Dataset Information

Association Between the New York Sepsis Care Mandate and In-Hospital Mortality for Pediatric Sepsis.

ABSTRACT: Importance:The death of a pediatric patient with sepsis motivated New York to mandate statewide sepsis treatment in 2013. The mandate included a 1-hour bundle of blood cultures, broad-spectrum antibiotics, and a 20-mL/kg intravenous fluid bolus. Whether completing the bundle elements within 1 hour improves outcomes is unclear. Objective:To determine the risk-adjusted association between completing the 1-hour pediatric sepsis bundle and individual bundle elements with in-hospital mortality. Design, Settings, and Participants:Statewide cohort study conducted from April 1, 2014, to December 31, 2016, in emergency departments, inpatient units, and intensive care units across New York State. A total of 1179 patients aged 18 years and younger with sepsis and septic shock reported to the New York State Department of Health who had a sepsis protocol initiated were included. Exposures:Completion of a 1-hour sepsis bundle within 1 hour compared with not completing the 1-hour sepsis bundle within 1 hour. Main Outcomes and Measures:Risk-adjusted in-hospital mortality. Results:Of 1179 patients with sepsis reported at 54 hospitals (mean [SD] age, 7.2 [6.2] years; male, 54.2%; previously healthy, 44.5%; diagnosed as having shock, 68.8%), 139 (11.8%) died. The entire sepsis bundle was completed in 1 hour in 294 patients (24.9%). Antibiotics were administered to 798 patients (67.7%), blood cultures were obtained in 740 patients (62.8%), and the fluid bolus was completed in 548 patients (46.5%) within 1 hour. Completion of the entire bundle within 1 hour was associated with lower risk-adjusted odds of in-hospital mortality (odds ratio [OR], 0.59 [95% CI, 0.38 to 0.93], P?=?.02; predicted risk difference [RD], 4.0% [95% CI, 0.9% to 7.0%]). However, completion of each individual bundle element within 1 hour was not significantly associated with lower risk-adjusted mortality (blood culture: OR, 0.73 [95% CI, 0.51 to 1.06], P?=?.10; RD, 2.6% [95% CI, -0.5% to 5.7%]; antibiotics: OR, 0.78 [95% CI, 0.55 to 1.12], P?=?.18; RD, 2.1% [95% CI, -1.1% to 5.2%], and fluid bolus: OR, 0.88 [95% CI, 0.56 to 1.37], P?=?.56; RD, 1.1% [95% CI, -2.6% to 4.8%]). Conclusions and Relevance:In New York State following a mandate for sepsis care, completion of a sepsis bundle within 1 hour compared with not completing the 1-hour sepsis bundle within 1 hour was associated with lower risk-adjusted in-hospital mortality among patients with pediatric sepsis and septic shock.

SUBMITTER: Evans IVR

PROVIDER: S-EPMC6500448 | biostudies-literature | 2018 Jul

REPOSITORIES: biostudies-literature

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Association Between the New York Sepsis Care Mandate and In-Hospital Mortality for Pediatric Sepsis.

Evans Idris V R IVR Phillips Gary S GS Alpern Elizabeth R ER Angus Derek C DC Friedrich Marcus E ME Kissoon Niranjan N Lemeshow Stanley S Levy Mitchell M MM Parker Margaret M MM Terry Kathleen M KM Watson R Scott RS Weiss Scott L SL Zimmerman Jerry J Seymour Christopher W CW

JAMA 20180701 4

<h4>Importance</h4>The death of a pediatric patient with sepsis motivated New York to mandate statewide sepsis treatment in 2013. The mandate included a 1-hour bundle of blood cultures, broad-spectrum antibiotics, and a 20-mL/kg intravenous fluid bolus. Whether completing the bundle elements within 1 hour improves outcomes is unclear.<h4>Objective</h4>To determine the risk-adjusted association between completing the 1-hour pediatric sepsis bundle and individual bundle elements with in-hospital m ...[more]

