1
|
van Staa TP, Pate A, Martin GP, Sharma A, Dark P, Felton T, Zhong X, Bladon S, Cunningham N, Gilham EL, Brown CS, Mirfenderesky M, Palin V, Ashiru-Oredope D. Sepsis and case fatality rates and associations with deprivation, ethnicity, and clinical characteristics: population-based case-control study with linked primary care and hospital data in England. Infection 2024; 52:1469-1479. [PMID: 38627354 PMCID: PMC11288984 DOI: 10.1007/s15010-024-02235-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/12/2024] [Indexed: 08/02/2024]
Abstract
PURPOSE Sepsis is a life-threatening organ dysfunction caused by dysregulated host response to infection. The purpose of the study was to measure the associations of specific exposures (deprivation, ethnicity, and clinical characteristics) with incident sepsis and case fatality. METHODS Two research databases in England were used including anonymized patient-level records from primary care linked to hospital admission, death certificate, and small-area deprivation. Sepsis cases aged 65-100 years were matched to up to six controls. Predictors for sepsis (including 60 clinical conditions) were evaluated using logistic and random forest models; case fatality rates were analyzed using logistic models. RESULTS 108,317 community-acquired sepsis cases were analyzed. Severe frailty was strongly associated with the risk of developing sepsis (crude odds ratio [OR] 14.93; 95% confidence interval [CI] 14.37-15.52). The quintile with most deprived patients showed an increased sepsis risk (crude OR 1.48; 95% CI 1.45-1.51) compared to least deprived quintile. Strong predictors for sepsis included antibiotic exposure in prior 2 months, being house bound, having cancer, learning disability, and diabetes mellitus. Severely frail patients had a case fatality rate of 42.0% compared to 24.0% in non-frail patients (adjusted OR 1.53; 95% CI 1.41-1.65). Sepsis cases with recent prior antibiotic exposure died less frequently compared to non-users (adjusted OR 0.7; 95% CI 0.72-0.76). Case fatality strongly decreased over calendar time. CONCLUSION Given the variety of predictors and their level of associations for developing sepsis, there is a need for prediction models for risk of developing sepsis that can help to target preventative antibiotic therapy.
Collapse
Affiliation(s)
- Tjeerd Pieter van Staa
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, Vaughan House, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK.
| | - Alexander Pate
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, Vaughan House, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Glen P Martin
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, Vaughan House, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Anita Sharma
- Chadderton South Health Centre, Eaves Lane, Chadderton, Oldham, OL9 8RG, UK
| | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Tim Felton
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Intensive Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Xiaomin Zhong
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, Vaughan House, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Sian Bladon
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, Vaughan House, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Neil Cunningham
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London, SW1P 3JR, UK
| | - Ellie L Gilham
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London, SW1P 3JR, UK
| | - Colin S Brown
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London, SW1P 3JR, UK
- NIHR Health Protection Unit in Healthcare-Associated Infection & Antimicrobial Resistance, Imperial College London, London, UK
| | - Mariyam Mirfenderesky
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London, SW1P 3JR, UK
| | - Victoria Palin
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, Vaughan House, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, The University of Manchester, Manchester, M13 9WL, UK
| | - Diane Ashiru-Oredope
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London, SW1P 3JR, UK
- School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
| |
Collapse
|
2
|
Sheikh F, Douglas W, Diao YD, Correia RH, Gregoris R, Machon C, Johnston N, Fox-Robichaud AE. Social determinants of health and sepsis: a case-control study. Can J Anaesth 2024:10.1007/s12630-024-02790-6. [PMID: 38955983 DOI: 10.1007/s12630-024-02790-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 03/17/2024] [Accepted: 04/04/2024] [Indexed: 07/04/2024] Open
Abstract
PURPOSE We aimed to identify whether social determinants of health (SDoH) are associated with the development of sepsis and assess the differences between individuals living within systematically disadvantaged neighbourhoods compared with those living outside these neighbourhoods. METHODS We conducted a single-centre case-control study including 300 randomly selected adult patients (100 patients with sepsis and 200 patients without sepsis) admitted to the emergency department of a large academic tertiary care hospital in Hamilton, ON, Canada. We collected data on demographics and a limited set of SDoH variables, including neighbourhood household income, smoking history, social support, and history of alcohol disorder. We analyzed study data using multivariate logistic regression models. RESULTS The study included 100 patients with sepsis with a median [interquartile range (IQR)] age of 75 [58-84] yr and 200 patients without sepsis with a median [IQR] age of 72 [60-83] yr. Factors significantly associated with sepsis included arrival by ambulance, absence of a family physician, higher Hamilton Early Warning Score, and a recorded history of dyslipidemia. Important SDoH variables, such as individual or household income and race, were not available in the medical chart. In patients with SDoH available in their medical records, no SDoH was significantly associated with sepsis. Nevertheless, compared with their proportion of the Hamilton population, the rate of sepsis cases and sepsis deaths was approximately two times higher among patients living in systematically disadvantaged neighbourhoods. CONCLUSIONS This study revealed the lack of available SDoH data in electronic health records. Despite no association between the SDoH variables available and sepsis, we found a higher rate of sepsis cases and sepsis deaths among individuals living in systematically disadvantaged neighbourhoods. Including SDoH in electronic health records is crucial to study their effect on the risk of sepsis and to provide equitable care.
Collapse
Affiliation(s)
- Fatima Sheikh
- Department of Health Research Methods, Evidence and Impact (HEI), Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
- Hamilton Health Sciences, Hamilton, ON, Canada.
- David Braley Research Institute (DBRI), C5-1B, 20 Copeland Ave., Hamilton, ON, L8L 2X2, Canada.
| | - William Douglas
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Yi David Diao
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Rebecca H Correia
- Department of Health Research Methods, Evidence and Impact (HEI), Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Rachel Gregoris
- Department of Biochemistry and Biomedical Sciences, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Christina Machon
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Neil Johnston
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Alison E Fox-Robichaud
- Hamilton Health Sciences, Hamilton, ON, Canada
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
3
|
Tu KJ, Vakkalanka JP, Okoro UE, Harland KK, Wymore C, Fuller BM, Campbell K, Swanson MB, Parker EA, Mack LJ, Bell A, DeJong K, Faine B, Zepeski A, Mueller K, Chrischilles E, Carpenter CR, Jones MP, Ward MM, Mohr NM. Provider-to-provider telemedicine for sepsis is used less frequently in communities with high social vulnerability. J Rural Health 2024. [PMID: 38924559 DOI: 10.1111/jrh.12861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 05/18/2024] [Accepted: 06/08/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE Sepsis disproportionately affects patients in rural and socially vulnerable communities. A promising strategy to address this disparity is provider-to-provider emergency department (ED)-based telehealth consultation (tele-ED). The objective of this study was to determine if county-level social vulnerability index (SVI) was associated with tele-ED use for sepsis and, if so, which SVI elements were most strongly associated. METHODS We used data from the TELEmedicine as a Virtual Intervention for Sepsis in Rural Emergency Department study. The primary exposures were SVI aggregate and component scores. We used multivariable generalized estimating equations to model the association between SVI and tele-ED use. FINDINGS Our study cohort included 1191 patients treated in 23 Midwestern rural EDs between August 2016 and June 2019, of whom 326 (27.4%) were treated with tele-ED. Providers in counties with a high SVI were less likely to use tele-ED (adjusted odds ratio [aOR] = 0.51, 95% confidence interval [CI] 0.31‒0.87), an effect principally attributable to the housing type and transportation component of SVI (aOR = 0.44, 95% CI 0.22-0.89). Providers who treated fewer sepsis patients (1‒10 vs. 31+ over study period) and therefore may have been less experienced in sepsis care, were more likely to activate tele-ED (aOR = 3.91, 95% CI 2.08‒7.38). CONCLUSIONS Tele-ED use for sepsis was lower in socially vulnerable counties and higher among providers who treated fewer sepsis patients. These findings suggest that while tele-ED increases access to specialized care, it may not completely ameliorate sepsis disparities due to its less frequent use in socially vulnerable communities.
