The association of lacking insurance with outcomes of severe sepsis: retrospective analysis of an administrative database*

Race, Ethnicity, and Gender Disparities in Management and Outcomes of Critically Ill Adults with Sepsis

Critical care pathologies are not immune to potential social challenges in both health equity and health disparities. Over the last century, as sepsis physiology and interventions have continued to improve clinical outcomes, recognition that such improvements are not seen in all diverse populations warrants an understanding of this disproportionate success. In this review, the authors evaluate sepsis incidence and outcomes across ethnicity, race, and sex and gender, taking into account social and biological categorization and the association of sepsis-related mortality and morbidity. Further, the authors review how such issues transcend across age groups, with vulnerability to sepsis.

Is Insurance Payor Associated With Hospital Admission of Emergency Department Adult Patients With Odontogenic Infections?

BACKGROUND

Patients who present to the emergency department (ED) with severe odontogenic infections are often hospitalized for surgical drainage and medical management. However, inpatient management of these patients can be financially burdensome. While medical indications for hospital admission are well established, it remains unclear if patient insurance status is associated with admission.

PURPOSE

The purpose of this study was to determine the nationally representative estimates of the incidence of hospital admission for patients with odontogenic infections and the association with insurance payor.

STUDY DESIGN, SETTING, SAMPLE

This retrospective cohort study used the 2018 Nationwide Emergency Department Sample. Patients with odontogenic infections (based on International Classification of Diseases, 10th Revision codes) were included. Patients aged <18 years or who had missing data were excluded.

PREDICTOR VARIABLE

The primary predictor variable was primary payor (private insurance, Medicare, Medicaid, self-pay, and other).

MAIN OUTCOME VARIABLE

The primary outcome variable was hospital admission (yes/no).

COVARIATES

Covariates included sociodemographic, medical, infection, and hospital variables.

ANALYSES

Descriptive, bivariate, and multivariable logistic regression analyses were used to determine national estimates and predictors of admission. Odds ratios and 99% confidence intervals were computed. Discharge weights were accounted for in all analyses to provide nationally representative estimates.

RESULTS

This study included 31,221 weighted ED encounters, of which 10,451 (33.5%) were admitted. In the study cohort, 7,687 (24.6%) had private insurance, 5,046 (16.2%) had Medicare, 10,070 (32.3%) had Medicaid, 7,436 (23.8%) were self-pay, and 982 (3.1%) had other. Bivariate analysis suggested that payor status was significantly associated with hospital admission (P < .01). The multivariable analysis showed that self-pay patients had significantly lower odds of hospital admission compared to those with private insurance (odds ratio, 0.54; 99% confidence interval, 0.42-0.70). Other independent predictors of hospital admission included infection in more than 1 location based on International Classification of Diseases, 10th Revision code, higher Charlson comorbidity index, and alcohol/substance use disorders.

CONCLUSION AND RELEVANCE

Approximately one-third of patients presenting to the ED with odontogenic infections were admitted. Patients with no insurance were less likely to be admitted compared to those with private insurance. This finding may reflect multiple possibilities, including hospital financial incentives.

Failure to rescue following emergency general surgery: A national analysis

Background

Failure to rescue (FTR) is increasingly recognized as a quality metric but remains understudied in emergency general surgery (EGS). We sought to identify patient and operative factors associated with FTR to better inform standardized metrics to mitigate this potentially preventable event.

Methods

All adult (≥18 years) non-elective hospitalizations for large bowel resection, small bowel resection, repair of perforated ulcer, laparotomy and lysis of adhesions were identified in the 2016-2020 National Readmissions Database. Patients undergoing trauma-related operations or procedures ≤2 days of admission were excluded. FTR was defined as in-hospital death following acute kidney injury requiring dialysis (AKI), myocardial infarction, pneumonia, respiratory failure, sepsis, stroke, or thromboembolism. Multilevel mixed-effect models were developed to assess factors linked with FTR.

Results

Among 826,548 EGS operations satisfying inclusion criteria, 298,062 (36.1 %) developed at least one MAE. Of those experiencing MAE, 43,477 (14.6 %) ultimately did not survive to discharge (FTR). Following adjustment for fixed hospital level effects, only 3.5 % of the variance in FTR was attributable to center-level differences. Relative to private insurance and the highest income quartile, Medicaid insurance (AOR 1.33; 95%CI, 1.23-1.43) and the lowest income quartile (AOR 1.22; 95%CI, 1.17-1.29) were linked with increased odds of FTR.A subset analysis stratified complication-specific rates of FTR by insurance status. Relative to private insurance, Medicaid coverage and uninsured status were linked with greater odds of FTR following perioperative sepsis, pneumonia, and AKI.

Conclusion

Our findings underscore the need for increased screening and vigilance following perioperative complications to mitigate disparities in patient outcomes following high-risk EGS.

Insurance-based Disparities in Outcomes and Extracorporeal Membrane Oxygenation Utilization for Hospitalized COVID-19 Patients

BACKGROUND

The objective of this study was to examine insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization in patients hospitalized with COVID-19.

METHODS

Using a national database of U.S. academic medical centers and their affiliated hospitals, the risk-adjusted association between mortality, nonhome discharge, and extracorporeal membrane oxygenation utilization and (1) the type of insurance coverage (private insurance, Medicare, dual enrollment in Medicare and Medicaid, and no insurance) and (2) the weekly hospital COVID-19 burden (0 to 5.0%; 5.1 to 10%, 10.1 to 20%, 20.1 to 30%, and 30.1% and greater) was evaluated. Modeling was expanded to include an interaction between payer status and the weekly hospital COVID-19 burden to examine whether the lack of private insurance was associated with increases in disparities as the COVID-19 burden increased.

RESULTS

Among 760,846 patients hospitalized with COVID-19, 214,992 had private insurance, 318,624 had Medicare, 96,192 were dually enrolled in Medicare and Medicaid, 107,548 had Medicaid, and 23,560 had no insurance. Overall, 76,250 died, 211,702 had nonhome discharges, 75,703 were mechanically ventilated, and 2,642 underwent extracorporeal membrane oxygenation. The adjusted odds of death were higher in patients with Medicare (adjusted odds ratio, 1.28 [95% CI, 1.21 to 1.35]; P < 0.0005), dually enrolled (adjusted odds ratio, 1.39 [95% CI, 1.30 to 1.50]; P < 0.0005), Medicaid (adjusted odds ratio, 1.28 [95% CI, 1.20 to 1.36]; P < 0.0005), and no insurance (adjusted odds ratio, 1.43 [95% CI, 1.26 to 1.62]; P < 0.0005) compared to patients with private insurance. Patients with Medicare (adjusted odds ratio, 0.47; [95% CI, 0.39 to 0.58]; P < 0.0005), dually enrolled (adjusted odds ratio, 0.32 [95% CI, 0.24 to 0.43]; P < 0.0005), Medicaid (adjusted odds ratio, 0.70 [95% CI, 0.62 to 0.79]; P < 0.0005), and no insurance (adjusted odds ratio, 0.40 [95% CI, 0.29 to 0.56]; P < 0.001) were less likely to be placed on extracorporeal membrane oxygenation than patients with private insurance. Mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization did not change significantly more in patients with private insurance compared to patients without private insurance as the COVID-19 burden increased.

