Update and review of racial disparities in sepsis

Racial Disparities in Failure to Rescue after Pediatric Heart Surgeries in the US

OBJECTIVE

To identify the trend in failure to rescue (FTR) and risk factors contributing to racial disparities in FTR after pediatric heart surgery using contemporary nationwide data.

STUDY DESIGN

We identified 85 267 congenital heart surgeries in patients <18 years of age from 2009 to 2019 using the Kid's Inpatient Database. The primary outcome was FTR. A mixed-effect logistic regression model with hospital random intercept was used to identify independent predictors of FTR.

RESULTS

Among 36 753 surgeries with postoperative complications, the FTR was 7.3%. The FTR decreased from 7.4% in 2009 to 6.3% in 2019 (P = .02). FTR was higher among Black than White children for all years. The FTR was higher among girls (7.2%) vs boys (6.6%), children aged <1 (9.6%) vs 12-17 years (2.4%), and those of Black (8.5%) vs White race (5.9%) (all P < .05). Black race was associated with a higher FTR odds (OR, 1.40; 95% CI, 1.20-1.65) after adjusting for demographics, medical complexity, nonelective admission, and hospital surgical volume. Higher hospital volume was associated with a lower odds of FTR for all racial groups, but fewer Black (19.7%) vs White (31%) children underwent surgery at high surgical volume hospitals (P < .001). If Black children were operated on in the same hospitals as White children, the racial differences in FTR would decrease by 47.3%.

CONCLUSIONS

Racial disparities exist in FTR after pediatric heart surgery in the US. The racial differences in the location of care may account for almost half the disparities in FTR.

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.

Racial Inequities in Sepsis Mortality Among Children in the United States

BACKGROUND

Racial inequities influence health outcomes in the United States, but their impact on sepsis outcomes among children is understudied. We aimed to evaluate for racial inequities in sepsis mortality using a nationally representative sample of pediatric hospitalizations.

METHODS

This population-based, retrospective cohort study used the 2006, 2009, 2012 and 2016 Kids' Inpatient Database. Eligible children 1 month to 17 years old were identified using sepsis-related International Classification of Diseases, Ninth Revision or International Classification of Diseases, Tenth Revision codes. We used modified Poisson regression to evaluate the association between patient race and in-hospital mortality, clustering by hospital and adjusting for age, sex and year. We used Wald tests to assess for modification of associations between race and mortality by sociodemographic factors, geographic region and insurance status.

RESULTS

Among 38,234 children with sepsis, 2555 (6.7%) died in-hospital. Compared with White children, mortality was higher among Hispanic (adjusted relative risk: 1.09; 95% confidence interval: 1.05-1.14), Asian/Pacific Islander (1.17, 1.08-1.27) and children from other racial minority groups (1.27, 1.19-1.35). Black children had similar mortality to White children overall (1.02, 0.96-1.07), but higher mortality in the South (7.3% vs. 6.4%; P < 0.0001). Hispanic children had higher mortality than White children in the Midwest (6.9% vs. 5.4%; P < 0.0001), while Asian/Pacific Islander children had higher mortality than all other racial categories in the Midwest (12.6%) and South (12.0%). Mortality was higher among uninsured children than among privately insured children (1.24, 1.17-1.31).

CONCLUSIONS

Risk of in-hospital mortality among children with sepsis in the United States differs by patient race, geographic region and insurance status.

Mitigating structural racism to reduce inequities in sepsis outcomes: a mixed methods, longitudinal intervention study

BACKGROUND

Sepsis affects 1.7 million patients in the US annually, is one of the leading causes of mortality, and is a major driver of US healthcare costs. African American/Black and LatinX populations experience higher rates of sepsis complications, deviations from standard care, and readmissions compared with Non-Hispanic White populations. Despite clear evidence of structural racism in sepsis care and outcomes, there are no prospective interventions to mitigate structural racism in sepsis care, nor are we aware of studies that report reductions in racial inequities in sepsis care as an outcome. Therefore, we will deliver and evaluate a coalition-based intervention to equip health systems and their surrounding communities to mitigate structural racism, driving measurable reductions in inequities in sepsis outcomes. This paper presents the theoretical foundation for the study, summarizes key elements of the intervention, and describes the methodology to evaluate the intervention.