Collapse
Affiliation(s)
- Kevin J Tu
- Department of Cell Biology and Molecular Genetics, University of Maryland, College Park, Maryland, USA
- University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - J Priyanka Vakkalanka
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Uche E Okoro
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Karisa K Harland
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Cole Wymore
- University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Brian M Fuller
- Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kalyn Campbell
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Morgan B Swanson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Edith A Parker
- Department of Community & Behavioral Health, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Luke J Mack
- Avel eCARE, Sioux Falls, South Dakota, USA
- Department of Family Medicine, University of South Dakota School of Medicine, Sioux Falls, South Dakota, USA
| | | | | | - Brett Faine
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Pharmacy Practice & Science, College of Pharmacy, University of Iowa, Iowa City, Iowa, USA
- Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
- Department of Health Management and Policy, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Anne Zepeski
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
- Department of Health Management and Policy, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Keith Mueller
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Elizabeth Chrischilles
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | | | - Michael P Jones
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Nicholas M Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
- Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| |
Collapse
|
4
|
Bladon S, Ashiru-Oredope D, Cunningham N, Pate A, Martin GP, Zhong X, Gilham EL, Brown CS, Mirfenderesky M, Palin V, van Staa TP. Rapid systematic review on risks and outcomes of sepsis: the influence of risk factors associated with health inequalities. Int J Equity Health 2024; 23:34. [PMID: 38383380 PMCID: PMC10882893 DOI: 10.1186/s12939-024-02114-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 01/19/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND AND AIMS Sepsis is a serious and life-threatening condition caused by a dysregulated immune response to an infection. Recent guidance issued in the UK gave recommendations around recognition and antibiotic treatment of sepsis, but did not consider factors relating to health inequalities. The aim of this study was to summarise the literature investigating associations between health inequalities and sepsis. METHODS Searches were conducted in Embase for peer-reviewed articles published since 2010 that included sepsis in combination with one of the following five areas: socioeconomic status, race/ethnicity, community factors, medical needs and pregnancy/maternity. RESULTS Five searches identified 1,402 studies, with 50 unique studies included in the review after screening (13 sociodemographic, 14 race/ethnicity, 3 community, 3 care/medical needs and 20 pregnancy/maternity; 3 papers examined multiple health inequalities). Most of the studies were conducted in the USA (31/50), with only four studies using UK data (all pregnancy related). Socioeconomic factors associated with increased sepsis incidence included lower socioeconomic status, unemployment and lower education level, although findings were not consistent across studies. For ethnicity, mixed results were reported. Living in a medically underserved area or being resident in a nursing home increased risk of sepsis. Mortality rates after sepsis were found to be higher in people living in rural areas or in those discharged to skilled nursing facilities while associations with ethnicity were mixed. Complications during delivery, caesarean-section delivery, increased deprivation and black and other ethnic minority race were associated with post-partum sepsis. CONCLUSION There are clear correlations between sepsis morbidity and mortality and the presence of factors associated with health inequalities. To inform local guidance and drive public health measures, there is a need for studies conducted across more diverse setting and countries.
Collapse
Affiliation(s)
- Siân Bladon
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK.
| | - Diane Ashiru-Oredope
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), UKHSA, London, SW1P 3JR, UK
- School of Pharmacy, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Neil Cunningham
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), UKHSA, London, SW1P 3JR, UK
| | - Alexander Pate
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Glen P Martin
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Xiaomin Zhong
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| | - Ellie L Gilham
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), UKHSA, London, SW1P 3JR, UK
| | - Colin S Brown
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), UKHSA, London, SW1P 3JR, UK
- NIHR Health Protection Unit in Healthcare-Associated Infection & Antimicrobial Resistance, Imperial College London, London, UK
| | - Mariyam Mirfenderesky
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), UKHSA, London, SW1P 3JR, UK
| | - Victoria Palin
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, The University of Manchester, Manchester, M13 9WL, UK
| | - Tjeerd P van Staa
- Centre for Health Informatics & Health Data Research UK North, Division of Informatics, Imaging and Data Science, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, M13 9PL, UK
| |
Collapse
|
5
|
Koimtzis G, Geropoulos G, Chalklin C, Karniadakis I, Szabo L, Ilham MA, Stephens M, Asderakis A, Khalid U. The influence of socioeconomic deprivation on outcomes in transplant patients infected with SARS-CoV-2 in Wales. Clin Transplant 2024; 38:e15245. [PMID: 38289884 DOI: 10.1111/ctr.15245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/03/2024] [Accepted: 01/08/2024] [Indexed: 02/01/2024]
Abstract
INTRODUCTION SARS-CoV-2 infection has had a significant impact on vulnerable individuals including transplant patients. Socioeconomic deprivation negatively affects outcomes of many health conditions. The aim of this study was to evaluate the effect of socioeconomic deprivation on the incidence and severity of SARS-CoV-2 infection among Welsh transplant patients. METHODS This study is a retrospective, cross-sectional study on the transplant population of Wales. The Welsh Index of Multiple Deprivation (WIMD) was used to assess the influence of socioeconomic deprivation on outcomes of Welsh transplant patients who developed SARS-CoV-2 infection. Outcome measures were the incidence of SARS-CoV-2 infection, rates of hospital and ICU admission, development of acute kidney injury (AKI) and mortality. A logistic binomial regression analysis was used to correlate the various risk factors with the incidence of SARS-CoV-2 infection. RESULTS Two hundred and sixty-six (25%) of regular follow up patients had SARS-CoV-2 infection; of these 55 (20.7%) were admitted, 15 (5.6%) to ICU, 37 (13.9%) developed AKI, and 23 (8.6%) died. In a regression analysis, patients of younger age were associated with more (p = .001) and those with SPK (simultaneous pancreas kidney) transplant less chance of infection (p = .038), whereas social deprivation was not associated with the chance of infection (p = .14). In regression analysis increased social deprivation was associated with higher chance of AKI post SARS-CoV-2 (p = .049). CONCLUSIONS Socioeconomic deprivation did not affect the rates or severity of SARS-CoV-2 infection apart from the degree of AKI in Welsh Transplant patients. Adherence to the preventive measures for this high-risk population must continue to remain a priority.
Collapse
Affiliation(s)
- Georgios Koimtzis
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Georgios Geropoulos
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Christopher Chalklin
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Ioannis Karniadakis
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Laszlo Szabo
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Mohammed Adel Ilham
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Michael Stephens
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Argiris Asderakis
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
- Wales Kidney Research Unit, Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Usman Khalid
- Cardiff Transplant Unit, Cardiff & Vale University Health Board, University Hospital of Wales, Cardiff, UK
- Wales Kidney Research Unit, Division of Infection and Immunity, Cardiff University, Cardiff, UK
| |
Collapse
|
6
|
Zhong X, Ashiru-Oredope D, Pate A, Martin GP, Sharma A, Dark P, Felton T, Lake C, MacKenna B, Mehrkar A, Bacon SC, Massey J, Inglesby P, Goldacre B, Hand K, Bladon S, Cunningham N, Gilham E, Brown CS, Mirfenderesky M, Palin V, van Staa TP. Clinical and health inequality risk factors for non-COVID-related sepsis during the global COVID-19 pandemic: a national case-control and cohort study. EClinicalMedicine 2023; 66:102321. [PMID: 38192590 PMCID: PMC10772239 DOI: 10.1016/j.eclinm.2023.102321] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 01/10/2024] Open
Abstract
Background Sepsis, characterised by significant morbidity and mortality, is intricately linked to socioeconomic disparities and pre-admission clinical histories. This study aspires to elucidate the association between non-COVID-19 related sepsis and health inequality risk factors amidst the pandemic in England, with a secondary focus on their association with 30-day sepsis mortality. Methods With the approval of NHS England, we harnessed the OpenSAFELY platform to execute a cohort study and a 1:6 matched case-control study. A sepsis diagnosis was identified from the incident hospital admissions record using ICD-10 codes. This encompassed 248,767 cases with non-COVID-19 sepsis from a cohort of 22.0 million individuals spanning January 1, 2019, to June 31, 2022. Socioeconomic deprivation was gauged using the Index of Multiple Deprivation score, reflecting indicators like income, employment, and education. Hospitalisation-related sepsis diagnoses were categorised as community-acquired or hospital-acquired. Cases were matched to controls who had no recorded diagnosis of sepsis, based on age (stepwise), sex, and calendar month. The eligibility criteria for controls were established primarily on the absence of a recorded sepsis diagnosis. Associations between potential predictors and odds of developing non-COVID-19 sepsis underwent assessment through conditional logistic regression models, with multivariable regression determining odds ratios (ORs) for 30-day mortality. Findings The study included 224,361 (10.2%) cases with non-COVID-19 sepsis and 1,346,166 matched controls. The most socioeconomic deprived quintile was associated with higher odds of developing non-COVID-19 sepsis than the least deprived quintile (crude OR 1.80 [95% CI 1.77-1.83]). Other risk factors (after adjusting comorbidities) such as learning disability (adjusted OR 3.53 [3.35-3.73]), chronic liver disease (adjusted OR 3.08 [2.97-3.19]), chronic kidney disease (stage 4: adjusted OR 2.62 [2.55-2.70], stage 5: adjusted OR 6.23 [5.81-6.69]), cancer, neurological disease, immunosuppressive conditions were also associated with developing non-COVID-19 sepsis. The incidence rate of non-COVID-19 sepsis decreased during the COVID-19 pandemic and rebounded to pre-pandemic levels (April 2021) after national lockdowns had been lifted. The 30-day mortality risk in cases with non-COVID-19 sepsis was higher for the most deprived quintile across all periods. Interpretation Socioeconomic deprivation, comorbidity and learning disabilities were associated with an increased odds of developing non-COVID-19 related sepsis and 30-day mortality in England. This study highlights the need to improve the prevention of sepsis, including more precise targeting of antimicrobials to higher-risk patients. Funding The UK Health Security Agency, Health Data Research UK, and National Institute for Health Research.