CONCLUSIONS

Among patients with COVID-19, insurance-based disparities in mortality, nonhome discharges, and extracorporeal membrane oxygenation utilization were substantial, but these disparities did not increase as the hospital COVID-19 burden increased.

EDITOR’S PERSPECTIVE

Racial and ethnic disparities post-hospitalization for COVID-19: barriers to access to care for survivors of COVID-19 acute respiratory distress syndrome

Racial and ethnic health disparities in the incidence and severity of Coronavirus Disease 2019 (COVID-19) have been observed globally and in the United States. Research has focused on transmission, hospitalization, and mortality among racial and ethnic minorities, but Long COVID-19 health disparities research is limited. This study retrospectively evaluated 195 adults who survived COVID-19 associated acute respiratory distress syndrome (C-ARDS) in New York City from March-April 2020. Among survivors, 54% met the criteria for Long COVID syndrome. Hispanic/Latinx patients, were more likely to be uninsured (p = 0.027) and were less frequently discharged to rehabilitation facilities (p < 0.001). A cross-sectional telephone survey and interview were conducted with a subset of survivors (n = 69). Among these, 11% reported a lack of follow-up primary care post-discharge and 38% had subsequent emergency room visits. Notably, 38% reported poor treatment within the health care system, with 67% attributing this to racial or ethnic bias. Thematic analysis of interviews identified four perceived challenges: decline in functional status, discrimination during hospitalization, healthcare system inequities, and non-healthcare-related structural barriers. Sources of resilience included survivorship, faith, and family support. This study highlights structural and healthcare-related barriers rooted in perceived racism and poverty as factors impacting post-COVID-19 care.

Identifying barriers and facilitators to seeking care for symptoms of bacterial sepsis: A qualitative study

AIM

Research suggests that early access to quality care is essential to improving bacteraemia outcomes and reducing the risk of developing sepsis because it allows for early intervention. Currently, there are limited data regarding the facilitators and barriers that alter the trajectory of arrival at the hospital when patients in the United States experience symptoms of bacteraemia and sepsis. This study sought to explore and describe the facilitators and barriers to seeking care for suspected bacteraemia and sepsis symptoms.

DESIGN

A qualitative descriptive study.

METHODS

Ten men and women were recruited using convenience sampling. The study used audio-recorded semi-structured interviews and the collection of socio-demographic data as the data collection techniques. Thematic analysis was used, including inductive and deductive approaches, to analyse the data.

RESULTS

During data analysis, the codes related to barriers and facilitators were collapsed into three themes-symptom recognition, psychosocial support and healthcare planning and coordination.

PATIENT CONTRIBUTION

The patients' participation in the study has contributed to our understanding of patients' perspectives and experiences in the pre-hospital phase and provides important insights into what barriers and facilitators are encountered. Study findings highlight the need to develop interventions to improve patient decision time, patient-provider interactions and knowledge of bacteraemia and sepsis through patient and provider education.

Linking Sepsis with chronic arterial hypertension, diabetes mellitus, and socioeconomic factors in the United States: A scoping review

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.

Order Set Usage is Associated With Lower Hospital Mortality in Patients With Sepsis

The Surviving Sepsis Campaign recommends standard operating procedures for patients with sepsis. Real-world evidence about sepsis order set implementation is limited.

OBJECTIVES

To estimate the effect of sepsis order set usage on hospital mortality.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Fifty-four acute care hospitals in the United States from December 1, 2020 to November 30, 2022 involving 104,662 patients hospitalized for sepsis.

MAIN OUTCOMES AND MEASURES

Hospital mortality.

RESULTS

The sepsis order set was used in 58,091 (55.5%) patients with sepsis. Initial mean sequential organ failure assessment score was 0.3 lower in patients for whom the order set was used than in those for whom it was not used (2.9 sd [2.8] vs 3.2 [3.1], p < 0.01). In bivariate analysis, hospital mortality was 6.3% lower in patients for whom the sepsis order set was used (9.7% vs 16.0%, p < 0.01), median time from emergency department triage to antibiotics was 54 minutes less (125 interquartile range [IQR, 68-221] vs 179 [98-379], p < 0.01), and median total time hypotensive was 2.1 hours less (5.5 IQR [2.0-15.0] vs 7.6 [2.5-21.8], p < 0.01) and septic shock was 3.2% less common (22.0% vs 25.4%, p < 0.01). Order set use was associated with 1.1 fewer median days of hospitalization (4.9 [2.8-9.0] vs 6.0 [3.2-12.1], p < 0.01), and 6.6% more patients discharged to home (61.4% vs 54.8%, p < 0.01). In the multivariable model, sepsis order set use was independently associated with lower hospital mortality (odds ratio 0.70; 95% CI, 0.66-0.73).

CONCLUSIONS AND RELEVANCE

In a cohort of patients hospitalized with sepsis, order set use was independently associated with lower hospital mortality. Order sets can impact large-scale quality improvement efforts.

Risk Factors for Pediatric Sepsis in the Emergency Department: A Machine Learning Pilot Study

OBJECTIVE

To identify underappreciated sepsis risk factors among children presenting to a pediatric emergency department (ED).

METHODS

A retrospective observational study (2017-2019) of children aged 18 years and younger presenting to a pediatric ED at a tertiary care children's hospital with fever, hypotension, or an infectious disease International Classification of Diseases (ICD)-10 diagnosis. Structured patient data including demographics, problem list, and vital signs were extracted for 35,074 qualifying ED encounters. According to the Improving Pediatric Sepsis Outcomes Classification, confirmed by expert review, 191 patients met clinical sepsis criteria. Five machine learning models were trained to predict sepsis/nonsepsis outcomes. Top features enabling model performance (N = 20) were then extracted to identify patient risk factors.

RESULTS

Machine learning methods reached a performance of up to 93% sensitivity and 84% specificity in identifying patients who received a hospital diagnosis of sepsis. A random forest classifier performed the best, followed by a classification and regression tree. Maximum documented heart rate was the top feature in these models, with importance coefficients (ICs) of 0.09 and 0.21, which represent how much an individual feature contributes to the model. Maximum mean arterial pressure was the second most important feature (IC 0.05, 0.13). Immunization status (IC 0.02), age (IC 0.03), and patient zip code (IC 0.02) were also among the top features enabling models to predict sepsis from ED visit data. Stratified analysis revealed changes in the predictive importance of risk factors by race, ethnicity, oncologic history, and insurance status.

CONCLUSIONS

Machine learning models trained to identify pediatric sepsis using ED clinical and sociodemographic variables confirmed well-established predictors, including heart rate and mean arterial pressure, and identified underappreciated relationships between sepsis and patient age, immunization status, and demographics.

Association Between Socioeconomic Disadvantage and Decline in Function, Cognition, and Mental Health After Critical Illness Among Older Adults : A Cohort Study

BACKGROUND

Older adults admitted to an intensive care unit (ICU) are at risk for developing impairments in function, cognition, and mental health. It is not known whether socioeconomically disadvantaged older persons are at greater risk for these impairments than their less vulnerable counterparts.

OBJECTIVE

To evaluate the association between socioeconomic disadvantage and decline in function, cognition, and mental health among older survivors of an ICU hospitalization.

DESIGN

Retrospective analysis of a longitudinal cohort study.

SETTING

Community-dwelling older adults in the National Health and Aging Trends Study (NHATS).

PARTICIPANTS

Participants with ICU hospitalizations between 2011 and 2017.