METHODS

Our aims are to: (1) deliver a coalition-based leadership intervention in eight U.S. health systems and their surrounding communities; (2) evaluate the impact of the intervention on organizational culture using a longitudinal, convergent mixed methods approach, and (3) evaluate the impact of the intervention on reduction of racial inequities in three clinical outcomes: a) early identification (time to antibiotic), b) clinical management (in-hospital sepsis mortality) and c) standards-based follow up (same-hospital, all-cause sepsis readmissions) using interrupted time series analysis.

DISCUSSION

This study is aligned with calls to action by the NIH and the Sepsis Alliance to address inequities in sepsis care and outcomes. It is the first to intervene to mitigate effects of structural racism by developing the domains of organizational culture that are required for anti-racist action, with implications for inequities in complex health outcomes beyond sepsis.

Risk of stroke and myocardial infarction after influenza-like illness in New York State

Background

Influenza may be associated with increased stroke and myocardial infarction (MI) risk. We hypothesized that risk of stroke and MI after influenza-like illness (ILI) would be higher in patients in New York State. We additionally assessed whether this relationship differed across a series of sociodemographic factors.

Methods

A case-crossover analysis of the 2012–2014 New York Statewide Planning and Research Cooperative System (SPARCS) was used to estimate odds of ischemic stroke and MI after ILI. Each patient’s case window (the time period preceding event) was compared to their control windows (same dates from the previous 2 years) in conditional logistic regression models used to estimate odds ratios and 95% confidence intervals (OR, 95% CI). We varied the case windows from 15 to 365 days preceding event as compared to control windows constructed using the same dates from the previous 2 years. Analyses were stratified by sex, race, and urban-rural status based on residential zip code.

Results

A total of 33,742 patients were identified as having ischemic stroke and 53,094 had MI. ILI events in the 15 days prior were associated with a 39% increase in odds of ischemic stroke (95% CI 1.09–1.77), increasing to an almost 70% increase in odds when looking at ILI events over the last year (95% CI 1.56, 1.83). In contrast, the effect of ILI hospitalization on MI was strongest in the 15 days prior (OR = 1.24, 95% CI 1.06–1.44). The risk of ischemic stroke after ILI was higher among individuals living in rural areas in the 90 days prior to stroke and among men in the year prior to event. In contrast, the association between ILI and MI varied only across race with whites having significantly higher ILI associated MI.

Conclusion

This study highlights risk period differences for acute cardiovascular events after ILI, indicating possible differences in mechanism behind the risk of stroke after ILI compared to the risk of MI. High risk populations for stroke after ILI include men and people living in rural areas, while whites are at high risk for MI after ILI. Future studies are needed to identify ways to mitigate these risks.

The Association between Limited English Proficiency and Sepsis Mortality

BACKGROUND

Limited English proficiency (LEP) has been implicated in poor health outcomes. Sepsis is a frequently fatal syndrome that is commonly encountered in hospital medicine. The impact of LEP on sepsis mortality is not currently known.

OBJECTIVE

To determine the association between LEP and sepsis mortality.

DESIGN

Retrospective cohort study.

SETTING

800-bed, tertiary care, academic medical center.

PATIENTS

Electronic health record data were obtained for adults admitted to the hospital with sepsis between June 1, 2012 and December 31, 2016.

MEASUREMENTS

The primary predictor was LEP. Patients were defined as having LEP if their self-reported primary language was anything other than English and interpreter services were required during hospitalization. The primary outcome was inpatient mortality. Mortality was compared across races stratified by LEP using chi-squared tests of significance. Bivariable and multivariable logistic regressions were performed to investigate the association between mortality, race, and LEP, adjusting for baseline characteristics, comorbidities, and illness severity.

