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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.
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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
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Bolte TB, Swanson MB, Kaldjian AM, Mohr NM, McDanel J, Ahmed A. Hospitals That Report Severe Sepsis and Septic Shock Bundle Compliance Have More Structured Sepsis Performance Improvement. J Patient Saf 2022; 18:e1231-e1236. [PMID: 35858483 PMCID: PMC9722504 DOI: 10.1097/pts.0000000000001062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE Sepsis is a common cause of death. The Centers for Medicare and Medicaid Services severe sepsis/septic shock (SEP-1) bundle is focused on improving sepsis outcomes, but it is unknown which quality improvement (QI) practices are associated with SEP-1 compliance and reduced sepsis mortality. The objectives of this study were to compare sepsis QI practices in SEP-1 reporting and nonreporting hospitals and to measure the association between sepsis QI processes, SEP-1 performance, and sepsis mortality. MATERIALS AND METHODS This study linked survey data on QI practices from Iowa hospitals to SEP-1 performance data and mortality. Characteristics of hospitals and sepsis QI practices were compared by SEP-1 reporting status. Univariable and multivariable logistic and linear regression estimated the association of QI practices with SEP-1 performance and observed-to-expected sepsis mortality ratios. RESULTS One hundred percent of Iowa's 118 hospitals completed the survey. SEP-1 reporting hospitals were more likely to have sepsis QI practices, including reporting sepsis quality to providers (64% versus 38%, P = 0.026) and using the case review process to develop sepsis care plans (87% versus 64%, P = 0.013). Sepsis QI practices were not associated with increased SEP-1 scores. A sepsis registry was associated with decreased odds of being in the bottom quartile of sepsis mortality (odds ratio, 0.37; 95% confidence interval, 0.14 to 0.96, P = 0.041), and presence of a sepsis committee was associated with lower hospital-specific mortality (observed-to-expected ratio, -0.11; 95% confidence interval, -0.20 to 0.01). CONCLUSIONS Hospitals reporting SEP-1 compliance conduct more sepsis QI practices. Most QI practices are not associated with increased SEP-1 performance or decreased sepsis mortality. Future work could explore how to implement these performance improvement practices in hospitals not reporting SEP-1 compliance.
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Affiliation(s)
- Ty B. Bolte
- Department of Emergency Medicine, University of Iowa Carver College of Medicine
| | - Morgan B. Swanson
- Department of Emergency Medicine, University of Iowa Carver College of Medicine
| | - Anna M. Kaldjian
- Department of Emergency Medicine, University of Iowa Carver College of Medicine
| | - Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa Carver College of Medicine
- Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine
| | - Jennifer McDanel
- Clinical Quality, Safety & Performance Improvement, University of Iowa Hospitals and Clinics
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine
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Sloan SN, Rodriguez N, Seward T, Sare L, Moore L, Stahl G, Johnson K, Goade S, Arnce R. Compliance with SEP-1 guidelines is associated with improved outcomes for septic shock but not for severe sepsis. JOURNAL OF INTENSIVE MEDICINE 2022; 2:167-172. [PMID: 36789014 PMCID: PMC9924005 DOI: 10.1016/j.jointm.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/11/2022] [Accepted: 03/13/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND In 2018, the Centers for Medicaid and Medicare Services (CMS) issued a protocol for the treatment of sepsis. This bundle protocol, titled SEP-1 is a multicomponent 3 h and 6 h resuscitation treatment for patients with the diagnosis of either severe sepsis or septic shock. The SEP-1 bundle includes antibiotic administration, fluid bolus, blood cultures, lactate measurement, vasopressors for fluid-refractory hypotension, and a reevaluation of volume status. We performed a retrospective analysis of patients diagnosed with either severe sepsis or septic shock comparing mortality outcomes based on compliance with the updated SEP-1 bundle at a rural community hospital. METHODS Mortality outcome and readmission data were extracted from an electronic medical records database from January 1, 2019, to June 30, 2020. International Classification of Diseases (ICD)-10 codes were used to identify patients with either severe sepsis or septic shock. Once identified, patients were separated into four populations: patients with severe sepsis who met SEP-1, patients with severe sepsis who failed SEP-1, patients with septic shock who met SEP-1, and patients with septic shock who failed SEP-1. A patient who met bundle criteria (SEP-1 criteria) received each component of the bundle in the time allotted. Using chi-squared test of homogeneity, mortality outcomes for population proportions were investigated. Two sample proportion summary hypothesis test and 95% confidence intervals (CI) determined significance in mortality outcomes. RESULTS Out of our 1122 patient population, 437 patients qualified to be measured by CMS criteria. Of the 437 patients, 195 met the treatment bundle and 242 failed the treatment bundle. Upon comparing the two groups, we found the probable difference in mortality rate between the met(14.87%) and failed bundle(27.69%) groups to be significant(95% CI: 5.28-20.34, P=0.0013). However, the driving force of this result lies in the subgroup of patients with severe sepsis with septic shock, which show a higher mortality rate compared to the subgroup with just severe sepsis. The difference was within the range of 3.31% to 29.71%. CONCLUSION This study shows that with septic shock obtained a benefit, decreased mortality, when the SEP-1 bundle was met. However, meeting the SEP-1 bundle had no benefit for patients who had the diagnosis of severe sepsis alone. The significant difference in mortality, found between the met and failed bundle groups, is primarily due to the number of patients with septic shock, and whether or not those patients with septic shock met or failed the bundle.