PMID: 30043064

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Project description:ImportanceMore evidence on associations between mandated paid sick leave and health service utilization among low-income adults is needed to guide health policy and legislation nationwide.ObjectiveTo evaluate the association between New York City's 2014 paid sick leave mandate and health care utilization among Medicaid-enrolled adults.Design setting and participantsThis retrospective cohort study used New York State Medicaid administrative data for adults 18 to 64 years old continuously enrolled in Medicaid from August 1, 2011, through July 31, 2017. A difference-in-differences approach with entropy balancing weights was used to compare New York City with the rest of New York State to assess the association of the paid sick leave mandate with health care utilization, and for those 40 to 64 years old, with preventive care utilization. The data analysis was performed from June through August 2020.ExposuresTemporal and spatial variation in exposure to the mandate.Main outcomes and measuresAnnual health care utilization (emergency care, specialist visits, and primary care clinician visits) per Medicaid-enrolled adult. Secondary outcomes include categories of emergency utilization and utilization of 5 preventive services.ResultsOf 552 857 individuals (mean [SD] age, 43 [12] years; 351 130 [64%] women) who met inclusion criteria, 99 181 (18%) were White, 162 492 (29%) Black, and 138 061 (25%) Hispanic. Paid sick leave was significantly associated with a reduction in the probability of emergency care (-0.6 percentage points [pp]; 95% CI, -0.7 to -0.5 pp; P < .001), including a 0.3 pp reduction (95% CI, -0.4 to -0.2; P < .001) in care for conditions treatable in a primary care setting and an increase in annual outpatient visits (0.124 pp; 95% CI, 0.040 to 0.208 pp; P < .001). Among those 40 to 64 years old, the mandate was significantly associated with increased probabilities of glycated hemoglobin A1c level testing (2.9 pp; 95% CI, 2.5-3.3 pp; P < .001), blood cholesterol testing (2.7 pp; 95% CI, 2.5-2.9 pp; P < .001), and colon cancer screening (0.4 pp; 95% CI, 0.2-0.6 pp; P < .001).Conclusions and relevanceThis retrospective cohort study of nonelderly adults enrolled in Medicaid New York State showed that mandated paid sick leave in New York City was significantly associated with differences in several dimensions of health care services use.

Project description:ImportanceBeginning in 2013, New York State implemented regulations mandating that hospitals implement evidence-based protocols for sepsis management, as well as report data on protocol adherence and clinical outcomes to the state government. The association between these mandates and sepsis outcomes is unknown.ObjectiveTo evaluate the association between New York State sepsis regulations and the outcomes of patients hospitalized with sepsis.Design, setting, and participantsRetrospective cohort study of adult patients hospitalized with sepsis in New York State and in 4 control states (Florida, Maryland, Massachusetts, and New Jersey) using all-payer hospital discharge data (January 1, 2011-September 30, 2015) and a comparative interrupted time series analytic approach.ExposuresHospitalization for sepsis before (January 1, 2011-March 31, 2013) vs after (April 1, 2013-September 30, 2015) implementation of the 2013 New York State sepsis regulations.Main outcomes and measuresThe primary outcome was 30-day in-hospital mortality. Secondary outcomes were intensive care unit admission rates, central venous catheter use, Clostridium difficile infection rates, and hospital length of stay.ResultsThe final analysis included 1 012 410 sepsis admissions to 509 hospitals. The mean age was 69.5 years (SD, 16.4 years) and 47.9% were female. In New York State and in the control states, 139 019 and 289 225 patients, respectively, were admitted before implementation of the sepsis regulations and 186 767 and 397 399 patients, respectively, were admitted after implementation of the sepsis regulations. Unadjusted 30-day in-hospital mortality was 26.3% in New York State and 22.0% in the control states before the regulations, and was 22.0% in New York State and 19.1% in the control states after the regulations. Adjusting for patient and hospital characteristics as well as preregulation temporal trends and season, mortality after implementation of the regulations decreased significantly in New York State relative to the control states (P = .02 for the joint test of the comparative interrupted time series estimates). For example, by the 10th quarter after implementation of the regulations, adjusted absolute mortality was 3.2% (95% CI, 1.0% to 5.4%) lower than expected in New York State relative to the control states (P = .004). The regulations were associated with no significant differences in intensive care unit admission rates (P = .09) (10th quarter adjusted difference, 2.8% [95% CI, -1.7% to 7.2%], P = .22), a significant relative decrease in hospital length of stay (P = .04) (10th quarter adjusted difference, 0.50 days [95% CI, -0.47 to 1.47 days], P = .31), a significant relative decrease in the C difficile infection rate (P < .001) (10th quarter adjusted difference, -1.8% [95% CI, -2.6% to -1.0%], P < .001), and a significant relative increase in central venous catheter use (P = .02) (10th quarter adjusted difference, 4.8% [95% CI, 2.3% to 7.4%], P < .001).Conclusions and relevanceIn New York State, mandated protocolized sepsis care was associated with a greater decrease in sepsis mortality compared with sepsis mortality in control states that did not implement sepsis regulations. Because baseline mortality rates differed between New York and comparison states, it is uncertain whether these findings are generalizable to other states.