RESULTS

Among 8,974 patients with sepsis, we found that 1 in 5 had LEP, 62% of whom were Asian. LEP was highly associated with death across all races except those identifying as Black and Latino. LEP was associated with a 31% increased odds of mortality after adjusting for illness severity, comorbidities, and other baseline characteristics, including race (OR 1.31, 95% CI 1.06-1.63, P = .02).

CONCLUSIONS

In a single-center study of patients hospitalized with sepsis, LEP was associated with mortality across nearly all races. This is a novel finding that will require further exploration into the causal nature of this association.

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.

Racial and Socioeconomic Disparities After Carotid Procedures

Background:

Race has been associated with inferior outcomes after multiple procedures, but the association of socioeconomic status with procedures for cerebrovascular disease is not well established.

Materials and Methods:

Elective carotid artery stenting (CAS) and carotid endarterectomy (CEA) procedures were identified in the National Inpatient Sample, 2012 to 2014. Median household income was estimated from patient ZIP codes. Chi-square and multivariable logistic regression analysis evaluated outcomes, accounting for age, race, gender, comorbidities, procedure, income, insurance, and hospital characteristics.

Results:

We identified 234 825 carotid procedures (205 835 CEA and 28 990 CAS). Blacks and Hispanics were more likely to be among the lowest quartile income patients (LQIPs) compared to whites (53.5% and 38.7% vs 27.0%, respectively; P < .0002). Compared to highest income quartile patients, LQIP had lower rates of private insurance (16.3% vs 22.0%) and higher Medicaid use (4.7% vs 2.0%; all P < .0002). Lowest quartile income patients were more likely to receive CAS (odds ratio [OR] = 1.32, 95% confidence interval [CI]: 1.27-1.37), as were blacks and Hispanics (OR = 1.09, 95% CI: 1.02-1.26; OR = 1.31, 95% CI: 1.24-1.40, respectively). In multivariable regression, postoperative stroke was associated with LQIP, black race, and Hispanic ethnicity (OR = 1.16, 95% CI: 1.06-1.28; OR = 1.52, 95% CI: 1.33-1.73; OR = 1.43, 95% CI: 1.24-1.64, respectively). Subgroup analysis demonstrated that whites also had higher odds of stroke in the lower income quartile (OR = 1.2, 95% CI: 1.1-1.4). Mortality was associated with LQIP (OR = 1.6, 95% CI: 1.2-2.1), black race (OR = 1.8, 95% CI: 1.4-2.5), and CAS (OR = 1.3, 95% CI: 1.1-1.6). Length of stay in the lowest income quartile was longer than in patients with the highest income ( P < .0001).

Conclusions:

Race was associated with increased hospital mortality, postoperative stroke, and overall complications after carotid procedures. Lower income was significantly associated with increased stroke and mortality irrespective of race. Disparate utilization and outcomes for carotid procedures are multifactorial. Efforts to reduce disparities will need to focus on race and other socioeconomic factors.

Hospital readmissions after elective lower extremity vascular procedures

Background This study evaluated risk factors associated with 30-day readmission after open and endovascular lower extremity revascularization. Methods Patients admitted with peripheral artery disease and lower extremity procedures were selected from national electronic medical record data, Cerner Health Facts® (2008-2014). Thirty-day readmission was determined. Logistic regression models identified characteristics independently associated with readmission. Results There were 2781 open and 2611 endovascular procedures. Readmission was 10.9% (9.6% open versus 12.3% endovascular, p<.0001). Greater disease severity was associated with readmission for both groups. Readmission factors for lower extremity bypass: blood transfusions (OR 2.25, 95% CI 1.62-3.13), hyponatremia (OR 1.72, 95% CI 1.15-2.57), heart failure (OR 1.57, 95% CI 1.07-2.29), bronchodilators (OR 1.50, 95% CI 1.13-2.00), black race (OR 1.43, 95% CI 1.03-1.99), and hypokalemia (OR 0.43, 95% CI 0.20-0.95). Readmission factors for endovascular procedures: vasodilators (OR 1.63, 95% CI 1.22-2.16), end-stage renal disease (OR 1.43, 95% CI 1.02-2.01), fluid and electrolyte disorders (OR 1.44, 95% CI 1.00-2.06), hypertension (OR 1.33, 95% CI 0.99-1.76), coronary artery disease (OR 1.31, 95% CI 1.02-1.67), and diuretics (OR 1.30, 95% CI 1.01-1.70). Conclusions Readmission after lower extremity revascularization is associated with disease severity for both procedures. Factors associated with readmission following lower extremity bypass included heart failure, transfusions, hyponatremia, black race, and bronchodilator use. Risk factors for endovascular readmissions were often chronic conditions including coronary artery disease, kidney disease, hypertension, and hypertensive medications. Awareness of risk factors may help providers identify high-risk patients who may benefit from increased surveillance and programs to lower readmission.