Collapse
Affiliation(s)
- Xiaomin Zhong
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, M13 9PL, UK
| | - Diane Ashiru-Oredope
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London SW1P 3JR, UK
- School of Pharmacy, University of Nottingham, Nottingham NG7 2RD, UK
| | - Alexander Pate
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, M13 9PL, UK
| | - Glen P. Martin
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, M13 9PL, UK
| | - Anita Sharma
- Chadderton South Health Centre, Eaves Lane, Chadderton, Oldham OL9 8RG, UK
| | - Paul Dark
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Tim Felton
- Division of Infection, Immunity and Respiratory Medicine, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
- Intensive Care Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Claire Lake
- Maples Medical Centre, 2 Scout Dr, Baguley, Manchester M23 2SY, UK
| | - Brian MacKenna
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
- NHS England, Wellington House, Waterloo Road, London SE1 8UG, UK
| | - Amir Mehrkar
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Sebastian C.J. Bacon
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Jon Massey
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Peter Inglesby
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Ben Goldacre
- Bennett Institute for Applied Data Science, Nuffield Department of Primary Care Health Sciences, University of Oxford, OX2 6GG, UK
| | - Kieran Hand
- Pharmacy Department, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Sian Bladon
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, M13 9PL, UK
| | - Neil Cunningham
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London SW1P 3JR, UK
| | - Ellie Gilham
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London SW1P 3JR, UK
| | - Colin S. Brown
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London SW1P 3JR, UK
- NIHR Health Protection Unit in Healthcare-Associated Infection & Antimicrobial Resistance, Imperial College London, London, UK
| | - Mariyam Mirfenderesky
- Healthcare-Associated Infection (HCAI), Fungal, Antimicrobial Resistance (AMR), Antimicrobial Use (AMU) & Sepsis Division, United Kingdom Health Security Agency (UKHSA), London SW1P 3JR, UK
| | - Victoria Palin
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, M13 9PL, UK
- Division of Developmental Biology and Medicine, Maternal and Fetal Research Centre, The University of Manchester, St Marys Hospital, Oxford Road, Manchester M13 9WL, UK
| | - Tjeerd Pieter van Staa
- Centre for Health Informatics, School of Health Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester, M13 9PL, UK
| |
Collapse
|
7
|
Stenberg H, Li X, Pello-Esso W, Larsson Lönn S, Thønnings S, Khoshnood A, Knudsen JD, Sundquist K, Jansåker F. The effects of sociodemographic factors and comorbidities on sepsis: A nationwide Swedish cohort study. Prev Med Rep 2023; 35:102326. [PMID: 37519448 PMCID: PMC10374593 DOI: 10.1016/j.pmedr.2023.102326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/04/2023] [Accepted: 07/12/2023] [Indexed: 08/01/2023] Open
Abstract
Sepsis is a severe condition, representing a significant public health concern, especially in the elderly. There is, however, little insight into the potential effects of sociodemographic factors and comorbidities on sepsis incidence and how these factors interact. This was a nationwide open cohort study including individuals (N = 6 746 010) in Sweden ≥ 18 years of age spanning from 1997 to 2018, with 116 175 995 person years of follow-up. The outcome was time to first occurrence of sepsis. The following variables were included in the analysis: sociodemographic factors (age, sex, income, education, marital status, region of residency, and country of origin), severe mental disorders (schizophrenia and bipolar disorders), and Charlson Comorbidity Index. Interaction tests were conducted. A total of 161 558 individuals were diagnosed with sepsis during the study period, corresponding to an incidence rate of 13.9 per 10 000 person years (95% CI: 13.8 - 14.0). The main findings were that male sex, high age, low education, and comorbid conditions were positively associated with sepsis, after adjustments for the other covariates. Being aged 80 years and above yielded a HR of 18.19 (95% CI: 17.84 - 18.55) and the effect of high age was more than twice as high in men than in women. In conclusion, this large nationwide cohort found that several sociodemographic factors and comorbid conditions were independently associated with sepsis and men were more affected by higher age than women. These findings can help improve sepsis awareness and preventive work in risk groups.
Collapse
Affiliation(s)
- Henning Stenberg
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Sweden
| | - Xinjun Li
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Sweden
| | - Wazah Pello-Esso
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Sweden
| | - Sara Larsson Lönn
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Sweden
| | - Sara Thønnings
- Department of Clinical Microbiology, Copenhagen University Hospital Hvidovre, Denmark
| | - Ardavan Khoshnood
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Sweden
- Department of Emergency Medicine, Skåne University Hospital Lund, Lund, Sweden
| | - Jenny Dahl Knudsen
- Department of Clinical Microbiology, Center of Diagnostic Investigations, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Kristina Sundquist
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Sweden
- Center for Community-based Healthcare Research and Education (CoHRE), Department of Functional Pathology, School of Medicine, Shimane University, Japan
- Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Filip Jansåker
- Center for Primary Health Care Research, Department of Clinical Sciences Malmö, Lund University, Sweden
- Department of Clinical Microbiology, Copenhagen University Hospital Hvidovre, Denmark
| |
Collapse
|
8
|
Yetmar ZA, Chesdachai S, Lahr BD, Challener DW, Arensman Hannan KN, Epps K, Stevens RW, Seville MT, Tande AJ, Virk A. Comparison of Oral and Intravenous Definitive Antibiotic Therapy for Beta-Hemolytic Streptococcus Species Bloodstream Infections from Soft Tissue Sources: a Propensity Score-Matched Analysis. Antimicrob Agents Chemother 2023; 67:e0012023. [PMID: 37191533 PMCID: PMC10269088 DOI: 10.1128/aac.00120-23] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/26/2023] [Indexed: 05/17/2023] Open
Abstract
Beta-hemolytic streptococci are common causes of bloodstream infection (BSI). There is emerging data regarding oral antibiotics for BSI but limited for beta-hemolytic streptococcal BSI. We conducted a retrospective study of adults with beta-hemolytic streptococcal BSI from a primary skin/soft tissue source from 2015 to 2020. Patients transitioned to oral antibiotics within 7 days of treatment initiation were compared to those who continued intravenous therapy, after propensity score matching. The primary outcome was 30-day treatment failure (composite of mortality, infection relapse, and hospital readmission). A prespecified 10% noninferiority margin was used for the primary outcome. We identified 66 matched pairs of patients treated with oral and intravenous antibiotics as definitive therapy. Based on an absolute difference in 30-day treatment failure of 13.6% (95% confidence interval 2.4 to 24.8%), the noninferiority of oral therapy was not confirmed (P = 0.741); on the contrary, the superiority of intravenous antibiotics is suggested by this difference. Acute kidney injury occurred in two patients who received intravenous treatment and zero who received oral therapy. No patients experienced deep vein thrombosis or other vascular complications related to treatment. In patients treated for beta-hemolytic streptococcal BSI, those who transitioned to oral antibiotics by day 7 showed higher rates of 30-day treatment failure than propensity-matched patients. This difference may have been driven by underdosing of oral therapy. Further investigation into optimal antibiotic choice, route, and dosing for definitive therapy of BSI is needed.