MEASUREMENTS

Socioeconomic disadvantage was assessed as dual-eligible Medicare-Medicaid status. The outcome of function was defined as the count of disabilities in 7 activities of daily living and mobility tasks, the cognitive outcome as the transition from no or possible to probable dementia, and the mental health outcome as the Patient Health Questionnaire-4 score in the NHATS interview after ICU hospitalization. The analytic sample included 641 ICU hospitalizations for function, 458 for cognition, and 519 for mental health.

RESULTS

After accounting for sociodemographic and clinical characteristics, dual eligibility was associated with a 28% increase in disability after ICU hospitalization (incidence rate ratio, 1.28; 95% CI, 1.00 to 1.64); and nearly 10-fold greater odds of transitioning to probable dementia (odds ratio, 9.79; 95% CI, 3.46 to 27.65). Dual eligibility was not associated with symptoms of depression and anxiety after ICU hospitalization (incidence rate ratio, 1.33; 95% CI, 0.99 to 1.79).

LIMITATION

Administrative data, variability in timing of baseline and outcome assessments, proxy selection.

CONCLUSION

Dual-eligible older persons are at greater risk for decline in function and cognition after an ICU hospitalization than their more advantaged counterparts. This finding highlights the need to prioritize low-income seniors in rehabilitation and recovery efforts after critical illness and warrants investigation into factors leading to this disparity.

PRIMARY FUNDING SOURCE

National Institute on Aging.

Racial and Socioeconomic Disparities in Necrotizing Soft-Tissue Infection

Necrotizing soft-tissue infection (NSTI) is a medical emergency. We investigated the impact of racial, socioeconomic disparities, and comorbidities on mortality, complications, length of stay, and charges in patients with NSTI.

Data were acquired from the National Inpatient Sample from Q4 2015 to 2017. ICD-10, Clinical Modification codes were utilized to identify relevant cases. Logistic regression was used to assess socioeconomic, racial, and health risk factors for adverse outcomes in NSTI patients.

Of 16,071,053 cases identified during the study period, 15,078 (0.094%) NSTI cases were recognized. Black patients had increased odds of amputation (OR 1.40 95% CI 1.24-1.58, p < 0.001), prolonged hospital stay (OR 1.40 95% CI 1.24-1.58, p < 0.001), excessive charges (OR 1.22 95% CI 1.03-1.43, p = 0.019), and adverse discharge disposition (OR 1.32 95% CI 1.19-1.46, p < 0.001) compared to white patients. Hispanic patients had increased odds of mortality (OR 1.30 95% CI 1.05-1.60, p = 0.014) and amputation (OR 1.21 95% CI 1.04-1.42, p = 0.016) compared to white patients. Medicare patients had increased odds of mortality (OR 1.35 95% CI 1.09-1.67, p = 0.006), Medicaid patients had increased odd of amputation (OR 1.33 95% CI 1.17-1.51, p < 0.001) and prolonged LOS (OR 1.33 95% CI 1.17-1.51, p < 0.001). Patients in the lower income quartiles had decreased odds of amputation compared to the highest income quartile, including the 26^th to 50^th income quartile (OR 0.84 95% CI 0.73-0.98, p = 0.022) and 51^st to 75^th income quartile (OR 0.84 95% CI 0.73-0.98, p = 0.022).

Racial and socioeconomic disparities exist for patients being treated for NSTIs.

Impact of Socioeconomic Status and Race on Sepsis Epidemiology and Outcomes

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.

Lower socioeconomic factors are associated with higher mortality in patients with septic shock

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.

Association of Health Insurance Status with Outcomes of Sepsis in Adult Patients: A Retrospective Cohort Study

(1) Background: Sepsis is a life-threatening disease, and various demographic and socioeconomic factors affect outcomes in sepsis. However, little is known regarding the potential association between health insurance status and outcomes of sepsis in Korea. We evaluated the association of health insurance and clinical outcomes in patients with sepsis. (2) Methods: Prospective cohort data of adult patients with sepsis and septic shock from March 2016 to December 2018 in three hospitals were retrospectively analyzed. We categorized patients into two groups according to their health insurance status: National Health Insurance (NHI) and Medical Aid (MA). The primary end point was in-hospital mortality. The multivariate logistic regression model and propensity score matching were used. (3) Results: Of a total of 2526 eligible patients, 2329 (92.2%) were covered by NHI, and 197 (7.8%) were covered by MA. The MA group had fewer males, more chronic kidney disease, more multiple sources of infection, and more patients with initial lactate > 2 mmol/L. In-hospital, 28-day, and 90-day mortality were not significantly different between the two groups and in-hospital mortality was not different in the subgroup analysis. Furthermore, health insurance status was not independently associated with in-hospital mortality in multivariate analysis and was not associated with survival outcomes in the propensity score-matched cohort. (4) Conclusions: Our propensity score-matched cohort analysis demonstrated that there was no significant difference in in-hospital mortality by health insurance status in patients with sepsis.

Hospital outcomes for children with severe sepsis in the USA by race or ethnicity and insurance status: a population-based, retrospective cohort study

BACKGROUND

Disparities in outcomes of adult sepsis are well described by insurance status and race and ethnicity. There is a paucity of data looking at disparities in sepsis outcomes in children. We aimed to determine whether hospital outcomes in childhood severe sepsis were influenced by race or ethnicity and insurance status, a proxy for socioeconomic position.

METHODS

This population-based, retrospective cohort study used data from the 2016 database release from the Healthcare Cost and Utilization Project Kids' Inpatient Database (KID). The 2016 KID included 3 117 413 discharges, accounting for 80% of national paediatric discharges from 4200 US hospitals across 47 states. Using multilevel logistic regression, clustered by hospital, we tested the association between race or ethnicity and insurance status and hospital mortality, adjusting for individual-level and hospital-level characteristics, in children with severe sepsis. The secondary outcome of length of hospital stay was examined through multilevel time to event (hospital discharge) regression, with death as a competing risk.

FINDINGS

12 297 children (aged 0-21 years) with severe sepsis with or without shock were admitted to 1253 hospitals in the 2016 KID dataset. 1265 (10·3%) of 12 297 patients did not have race or ethnicity data recorded, 15 (0·1%) were missing data on insurance, and 1324 (10·8%) were transferred out of hospital, resulting in a final cohort of 9816 children. Black children had higher odds of death than did White children (adjusted odds ratio [OR] 1·19, 95 % CI 1·02-1·38; p=0·028), driven by higher Black mortality in the south (1·30, 1·04-1·62; p=0·019) and west (1·58, 1·05-2·38; p=0·027) of the USA. We found evidence of longer hospital stays for Hispanic children (adjusted hazard ratio 0·94, 95% CI 0·88-1·00; p=0·049) and Black children (0·88, 0·82-0·94; p=0·0002), particularly Black neonates (0·53, 95% CI 0·36-0·77; p=0·0011). We observed no difference in survival between publicly and privately insured children; however, other insurance status (self-pay, no charge, and other) was associated with increased mortality (adjusted OR 1·30, 95% CI 1·04-1·61; p=0·021).

INTERPRETATION

In this large, representative analysis of paediatric severe sepsis in the USA, we found evidence of outcome disparities by race or ethnicity and insurance status. Our findings suggest that there might be differential sepsis recognition, approaches to treatment, access to health-care services, and provider bias that contribute to poorer sepsis outcomes for racial and ethnic minority patients and those of lower socioeconomic position. Studies are warranted to investigate the mechanisms of poorer sepsis outcomes in Black and Hispanic children.