Project description:ObjectivesInitial evidence suggests that state-level regulatory mandates for sepsis quality improvement are associated with decreased sepsis mortality. However, sepsis mandates require financial investments on the part of hospitals and may lead to increased spending. We evaluated the effects of the 2013 New York State sepsis regulations on the costs of care for patients hospitalized with sepsis.DesignRetrospective cohort study using state discharge data from the U.S. Healthcare Costs and Utilization Project and a comparative interrupted time series analytic approach. Costs were calculated from admission-level charge data using hospital-specific cost-to-charge ratios.SettingGeneral, short stay, acute care hospitals in New York, and four control states: Florida, Massachusetts, Maryland, and New Jersey.PatientsAll patients hospitalized with sepsis between January 1, 2011, and September 30, 2015.InterventionsThe 2013 New York mandate that all hospitals develop and implement protocols for sepsis identification and treatment, educate staff, and report performance data to the state.Measurements and main resultsThe analysis included 1,026,664 admissions in 520 hospitals. Mean unadjusted costs per hospitalization in New York State were $42,036 ± $60,940 in the pre-regulation period and $39,719 ± $59,063 in the post-regulation period, compared with $34,642 ± $52,403 pre-regulation and $31,414 ± $48,155 post-regulation in control states. In the comparative interrupted time series analysis, the regulations were not associated with a significant difference in risk-adjusted mean cost per hospitalization (p = 0.12) or risk-adjusted mean cost per hospital day (p = 0.44). For example, in the 10th quarter after implementation of the regulations, risk-adjusted mean cost per hospitalization was $3,627 (95% CI, -$681 to $7,934) more than expected in New York State relative to control states.ConclusionsMandated protocolized sepsis care was not associated with significant changes in hospital costs in patients hospitalized with sepsis in New York State.

Project description:BackgroundHospital segregation by race, ethnicity, and health insurance coverage is prevalent, with some hospitals providing a disproportionate share of undercompensated care. We assessed whether New York City (NYC) hospitals serving a higher proportion of Medicaid and uninsured patients pre-pandemic experienced greater critical care strain during the first wave of the COVID-19 pandemic, and whether this greater strain was associated with higher rates of in-hospital mortality.MethodsIn a retrospective analysis of all-payer NYC hospital discharge data, we examined changes in admissions, stratified by use of intensive care unit (ICU), from the baseline period in early 2020 to the first COVID-19 wave across hospital quartiles (265,329 admissions), and crude and risk-adjusted inpatient mortality rates, also stratified by ICU use, in the first COVID wave across hospital quartiles (23,032 inpatient deaths), based on the proportion of Medicaid or uninsured admissions from 2017-2019 (quartile 1 lowest to 4 highest). Logistic regressions were used to assess the cross-sectional association between ICU strain, defined as ICU volume in excess of the baseline average, and patient-level mortality.ResultsICU admissions in the first COVID-19 wave were 84%, 97%, 108%, and 123% of the baseline levels by hospital quartile 1-4, respectively. The risk-adjusted mortality rates for ICU admissions were 36.4 (CI = 34.7,38.2), 43.6 (CI = 41.5,45.8), 45.9 (CI = 43.8,48.1), and 45.7 (CI = 43.6,48.0) per 100 admissions, and those for non-ICU admissions were 8.6 (CI = 8.3,9.0), 10.9 (CI = 10.6,11.3), 12.6 (CI = 12.1,13.0), and 12.1 (CI = 11.6,12.7) per 100 admissions by hospital quartile 1-4, respectively. Compared with the reference group of 100% or less of the baseline weekly average, ICU admissions on a day for which the ICU volume was 101-150%, 151-200%, and > 200% of the baseline weekly average had odds ratios of 1.17 (95% CI = 1.10, 1.26), 2.63 (95% CI = 2.31, 3.00), and 3.26 (95% CI = 2.82, 3.78) for inpatient mortality, and non-ICU admissions on a day for which the ICU volume was 101-150%, 151-200%, and > 200% of the baseline weekly average had odds ratios of 1.28 (95% CI = 1.22, 1.34), 2.60 (95% CI = 2.40, 2.82), and 3.44 (95% CI = 3.11, 3.63) for inpatient mortality.ConclusionsOur findings are consistent with hospital segregation as a potential driver of COVID-related mortality inequities and highlight the need to desegregate health care to address structural racism, advance health equity, and improve pandemic resiliency.