Collapse
Affiliation(s)
- Zachary A. Yetmar
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Supavit Chesdachai
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian D. Lahr
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas W. Challener
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Kevin Epps
- Department of Pharmacy, Mayo Clinic, Jacksonville, Florida, USA
| | - Ryan W. Stevens
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Aaron J. Tande
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Abinash Virk
- Division of Public Health, Infectious Diseases, and Occupational Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
9
|
Ahlberg CD, Wallam S, Tirba LA, Itumba SN, Gorman L, Galiatsatos P. Linking Sepsis with chronic arterial hypertension, diabetes mellitus, and socioeconomic factors in the United States: A scoping review. J Crit Care 2023; 77:154324. [PMID: 37159971 DOI: 10.1016/j.jcrc.2023.154324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/11/2023]
Abstract
RATIONALE Sepsis is a syndrome of life-threatening organ dysfunction caused by a dysregulated host immune response to infection. Social risk factors including location and poverty are associated with sepsis-related disparities. Understanding the social and biological phenotypes linked with the incidence of sepsis is warranted to identify the most at-risk populations. We aim to examine how factors in disadvantage influence health disparities related to sepsis. METHODS A scoping review was performed for English-language articles published in the United States from 1990 to 2022 on PubMed, Web of Science, and Scopus. Of the 2064 articles found, 139 met eligibility criteria and were included for review. RESULTS There is consistency across the literature of disproportionately higher rates of sepsis incidence, mortality, readmissions, and associated complications, in neighborhoods with socioeconomic disadvantage and significant poverty. Chronic arterial hypertension and diabetes mellitus also occur more frequently in the same geographic distribution as sepsis, suggesting a potential shared pathophysiology. CONCLUSIONS The distribution of chronic arterial hypertension, diabetes mellitus, social risk factors associated with socioeconomic disadvantage, and sepsis incidence, are clustered in specific geographical areas and linked by endothelial dysfunction. Such population factors can be utilized to create equitable interventions aimed at mitigating sepsis incidence and sepsis-related disparities.
Collapse
Affiliation(s)
- Caitlyn D Ahlberg
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Sara Wallam
- The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Lemya A Tirba
- The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Stephanie N Itumba
- The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Linda Gorman
- Harrison Medical Library, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, USA
| | - Panagis Galiatsatos
- Division of Pulmonary and Critical Care Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
| |
Collapse
|
10
|
Ye X, Wang Y, Zou Y, Tu J, Tang W, Yu R, Yang S, Huang P. Associations of socioeconomic status with infectious diseases mediated by lifestyle, environmental pollution and chronic comorbidities: a comprehensive evaluation based on UK Biobank. Infect Dis Poverty 2023; 12:5. [PMID: 36717939 PMCID: PMC9885698 DOI: 10.1186/s40249-023-01056-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/16/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Socioeconomic status (SES) inequity was recognized as a driver of some certain infectious diseases. However, few studies evaluated the association between SES and the burden of overall infections, and even fewer identified preventable mediators. This study aimed to assess the association between SES and overall infectious diseases burden, and the potential roles of factors including lifestyle, environmental pollution, chronic disease history. METHODS We included 401,009 participants from the UK Biobank (UKB) and defined the infection status for each participant according to their diagnosis records. Latent class analysis (LCA) was used to define SES for each participant. We further defined healthy lifestyle score, environment pollution score (EPS) and four types of chronic comorbidities. We used multivariate logistic regression to test the associations between the four above covariates and infectious diseases. Then, we performed the mediation and interaction analysis to explain the relationships between SES and other variables on infectious diseases. Finally, we employed seven types of sensitivity analyses, including considering the Townsend deprivation index as an area level SES variable, repeating our main analysis for some individual or composite factors and in some subgroups, as well as in an external data from the US National Health and Nutrition Examination Survey, to verify the main results. RESULTS In UKB, 60,771 (15.2%) participants were diagnosed with infectious diseases during follow-up. Lower SES [odds ratio (OR) = 1.5570] were associated with higher risk of overall infections. Lifestyle score mediated 2.9% of effects from SES, which ranged from 2.9 to 4.0% in different infection subtypes, while cardiovascular disease (CVD) mediated a proportion of 6.2% with a range from 2.1 to 6.8%. In addition, SES showed significant negative interaction with lifestyle score (OR = 0.8650) and a history of cancer (OR = 0.9096), while a significant synergy interaction was observed between SES and EPS (OR = 1.0024). In subgroup analysis, we found that males and African (AFR) with lower SES showed much higher infection risk. Results from sensitivity and validation analyses showed relative consistent with the main analysis. CONCLUSIONS Low SES is shown to be an important risk factor for infectious disease, part of which may be mediated by poor lifestyle and chronic comorbidities. Efforts to enhance health education and improve the quality of living environment may help reduce burden of infectious disease, especially for people with low SES.
Collapse
Affiliation(s)
- Xiangyu Ye
- grid.89957.3a0000 0000 9255 8984Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Yidi Wang
- grid.89957.3a0000 0000 9255 8984Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Yixin Zou
- grid.89957.3a0000 0000 9255 8984Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Junlan Tu
- grid.89957.3a0000 0000 9255 8984Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Weiming Tang
- grid.89957.3a0000 0000 9255 8984Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China ,grid.410711.20000 0001 1034 1720Institute of Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, CA USA
| | - Rongbin Yu
- grid.89957.3a0000 0000 9255 8984Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Sheng Yang
- grid.89957.3a0000 0000 9255 8984Department of Biostatistics, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Peng Huang
- grid.89957.3a0000 0000 9255 8984Department of Epidemiology, Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| |
Collapse
|
11
|
Lehman KD. Evidence-based updates to the 2021 Surviving Sepsis Campaign guidelines Part 2: Guideline review and clinical application. Nurse Pract 2022; 47:28-35. [PMID: 36399145 DOI: 10.1097/01.npr.0000884888.21622.e3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
ABSTRACT NPs should be prepared to screen for sepsis, initiate treatment, and optimize care for sepsis survivors. The 2021 Surviving Sepsis Campaign guidelines offer best practices for identification and management of sepsis and septic shock. This article, second in a 2-part series, presents evidence updates and discusses implications for NPs.
Collapse
Affiliation(s)
- Karen D Lehman
- Karen D. Lehman is a hospitalist NP and PRN ED NP at NMC Health in Newton, Kan., an ED NP with Docs Who Care based in Olathe, Kan., and a hospice NP with Harry Hynes Memorial Hospice in Wichita, Kan
| |
Collapse
|
12
|
Social Determinants of Health Associated With the Development of Sepsis in Adults: A Scoping Review. Crit Care Explor 2022; 4:e0731. [PMID: 36818749 PMCID: PMC9937691 DOI: 10.1097/cce.0000000000000731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Evaluating risk for sepsis is complicated due to limited understanding of how social determinants of health (SDoH) influence the occurence of the disease. This scoping review aims to identify gaps and summarize the existing literature on SDoH and the development of sepsis in adults. DATA SOURCES A literature search using key terms related to sepsis and SDoH was conducted using Medline and PubMed. STUDY SELECTION Studies were screened by title and abstract and then full text in duplicate. Articles were eligible for inclusion if they: 1) evaluated at least one SDoH on the development of sepsis, 2) participants were 18 years or older, and 3) the studies were written in English between January 1970 and January 2022. Systematic reviews, meta-analyses, editorials, letters, commentaries, and studies with nonhuman participants were excluded. DATA EXTRACTION Data were extracted in duplicate using a standardized data extraction form. Studies were grouped into five categories according to the SDoH they evaluated (race, socioeconomic status [SES], old age and frailty, health behaviors, and social support). The study characteristics, key outcomes related to incidence of sepsis, mortality, and summary statements were included in tables. DATA SYNTHESIS The search identified 637 abstracts, 20 of which were included after full-text screening. Studies evaluating SES, old age, frailty, and gender demonstrated an association between sepsis incidence and the SDoH. Studies that examined race demonstrated conflicting conclusions as to whether Black or White patients were at increased risk of sepsis. Overall, a major limitation of this analysis was the methodological heterogeneity between studies. CONCLUSIONS There is evidence to suggest that SDoH impacts sepsis incidence, particularly SES, gender, old age, and frailty. Future prospective cohort studies that use standardized methods to collect SDoH data, particularly race-based data, are needed to inform public health efforts to reduce the incidence of sepsis and help clinicians identify the populations most at risk.