FUNDING

None.

Disparities Associated with Sepsis Mortality in Critically Ill Children

Disparities in health care related to socioeconomic status and race/ethnicity are well documented in adult and neonatal sepsis, but they are less characterized in the critically ill pediatric population. This study investigated whether socioeconomic status and/or race/ethnicity is associated with mortality among children treated for sepsis in the pediatric intensive care unit (PICU). A retrospective cohort study was conducted using information from 48 children's hospitals included in the Pediatric Health Information System database. We included visits by children ≤ 21 years with All Patients Refined Diagnosis-Related Groups (APR-DRG) diagnosis codes of septicemia and disseminated infections that resulted in PICU admission from 2010 to 2016. Multivariable logistic regression was used to measure the effect of race/ethnicity and socioeconomic status (insurance status and median household income for zip code) on mortality after adjustment for age, gender, illness severity, and presence of complex chronic condition. Among the 14,276 patients with sepsis, the mortality rate was 6.8%. In multivariable analysis, socioeconomic status, but not race/ethnicity, was associated with mortality. In comparison to privately insured children, nonprivately insured children had increased odds of mortality (public: adjusted odds ratio [aOR]: 1.2 [1.0, 1.5]; uninsured: aOR: 2.1 [1.2, 3.7]). Similarly, children living in zip codes with the lowest quartile of annual household income had higher odds of mortality than those in the highest quartile (aOR: 1.5 [1.0, 2.2]). These data suggest the presence of socioeconomic, but not racial/ethnic, disparities in mortality among children treated for sepsis. Further research is warranted to understand why such differences exist and how they may be addressed.

Outcomes for Patients with Sepsis Following Admission to the Intensive Care Unit Based on Health Insurance Status: A Study from the Medical Information Mart for Intensive Care-III (MIMIC-III) Database

BACKGROUND Previous research has focused on poor outcomes from a lack of insurance, but the effects of different types of insurance for patients with sepsis in the intensive care unit (ICU) have not been well studied. We aimed to investigate whether private health insurance was better than government-run health insurance in the United States in terms of clinical outcomes of patients with sepsis in the ICU. MATERIAL AND METHODS Patients with sepsis were identified from the Medical information Mart for Intensive Care-III database. Patients were grouped as having private and government-run health insurance. Clinical outcomes were compared in univariate and multivariate analyses. Propensity score match (PSM) and subgroup analysis were used to check the robustness of results. RESULTS Data from 13,957 patients were extracted. After adjustment by multivariate model, the private insurance group had similar rates of ICU mortality (relative risk [RR] [95% confidence interval CI]=1.052 [0.919-1.205], P=.463) and 90-day (RR [95% CI]=.964 [0.885-1.051], P=.406) compared with the group with government-run insurance. The private insurance group had longer ICU stays (strictly standardized mean difference=0.092, P<.001) and better long-term survival (hazard ratio [95% CI]=0.875 [0.825-0.928], P<.001) than the government-run insurance group in the PSM cohorts. Subgroup analysis indicated little variation in results for specific conditions. CONCLUSIONS Patients with sepsis who had private insurance had longer ICU stays but similar ICU mortality and 90-day mortality rates than similar patients with government-run insurance; they seemed to have better long-term survival, but more evidence may be required to support this conclusion.

Factors associated with sepsis risk in immune-mediated inflammatory diseases receiving tumor necrosis factor inhibitors: a nationwide study

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.

Treatment of Acute Cholecystitis: Do Medicaid and Non-Medicaid Enrolled Patients Receive the Same Care?

BACKGROUND

Nationally, Medicaid enrollees with emergency surgical conditions experience worse outcomes overall when compared with privately insured patients. The goal of this study is to investigate disparities in the treatment of cholecystitis based on insurance type and to identify contributing factors.

METHODS

Adults with cholecystitis at a safety-net hospital in Central Massachusetts from 2017-2018 were included. Sociodemographic and clinical characteristics were compared based on Medicaid enrollment status (Medicare excluded). Univariate and multivariate analyses were used to compare the frequency of surgery, time to surgery (TTS), length of stay (LOS), and readmission rates between groups.

RESULTS

The sample (n = 203) included 69 Medicaid enrollees (34%), with a mean age of 44.4 years. Medicaid enrollees were younger (p = 0.0006), had lower levels of formal education (high school diploma attainment, p < 0.0001), were more likely to be unmarried (p < 0.0001), Non-White (p = 0.0012), and require an interpreter (p < 0.0001). Patients in both groups experienced similar rates of laparoscopic cholecystectomy, TTS, and LOS; however, Medicaid enrollees experienced more readmissions within 30 days of discharge (30.4% vs 17.9%, p < 0.001).

CONCLUSION

Despite anticipated population differences, the treatment of acute cholecystitis was similar between Medicaid and Non-Medicaid enrollees, with the exception of readmission. Further research is needed to identify patient, provider, and/or population factors driving this disparity.

The impact of social determinants of health on laryngotracheal stenosis development and outcomes

OBJECTIVES

The social determinants of health affect a wide range of health outcomes and risks. To date, there have been no studies evaluating the impact of social determinants of health on laryngotracheal stenosis (LTS). We sought to describe the social determinants in a cohort of LTS patients and explore their association with treatment outcome.

METHODS

Subjects diagnosed with LTS undergoing surgical procedures between 2013 and 2018 were identified. Matched controls were identified from intensive care unit (ICU) patients who underwent intubation for greater than 24 hours. Medical comorbidities, stenosis characteristics, and patient demographics were abstracted from the clinical record. Tracheostomy at last follow-up was recorded from the medical record and phone calls. Socioeconomic data was obtained from the American Community Survey.

RESULTS

One hundred twenty-two cases met inclusion criteria. Cases had significantly lower education compared to Tennessee (P = .009) but similar education rates as ICU controls. Cases had significantly higher body mass index (odds ratio [OR]: 1.04, P = .035), duration of intubation (OR: 1.21, P < .001), and tobacco use (OR: 1.21, P = .006) in adjusted analysis when compared to controls. Tracheostomy dependence within the case cohort was significantly associated with public insurance (OR: 1.33, P = .016) and chronic obstructive pulmonary disease (OR: 1.34, P = .018) in adjusted analysis.

CONCLUSION

Intubation practices, medical comorbidities and social determinants of health may influence the development of LTS and tracheostomy dependence after treatment. Identification of at-risk populations in ICUs may allow for prevention of tracheostomy dependence through the use of early tracheostomy and specialized follow-up.

LEVEL OF EVIDENCE

Level 3, retrospective review comparing cases and controls Laryngoscope, 130:1000-1006, 2020.

