Dataset Information

Hospital Variation in Renal Replacement Therapy for Sepsis in the United States.

ABSTRACT: OBJECTIVES:Acute renal replacement therapy in patients with sepsis has increased dramatically with substantial costs. However, the extent of variability in use across hospitals-and whether greater use is associated with better outcomes-is unknown. DESIGN:Retrospective cohort study. SETTING:Nationwide Inpatient Sample in 2011. PATIENTS:Eighteen years old and older with sepsis and acute kidney injury admitted to hospitals sampled by the Nationwide Inpatient Sample in 2011. INTERVENTIONS:We estimated the risk- and reliability-adjusted rate of acute renal replacement therapy use for patients with sepsis and acute kidney injury at each hospital. We examined the association between hospital-specific renal replacement therapy rate and in-hospital mortality and hospital costs after adjusting for patient and hospital characteristics. MEASUREMENTS AND MAIN RESULTS:We identified 293,899 hospitalizations with sepsis and acute kidney injury at 440 hospitals, of which 6.4% (n = 18,885) received renal replacement therapy. After risk and reliability adjustment, the median hospital renal replacement therapy rate for patients with sepsis and acute kidney injury was 3.6% (interquartile range, 2.9-4.5%). However, hospitals in the top quintile of renal replacement therapy use had rates ranging from 4.8% to 13.4%. There was no significant association between hospital-specific renal replacement therapy rate and in-hospital mortality (odds ratio per 1% increase in renal replacement therapy rate: 1.03; 95% CI, 0.99-1.07; p = 0.10). Hospital costs were significantly higher with increasing renal replacement therapy rates (absolute cost increase per 1% increase in renal replacement therapy rate: $1,316; 95% CI, $157-$2,475; p = 0.03). CONCLUSIONS:Use of renal replacement therapy in sepsis varied widely among nationally sampled hospitals without associated differences in mortality. Improving renal replacement standards for the initiation of therapy for sepsis may reduce healthcare costs without increasing mortality.

SUBMITTER: Valley TS

PROVIDER: S-EPMC5771975 | biostudies-literature | 2018 Feb

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Hospital Variation in Renal Replacement Therapy for Sepsis in the United States.

Valley Thomas S TS Nallamothu Brahmajee K BK Heung Michael M Iwashyna Theodore J TJ Cooke Colin R CR

Critical care medicine 20180201 2

<h4>Objectives</h4>Acute renal replacement therapy in patients with sepsis has increased dramatically with substantial costs. However, the extent of variability in use across hospitals-and whether greater use is associated with better outcomes-is unknown.<h4>Design</h4>Retrospective cohort study.<h4>Setting</h4>Nationwide Inpatient Sample in 2011.<h4>Patients</h4>Eighteen years old and older with sepsis and acute kidney injury admitted to hospitals sampled by the Nationwide Inpatient Sample in 2 ...[more]

PMID: 29206766

Similar Datasets

Project description:BackgroundSepsis remains the leading cause of mortality in-hospital in the intensive care unit (ICU). Continuous renal replacement therapy (CRRT) is recommended as an adjuvant therapy for hemodynamics management in patients with sepsis. The aim of this study was to develop an adaptive least absolute shrinkage and selection operator (LASSO) for the Cox regression model to predict the hospital mortality in patients with Sepsis-3.0 undergoing CRRT using Medical Information Martin Intensive Care (MIMIC)-III v1.4.MethodsPatients who met the Sepsis-3.0 definition were identified using the MIMIC-III v1.4. Among them, patients who received CRRT during ICU hospitalization were included in this study. According to the survival status, patients were split into death or survival group. Adaptive LASSO for the Cox regression model was constructed by STATA software. At last, nomogram and Kaplan-Meier curves were drawn to validate the model.ResultsA total of 181 patients who met Sepsis 3.0 criteria received CRRT were included in the study, in which, there were 31 deaths and 150 survivals during hospitalization, respectively. The overall in-hospital mortality was 17.1%. According to the results of multivariate Cox-LASSO regression analysis, use of vasopressor, international normalized ratio (INR) ≥1.5, and quick sequential organ failure assessment (qSOFA) score were associated with hospital mortality in patients with sepsis who underwent CRRT, but lactate level, mechanical ventilation (MV) support, PaO2/FiO2, platelet count, and indicators of acute kidney injury (AKI), such as blood urea nitrogen (BUN) and creatinine, were not independently associated with hospital mortality after adjusted by qSOFA. The risk nomogram and Kaplan-Meier curves verified that the use of vasopressor and INR ≥1.5 possess significant predictive value.ConclusionsUsing the Cox-LASSO regression model, use of vasopressor, INR ≥1.5, and qSOFA score are found to be associated with hospital mortality in patients with Sepsis-3.0 who received CRRT. This finding may assist clinicians in tailoring precise management and therapy for these patients who underwent CRRT.