Collapse
|
13
|
Detelich JF, Kyaw NT, Judd SE, Bennett A, Wang HE, Kramer MR, Waller LA, Martin GS, Kempker JA. Home-to-Hospital Distance and Outcomes Among Community-Acquired Sepsis Hospitalizations. Ann Epidemiol 2022; 72:26-31. [PMID: 35551996 PMCID: PMC9629891 DOI: 10.1016/j.annepidem.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/31/2022] [Accepted: 05/02/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE To examine the hypothesis that longer distance from home-to-hospital is associated with worse outcomes among hospitalizations for community-acquired sepsis. METHODS A secondary analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) prospective cohort of 30,239 white and black US adults ≥ 45 years old was conducted. Self-reported hospitalizations for serious infection between 2003-2012 fulfilling 2/4 systemic inflammatory response syndrome criteria were included. Estimated driving distance was derived from geocoded data and evaluated continuously and as quartiles of very close, close, far, very far (<3.1, 3.1-5.8, 5.9-11.5, and >11.5 miles respectively). The primary outcome was 30-day mortality while the secondary outcome was sequential organ failure assessment (SOFA) score on arrival. RESULTS 912 hospitalizations for community-acquired sepsis had adequate data for analysis. The median (interquartile range) estimated driving distance was 5.8 miles (3.1,11.7), and 54 (5.9%) experienced the primary outcome. Compared to living very close, participants living very far had a mortality odds ratio of 1.30 (95% CI 0.64,2.62) and presenting SOFA score difference of 0.33 (95% CI -0.03,0.68). CONCLUSIONS Among a national sample of community-acquired sepsis hospitalizations, there was no significant association between home-to-hospital distance and either 30-day mortality or SOFA score on hospital presentation.
Collapse
Affiliation(s)
- Joshua F Detelich
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA.
| | - Nang Thu Kyaw
- Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, Atlanta, GA
| | - Suzanne E Judd
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
| | - Aleena Bennett
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
| | - Henry E Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, OH
| | - Michael R Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Lance A Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jordan A Kempker
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA
| |
Collapse
|
14
|
Fleischmann-Struzek C, Rose N, Reinhart K. [Sepsis-associated deaths in Germany: characteristics and regional variation]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2021; 65:388-395. [PMID: 34750647 PMCID: PMC8575348 DOI: 10.1007/s00103-021-03427-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/02/2021] [Indexed: 11/04/2022]
Abstract
Hintergrund Sepsis ist weltweit jährlich für geschätzt 11 Mio. Todesfälle verantwortlich. Die Epidemiologie sepsisassoziierter Todesfälle ist in Deutschland unzureichend verstanden, da Sepsis bisher nicht über die deutsche unikausale Todesursachenstatistik erfasst werden kann. Ziel der Arbeit Epidemiologie und Charakteristika sepsisassoziierter Krankenhaustodesfälle sollen analysiert sowie regionale Unterschiede beschrieben werden. Material und Methoden Retrospektive Beobachtungsstudie basierend auf der deutschlandweiten fallpauschalenbezogenen Krankenhausstatistik (DRG-Statistik) 2016. Sepsisassoziierte Krankenhaustodesfälle wurden über explizite und implizite Sepsis-ICD-10-GM(Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme, 10. Revision, German Modification)-Codierungen identifiziert. Verstorbene wurden anhand der klinischen Merkmale und ihres Wohnortes entsprechend Amtlichem Gemeindeschlüssel (AGS-5-Steller) charakterisiert. Basierend auf der Bevölkerungsstatistik wurde der Anteil an den Gesamttodesfällen ermittelt. Ergebnisse 2016 gab es in Deutschland 58.689 mit explizit codierter Sepsis assoziierte Krankenhaustodesfälle (14,1 % aller Krankenhaustodesfälle). Die Mortalität betrug 73/100.000 Einwohner und variierte 1,8-fach zwischen den Bundesländern und 7,9-fach zwischen den Kreisen. 6,4 % der deutschlandweiten Todesfälle waren sepsisassoziierte Krankenhaustodesfälle. Dieser Anteil war am höchsten in der Altersgruppe der 40- bis 64-Jährigen (9,6 %) und höher bei Männern als bei Frauen (7,7 % vs. 5,2 %). Im Vergleich dazu betrug der Anteil von implizit codierten sepsisassoziierten Krankenhaustodesfällen 47,2 % an allen Krankenhaustodesfällen und 21,6 % an allen Todesfällen. Diskussion Auch wenn die direkte Todesursache nicht sicher ableitbar ist, lässt sich aus dem hohen Anteil sepsisassoziierter Todesfälle an den Krankenhaustodesfällen der Bedarf weiterer Forschung und epidemiologischer Surveillance ableiten, zum Beispiel in Kohortenstudien oder auf Basis von multikausalen Todesursachenstatistiken. Zusatzmaterial online Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00103-021-03427-5) enthalten.
Collapse
Affiliation(s)
- Carolin Fleischmann-Struzek
- Institut für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland. .,Center for Sepsis Control and Care, Universitätsklinikum Jena, Jena, Deutschland.
| | - Norman Rose
- Institut für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland.,Center for Sepsis Control and Care, Universitätsklinikum Jena, Jena, Deutschland
| | - Konrad Reinhart
- Klinik für Anästhesiologie m. S. operative Intensivmedizin, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| |
Collapse
|
15
|
Mitchell E, Pearce M, Roberts A, Newton J. Predictive factors of in-hospital mortality in patients with laboratory-confirmed Escherichia coli, Klebsiella species or Pseudomonas aeruginosa bloodstream infections. PLoS One 2021; 16:e0259305. [PMID: 34727130 PMCID: PMC8562814 DOI: 10.1371/journal.pone.0259305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/16/2021] [Indexed: 11/18/2022] Open
Abstract
Gram-negative bloodstream infections (GNBSI) are confirmed by the presence of gram-negative bacteria in the bloodstream and pose a significant healthcare issue as they increase the risk of sepsis and mortality. In England, the aim is to reduce GNBSI cases and further deterioration through enhanced population surveillance of patients with a laboratory-confirmed GNBSI to inform on healthcare policies. The objective of this study was to evaluate the factors associated with in-hospital mortality in patients with a laboratory-confirmed Escherichia coli, Klebsiella or Pseudomonas aeruginosa GNBSIs, with data obtained from the enhanced data capture for the surveillance of GNBSIs. All patients with a laboratory-confirmed GNBSI at a single centre, admitted between April 2017 and March 2019, were included in this retrospective observational study. Demographic and recent exposure to healthcare risk factors were collected and assessed for the association with in-hospital mortality. In 1113 patients with laboratory-confirmed GNBSIs, the in-hospital mortality rate was 13%. Multivariable analysis confirmed that patients with respiratory (OR = 3.73, 95%CI = 2.05-6.76), gastrointestinal (2.61; 1.22-5.58) or skin (3.61; 1.24-10.54) infection primary focus had a greater risk of in-hospital mortality, compared to upper urinary tract infections. Increased risk of in-hospital mortality was also observed in patients with hospital-onset GNBSIs (OR = 1.87; 1.17-2.97) compared with community-onset healthcare acquired GNBSIs, or who were on dialysis at the time of the GNBSI (3.28; 1.01-10.14), as well as in patients who had recently been discharged from hospital (1.55; 1.01-2.38), or had a vascular device recently manipulated (2.41; 1.01-5.74). Results confirm that the data obtained from the enhanced data capture for GNBSIs in England can predict in-hospital mortality in patients with a GNBSI. Several factors associated with an increased risk of in-hospital mortality have been identified. Results should be reported back to clinicians in order to identify patients at a greater risk of dying in-hospital who may benefit from further monitoring.