Association of Economic Status and Mortality in Patients with Acute Respiratory Distress Syndrome

The high cost of treatment for acute respiratory distress syndrome (ARDS) is a concern for healthcare systems, while the impact of patients’ socio-economic status on the risk of ARDS-associated mortality remains controversial. This study investigated associations between patients’ income at the time of ARDS diagnosis and ARDS-specific mortality rate after treatment initiation. Data from records provided by the National Health Insurance Service of South Korea were used. Adult patients admitted for ARDS treatment from 2013 to 2017 were included in the study. Patients’ income in the year of diagnosis was evaluated. A total of 14,600 ARDS cases were included in the analysis. The 30-day and 1-year mortality rates were 48.6% and 70.3%, respectively. In multivariable Cox regression model, we compared income quartiles, showing that compared to income strata Q1, the Q2 (p = 0.719), Q3 (p = 0.946), and Q4 (p = 0.542) groups of income level did not affect the risk of 30-day mortality, respectively. Additionally, compared to income strata Q1, the Q2 (p = 0.762), Q3 (p = 0.420), and Q4 (p = 0.189) strata did not affect the risk of 1-year mortality. Patient income at the time of ARDS diagnosis did not affect the risk of 30-day or 1-year mortality in the present study based on South Korea’s health insurance data.

Health Disparities and Sepsis: a Systematic Review and Meta-Analysis on the Influence of Race on Sepsis-Related Mortality

RATIONALE

Racial disparities in sepsis outcomes have been previously reported. However, recently, there have been inconsistencies in identifying which socioeconomic variables, such as race, account for these disparities. The objective of this study was to perform a systematic review in order to examine the impact of race on sepsis-attributable mortality.

METHODS

Systematic searches for English-language articles identified through MEDLINE, EBSCOhost, PubMed, ERIC, and Cochrane Library databases from 1960 to 1 February 2017. Included studies examined sepsis outcomes in the context of sepsis incidence and/or mortality. Two investigators independently extracted data and assessed study quality. The meta-analysis was performed in accordance with the Cochrane Collaboration guidelines.

RESULTS

Twenty-one studies adhered to the predefined selection criteria and were included in the review. Of the 21 studies, we pooled data from 6 studies comparing African American/Black race as a risk factor for sepsis-related mortality disparities (reference group being Caucasian/White). From the meta-analysis on these six studies, African American/Black race was found to have no statistical significant relationship with sepsis-related mortality (odds ratio 1.20, 95% CI, 0.81 to 1.77). Similar results were found for other races (Native Americans, Asians) and ethnicities (Hispanic/Latinos).

CONCLUSION

On the basis of available evidence from a limited number of observation retrospective studies, race alone cannot fully explain sepsis-related disparities, especially sepsis-attributable mortality.

Lack of insurance as a barrier to care in sepsis: A retrospective cohort study

Nationally-representative data suggest an association between lack of insurance and in-hospital death from sepsis (Kumar et al., 2014). It remains to be determined whether this association is attributable to differences in baseline health, care-seeking behaviors, hospital care, or other factors.

PURPOSE

To determine whether organ dysfunction present on admission for community-onset sepsis mediates the association between lack of insurance and mortality in sepsis.

MATERIALS AND METHODS

Retrospective cohort study using public discharge data from the California Office of Statewide Health Planning and Development. Inpatients age 18-64 with community-onset sepsis at California hospitals in 2010 were identified by diagnosis codes.

RESULTS

Controlling for demographics, comorbidities, infection source, and hospital characteristics, lack of insurance was associated with an adjusted odds ratio (OR) of 1.26 (absolute risk difference 4.75%, p<0.001) for organ dysfunction present on admission for community-onset sepsis. Lack of insurance predicted in-hospital mortality (adjusted OR 1.15, p<0.001). Organ dysfunction present on admission was the only significant mediator, explaining 22.3% (p<0.001) of the effect of lack of insurance.

CONCLUSIONS

The association between lack of insurance and organ dysfunction on admission in community-onset sepsis suggests that lack of insurance may impede timely care for patients with community-onset infections.

Insurance Coverage Predicts Mortality in Patients Transferred Between Hospitals: a Cross-Sectional Study

BACKGROUND

Patients transferred between hospitals are at high risk of adverse events and mortality. The relationship between insurance status, transfer practices, and outcomes has not been definitively characterized.

OBJECTIVE

To identify the association between insurance coverage and mortality of patients transferred between hospitals.

DESIGN

We conducted a single-institution observational study, and validated results using a national administrative database of inter-hospital transfers.

SETTING

Three ICUs at an academic tertiary care center validated by a nationally representative sample of inter-hospital transfers.

PATIENTS

The single-institution analysis included 652 consecutive patients transferred from 57 hospitals between 2011 and 2012. The administrative database included 353,018 patients transferred between 437 hospitals.

MEASUREMENTS

Adjusted inpatient mortality and 24-h mortality, stratified by insurance status.

RESULTS

Of 652 consecutive transfers to three ICUs, we observed that uninsured patients had higher adjusted inpatient mortality (OR 2.67, p = 0.021) when controlling for age, race, gender, Apache-II, and whether the patient was transferred from an ED. Uninsured were more likely to be transferred from ED (OR 2.3, p = 0.026), and earlier in their hospital course (3.9 vs 2.0 days, p = 0.002). Using an administrative dataset, we validated these observations, finding that the uninsured had higher adjusted inpatient mortality (OR 1.24, 95% CI 1.13-1.36, p < 0.001) and higher mortality within 24 h (OR 1.33 95% CI 1.11-1.60, p < 0.002). The increase in mortality was independent of patient demographics, referral patterns, or diagnoses.

LIMITATIONS

This is an observational study where transfer appropriateness cannot be directly assessed.

CONCLUSIONS

Uninsured patients are more likely to be transferred from an ED and have higher mortality. These data suggest factors that drive inter-hospital transfer of uninsured patients have the potential to exacerbate outcome disparities.

Factors Underlying Racial Disparities in Sepsis Management

Sepsis, a syndrome characterized by systemic inflammation during infection, continues to be one of the most common causes of patient mortality in hospitals across the United States. While standardized treatment protocols have been implemented, a wide variability in clinical outcomes persists across racial groups. Specifically, black and Hispanic populations are frequently associated with higher rates of morbidity and mortality in sepsis compared to the white population. While this is often attributed to systemic bias against minority groups, a growing body of literature has found patient, community, and hospital-based factors to be driving racial differences. In this article, we provide a focused review on some of the factors driving racial disparities in sepsis. We also suggest potential interventions aimed at reducing health disparities in the prevention, early identification, and clinical management of sepsis.

Risk factors for sepsis morbidity in a rural hospital population: A case-control study

BACKGROUND

The aim of the study was to identify risk factors for sepsis morbidity in a rural hospital population.

METHODS

We used a case-control study design. Patients included adult admissions to a rural health system between January 1, 2012, and December 31, 2015. Case selection was by electronic medical record search for codes of the ICD-9-CM. Cases were validated against Quick Sequential Organ Failure Assessment criteria. Multiple logistic regression modeling was performed to determine which predefined variables were significantly associated with sepsis diagnosis.

RESULTS

A total of 220 patients were studied (110 cases and 110 controls). Cases had an in-hospital mortality of 20% compared with 0% of the controls. Indwelling medical device use during hospitalization (adjusted odds ratio [OR], 3.02; 95% confidence interval [CI], 1.44-6.30; P = .003), coronary heart disease (adjusted OR, 2.59; 95% CI, 1.13-5.97; P = .03), and type of health insurance (adjusted OR, 2.36; 95% CI, 1.13-4.93; P = .02) were independently associated with sepsis diagnosis after adjusting for potential confounders.

CONCLUSIONS

This study underscores the need for implementation and maintenance of infection control measures during management of patients with indwelling medical devices at a rural hospital.