Infection-related mortality in Hispanic and non-Hispanic children with cancer

BACKGROUND

Hispanic children with cancer experience poorer survival than their White counterparts. Infection is a known cause of cancer-related mortality; however, little is known about the risk of infection-related death among Hispanic children with cancer. We examine the association of Hispanic ethnicity with infection-related mortality and life-threatening events among children with cancer.

PROCEDURE

For a cohort of all pediatric cancer patients diagnosed from 1986 to 2012 and treated at a single tertiary care center, we obtained national death records to determine all-cause mortality and infection-related mortality, as well as intensive care unit (ICU) admissions as a surrogate for life-threatening events. Cox proportional hazard models assessed all-cause mortality and infection-related mortality using ethnicity as the main independent variable. ICU admission rates were modeled using a zero-inflated Poisson regression model. Models were adjusted for gender, diagnosis year, age, residential location, and diagnosis.

RESULTS

Of 6,198 patients, 741 (12%) were Hispanic. Mean follow-up was 11 years (SD = 8.04). There were 1,205 deaths, with 193 attributable to infection. Differences in all-cause mortality between Hispanic and non-Hispanic patients did not reach significance (hazard ratio [HR] = 1.14, 95% confidence interval [CI]: 0.96-1.36). However, Hispanic patients were 68% (HR = 1.68, 95% CI: 1.16-2.43) more likely to have an infection-related cause of death. Hispanic ethnicity was statistically associated with a higher rate of ICU admissions (rate ratio = 1.32, 95% CI: 1.12-1.56).

CONCLUSION

Hispanic pediatric cancer patients were more likely to have an infection-related death and higher rates of ICU admissions than non-Hispanic patients. Infection may be an overlooked contributor to poorer outcomes among Hispanic patients.

Alternative pathways for angiotensin II production as an important determinant of kidney damage in endotoxemia

Sepsis is an uncontrolled systemic inflammatory response against an infection and a major public health issue worldwide. This condition affects several organs, and, when caused by Gram-negative bacteria, kidneys are particularly damaged. Due to the importance of renin-angiotensin system (RAS) in regulating renal function, in the present study, we aimed to investigate the effects of endotoxemia over the renal RAS. Wistar rats were injected with Escherichia coli lipopolysaccharide (LPS) (4 mg/kg), mimicking the endotoxemia induced by Gram-negative bacteria. Three days after treatment, body mass, blood pressure, and plasma nitric oxide (NO) were reduced, indicating that endotoxemia triggered cardiovascular and metabolic consequences and that hypotension was maintained by NO-independent mechanisms. Regarding the effects in renal tissue, inducible NO synthase (iNOS) was diminished, but no changes in the renal level of NO were detected. RAS was also highly affected by endotoxemia, since renin, angiotensin-converting enzyme (ACE), and ACE2 activities were altered in renal tissue. Although these enzymes were modulated, only angiotensin (ANG) II was augmented in kidneys; ANG I and ANG 1-7 levels were not influenced by LPS. Cathepsin G and chymase activities were increased in the endotoxemia group, suggesting alternative pathways for ANG II formation. Taken together, our data suggest the activation of noncanonical pathways for ANG II production and the presence of renal vasoconstriction and tissue damage in our animal model. In summary, the systemic administration of LPS affects renal RAS, what may contribute for several deleterious effects of endotoxemia over kidneys.