Collapse
Affiliation(s)
- Eleanor Mitchell
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Mark Pearce
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Anthony Roberts
- Academic Health Science Network – North East & North Cumbria, Newcastle upon Tyne, United Kingdom
- North East Quality Observatory Service (NEQOS), Newcastle upon Tyne, United Kingdom
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom
| | - Julia Newton
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- Academic Health Science Network – North East & North Cumbria, Newcastle upon Tyne, United Kingdom
- North East Quality Observatory Service (NEQOS), Newcastle upon Tyne, United Kingdom
| |
Collapse
|
16
|
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 894] [Impact Index Per Article: 298.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
17
|
Minejima E, Wong-Beringer A. Impact of Socioeconomic Status and Race on Sepsis Epidemiology and Outcomes. J Appl Lab Med 2021; 6:194-209. [PMID: 33241269 DOI: 10.1093/jalm/jfaa151] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/05/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Socioeconomic status (SES) is a complex variable that is derived primarily from an individual's education, income, and occupation and has been found to be inversely related to outcomes of health conditions. Sepsis is the sixth most common admitting diagnosis and one of the most costly conditions for in-hospital spending in the United States. The objective of this review is to report on the relationship between SES and sepsis incidence and associated outcomes. CONTENT Sepsis epidemiology varies when explored by race, education, geographic location, income, and insurance status. Sepsis incidence was significantly increased in individuals of Black race compared with non-Hispanic white race; in persons who have less formal education, who lack insurance, and who have low income; and in certain US regions. People with low SES are likely to have onset of sepsis significantly earlier in life and to have poorly controlled comorbidities compared with those with higher SES. Sepsis mortality and hospital readmission is increased in individuals who lack insurance, who reside in low-income or medically underserved areas, who live far from healthcare, and who lack higher level education; however, a person's race was not consistently found to increase mortality. SUMMARY Interventions to minimize healthcare disparity for individuals with low SES should target sepsis prevention with increasing measures for preventive care for chronic conditions. Significant barriers described for access to care by people with low SES include cost, transportation, poor health literacy, and lack of a social network. Future studies should include polysocial risk scores that are consistently defined to allow for meaningful comparison across studies.
Collapse
Affiliation(s)
- Emi Minejima
- Department of Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, USA.,Department of Pharmacy, Los Angeles County and University of Southern California Medical Center, Los Angeles, CA, USA
| | - Annie Wong-Beringer
- Department of Pharmacy, University of Southern California School of Pharmacy, Los Angeles, CA, USA.,Department of Pharmacy, Huntington Hospital, Pasadena, CA, USA
| |
Collapse
|
18
|
Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1459] [Impact Index Per Article: 486.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
| |
Collapse
|
19
|
Dellinger RP, Levy MM, Schorr CA, Townsend SR. 50 Years of Sepsis Investigation/Enlightenment Among Adults-The Long and Winding Road. Crit Care Med 2021; 49:1606-1625. [PMID: 34342304 DOI: 10.1097/ccm.0000000000005203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- R Phillip Dellinger
- Cooper Medical School of Rowan University and Cooper University Health, Camden, NJ
| | | | - Christa A Schorr
- Cooper Medical School of Rowan University and Cooper University Health, Camden, NJ
| | - Sean R Townsend
- University of California Pacific Medical Center, (Sutter Health), San Francisco, CA
| |
Collapse
|
20
|
Rose N, Matthäus-Krämer C, Schwarzkopf D, Scherag A, Born S, Reinhart K, Fleischmann-Struzek C. Association between sepsis incidence and regional socioeconomic deprivation and health care capacity in Germany - an ecological study. BMC Public Health 2021; 21:1636. [PMID: 34493250 PMCID: PMC8424852 DOI: 10.1186/s12889-021-11629-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/13/2021] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis is a substantial health care burden. Data on regional variation in sepsis incidence in Germany and any possible associations with regional socioeconomic deprivation and health care capacity is lacking. Methods Ecological study based on the nationwide hospital Diagnosis-related Groups (DRG) statistics data of 2016. We identified sepsis by ICD-10-codes and calculated crude and age-standardized incidence proportions in the 401 administrative German districts. Associations between socioeconomic and health care capacity indicators and crude and age-adjusted sepsis incidence were investigated by simple and multiple negative binomial (NB) regressions. Results In 2016, sepsis incidence was 178 per 100,000 inhabitants and varied 10-fold between districts. We found that the rate of students leaving school without certificate was significantly associated with crude and age-standardized explicit sepsis incidence in the simple and multiple NB regressions. While we observed no evidence for an association to the capacity of hospital beds and general practitioners, the distance to the nearest pharmacy was associated with crude- and age-standardized sepsis incidence. In the multiple regression analyses, an increase of the mean distance + 1000 m was associated with an expected increase by 21.6 [95% CI, 10.1, 33.0] (p < 0.001), and 11.1 [95% CI, 1.0, 21.2]/100,000 population (p = .026) after adjusting for age differences between districts. Conclusions Residence in districts with lower socioeconomic status (e.g., less education) and further distance to pharmacies are both associated with an increased sepsis incidence. This warrants further research with individual-level patient data to better model and understand such dependencies and to ultimately design public health interventions to address the burden of sepsis in Germany. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11629-4.
Collapse
Affiliation(s)
- Norman Rose
- Center for Sepsis Control and Care, Jena University Hospital, Bachstraße 18, 07743, Jena, Germany.,Institute of Infectious Diseases and Infection Control, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Claudia Matthäus-Krämer
- Center for Sepsis Control and Care, Jena University Hospital, Bachstraße 18, 07743, Jena, Germany
| | - Daniel Schwarzkopf
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.,Department for Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07740, Jena, Germany
| | - André Scherag
- Institute of Medical Statistics, Computer and Data Sciences, Jena University Hospital, Bachstraße 18, 07743, Jena, Germany
| | - Sebastian Born
- Center for Sepsis Control and Care, Jena University Hospital, Bachstraße 18, 07743, Jena, Germany.,Institute of Infectious Diseases and Infection Control, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Carolin Fleischmann-Struzek
- Center for Sepsis Control and Care, Jena University Hospital, Bachstraße 18, 07743, Jena, Germany. .,Institute of Infectious Diseases and Infection Control, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
| |
Collapse
|
21
|
Chen HH, Lin CH, Wang CY, Chao WC. Association of Hospitalised Infection With Socioeconomic Status in Patients With Rheumatoid Arthritis Receiving Biologics or Tofacitinib: A Population-Based Cohort Study. Front Med (Lausanne) 2021; 8:696167. [PMID: 34322506 PMCID: PMC8311461 DOI: 10.3389/fmed.2021.696167] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/07/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives: Use of biologics or targeted synthetic disease-modifying anti-rheumatic drugs (b/tsDMARDs) is associated with infection in patients with rheumatoid arthritis (RA). Socioeconomic status is substantial in infectious diseases; however, the impact of socioeconomic status on risk for infection in patients with RA receiving b/tsDMARD remains unclear. Methods: We used the 2003-2017 Taiwanese National Health Insurance Research Database to identify patients with RA receiving b/tsDMARDs. A Cox regression analysis was used to estimate the associations of covariates with the risk of hospitalised infection shown as hazard ratios (HRs) with 95% confidence interval (CIs). Results: We identified 7,647 RA patients who started their first bDMARD/tsDMARD treatment. Log-rank analyses demonstrated the association between age (p < 0.001), urbanisation (p = 0.001), the insured amount (p = 0.021), and the hospitalisation. Cox proportional regression analyses showed that age was independently associated with hospitalised infection in a dose-response manner, whereas a high-income category had an inverse association (HR 0.48, 95% CI 0.23-0.96). Hospitalisation for infection within 5 years was a strong risk factor (HR 5.63, 95% CI 1.91-16.62), and living in a rural area tended to be a risk factor (HR 1.76, 95% CI 0.98-3.14) for incident hospitalised infection. Conclusions: This study showed the crucial impacts of age, socioeconomic status, and history of infection on hospitalised infection in patients with RA receiving b/tsDMARDs. These findings highlight the largely ignored role of socioeconomic status in risk stratification among patients receiving b/tsDMARDs for RA.