The effect of community socioeconomic status on sepsis-attributable mortality

PURPOSE

Community factors may play a role in determining individual risk for sepsis, as well as sepsis-related morbidity and mortality. We sought to define the relationship between community socioeconomic status and mortality due to sepsis in an urban locale.

METHODS

Using community statistical areas of Baltimore City, we dichotomized neighborhoods at median household income, and compared distribution of outcomes of interest within the two income categories. We performed multivariable regression analyses to determine the relationship between socioeconomic variables and sepsis-attributable mortality.

RESULTS

The collective median household income was $38,660 (IQR $32,530, 54,480), family poverty rate was 28.4% (IQR 13.5, 38.8%), and rate of death from sepsis was 3.1 per 10,000 persons (IQR 2.60, 4.10). Lower household income communities demonstrated higher rates of death from sepsis (3.65 (IQR 2.78, 4.40)) than higher household income communities (2.80 (IQR 2.05, 3.55)) (p = .02). In regression models, household income (β = -8.42, p = .006) and percentage of poverty in communities (β = 2.71, p = .01) demonstrated associations with sepsis-attributable mortality.

DISCUSSION

Our findings suggest that socioeconomic variables play significant role in sepsis-attributable mortality. Such confirmation of regional disparities in mortality due to sepsis warrants further consideration, as well as integration, for future national sepsis policies.

Epidemiology and Outcomes

Sepsis is a global public health concern. Internationally it contributes to more than 5 million deaths annually. Although rates are variable between countries, over the past 40 years reported incidence has continued to increase. Aside from potential differences in patient populations, the variation in reported rates also reflects differences in identification strategies, access to health care, and awareness of the diagnosis. Factors such as age, sex, socioeconomic status, comorbid disease, and type and site of infection impact the development of and outcomes from sepsis. Although advances have been made in treatment, its impact remains substantial.

Evidence of High Mortality and Increasing Burden of Sepsis in a Regional Sample of the New Zealand Population

Background

Sepsis is a life-threatening complication of infection. The incidence of sepsis is thought to be on the increase, but estimates making use of administrative data in the United States may be affected by administrative bias.

Methods

We studied the population-based incidence of sepsis in the Waikato region of New Zealand from 2007 to 2012 using International Classification of Diseases, Tenth Revision, Australian Modification, which lacks a specific code for sepsis.

Results

Between 2007 and 2012, 1643 patients met coding criteria for sepsis in our hospitals. Sixty-three percent of patients were 65 or over, 17% of cases were admitted to an intensive care unit, and the in-hospital and 1-year mortality with sepsis was 19% and 38%, respectively. Age-standardized rate ratios (ASRRs) demonstrated that sepsis was associated with male sex (ASRR 1.4; 95% confidence interval [CI], 1.23–1.59), Maori ethnicity (ASRR 3.22 compared with non-Maori; 95% CI, 2.85–3.65), study year (ASRR 1.62 comparing 2012 with 2008; 95% CI, 1.18–2.24), and socioeconomic deprivation (ASRR 1.72 comparing the highest with the lowest quintile of socioeconomic deprivation; 95% CI, 1.5–1.97). Multiorgan failure was present in approximately 20% of cases in all age groups. Intensive care unit admission rate fell from 30% amongst 25- to 34-year-olds to less than 10% amongst those aged 75 and over.

Conclusions

In a 9% sample of the New Zealand population, the incidence of sepsis increased by 62% over a 5-year period. Maori, elderly, and disadvantaged populations were most affected.

Differences in Use of High-quality and Low-quality Hospitals Among Working-age Individuals by Insurance Type

BACKGROUND

Research suggests that individuals with Medicaid or no insurance receive fewer evidence-based treatments and have worse outcomes than those with private insurance for a broad range of conditions. These differences may be due to patients' receiving care in hospitals of different quality.

RESEARCH DESIGN

We used the Healthcare Cost and Utilization Project State Inpatient Databases 2009-2010 data to identify patients aged 18-64 years with private insurance, Medicaid, or no insurance who were hospitalized with acute myocardial infarction, heart failure, pneumonia, stroke, or gastrointestinal hemorrhage. Multinomial logit regressions estimated the probability of admissions to hospitals classified as high, medium, or low quality on the basis of risk-adjusted, in-hospital mortality.

RESULTS

Compared with patients who have private insurance, those with Medicaid or no insurance were more likely to be minorities and to reside in areas with low-socioeconomic status. The probability of admission to high-quality hospitals was similar for patients with Medicaid (23.3%) and private insurance (23.0%) but was significantly lower for patients without insurance (19.8%, P<0.01) compared with the other 2 insurance groups. Accounting for demographic, socioeconomic, and clinical characteristics did not influence the results.

CONCLUSIONS

Previously noted disparities in hospital quality of care for Medicaid recipients are not explained by differences in the quality of hospitals they use. Patients without insurance have lower use of high-quality hospitals, a finding that needs exploration with data after 2013 in light of the Affordable Care Act, which is designed to improve access to medical care for patients without insurance.

Impact of Insurance Status on Outcomes and Use of Rehabilitation Services in Acute Ischemic Stroke: Findings From Get With The Guidelines-Stroke

Background

Insurance status affects access to care, which may affect health outcomes. The objective was to determine whether patients without insurance or with government‐sponsored insurance had worse quality of care or in‐hospital outcomes in acute ischemic stroke.

Methods and Results

Multivariable logistic regressions with generalized estimating equations stratified by age under or at least 65 years were adjusted for patient demographics and comorbidities, presenting factors, and hospital characteristics to determine differences in in‐hospital mortality and postdischarge destination. We included 589 320 ischemic stroke patients treated at 1604 US hospitals participating in the Get With The Guidelines‐Stroke program between 2012 and 2015. Uninsured patients with hypertension, high cholesterol, or diabetes mellitus were less likely to be taking appropriate control medications prior to stroke, to use an ambulance to arrive to the ED, or to arrive early after symptom onset. Even after adjustment, the uninsured were more likely than the privately insured to die in the hospital (<65 years, OR 1.33 [95% CI 1.22‐1.45]; ≥65 years OR 1.54 [95% CI 1.34‐1.75]), and among survivors, were less likely to go to inpatient rehab (<65 OR 0.63 [95% CI 0.6‐0.67]; ≥65 OR 0.56 [95% CI 0.5‐0.63]). In contrast, patients with Medicare and Medicaid were more likely to be discharged to a Skilled Nursing Facility (<65 years OR 2.08 [CI 1.96‐2.2]; OR 2.01 [95% CI 1.91‐2.13]; ≥65 years OR 1.1 [95% CI 1.07‐1.13]; OR 1.41 [95% CI 1.35‐1.46]).

Conclusions

Preventative care prior to ischemic stroke, time to presentation for acute treatment, access to rehabilitation, and in‐hospital mortality differ by patient insurance status.

Differences in Transitional Care Provided to Mexican American and Non-Hispanic White Older Adults

Background:Transitional care, assisting patients to move safely through multiple health care settings, may be insufficient for older Hispanic patients. Purpose: Describe home health care services referral rates for Hispanic and non-Hispanic White (NHW) patients and factors that influence case managers’ (CMs’) discharge planning processes. Design: Organized by the Ethno-Cultural Gerontological Nursing Model, health records were reviewed ( n = 33,597 cases) and supplemented with qualitative description ( n = 8 CMs). Findings: Controlling for gender, insurance type, age, and hospital length of stay, NHW older adults received more home health care services referrals (odds ratio = 1.23). Insurance coverage was the most frequent determinant of CMs’ post–hospital care choices, rather than patients’ being Hispanic. NHW older adults were more likely to have insurance than Hispanic older adults. Implications: Insurance coverage being CMs’ primary consideration in determining patients’ dispositions is a form of systems-level discrimination for Hispanic vulnerable groups, which combined with other hospital-level constraints, should be addressed with policy-level interventions.