Black-white racial disparities in sepsis: a prospective analysis of the REasons for Geographic And Racial Differences in Stroke (REGARDS) cohort

INTRODUCTION

Sepsis is a major public health problem. Prior studies using hospital-based data describe higher rates of sepsis among black than whites participants. We sought to characterize racial differences in incident sepsis in a large cohort of adult community-dwelling adults.

METHODS

We analyzed data on 29,690 participants from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. We determined the associations between race and first-infection and first-sepsis events, adjusted for participant sociodemographics, health behaviors, chronic medical conditions and biomarkers. We also determined the association between race and first-sepsis events limited to first-infection events. We contrasted participant characteristics and hospital course between black and white sepsis hospitalizations.

RESULTS

Among eligible REGARDS participants there were 12,216 (41.1%) black and 17,474 (58.9%) white participants. There were 2,600 first-infection events; the incidence of first-infection events was lower for black participants than for white participants (12.10 vs. 15.76 per 1,000 person-years; adjusted HR 0.65; 95% CI, 0.59-0.71). There were 1,526 first-sepsis events; the incidence of first-sepsis events was lower for black participants than for white participants (6.93 vs. 9.10 per 1,000 person-years, adjusted HR 0.64; 95% CI, 0.57-0.72). When limited to first-infection events, the odds of sepsis were similar between black and white participants (adjusted OR 1.01; 95% CI, 0.84-1.21). Among first-sepsis events, black participants were more likely to be diagnosed with severe sepsis (76.9% vs. 71.5%).

CONCLUSION

In the REGARDS cohort, black participants were less likely than white participants to experience infection and sepsis events. Further efforts should focus on elucidating the underlying reasons for these observations, which are in contrast to existing literature.

How equity is addressed in clinical practice guidelines: a content analysis

OBJECTIVES

Considering equity into guidelines presents methodological challenges. This study aims to qualitatively synthesise the methods for incorporating equity in clinical practice guidelines (CPGs).

SETTING

Content analysis of methodological publications.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Methodological publications were included if they provided checklists/frameworks on when, how and to what extent equity should be incorporated in CPGs.

DATA SOURCES

We electronically searched MEDLINE, retrieved references, and browsed guideline development organisation websites from inception to January 2013. After study selection by two authors, general characteristics and checklists items/framework components from included studies were extracted. Based on the questions or items from checklists/frameworks (unit of analysis), content analysis was conducted to identify themes and questions/items were grouped into these themes.

PRIMARY OUTCOMES

The primary outcomes were methodological themes and processes on how to address equity issues in guideline development.

RESULTS

8 studies with 10 publications were included from 3405 citations. In total, a list of 87 questions/items was generated from 17 checklists/frameworks. After content analysis, questions were grouped into eight themes ('scoping questions', 'searching relevant evidence', 'appraising evidence and recommendations', 'formulating recommendations', 'monitoring implementation', 'providing a flow chart to include equity in CPGs', and 'others: reporting of guidelines and comments from stakeholders' for CPG developers and 'assessing the quality of CPGs' for CPG users). Four included studies covered more than five of these themes. We also summarised the process of guideline development based on the themes mentioned above.

CONCLUSIONS

For disadvantaged population-specific CPGs, eight important methodological issues identified in this review should be considered when including equity in CPGs under the guidance of a scientific guideline development manual.

Frequency and predictors of complications in neurological surgery: national trends from 2006 to 2011

OBJECT

Surgical complications increase the cost of health care worldwide and directly contribute to patient morbidity and mortality. In an effort to mitigate morbidity and incentivize best practices, stakeholders such as health insurers and the US government are linking reimbursement to patient outcomes. In this study the authors analyzed a national database to determine basic metrics of how comorbidities specifically affect the subspecialty of neurosurgery.

METHODS

Data on 1,777,035 patients for the years 2006-2011 were acquired from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Neurosurgical cases were extracted by querying the data for which the surgical specialty was listed as "neurological surgery." Univariate statistics were calculated using the chi-square test, and 95% confidence intervals were determined for the resultant risk ratios. A multivariate model was constructed using significant variables from the univariate analysis (p < 0.05) with binary logistic regression.