Collapse
Affiliation(s)
- Hsin-Hua Chen
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.,Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Institute of Biomedical Science and Rong Hsing Research Centre for Translational Medicine, Chung Hsing University, Taichung, Taiwan.,Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan.,School of Medicine, China Medical University, Taichung, Taiwan.,Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan.,Big Data Center, Chung Hsing University, Taichung, Taiwan
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan.,Institute of Public Health and Community Medicine Research Center, National Yang-Ming University, Taipei, Taiwan.,Department of Healthcare Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.,Department of Public Health, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Chen-Yu Wang
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Nursing, Hung Kuang University, Taichung, Taiwan
| | - Wen-Cheng Chao
- Big Data Center, Chung Hsing University, Taichung, Taiwan.,Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Computer Science, Tunghai University, Taichung, Taiwan.,Department of Automatic Control Engineering, Feng Chia University, Taichung, Taiwan
| |
Collapse
|
22
|
Lee JY, Molani S, Fang C, Jade K, O'Mahony DS, Kornilov SA, Mico LT, Hadlock JJ. Ambulatory Risk Models for the Long-Term Prevention of Sepsis: Retrospective Study. JMIR Med Inform 2021; 9:e29986. [PMID: 34086596 PMCID: PMC8299345 DOI: 10.2196/29986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/02/2021] [Indexed: 12/29/2022] Open
Abstract
Background Sepsis is a life-threatening condition that can rapidly lead to organ damage and death. Existing risk scores predict outcomes for patients who have already become acutely ill. Objective We aimed to develop a model for identifying patients at risk of getting sepsis within 2 years in order to support the reduction of sepsis morbidity and mortality. Methods Machine learning was applied to 2,683,049 electronic health records (EHRs) with over 64 million encounters across five states to develop models for predicting a patient’s risk of getting sepsis within 2 years. Features were selected to be easily obtainable from a patient’s chart in real time during ambulatory encounters. Results The models showed consistent prediction scores, with the highest area under the receiver operating characteristic curve of 0.82 and a positive likelihood ratio of 2.9 achieved with gradient boosting on all features combined. Predictive features included age, sex, ethnicity, average ambulatory heart rate, standard deviation of BMI, and the number of prior medical conditions and procedures. The findings identified both known and potential new risk factors for long-term sepsis. Model variations also illustrated trade-offs between incrementally higher accuracy, implementability, and interpretability. Conclusions Accurate implementable models were developed to predict the 2-year risk of sepsis, using EHR data that is easy to obtain from ambulatory encounters. These results help advance the understanding of sepsis and provide a foundation for future trials of risk-informed preventive care.
Collapse
Affiliation(s)
- Jewel Y Lee
- Institute for Systems Biology, Seattle, WA, United States
| | - Sevda Molani
- Institute for Systems Biology, Seattle, WA, United States
| | - Chen Fang
- Institute for Systems Biology, Seattle, WA, United States
| | - Kathleen Jade
- Institute for Systems Biology, Seattle, WA, United States
| | - D Shane O'Mahony
- Swedish Center for Research and Innovation, Swedish Medical Center, Seattle, WA, United States
| | | | | | | |
Collapse
|
23
|
Lower socioeconomic factors are associated with higher mortality in patients with septic shock. Heart Lung 2021; 50:477-480. [PMID: 33831699 DOI: 10.1016/j.hrtlng.2021.02.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 02/09/2021] [Accepted: 02/11/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Previous studies have explored the relationship between socioeconomic status and sepsis outcomes OBJECTIVES: The purpose of this investigation is to determine if race, ethnicity, economic stability, neighborhood environment, and access to health care are predictive of mortality in patients with septic shock. METHODS Retrospective study of septic shock patients admitted to two medical centers. RESULTS Caucasian patients had higher proportion of outpatient physician visits in the year prior to admission and were less likely to be Medicare or Medicaid beneficiaries. Thirty-day mortality was lower for the Caucasian cohort (39.3% vs. 48.7%, p < 0.01). Multivariate logistic regression found several predictors of 30-day mortality including Minority race/ethnicity (OR 1.44, 95% CI 1.12-1.86), unemployment (OR 1.40, 95% CI 1.09-1.81), and neighborhood poverty rate ≥10% (OR 1.43, 95% CI 1.01-2.01). CONCLUSIONS Minority patients, unemployed patients, and those living in neighborhoods with poverty rates greater than 10% suffered from higher 30-day mortality when admitted for septic shock.
Collapse
|
24
|
Zeeb M, Kerrinnes T, Cicin-Sain L, Guzman CA, Puppe W, Schulz TF, Peters A, Berger K, Castell S, Karch A. Seropositivity for pathogens associated with chronic infections is a risk factor for all-cause mortality in the elderly: findings from the Memory and Morbidity in Augsburg Elderly (MEMO) Study. GeroScience 2020; 42:1365-1376. [PMID: 32648237 PMCID: PMC7525922 DOI: 10.1007/s11357-020-00216-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/11/2020] [Indexed: 12/17/2022] Open
Abstract
Immunostimulation by chronic infection has been linked to an increased risk for different non-communicable diseases, which in turn are leading causes of death in high- and middle-income countries. Thus, we investigated if a positive serostatus for pathogens responsible for common chronic infections is individually or synergistically related to reduced overall survival in community dwelling elderly. We used data of 365 individuals from the German MEMO (Memory and Morbidity in Augsburg Elderly) cohort study with a median age of 73 years at baseline and a median follow-up of 14 years. We examined the effect of a positive serostatus at baseline for selected pathogens associated with chronic infections (Helicobacter pylori, Borrelia burgdorferi sensu lato, Toxoplasma gondii, cytomegalovirus, Epstein-Barr virus, herpes simplex virus 1/2, and human herpesvirus 6) on all-cause mortality with multivariable parametric survival models. We found a reduced survival time in individuals with a positive serostatus for Helicobacter pylori (accelerated failure time (AFT) - 15.92, 95% CI - 29.96; - 1.88), cytomegalovirus (AFT - 22.81, 95% CI - 36.41; - 9.22) and Borrelia burgdorferi sensu lato (AFT - 25.25, 95% CI - 43.40; - 7.10), after adjusting for potential confounders. The number of infectious agents an individual was seropositive for had a linear effect on all-cause mortality (AFT per additional infection - 12.42 95% CI - 18.55; - 6.30). Our results suggest an effect of seropositivity for Helicobacter pylori, cytomegalovirus, and Borrelia burgdorferi sensu lato on all-cause mortality in older community dwelling individuals. Further research with larger cohorts and additional biomarkers is required, to assess mediators and molecular pathways of this effect.