Determinants of Home Discharge Among Survivors of Necrotizing Fasciitis: A Population-Level Analysis

BACKGROUND

The majority of patients with necrotizing fasciitis (NF) in the United Sates survive their illness, and there is increasing interest in addressing the ability of survivors to return to their community following hospitalization. However, there are no data on the factors affecting home discharge among survivors of NF.

METHODS

We used the Texas Inpatient Public Use Data File to conduct a retrospective population-based examination of hospitalizations with NF aged 15 years or older between 2001 and 2010. Multivariate logistic regression modeling was used to explore predictors of home discharge among hospital survivors.

RESULTS

There were 10,724 NF hospitalizations surviving to discharge during study period, of which 62.5% were discharged home. The following key predictors have adversely affected odds of home discharge (odds ratio and 95% confidence intervals): age ≥ 75 years (0.349 (0.292 - 0.417)), Medicare insurance (0.582 (0.510 - 0.663)), congestive heart failure (0.836 (0.719 - 0.972)), chronic liver disease (0.684 (0.522 - 0.895)), respiratory failure (0.464 (0.386 - 0.558)), neurological failure (0.573 (0.418 - 0.787)), and need for mechanical ventilation (0.339 (0.199 - 0.578)). Increased odds of home discharge were found among males (1.116 (1.058 - 1.285)), Hispanics (1.193 (1.056 - 1.349)), those lacking health insurance (2.161 (1.183 - 2.521)) or managed at a teaching hospital (1.264 (1.127 - 1.418)).

CONCLUSIONS

In this first population-level examination of the determinants of home discharge among survivors of NF, older age, Medicare insurance, selected comorbidities, and development of organ failure decreased patients' odds of home discharge. Unexpectedly, male gender, Hispanic ethnicity, lack of health insurance, and being managed at a teaching hospital were associated with favorable impact on patients' discharge disposition. Further studies are warranted in other populations and healthcare environments to corroborate the present findings and to refine our understanding of the factors affecting short-term outcomes among NF survivors.

Outcomes and Resource Use of Sepsis-associated Stays by Presence on Admission, Severity, and Hospital Type

OBJECTIVE

To establish a baseline for the incidence of sepsis by severity and presence on admission in acute care hospital settings before implementation of a broad sepsis screening and response initiative.

METHODS

A retrospective cohort study using hospital discharge abstracts of 5672 patients, aged 18 years and above, with sepsis-associated stays between February 2012 and January 2013 at an academic medical center and 5 community hospitals in Texas.

RESULTS

Sepsis was present on admission in almost 85% of cases and acquired in-hospital in the remainder. The overall inpatient death rate was 17.2%, but was higher in hospital-acquired sepsis (38.6%, medical; 29.2%, surgical) and Stages 2 (17.6%) and 3 (36.4%) compared with Stage 1 (5.9%). Patients treated at the academic medical center had a higher death rate (22.5% vs. 15.1%, P<0.001) and were more costly ($68,050±184,541 vs. $19,498±31,506, P<0.001) versus community hospitals.

CONCLUSIONS

Greater emphasis is needed on public awareness of sepsis and the detection of sepsis in the prehospitalization and early hospitalization period. Hospital characteristics and case mix should be accounted for in cross-hospital comparisons of sepsis outcomes and costs.

Initial blood pressure is associated with stroke severity and is predictive of admission cost and one-year outcome in different stroke subtypes: a SRICHS registry study

Background

To investigate if initial blood pressure (BP) on admission is associated with stroke severity and predictive of admission costs and one-year-outcome in acute ischemic (IS) and hemorrhagic stroke (HS).

Methods

This is a single-center retrospective cohort study. Stroke patients admitted within 3 days after onset between January 1^st and December 31^st in 2009 were recruited. The initial BP on admission was subdivided into high (systolic BP ≥ 211 mmHg or diastolic BP ≥ 111 mmHg), medium (systolic BP 111–210 mmHg or diastolic BP 71–110 mmHg), and low (systolic BP ≤ 110 mmHg or diastolic BP ≤ 70 mmHg) groups and further subgrouped with 25 mmHg difference in systole and 10 mmHg difference in diastole for the correlation analysis with demographics, admission cost and one-year modified Rankin scale (mRS).

Results

In 1173 IS patients (mean age: 67.8 ± 12.8 years old, 61.4 % male), low diastolic BP group had higher frequency of heart disease (p =0.001), dehydration (p =0.03) and lower hemoglobin level (p <0.001). The extremely high and low systolic BP subgroups had worse National Institutes of Health Stroke Scale (NIHSS) score (p =0.03), higher admission cost (p <0.001), and worse one-year mRS (p =0.03), while extremely high and low diastolic BP subgroups had higher admission cost (p <0.01). In 282 HS patients (mean age: 62.4 ± 15.4 years old, 60.6 % male), both low systolic and diastolic BP groups had lower hemoglobin level (systole: p =0.05; diastole: p <0.001). The extremely high and low BP subgroups had worse NIHSS score (p =0.01 and p <0.001, respectively), worse one-year mRS (p =0.002 and p =0.001, respectively), and higher admission cost (diastole: p <0.002).

Conclusions

Stroke patients with extremely high and low BP on admission have not only worse stroke severity but also higher admission cost and/or worse one-year outcome. In those patients with low BP, low admission hemoglobin might be a contributing factor.

Uninsured status may be more predictive of outcomes among the severely injured than minority race

AIM

Worse outcomes in trauma in the United States have been reported for both the uninsured and minority race. We sought to determine whether disparities would persist among severely injured patients treated at trauma centres where standard triage trauma protocols limit bias from health systems and providers.

METHODS

We performed a retrospective analysis of the 2010-2012 National Sample Program from the National Trauma Databank, which is a nationally representative sample of trauma centre performance in the United States. The database was screened for adults ages 18-64 who had a known insurance status. Outcomes measured were in-hospital mortality and post-hospital care.

RESULTS

There were 739,149 injured patients included in the analysis. Twenty-eight percent were uninsured, and 34 percent were of minority race. In the adjusted analysis, uninsured status (OR 1.60, 1.29-1.98, p<0.001) and black race (OR 1.24, 1.04-1.49, p=0.019) were significant predictors of mortality. Only uninsured status was a significant negative predictor of post-hospital care (OR 0.43, 0.36-0.51, p<0.001). As injury severity increased, only insurance status was a significant predictor of both increased mortality (OR 1.68, 1.29-2.19, p<0.001) and decreased post-hospital care (OR 0.45, 0.32-0.63, p<0.001).

CONCLUSION

Uninsured status is independently associated with higher in-hospital mortality and decreased post-hospital care in patients with severe injuries in a nationally representative sample of trauma centres in the United States. Increased in-hospital mortality is likely due to endogenous patient factors while decreased post-hospital care is likely due to economic constraints. Minority race is less of a factor influencing disparate outcomes among the severely injured.

