Assessing Variability in Hospital-Level Mortality Among US Medicare Beneficiaries With Hospitalizations for Severe Sepsis and Septic Shock*

• Authors: Kelly M. Hatfield, Centers for Disease Control and Prevention; Raymund B. Dantes, Emory University; James Baggs, Centers for Disease Control and Prevention; Mathew R. P. Sapiano, Centers for Disease Control and Prevention; Anthony E. Fiore, Centers for Disease Control and Prevention; John A Jernigan, Emory University; Lauren Epstein, Centers for Disease Control and Prevention
• Journal Title: Critical Care Medicine
• Volume: Volume 46, Number 11
• Publisher: Lippincott, Williams & Wilkins | 2018-11-01, Pages 1753-1760
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1097/CCM.0000000000003324
• Subjects: Health Sciences, Medicine and Surgery; Health Sciences, Public Health
• Keywords: Science & Technology; Life Sciences & Biomedicine; Critical Care Medicine; General & Internal Medicine; epidemiology; hospitalization; mortality; outcomes; sepsis; ADMINISTRATIVE CLAIMS; UNITED-STATES; EPIDEMIOLOGY; OUTCOMES; HEALTH; TRENDS; CARE; COSTS; RATES

Abstract

Objectives: To assess the variability in short-term sepsis mortality by hospital among Centers for Medicare and Medicaid Services benefciaries in the United States during 2013-2014. Design: A retrospective cohort design. Setting: Hospitalizations from 3,068 acute care hospitals that participated in the Centers for Medicare and Medicaid Services inpatient prospective payment system in 2013 and 2014. Patients: Medicare fee-for-service benefciaries greater than or equal to 65 years old who had an inpatient hospitalization coded with present at admission severe sepsis or septic shock. Interventions: None. Measurements and Main Results: Individual level mortality was assessed as death at or within 7 days of hospital discharge and aggregated to calculate hospital-level mortality rates. We used a logistic hierarchal linear model to calculate mortality risk-adjusted for patient characteristics. We quantifed variability among hospitals using the median odds ratio and calculated risk-standardized mortality rates for each hospital. The overall crude mortality rate was 34.7%. We found signifcant variability in mortality by hospital (p < 0.001). The middle 50% of hospitals had similar riskstandardized mortality rates (32.7-36.9%), whereas the decile of hospitals with the highest risk-standardized mortality rates had a median mortality rate of 40.7%, compared with a median of 29.2% for hospitals in the decile with the lowest risk-standardized mortality rates. The median odds ratio (1.29) was lower than the adjusted odds ratios for several measures of patient comorbidities and severity of illness, including present at admission organ dysfunction, no identifed source of infection, and age. Conclusions: In a large study of present at admission sepsis among Medicare benefciaries, we showed that mortality was most strongly associated with underlying comorbidities and measures of illness on arrival. However, after adjusting for patient characteristics, mortality also modestly depended on where a patient with sepsis received care, suggesting that efforts to improve sepsis outcomes in lower performing hospitals could impact sepsis survival.