Collapse
Affiliation(s)
- Marius Zeeb
- Institute for Medical Information Science, Biometry and Epidemiology, Ludwig Maximilians University, Munich, Germany
- Pettenkofer School of Public Health, Munich, Germany
- Department for Epidemiology, Helmholtz Centre for Infection Research, Brunswick, Germany
| | - Tobias Kerrinnes
- Department for Epidemiology, Helmholtz Centre for Infection Research, Brunswick, Germany
| | - Luka Cicin-Sain
- Department of Vaccinology and Applied Microbiology, Helmholtz Centre for Infection Research, Braunschweig, Germany
- Cluster of Excellence RESIST (EXC 2155), Hannover Medical School (MHH), Hannover, Germany
- Centre for Individualised Infection Medicine (CIIM), a joint venture of HZI and MHH, Hannover, Germany
- German Centre for Infection Research (DZIF), Hannover-Braunschweig site, Braunschweig, Germany
| | - Carlos A Guzman
- Department of Vaccinology and Applied Microbiology, Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Wolfram Puppe
- Cluster of Excellence RESIST (EXC 2155), Hannover Medical School (MHH), Hannover, Germany
- German Centre for Infection Research (DZIF), Hannover-Braunschweig site, Braunschweig, Germany
- Institute for Virology, Hannover Medical School (MHH), Hannover, Germany
| | - Thomas F Schulz
- Cluster of Excellence RESIST (EXC 2155), Hannover Medical School (MHH), Hannover, Germany
- German Centre for Infection Research (DZIF), Hannover-Braunschweig site, Braunschweig, Germany
- Institute for Virology, Hannover Medical School (MHH), Hannover, Germany
| | - Annette Peters
- Institute for Medical Information Science, Biometry and Epidemiology, Ludwig Maximilians University, Munich, Germany
- German Research Center for Environmental Health, Munich, Germany
| | - Klaus Berger
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Stefanie Castell
- Department for Epidemiology, Helmholtz Centre for Infection Research, Brunswick, Germany
| | - André Karch
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany.
| |
Collapse
|
25
|
Chao WC, Wang CY, Hsu BC, Lin CH, Huang WN, Chen YH, Wu CL, Chen HH. Factors associated with sepsis risk in immune-mediated inflammatory diseases receiving tumor necrosis factor inhibitors: a nationwide study. Ther Adv Musculoskelet Dis 2020; 12:1759720X20929208. [PMID: 32595776 PMCID: PMC7298427 DOI: 10.1177/1759720x20929208] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 04/30/2020] [Indexed: 01/03/2023] Open
Abstract
Background: Risk factors for sepsis have not been assessed in patients receiving tumor
necrosis factor-alpha inhibitors (TNFi) for immune-mediated inflammatory
diseases (IMIDs) who are vulnerable to serious/hospitalized infections. Methods: Data from 2003–2017 were obtained from Taiwan’s National Health Insurance
Research Database to identify patients receiving TNFi, including etanercept,
adalimumab, and golimumab, for IMIDs including rheumatoid arthritis (RA),
ankylosing spondylitis (AS), psoriasis (PsO), psoriatic arthritis (PsA),
Crohn’s disease (CD), and ulcerative colitis (UC). To investigate risk
factors for sepsis, we used the Sepsis-3 definition and calculated hazard
ratios (HRs) with 95% confidence intervals (CIs) using Cox regression
analysis. Results: There were 17,764 patients (mean age 49.3 ± 14.3 years; females, 57.6%)
receiving TNFi for IMIDs, including RA (58.6%), AS (19.1%), PsO (15.1%), PsA
(2.5%), CD (3.0%), and UC (1.7%). The overall incidence rate of sepsis was
1088 per 100,000 person-years. After adjustment for potential confounders,
recent sepsis within 3 months before TNFi initiation (HR, 2.35; 95% CI,
1.73–3.20), CD (HR, 3.36; 95% CI 2.11–5.34; reference group: AS) and
glucocorticoid use (prednisolone-equivalent dose, mg/day HR, 1.05; 95% CI,
1.05–1.06) were associated with the risk of sepsis. Intriguingly, golimumab
users appeared to have a lower risk of sepsis compared with etanercept users
(HR, 0.56; 95% CI, 0.38–0.83). In addition, socioeconomic status, including
urbanization level and insured amount, was associated with sepsis in a
dose-response manner. Conclusions: Recent sepsis, CD, concomitant glucocorticoid use, and low socioeconomic
status, which were associated with an increased risk of sepsis, are crucial
for individualized risk management plans.
Collapse
Affiliation(s)
- Wen-Cheng Chao
- Department of Critical Care Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, ROC
| | - Chen-Yu Wang
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung
| | - Bo-Chueh Hsu
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung
| | - Wen-Nan Huang
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung
| | - Yi-Hsing Chen
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung
| | - Chieh-Liang Wu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung
| | - Hsin-Hua Chen
- Department of Medical Research, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, ROC
| |
Collapse
|
26
|
Aitavaara-Anttila M, Liisanantti J, Ehrola A, Spalding M, Ala-Kokko T, Raatiniemi L. Use of prehospital emergency medical services according to income of residential area. Emerg Med J 2020; 37:429-433. [DOI: 10.1136/emermed-2019-208834] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 02/27/2020] [Accepted: 03/03/2020] [Indexed: 11/04/2022]
Abstract
BackgroundThe increasing usage of emergency medical services (EMS) missions is a challenge in modern practice. This study was designed to examine the association of the income level of residential areas on the rate of EMS missions and the frequency of EMS use in these areas.MethodsAll EMS missions for adult patients (>18 years) encountered by one rescue department in Northern Finland between June 2015 and May 2017 were analysed. The area served was categorised into four categories, according to the median annual income of the postal code areas. EMS missions per 1000 person-years, rate of non-transport missions and the number of dispatches to frequent (>4 EMS calls/year and highly frequent (>10 calls/year)EMS users per area were investigated.ResultsThere were 62 759 EMS missions, 34.8% of which resulted in non-transport. The crude rate of EMS dispatches was higher in the low-income area compared with other income areas (133.3 vs 108.9 vs 111.3 vs 73.6/1000 person-years) as well as the rate of high-frequency user dispatches (21.5 vs 11.5 vs 7.2 vs 4.3/1000-person years). The rate of non-transports missions was higher also (69.4 vs 43.4 vs 42.5. vs 30.6/1000 person-years). The highest crude rate of EMS use was found in people older than 65 years living in the lowest income areas (294.8/1000 person-years). After age adjustment, the highest rate of EMS use was found in rural areas with the lowest income (146.3/1000 person-years).ConclusionsThe rate of the EMS missions and non-transport missions differs significantly among different income areas. Resource usage was significantly higher in the low income areas. This information can be used in planning allocation of EMS and preventive healthcare resources.
Collapse
|
27
|
Hennessy DA, Soo A, Niven DJ, Jolley RJ, Posadas-Calleja J, Stelfox HT, Doig CJ. Socio-demographic characteristics associated with hospitalization for sepsis among adults in Canada: a Census-linked cohort study. Can J Anaesth 2020; 67:408-420. [PMID: 31792835 DOI: 10.1007/s12630-019-01536-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 10/16/2019] [Accepted: 10/22/2019] [Indexed: 02/01/2023] Open
Abstract
PURPOSE Sepsis is a considerable health system burden. Population-based epidemiological surveillance of sepsis is limited to basic data available in administrative databases. We sought to determine if routinely collected Census data, linked to hospitalization data, can provide a broad socio-demographic profile of patients admitted to Canadian hospitals with sepsis. METHODS Linking the 2006 long-form Canadian Census (most recent available for linkage) to the Discharge Abstract Data from 2006/2007 to 2008/2009, we created a population-based cohort of approximately 3,433,900 Canadians. Patients admitted to hospital with sepsis were identified using the Canadian Institute for Health Information administrative data definition. Age-standardized hospital admission rates for sepsis were calculated. Multivariable modelling was used to examine the relationship between Census characteristics and hospitalization with sepsis. RESULTS Of those individuals successfully linked to the 2006 long-form Canadian Census, 10,400 patients of 18 yr and older were admitted to hospital with sepsis between the fiscal years 2006/2007 and 2008/2009. These individuals represented a weighted count of approximately 49,000 Canadians from all provinces and territories, excluding Quebec. The age-standardized rate of sepsis hospitalization was 96 cases/100,000 population. Of these, 37/100,000 cases were classified as severe sepsis. The association of Census characteristics with sepsis hospitalization varied with age. In all age-specific models, male sex, never being married, visible minority status, having functional limitations, and not being in the labour force were associated with an increased odds of hospital admission. CONCLUSIONS Census data identified broad socio-demographic risk factors for admission to hospital with sepsis. Consideration should be given to incorporating Census data linked to administrative hospital data in population-based epidemiologic surveillance.
Collapse
Affiliation(s)
- Deirdre A Hennessy
- Health Analysis Division, Statistics Canada, 100 Tunney's Pasture Driveway, Ottawa, ON, K1A 0T6, Canada.
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
| | - Andrea Soo
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Daniel J Niven
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Rachel J Jolley
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Juan Posadas-Calleja
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Henry T Stelfox
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| | - Christopher J Doig
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| |
Collapse
|