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Affiliation(s)
- Shelly N.B. Sloan
- Department of Primary Care, College of Medicine, Kansas City University, 2901St. Johns Blvd., Joplin, MO 64804, USA
| | - Nate Rodriguez
- Department of Primary Care, College of Medicine, Kansas City University, 2901St. Johns Blvd., Joplin, MO 64804, USA
| | - Thomas Seward
- Department of Primary Care, College of Medicine, Kansas City University, 2901St. Johns Blvd., Joplin, MO 64804, USA
| | - Lucy Sare
- Department of Primary Care, College of Medicine, Kansas City University, 2901St. Johns Blvd., Joplin, MO 64804, USA
| | - Lukas Moore
- Department of Primary Care, College of Medicine, Kansas City University, 2901St. Johns Blvd., Joplin, MO 64804, USA
| | - Greg Stahl
- Department of Quality Improvement, Freeman Health System, Joplin, MO 64804, USA
| | - Kerry Johnson
- Department of Mathematics, Missouri Southern State University, Joplin, MO 64801, USA
| | - Scott Goade
- Department of Pharmacy, Freeman Health System, Joplin, MO 64804, USA
| | - Robert Arnce
- Department of Primary Care, College of Medicine, Kansas City University, 2901St. Johns Blvd., Joplin, MO 64804, USA
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Whitley JA, Kieran K. Geographic Variations in Pharmacy Services and Availability of Commonly Prescribed Pediatric Urology Medications: An Opportunity to Improve Health Equity in Washington State. Urology 2021; 165:285-293. [PMID: 34808141 DOI: 10.1016/j.urology.2021.10.028] [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: 04/06/2021] [Revised: 09/29/2021] [Accepted: 10/13/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To describe geographic and sociodemographic variations in operating hours and availability of medications commonly prescribed by pediatric urologists at Washington State retail pharmacies. METHODS We identified all retail pharmacies in the state. We stratified counties by population density and household income (HI) and compared differences in pharmacy operating hours and availability of 10 commonly prescribed medications. RESULTS 1057/1058 pharmacies were contacted. All pharmacies had liquid formulations of oxycodone, hydrocodone, ibuprofen, acetaminophen, amoxicillin, and trimethoprim-sulfamethoxazole in stock. Liquid formulations of ciprofloxacin (10%) and oxybutynin (14.3%) were uncommonly stocked, while 92.5% of pharmacies stocked nitrofurantoin suspension, and 80.9% nitrofurantoin capsules. Statewide, 108 (10.2%) of pharmacies were closed on Saturdays and 297 (28.1%) closed on Sunday. More high (HPDC) than low population density (LPDC) (62.5% vs 0%, P < .001) and high-HI than low-HI counties (62.5% vs 0%, P = .30) had 24-hour pharmacies. A larger proportion of pharmacies were open 7-days in HPDC than LPDC (75.6% vs 56.2%, P < .0001) and in high-HI than low-HI counties (100% vs 62.5%, P = .30). The likelihood of a pharmacy being open 7 days/week was significantly higher in HPDC (vs LPDC; OR = 13.2, 95% CI: 4.39-39.7) and high-HI (vs low-HI; OR = 4.98, 95% CI: 2.58-9.60) counties. CONCLUSION Most pharmacies in Washington State carry medications commonly prescribed by pediatric urologists. However, retail pharmacy operating hours are widely variable and create geographic and temporal barriers in rural and poor areas that may limit the timely administration of prescription medication. Providers should consider a patient's practical ability to fill a prescription when starting a time-sensitive medication.