Project description:ImportanceSepsis is associated with a high burden of inpatient mortality. Treatment in intensive care units (ICUs) that have more experience treating patients with sepsis may be associated with lower mortality.ObjectiveTo assess the association between the volume of patients with sepsis receiving care in an ICU and hospital mortality from sepsis in the UK.Design, setting, and participantsThis retrospective cohort study used data from adult patients with sepsis from 231 UK ICUs between 2010 and 2016. Demographic and clinical data were extracted from the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme database. Data were analyzed from January 1, 2010, to December 31, 2016.ExposuresAnnual sepsis case volume in an ICU in the year of a patient's admission.Main outcomes and measuresHospital mortality after ICU admission for sepsis assessed using a mixed-effects logistic model in a 3-level hierarchical structure based on the number of individual patients nested in years nested within ICUs.ResultsAmong 273 001 patients included in the analysis, the median age was 66 years (interquartile range, 53-76 years), 148 149 (54.3%) were male, and 248 275 (91.0%) were White. The mean ICNARC-2018 illness severity score was 21.0 (95% CI, 20.9-21.0). Septic shock accounted for 19.3% of patient admissions, and 54.3% of patients required mechanical ventilation. The median annual sepsis volume per ICU was 242 cases (interquartile range, 177-334 cases). The study identified a significant association between the volume of sepsis cases in the ICU and mortality from sepsis; in the logistic regression model, hospital mortality was significantly lower among patients admitted to ICUs in the highest quartile of sepsis volume compared with the lowest quartile (odds ratio [OR], 0.89; 95% CI, 0.82-0.96; P = .002). With volume modeled as a restricted cubic spline, treatment in a larger ICU was associated with lower hospital mortality. A lower annual volume threshold of 215 patients above which hospital mortality decreased significantly was found; 38.8% of patients were treated in ICUs below this threshold volume. There was no significant interaction between ICU volume and severity of illness as described by the ICNARC-2018 score (β [SE], -0.00014 [0.00024]; P = .57).Conclusions and relevanceThe findings suggest that patients with sepsis in the UK have higher odds of survival if they are treated in an ICU with a larger sepsis case volume. The benefit of a high sepsis case volume was not associated with the severity of the sepsis episode.

Project description:Objective: This study aimed to explore the association between the variability in electrolytes and the in-hospital mortality in critically ill children admitted into intensive care units (ICUs). Design: This is a retrospective case-control study. Setting and Participants: Total of 11,245 children have been admitted to ICUs of Children's Hospital of Zhejiang University from 2010 to 2018. Methods: The coefficient of variation (CV), standard deviation (SD), and variability independent of the mean (VIM) were calculated as variability indices. High variability was defined as having values in the highest quartile for each parameter. Age, sex, diagnoses of disease, and surgical treatment were adjusted in the multivariable-adjusted logistic regression model. Results: A total of 11,245 children were included, and 660 patients died in the hospital. The median (P25, P75) potassium, sodium, and chloride of all patients were 3.8 (3.58, 4.09), 136.83 (135.11, 138.60), and 108.67 (105.71, 111.17), respectively. U-shaped relationships between the mean, lowest, and highest levels of potassium, sodium, and chloride and the in-hospital mortality were observed. The lowest mortality was noted when serum potassium, sodium, and chloride were between ~3.5 and 5.0, 135 and 145, and 105 and 115 mmol/l, respectively. The areas under the curve (AUCs) of three indices of variability in electrolytes were larger than those of the mean and lowest levels of electrolytes in predicting the in-hospital mortality. In the multivariable-adjusted model, the odds ratios and 95% confidence interval (CI) of the in-hospital mortality were 3.14 (2.44-4.04) for one parameter, 5.85 (4.54-7.53) for two parameters, and 10.32 (7.81-13.64) for three parameters compared with subjects having no parameters of high variability measured as the CV. The results were consistent when the variability was determined using the SD and VIM (all P for trend <0.001). Consistent results were noted in various subgroup analyses. Conclusions: This study showed that individuals with higher variability of each parameter were related with higher risk of in-hospital mortality. There was a linear association between the number of high variability parameters and the in-hospital mortality. The variability of electrolytes might be a good predictor for in-hospital mortality of children in ICUs.

Dataset Information

Association Between the New York Sepsis Care Mandate and In-Hospital Mortality for Pediatric Sepsis.

Publications

Association Between the New York Sepsis Care Mandate and In-Hospital Mortality for Pediatric Sepsis.

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