RESULTS

Over 38,000 neurosurgical cases were analyzed, with complications occurring in 14.3%. Cranial cases were 2.6 times more likely to have complications than spine cases, and African Americans and Asians/Pacific Islanders were also at higher risk. The most frequent complications were bleeding requiring transfusion (4.5% of patients) and reoperation within 30 days of the initial operation (4.3% of patients), followed by failure to wean from mechanical ventilation postoperatively (2.5%). Significant predictors of complications included preoperative stroke, sepsis, blood transfusion, and chronic steroid use.

CONCLUSIONS

Understanding the landscape of neurosurgical complications will allow better targeting of the most costly and harmful complications of preventive measures. Data from the ACS NSQIP database provide a starting point for developing paradigms of improved care of neurosurgical patients.

Has the rate of in-hospital infections after total joint arthroplasty decreased?

BACKGROUND

Although infections are a major cause of morbidity and mortality after total joint arthroplasty (TJA), little is known about nationwide epidemiology and trends of infections after TJA.

QUESTIONS/PURPOSES

We therefore determined (1) trends of postoperative pneumonia, urinary tract infection (UTI), surgical site infection (SSI), sepsis, and severe sepsis after TJA; (2) risk factors of these infections; (3) effect of these infections on length of stay (LOS) and hospital charges; and (4) the infection-related mortality rate and its predictors.

METHODS

The International Classification of Diseases, 9th Revision codes were used to identify patients who underwent TJA and were diagnosed with aforementioned infections during hospitalization in the Nationwide Inpatient Sample database from 2002 to 2010. Multivariate analysis was performed to identify risk factors of these infections.

RESULTS

Rates of pneumonia, UTI, SSI, sepsis, and severe sepsis were 0.74%, 3.26%, 0.31%, 0.25%, and 0.15%, respectively. Number of comorbidities and type of TJA were independent predictors of infection. Mortality decreased during the study period (odds ratio, 0.87; 95% confidence interval, 0.86-0.89). The median LOS was 3 days without complications but increased in the presence of SSI (median, 7 days), sepsis (median, 12 days), and severe sepsis (median, 15 days). Occurrence of pneumonia, sepsis, and severe sepsis increased risk of mortality 5.2, 8.5, and 66.2 times, respectively.

CONCLUSIONS

Rates of UTI, pneumonia, and SSI but not sepsis and severe sepsis are apparently decreasing. The likelihood of infection is increasing with number of comorbidities and revision surgeries. Rate of sepsis-related mortality is also decreasing.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Contemporary trends in necrotizing soft-tissue infections in the United States

BACKGROUND

Necrotizing soft-tissue infections (NSTI) are rare, potentially fatal, operative emergencies. We studied a national cohort of patients to determine recent trends in incidence, treatment, and outcomes for NSTI.

METHODS

We queried the Nationwide Inpatient Sample (1998-2010) for patients with a primary diagnosis of NSTI. Temporal trends in patient characteristics, treatment (debridement, amputation, hyperbaric oxygen therapy [HBOT]), and outcomes were determined with Cochran-Armitage trend tests and linear regression. To account for trends in case mix (age, sex, race, insurance, Elixhauser index) or receipt of HBOT on outcomes, multivariable analyses were conducted to determine the independent effect of year of treatment on mortality, any major complication, and hospital length of stay (LOS) for NSTI.