Project description:Controversy exists regarding perceived benefits of early tracheostomy to facilitate weaning among mechanically ventilated patients, potentially leading to significant practice-pattern variation with implications for outcomes and resource utilization. We sought to determine practice-pattern variation and outcomes associated with tracheostomy timing in the United States.In a retrospective cohort study, we identified mechanically ventilated patients with the most common causes of respiratory failure leading to tracheostomy: pneumonia/sepsis and trauma. "Early tracheostomy" was performed within the first week of mechanical ventilation. We determined between-hospital variation in early tracheostomy utilization and the association of early tracheostomy with patient outcomes using hierarchical regression.2012 National Inpatient Sample.A total of 6,075 pneumonia/sepsis patients and 12,030 trauma patients with tracheostomy.None.Trauma patients were twice as likely as pneumonia/sepsis patients to receive early tracheostomy (44.5% vs 21.7%; p < 0.001). Admission to hospitals with higher early tracheostomy-to-total-tracheostomy ratios was associated with increased risk for tracheostomy among mechanically ventilated trauma patients (adjusted odds ratio = 1.04; 95% CI, 1.01-1.07) but not pneumonia/sepsis (adjusted odds ratio =1.00; 95% CI, 0.98-1.02). We observed greater between-hospital variation in early tracheostomy rates among trauma patients (21.9-81.9%) compared with pneumonia/sepsis (14.9-38.3%; p < 0.0001). We found no evidence of improved hospital mortality. Pneumonia/sepsis patients with early tracheostomy had fewer feeding tube procedures and higher odds of discharge home.Early tracheostomy is potentially overused among mechanically ventilated trauma patients, with nearly half of tracheostomies performed within the first week of mechanical ventilation and large unexplained hospital variation, without clear benefits. Future studies are needed to characterize potentially differential benefits for early tracheostomy between disease subgroups and to investigate factors driving hospital variation in tracheostomy timing.

Project description:BackgroundLittle is known about variation in use of rehabilitation services provided in acute care hospitals for people who have had a stroke.ObjectiveThe objective was to examine patient and hospital sources of variation in acute care rehabilitation services provided for stroke.DesignThis was a retrospective, cohort design.MethodsThe sample consisted of Medicare fee-for-service beneficiaries with ischemic stroke admitted to acute care hospitals in 2010. Medicare claims data were linked to the Provider of Services file to gather information on hospital characteristics and the American Community Survey for sociodemographic data. Chi-square tests compared patient and hospital characteristics stratified by any rehabilitation use. We used multilevel, multivariable random effect models to identify patient and hospital characteristics associated with the likelihood of receiving any rehabilitation and with the amount of therapy received in minutes.ResultsAmong 104,295 patients, 85.2% received rehabilitation (61.5% both physical therapy and occupational therapy; 22.0% physical therapy only; and 1.7% occupational therapy only). Patients received 123 therapy minutes on average (median [SD] = 90.0 [99.2] minutes) during an average length of stay of 4.8 [3.5] days. In multivariable analyses, male sex, dual enrollment in Medicare and Medicaid, prior hospitalization, ICU stay, and feeding tube were associated with lower odds of receiving any rehabilitation services. These same variables were generally associated with fewer minutes of therapy. Patients treated by tissue plasminogen activator, in limited-teaching and nonteaching hospitals, and in hospitals with inpatient rehabilitation units, were more likely to receive more therapy minutes.LimitationThe findings are limited to patients with ischemic stroke.ConclusionOnly 61% of patients with ischemic stroke received both physical therapy and occupational therapy services in the acute setting. We identified considerable variation in the use of rehabilitation services in the acute care setting following a stroke.

Project description:ObjectivesTimely empiric antimicrobial therapy is associated with improved outcomes in pediatric sepsis, but minimal data exist to guide empiric therapy. We sought to describe the prevalence of four pathogens that are not part of routine empiric coverage (e.g., Staphylococcus aureus, Pseudomonas aeruginosa, Clostridium difficile, and fungal infections) in pediatric sepsis patients in a contemporary nationally representative sample.DesignThis was a retrospective cohort study using administrative data.SettingWe used the Nationwide Readmissions Database from 2014, which is a nationally representative dataset that contains data from nearly half of all discharges from nonfederal hospitals in the United States.PatientsDischarges of patients who were less than 19 years old at discharge and were not neonatal with a discharge diagnosis of sepsis.InterventionsNone.Measurements and main resultsOf the 19,113 pediatric admissions with sepsis (6,300 [33%] previously healthy and 12,813 [67%] with a chronic disease), 31% received mechanical ventilation, 19% had shock, and 588 (3.1%) died during their hospitalization. Among all admissions, 8,204 (42.9%) had a bacterial or fungal pathogen identified. S. aureus was the most common pathogen identified in previously healthy patients (n = 593, 9.4%) and those with any chronic disease (n = 1,430, 11.1%). Methicillin-resistant S. aureus, P. aeruginosa, C. difficile, and fungal infections all had high prevalence in specific chronic diseases associated with frequent contact with the healthcare system, early surgery, indwelling devices, or immunosuppression.ConclusionsIn this nationally representative administrative database, the most common identified pathogen was S. aureus in previously healthy and chronically ill children. In addition, a high proportion of children with sepsis and select chronic diseases had infections with methicillin-resistant S. aureus, fungal infections, Pseudomonas infections, and C. difficile. Clinicians caring for pediatric patients should consider coverage of these organisms when administering empiric antimicrobials for sepsis.