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Affiliation(s)
- Jorge A Whitley
- Division of Urology, Seattle Children's Hospital, Seattle, WA
| | - Kathleen Kieran
- Division of Urology, Seattle Children's Hospital, Seattle, WA; Department of Urology, University of Washington, Seattle, WA.
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Greenwood-Ericksen M, Kamdar N, Lin P, George N, Myaskovsky L, Crandall C, Mohr NM, Kocher KE. Association of Rural and Critical Access Hospital Status With Patient Outcomes After Emergency Department Visits Among Medicare Beneficiaries. JAMA Netw Open 2021; 4:e2134980. [PMID: 34797370 PMCID: PMC8605483 DOI: 10.1001/jamanetworkopen.2021.34980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Rural US residents disproportionately rely on emergency departments (ED), yet little is known about patient outcomes after ED visits to rural hospitals or critical access hospitals (CAHs). OBJECTIVE To compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals. DESIGN, SETTING, AND PARTICIPANTS This propensity-matched, retrospective cohort study used a 20% sample of national Medicare fee-for-service beneficiaries from January 1, 2011, to October 31, 2015. Rural and urban ED visits were matched on demographics, patient prior use of EDs, comorbidities, and diagnoses. Thirty-day outcomes overall and stratified by 25 common ED diagnoses were evaluated, with similar analysis of CAHs vs non-CAHs. Data were analyzed from February 15, 2020, to May 17, 2021. MAIN OUTCOMES AND MEASURES The primary outcome was 30-day all-cause mortality. Secondary outcomes were ED revisits with and without hospitalization. RESULTS The matched cohort included 473 152 rural and urban Medicare beneficiaries with a mean (SD) age of 75.1 (7.9) years (59.1% and 59.3% women, respectively; 86.9% and 87.1% White, respectively). Medicare beneficiaries at rural vs urban EDs experienced similar all-cause 30-day mortality (3.9% vs 4.1%; effect size, 0.01), ED revisits (18.1% vs 17.8%; effect size, 0.00), and ED revisits with hospitalization (6.0% vs 8.1%; effect size, 0.00). Rural ED visits were associated with more transfer (6.2% vs 2.0%; effect size, 0.22) and fewer hospitalizations (24.7% vs 39.2; effect size, 0.31). Stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced more transfer with 30-day mortality similar to that of patients in urban EDs. In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses, including chest pain (odds ratio [OR], 1.54 [95% CI, 1.25-1.89]), nausea and vomiting (OR, 1.68 [95% CI, 1.26-2.24), and abdominal pain (OR, 1.73 [95% CI, 1.42-2.10]). All findings were similar for CAHs. CONCLUSIONS AND RELEVANCE The findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings. Further research is needed to understand the sources of greater rural ED mortality for symptom-based conditions. These findings underscore the importance of ensuring access to treatment of life-threatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures.
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Affiliation(s)
- Margaret Greenwood-Ericksen
- Department of Emergency Medicine, University of New Mexico, Albuquerque
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque
| | - Neil Kamdar
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | - Paul Lin
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Naomi George
- Department of Emergency Medicine, University of New Mexico, Albuquerque
- Division of Critical Care, Department of Emergency Medicine, University of New Mexico, Albuquerque
| | - Larissa Myaskovsky
- Center for Healthcare Equity in Kidney Disease, Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque
| | - Cameron Crandall
- Department of Emergency Medicine, University of New Mexico, Albuquerque
| | - Nicholas M. Mohr
- Department of Emergency Medicine, University of Iowa, Iowa City
- Department of Anesthesia–Critical Care Medicine, University of Iowa, Iowa City
| | - Keith E. Kocher
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Learning Health Sciences, University of Michigan, Ann Arbor
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Sepsis Bundles That Focus on Clinician Judgment and Proven Interventions Are Needed to Increase Bundle Compliance and Effectiveness. Crit Care Med 2021; 48:602-605. [PMID: 32205611 DOI: 10.1097/ccm.0000000000004263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Berdahl CT, Schuur JD, Rothenberg C, Samadian K, Sharma D, Tarrant N, Goyal P, Venkatesh AK. Practice structure and quality improvement activities among emergency departments in the Emergency Quality (E-QUAL) Network. J Am Coll Emerg Physicians Open 2020; 1:839-844. [PMID: 33145529 PMCID: PMC7593479 DOI: 10.1002/emp2.12078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/31/2020] [Accepted: 04/03/2020] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Little academic investigation has been done to describe emergency department (ED) practice structure and quality improvement activities. Our objective was to describe staffing, payment mechanisms, and quality improvement activities among EDs in a nationwide quality improvement network and also stratify results to descriptively compare (1) single- versus multi-site EDs and (2) small-group