RESULTS

We identified 56,527 weighted NSTI admissions, with an incidence ranging from approximately 3,800-5,800 cases annually. The number of cases peaked in 2004 and then decreased between 1998 and 2010 (P < .0001). The percentage of female patients decreased slightly over time (38.6-34.1%, P < .0001). Patients were increasingly in the 18- to 34-year-old (8.8-14.6%, P < .0001) and 50- to 64-year-old age groups (33.2-43.5, P < .0001), Hispanic (6.8-10.5%, P < .0001), obese (8.9-24.6%, P < .0001), and admitted with >3 comorbidities (14.5-39.7%, P < .0001). The percentage of patients requiring only one operative debridement increased somewhat (43.2-46.2%, P < .0001), whereas the use of HBOT was rare and decreasing (1.6-0.8%, P < .0001). The percentage of patients requiring operative wound closure decreased somewhat (23.5-20.8%, P < .0001). Although major complication rates increased (30.9-48.2%, P < .0001), hospital LOS remained stable (18-19 days) and mortality decreased (9.0-4.9%, P < .0001) on univariate analyses. On multivariable analyses each 1-year incremental increase in year was associated with a 5% increased odds of complication (odds ratio 1.05), 0.4 times decrease in hospital LOS (coefficient -0.41), and 11% decreased odds of mortality (odds ratio 0.89).

CONCLUSION

There were potentially important national trends in patient characteristics and treatment patterns for NSTI between 1998 and 2010. Importantly, though patient acuity worsened and complication rates increased, but LOS remained relatively stable and mortality decreased. Improvements in early diagnosis, wound care, and critical care delivery may be the cause.

Impact of infectious complications after elective surgery on hospital readmission and late deaths in the U.S. Medicare population

BACKGROUND AND PURPOSE

Whereas the negative impact of infectious complications (IC) during the index hospitalization after elective surgery is well established, the long-term ramifications of hospital-acquired post-operative infections are not well studied. This analysis evaluated the impact of a hospital-acquired IC after open abdominal vascular surgery on the readmission rate and the mortality rates 30 and 90 days after initial discharge.

METHODS

Data from all hospitals in the United States that performed elective open abdominal vascular operations in the Medicare population from 2005 to 2007 were extracted from the national Medicare Provider Analysis and Review database. The cohort consisted of all patients undergoing open abdominal vascular operations, including aortic, iliac, and visceral procedures. The ICs evaluated were pneumonia, urinary tract infection (UTI), postoperative sepsis (sepsis), surgical site infection (SSI), and Clostridium difficile infection (CDI). Patients were categorized as either developing an IC during their initial hospitalization (Index+INF) or not developing an IC (No INF). The rates of 30-day readmission, 30-day IC, and 30- and 90-day mortality after the initial discharge were evaluated longitudinally and compared in patients with and without an IC.

RESULTS

A total of 29,549 open abdominal vascular procedures were identified, and 4,016 patients (13.6%) developed an IC during their index hospitalization: Pneumonia (5.1% of the total), UTI (2.7%), sepsis (1.6%), SSI (1.4%), and CDI (0.6%). Additionally, 1.13% of patients developed pneumonia, UTI, SSI, or CDI complicated by sepsis. The hospital mortality rate during the initial hospitalization was 13.7% (Index+INF) versus 4.0% (No INF) (p<0.0002). Infectious processes (pneumonia, UTI, SSI, and CDI) complicated by sepsis had an in-hospital mortality rate significantly higher than patients having an IC alone (50.9% vs. 13.7%; p<0.002). The mortality rate 30 and 90 days after the initial discharge was significantly higher for Index+INF than for No INF (4.4% vs. 1.2% and 8.6% vs. 2.6%, respectively; p<0.0002). The highest 30-day mortality rates after discharge were found after CDI+sepsis (30%), pneumonia+sepsis (12.6%), and postoperative sepsis alone (8.6%). The same rank was found for the 90-day mortality rate: 30%, 22.5%, and 13.8%. Overall, readmission was more likely for Index+INF than for No INF (33.7% vs. 21.5%; p<0.0002). Rates of 30-day readmission after an index IC ranged from 32% to 50%.

CONCLUSION

For Medicare beneficiaries undergoing elective open abdominal vascular procedures, the development of any IC significantly increased not only the in-hospital mortality rate but also the mortality rates 30 and 90 days after discharge from the hospital. Index ICs also were associated with a higher 30-day readmission rate. Hospital-acquired infections have a profound late effect on outcomes after discharge. Future programs targeting high-risk patients may improve long-term survival and minimize readmissions.