 2014 Nation- wide Readmissions Database calculated readmission rates for all cellulitis admissions and subsets of admissions. The multicenter population-based cohort included adult patients admitted for conditions other than obstetrical or newborn care. Data were collected from Janu- ary 1 through November 30, 2014, and analyzed from February 1 through September 18, 2018. Bivariate logistic regression models were used to assess differences in readmission rates by patient characteristics. Costs were calculated for all readmissions after discharge from hos- pitalization for cellulitis (hereinafter referred to as cellulitis discharge) and by readmission diagnosis. EXPOSURES Admission with a primary diagnosis of cellulitis. MAIN OUTCOMES AND MEASURES Proportion of cellulitis admissions associated with nonelec- tive readmission within 30 days, characteristics of patients readmitted after cellulitis discharge, and costs associated with cellulitis readmission. RESULTS A total of 447 080 (95% CI, 429 927-464 233) index admissions with a primary diagnosis of cellulitis (53.8% male [95% CI, 53.5%-54.2%]; mean [SD] age, 56.1 [18.9] years) were included. Overall 30-day all-cause nonelective readmis- sion rate after cellulitis discharge was 9.8% (95% CI, 9.6%-10.0%). Among patients with cellulitis, age (odds ratio for 45-64 years, 0.78; 95% CI, 0.75-0.81; P = .001) and insurance status (odds ratio for Medicare, 2.45; 95% CI, 2.33-2.58; P< .001) were associated with increased read- mission rates. The most common diagnosis of readmissions included skin and subcutaneous tissue infections. The total cost associated with nonelective readmissions attributed to skin and subcutaneous infections within 30 days of a cel- lulitis discharge during the study period was $114.4 million (95% CI, $106.8-$122.0 million). CONCLUSIONS AND RELEVANCE Readmission after hospitalization for cellulitis is common and costly and may be preventable with improved diagnostics, therapeutics, and discharge care coordination. Analysis of Readmissions Following Hospitali- zation for Cellulitis in the United States. JAMA Dermatol 2019 Feb 27;[EPub Ahead of Print], JM Fisher, JY Feng, SY Tan, A Mostaghimi. www.practiceupdate.com/c/80506

• This retrospective analysis utilizing the Nationwide Readmissions Database included data from 447,080 admissions with a primary diagnosis of cellulitis from January 1 through November 30, 2014. The overall all-cause nonelective readmission rate for the 30 days following discharge was 9.8%, which was most commonly associated with a diagnosis of skin and subcutaneous tissue infections (29.7%), followed by diseases of the heart (8.3%), and bacterial infection (8.0%). The readmission rate observed in this study was slightly lower than the reported national readmission rate after index admissions for any diagnosis, which is estimated to be 14.5%. • Patients 65 years of age or older and those insured by Medicare or Medicaid were more likely to be readmitted. Overall healthcare costs for readmissions after discharge for cellulitis was estimated at USD$553.3 million, with USD$114.4 million attributable to skin and subcutaneous tissue infections. Caitlyn T. Reed, MD

COMMENT By Lindy Fox MD T his study used data collected from the 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database (from January 1 to November 30, 2014) to evaluate the rate of, risk factors for, and costs associ- ated with non-elective readmission within 30 days after an initial hospitalization for cellulitis. Cellulitis accounted for the admission diagnosis in 2.2% of all patients admitted (447,080 of 19,882,317) dur- ing the study time period. The all-cause readmission rate was 9.8%. Risk factors significantly associated with readmission included age ≥65 years and insurance with Medicare or Medicaid (compared with private insurance). The most com- mon readmission diagnosis was skin and subcutaneous tissue infection. The second most common reason for read- mission was diseases of the heart. The total cost of readmission was USD$533.3 million, with the cost of skin and subcu- taneous tissue infection accounting for USD$114.4 million. The authors propose that one possible reason (among others) for readmission for cellulitis is misdiagnosis, as 30% of

patients admitted through the emer- gency room for cellulitis actually have an alternate diagnosis. Correctly identifying cellulitis and its mimickers is one area where dermatologists are indispensable. Including our expertise in the evaluation of such patients has positive impacts on the healthcare system, the patients it serves, and the reputation of dermatology in the house of medicine. serves, and the reputation of dermatology in the house of medicine. " " Correctly identifying cellulitis and its mimickers is one area where dermatologists are indispensable. Including our expertise in the evaluation of such patients has positive impacts on the healthcare system, the patients it

Dr. Fox is Associate Professor of Clinical Dermatology, Director of Hospital Consultation Service, and Director of Complex Medical Dermatology Fellowship in the Department of Dermatology, University of California in San Francisco, California.

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