versus large-group EDs. METHODS Observational study examining EDs that completed activities for the 2018 wave of the Emergency Quality Network (E-QUAL), a voluntary network of EDs nationwide that self-report quality improvement activities. EDs were defined as single-site or multi-site based on self-reported billing practices; additionally, EDs were defined as large-group if they and a majority of other sites with the same group name also identified as multi-site. All other sites were deemed small-group. RESULTS Data from 377 EDs were included. For staffing, the median number of clinicians was 17 overall (16 single-site; 19 multi-site). For payment, 376 of 377 EDs (99.7%) participated in the Merit-Based Incentive Payment System. Thirty-five EDs (9.2%) participated in a federal alternative payment model, and 19 (5.0%) participated in a commercial alternative payment model. For quality improvement, single- and multi-site EDs reported similar progress on quality improvement strategies; however, small-group EDs reported more advanced quality improvement strategies compared to large-group EDs for 8/10 quality improvement strategies included in a survey (eg, "achieved a formal plan to eliminate waste"). CONCLUSION Among EDs in E-QUAL, staffing, payment, and quality improvement activities are similar between single- and multi-site EDs. Group-level analysis suggests that practice structure may influence adoption of quality improvement strategies. Future work is needed to further evaluate practice structure and its influence on quality improvement activities and quality.
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Affiliation(s)
- Carl T. Berdahl
- Departments of Medicine and Emergency MedicineCedars‐Sinai Medical CenterWest HollywoodCalifornia
| | - Jeremiah D. Schuur
- Department of Emergency MedicineThe Warren Alpert Medical School of Brown UniversityProvidenceRhode Island
| | - Craig Rothenberg
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticut
| | - Kian Samadian
- University of Massachusetts School of MedicineWorcesterMassachusetts
| | - Dhruv Sharma
- American College of Emergency PhysiciansIrvingTexas
| | | | - Pawan Goyal
- American College of Emergency PhysiciansIrvingTexas
| | - Arjun K. Venkatesh
- Department of Emergency MedicineYale University School of MedicineNew HavenConnecticut
- Center for Outcomes Research and EvaluationYale New Haven Hospital New HavenConnecticut
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Wang J, Strich JR, Applefeld WN, Sun J, Cui X, Natanson C, Eichacker PQ. Driving blind: instituting SEP-1 without high quality outcomes data. J Thorac Dis 2020; 12:S22-S36. [PMID: 32148923 DOI: 10.21037/jtd.2019.12.100] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In 2015, the Centers for Medicare and Medicaid Services (CMS) instituted an all-or-none sepsis performance measure bundle (SEP-1) to promote high-quality, cost-effective care. Systematic reviews demonstrated only low-quality evidence supporting most of SEP-1's interventions. CMS has removed some but not all of these unproven components. The current SEP-1 version requires patients with suspected sepsis have a lactate level, blood cultures, broad-spectrum antibiotics and, if hypotensive, a fixed 30 mL/kg fluid infusion within 3 hours, and a repeat lactate if initially elevated within 6 hours. Experts have continued to raise concerns that SEP-1 remains overly prescriptive, lacks a sound scientific basis and presents risks (overuse of antibiotics and inappropriate fluids not titrated to need). To incentivize compliance with SEP-1, CMS now publicly publishes how often hospitals complete all interventions in individual patients. However, compliance measured across hospitals (5 studies, 48-2,851 hospitals) or patients (three studies, 110-851 patients) has been low (approximately 50%) which is not surprising given SEP-1's lack of scientific basis. The largest observational study (1,738 patients) reporting survival rates employing SEP-1 found they were not significantly improved with the measure (P=0.53) as did the next largest study (851 patients, adjusted survival odds ratio 1.36, 95% CI, 0.85 to 2.18). Two smaller observational studies (158 and 450 patients) reported SEP-1 improved unadjusted survival (P≤0.05) but were confounded either by baseline imbalances or by simultaneous introduction of a code sepsis protocol to improve compliance. Regardless, retrospective studies have well known biases related to non-randomized designs, uncontrolled data collection and failure to adjust for unrecognized influential variables. Such low-quality science should not be the basis for a national mandate compelling care for a rapidly lethal disease with a high mortality rate. Instead, SEP-1 should be based on high quality reproducible evidence from randomized controlled trials (RCT) demonstrating its benefit and thereby safety. Otherwise we risk not only doing harm but standardizing it.
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Affiliation(s)
- Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Willard N Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Xizhong Cui
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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