Self-Administered Outpatient Antimicrobial Infusion by Uninsured Patients Discharged from a Safety-Net Hospital: A Propensity-Score-Balanced Retrospective Cohort Study

BACKGROUND

Outpatient parenteral antimicrobial therapy (OPAT) is accepted as safe and effective for medically stable patients to complete intravenous (IV) antibiotics in an outpatient setting. Since, however, uninsured patients in the United States generally cannot afford OPAT, safety-net hospitals are often burdened with long hospitalizations purely to infuse antibiotics, occupying beds that could be used for patients requiring more intensive services. OPAT is generally delivered in one of four settings: infusion centers, nursing homes, at home with skilled nursing assistance, or at home with self-administered therapy. The first three-termed healthcare-administered OPAT (H-OPAT)--are most commonly used in the United States by patients with insurance funding. The fourth--self-administered OPAT (S-OPAT)--is relatively uncommon, with the few published studies having been conducted in the United Kingdom. With multidisciplinary planning, we established an S-OPAT clinic in 2009 to shift care of selected uninsured patients safely to self-administration of their IV antibiotics at home. We undertook this study to determine whether the low-income mostly non-English-speaking patients in our S-OPAT program could administer their own IV antimicrobials at home with outcomes as good as, or better than, those receiving H-OPAT.

METHODS AND FINDINGS

Parkland Hospital is a safety-net hospital serving Dallas County, Texas. From 1 January 2009 to 14 October 2013, all uninsured patients meeting criteria were enrolled in S-OPAT, while insured patients were discharged to H-OPAT settings. The S-OPAT patients were trained through multilingual instruction to self-administer IV antimicrobials by gravity, tested for competency before discharge, and thereafter followed at designated intervals in the S-OPAT outpatient clinic for IV access care, laboratory monitoring, and physician follow-up. The primary outcome was 30-d all-cause readmission, and the secondary outcome was 1-y all-cause mortality. The study was adequately powered for readmission but not for mortality. Clinical, sociodemographic, and outcome data were collected from the Parkland Hospital electronic medical records and the US census, constituting a historical prospective cohort study. We used multivariable logistic regression to develop a propensity score predicting S-OPAT versus H-OPAT group membership from covariates. We then estimated the effect of S-OPAT versus H-OPAT on the two outcomes using multivariable proportional hazards regression, controlling for selection bias and confounding with the propensity score and covariates. Of the 1,168 patients discharged to receive OPAT, 944 (81%) were managed in the S-OPAT program and 224 (19%) by H-OPAT services. In multivariable proportional hazards regression models controlling for confounding and selection bias, the 30-d readmission rate was 47% lower in the S-OPAT group (adjusted hazard ratio [aHR], 0.53; 95% CI 0.35-0.81; p = 0.003), and the 1-y mortality rate did not differ significantly between the groups (aHR, 0.86; 95% CI 0.37-2.00; p = 0.73). The S-OPAT program shifted a median 26 d of inpatient infusion per patient to the outpatient setting, avoiding 27,666 inpatient days. The main limitation of this observational study-the potential bias from the difference in healthcare funding status of the groups-was addressed by propensity score modeling.

CONCLUSIONS

S-OPAT was associated with similar or better clinical outcomes than H-OPAT. S-OPAT may be an acceptable model of treatment for uninsured, medically stable patients to complete extended courses of IV antimicrobials at home.

Evolving trends in the epidemiology, resource utilization, and outcomes of pregnancy-associated severe sepsis: a population-based cohort study

Background

Infections are a well-known complication of pregnancy. However, pregnancy-associated severe sepsis (PASS) has not been as well-characterized, with limited population-level data reported to date. We performed a population-based study of the evolving patterns of the epidemiology, clinical characteristics, resource utilization, and outcomes of PASS in Texas over the past decade.

Methods

The Texas Inpatient Public Use Data File was used to identify pregnancy-associated hospitalizations and PASS hospitalizations for the years 2001 - 2010. The Texas Center for Health Statistics reports of live births, abortions and fetal deaths, and a previously reported population-based, age-specific linkage study on miscarriage were used to derive the annual total estimated pregnancies (TEPs). The incidence, demographics, clinical characteristics, resource utilization and outcomes of PASS were examined. Logistic regression modeling was used to explore the predictors of PASS and its associated mortality.

Results

There were 4,060,201 pregnancy-associated hospitalizations and 1,007 PASS hospitalizations during study period. The incidence of PASS was increased by 236% over the past decade, rising from 11 to 26 hospitalizations per 100,000 TEPs. The key changes between 2001 - 2002 and 2009 - 2010 within PASS hospitalizations included: admission to ICU 78% vs. 90% (P = 0.002); development of ≥ 3 organ failures 9% vs. 35% (P < 0.0001); and inflation-adjusted median hospital charges (2,010 dollars) $64,034 vs. $89,895 (P = 0.0141). Hospital mortality (11%) remained unchanged during study period. Chronic liver disease (adjusted odds ratio (aOR) 41.4) and congestive heart failure (CHF) (aOR 20.5) were associated with the highest risk of PASS, in addition to black race, poverty, drug abuse, and lack of health insurance. The highest risk of death was among women with HIV infection (aOR 45.5), need for mechanical ventilation (aOR 4.5), drug abuse (aOR 3.0), and lacking health insurance (aOR 2.9).

Conclusions

The incidence, severity, and fiscal burden of PASS rose substantially over the past decade. Case fatality was lower than that for severe sepsis in the general population. Chronic liver disease and CHF pose especially high risk of PASS. Pregnant women with history of drug abuse and lacking health insurance are at high risk of both developing and dying with PASS, requiring extra vigilance for early diagnosis and targeted intervention.

Applications of the MapReduce programming framework to clinical big data analysis: current landscape and future trends

The emergence of massive datasets in a clinical setting presents both challenges and opportunities in data storage and analysis. This so called "big data" challenges traditional analytic tools and will increasingly require novel solutions adapted from other fields. Advances in information and communication technology present the most viable solutions to big data analysis in terms of efficiency and scalability. It is vital those big data solutions are multithreaded and that data access approaches be precisely tailored to large volumes of semi-structured/unstructured data. THE MAPREDUCE PROGRAMMING FRAMEWORK USES TWO TASKS COMMON IN FUNCTIONAL PROGRAMMING: Map and Reduce. MapReduce is a new parallel processing framework and Hadoop is its open-source implementation on a single computing node or on clusters. Compared with existing parallel processing paradigms (e.g. grid computing and graphical processing unit (GPU)), MapReduce and Hadoop have two advantages: 1) fault-tolerant storage resulting in reliable data processing by replicating the computing tasks, and cloning the data chunks on different computing nodes across the computing cluster; 2) high-throughput data processing via a batch processing framework and the Hadoop distributed file system (HDFS). Data are stored in the HDFS and made available to the slave nodes for computation. In this paper, we review the existing applications of the MapReduce programming framework and its implementation platform Hadoop in clinical big data and related medical health informatics fields. The usage of MapReduce and Hadoop on a distributed system represents a significant advance in clinical big data processing and utilization, and opens up new opportunities in the emerging era of big data analytics. The objective of this paper is to summarize the state-of-the-art efforts in clinical big data analytics and highlight what might be needed to enhance the outcomes of clinical big data analytics tools. This paper is concluded by summarizing the potential usage of the MapReduce programming framework and Hadoop platform to process huge volumes of clinical data in medical health informatics related fields.