Assessing Variability in Hospital-Level Mortality Among U.S. Medicare Beneficiaries With Hospitalizations for Severe Sepsis and Septic Shock.
Assessing Variability in Hospital-Level Mortality Among U.S. Medicare Beneficiaries With Hospitalizations for Severe Sepsis and Septic Shock.
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DOI：
10.1097/ccm.0000000000003324
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发表时间：
2018-11
影响因子：
8.8
通讯作者：
Epstein L
中科院分区：
文献类型：
--
作者：
Hatfield KM;Dantes RB;Baggs J;Sapiano MRP;Fiore AE;Jernigan JA;Epstein L
评估2013-2014年期间美国医疗保险和医疗补助服务中心受益人中医院短期败血症死亡率的变异性。一项回顾性队列设计，来自2013年和2014年参加医疗保险和医疗补助服务中心住院前瞻性支付系统的3，068家急性护理医院的住院治疗。Medicare按服务付费受益人年龄大于或等于65岁，住院时编码为严重脓毒症或脓毒性休克。没有。个体水平死亡率评估为出院时或出院后7天内的死亡，并汇总以计算医院水平死亡率。我们使用逻辑分层线性模型计算根据患者特征调整的死亡率风险。我们使用中位比值比（莫尔）量化医院间的变异性，并计算每家医院的风险标准化死亡率（风险标准化死亡率）。总体粗死亡率为34.7%。我们发现不同医院的死亡率存在显著差异（p<0.001）。中间50%的医院具有相似的风险标准化死亡率（32.7-36.9%），而风险标准化死亡率最高的医院的中位死亡率为40.7%，而风险标准化死亡率最低的医院的中位死亡率为29.2%。中位比值比（1.29）低于患者合并症和疾病严重程度的几个指标的校正比值比，包括入院时存在器官功能障碍，未确定感染源和年龄。在一项针对医疗保险受益人入院时败血症的大型研究中，我们表明死亡率与潜在的合并症和入院时的疾病指标关系最为密切。然而，在调整患者特征后，死亡率也适度取决于脓毒症患者接受护理的地点，这表明在低绩效医院改善脓毒症结局的努力可能会影响脓毒症生存。
To assess the variability in short term sepsis mortality by hospital among Centers for Medicare and Medicaid Services beneficiaries in the United States during 2013–2014. A retrospective cohort design Hospitalizations from 3,068 acute care hospitals that participated in the Centers for Medicare and Medicaid Services inpatient prospective payment system in 2013 and 2014. Medicare fee-for-service beneficiaries greater than or equal to 65 years old who had an inpatient hospitalization coded with present at admission severe sepsis or septic shock. None. Individual level mortality was assessed as death at or within 7 days of hospital discharge and aggregated to calculate hospital-level mortality rates. We used a logistic hierarchal linear model to calculate mortality risk-adjusted for patient characteristics. We quantified variability among hospitals using the median odds ratio (MOR), and calculated risk-standardized mortality rates (risk-standardized mortality rates) for each hospital. The overall crude mortality rate was 34.7%. We found significant variability in mortality by hospital (p<0.001). The middle 50% of hospitals had similar risk-standardized mortality rates (32.7–36.9%), whereas the decile of hospitals with the highest risk-standardized mortality rates had a median mortality rate of 40.7%, compared to a median of 29.2% for hospitals in the decile with the lowest risk-standardized mortality rates. The median odds ratio (1.29) was lower than the adjusted odds ratios for several measures of patient comorbidities and severity of illness, including present at admission organ dysfunction, no identified source of infection, and age. In a large study of present at admission sepsis among Medicare beneficiaries, we showed that mortality was most strongly associated with underlying comorbidities and measures of illness on arrival. However, after adjusting for patient characteristics, mortality also modestly depended on where a patient with sepsis received care, suggesting that efforts to improve sepsis outcomes in lower performing hospitals could impact sepsis survival.