Project description:In the United States, sepsis is a major public health problem accounting for over 200,000 annual deaths. The aims of this study were to identify U.S. counties with high sepsis mortality and to assess the community characteristics associated with increased sepsis mortality.We performed a descriptive analysis of 2003 through 2012 Compressed Mortality File data. We defined sepsis deaths as deaths associated with an infection, classified according to the International Classification of Diseases, 10th Version.Three thousand one hundred and eight counties in the contiguous U.S. counties, excluding Hawaii and Alaska.Using geospatial autocorrelation methods, we defined county-level sepsis mortality as strongly clustered, moderately clustered, and nonclustered. We approximated the mean crude, age-adjusted, and community-adjusted sepsis mortality rates nationally and for clustering groups. We contrasted demographic and community characteristics between clustering groups. We performed logistic regression for the association between strongly clustered counties and community characteristics. Among 3,108 U.S. counties, the age-adjusted sepsis mortality rate was 59.6 deaths per 100,000 persons (95% CI, 58.9-60.4). Sepsis mortality was higher in the Southern U.S. and clustered in three major regions: Mississippi Valley, Middle Georgia, and Central Appalachia. Among 161 (5.2%) strongly clustered counties, age-adjusted sepsis mortality was 93.1 deaths per 100,000 persons (95% CI, 90.5-95.7). Strongly clustered sepsis counties were more likely to be located in the south (92.6%; p < 0.001), exhibit lower education, higher impoverished population, without medical insurance, higher medically uninsured rates, and had higher unemployment rates (p < 0.001).Sepsis mortality is higher in the Southern United States, with three regional clusters: "Mississippi Valley," "Middle Georgia," and "Central Appalachia": Regions of high sepsis mortality are characterized by lower education, income, employment, and insurance coverage.

Project description:ImportanceAlthough the majority of children with an unplanned admission to the hospital are admitted through the emergency department (ED), direct admissions constitute a significant proportion of hospital admissions nationally. Despite this, past studies of children have not characterized direct admission practices or outcomes. Pneumonia is the leading cause of pediatric hospitalization in the United States, providing an ideal lens to examine variation and outcomes associated with direct admissions.ObjectivesTo describe rates and patterns of direct admission in a large sample of US hospitals and to compare resource utilization and outcomes between children with pneumonia admitted directly to a hospital and those admitted from an ED.Design, setting, and participantsRetrospective cohort study of children 1 to 17 years of age with pneumonia who were admitted to hospitals contributing data to Perspective Data Warehouse. We developed hierarchical generalized linear models to examine associations between admission type and outcomes.Main outcomes and measuresOutcome measures included (1) length of stay, (2) high turnover hospitalization, (3) total hospital cost, (4) transfer to the intensive care unit, and (5) readmission within 30 days of hospital discharge.ResultsA total of 19,736 children from 278 hospitals met eligibility criteria, including 7100 (36.0%) who were admitted directly and 12,636 (64.0%) through the ED. Rates of direct admission varied considerably across hospitals, with a median direct admission rate of 33.3% (interquartile range, 11.1%-50.0%). Children admitted directly were more likely to be white, to have private health insurance, and to be admitted to small, general community hospitals. In adjusted models, children admitted directly had a 9% higher length of stay (risk ratio, 1.09 [95% CI, 1.07-1.11]), 39% lower odds of high turnover hospitalization (odds ratio [OR], 0.61 [95% CI, 0.56-0.66]), and 12% lower cost (risk ratio, 0.88 [95% CI, 0.87-0.90]) than those admitted through the ED, with no significant differences in transfers to the intensive care unit (OR, 1.29 [95% CI, 0.83-2.00]) or 30-day readmissions (OR, 0.80 [95% CI, 0.57-1.13]).Conclusions and relevanceIncreasing rates of direct admission among children with access to outpatient care might be an effective strategy to reduce hospital costs and the volume of patients in the ED. Additional research is needed to establish direct admission policies and procedures that are safe and cost-effective.

Dataset Information

Hospital Variation in Renal Replacement Therapy for Sepsis in the United States.

Publications

Hospital Variation in Renal Replacement Therapy for Sepsis in the United States.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets