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. 2023 Nov 1;51(11):1479-1491.
doi: 10.1097/CCM.0000000000005973. Epub 2023 Jun 20.

The Relationship Between Hospital Capability and Mortality in Sepsis: Development of a Sepsis-Related Hospital Capability Index

Uchenna R Ofoma  1 , Elena Deych  2 , Nicholas M Mohr  3 , Allan Walkey  4   5 , Marin Kollef  6 , Fei Wan  7 , Karen E Joynt Maddox  2
Affiliations

The Relationship Between Hospital Capability and Mortality in Sepsis: Development of a Sepsis-Related Hospital Capability Index

Uchenna R Ofoma et al. Crit Care Med. .

Abstract

Objectives: Regionalized sepsis care could improve sepsis outcomes by facilitating the interhospital transfer of patients to higher-capability hospitals. There are no measures of sepsis capability to guide the identification of such hospitals, although hospital case volume of sepsis has been used as a proxy. We evaluated the performance of a novel hospital sepsis-related capability (SRC) index as compared with sepsis case volume.

Design: Principal component analysis (PCA) and retrospective cohort study.

Setting: A total of 182 New York (derivation) and 274 Florida and Massachusetts (validation) nonfederal hospitals, 2018.

Patients: A total of 89,069 and 139,977 adult patients (≥ 18 yr) with sepsis were directly admitted into the derivation and validation cohort hospitals, respectively.

Interventions: None.

Measurements and main results: We derived SRC scores by PCA of six hospital resource use characteristics (bed capacity, annual volumes of sepsis, major diagnostic procedures, renal replacement therapy, mechanical ventilation, and major therapeutic procedures) and classified hospitals into capability score tertiles: high, intermediate, and low. High-capability hospitals were mostly urban teaching hospitals. Compared with sepsis volume, the SRC score explained more variation in hospital-level sepsis mortality in the derivation (unadjusted coefficient of determination [ R2 ]: 0.25 vs 0.12, p < 0.001 for both) and validation (0.18 vs 0.05, p < 0.001 for both) cohorts; and demonstrated stronger correlation with outward transfer rates for sepsis in the derivation (Spearman coefficient [ r ]: 0.60 vs 0.50) and validation (0.51 vs 0.45) cohorts. Compared with low-capability hospitals, patients with sepsis directly admitted into high-capability hospitals had a greater number of acute organ dysfunctions, a higher proportion of surgical hospitalizations, and higher adjusted mortality (odds ratio [OR], 1.55; 95% CI, 1.25-1.92). In stratified analysis, worse mortality associated with higher hospital capability was only evident among patients with three or more organ dysfunctions (OR, 1.88 [1.50-2.34]).

Conclusions: The SRC score has face validity for capability-based groupings of hospitals. Sepsis care may already be de facto regionalized at high-capability hospitals. Low-capability hospitals may have become more adept at treating less complicated sepsis.

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Conflict of interest statement

Dr. Ofoma’s institution received funding from the National Institute on Aging. Drs. Ofoma and Maddox received support for article research from the National Institutes of Health (NIH). Dr. Mohr’s institution received funding from Endpoint Health. Dr. Maddox’s institution received funding from the NIH; she received funding from Humana and Centene. Dr. Kollef is supported by the Barnes-Jewish Hospital Foundation. Dr. Joynt Maddox receives research support from the National Heart, Lung, and Blood Institute (R01HL143421 and R01HL164561), the National Institute of Nursing Research (U01NR020555), the National Institute on Aging (R01AG060935, R01AG063759, and R21AG065526), and from Humana. She also serves on the Health Policy Advisory Council for the Centene Corporation (St. Louis, MO). The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1:
Figure 1:
Conceptual map of Sepsis-Related Hospital Characteristics Conceptual map depicts three broad themes which then devolve into terminal branches that represent hospital characteristics and capabilities that relate to sepsis care delivery, potentially explain sepsis volume-outcome effects, or necessitate interhospital transfer. The directed arrows link a few related characteristics across broad themes. For example, ‘ICU Capability’ is linked by a directed arrow to ‘ICU Case Volume’ and ‘ICU Capacity’ as Clinical Expertise (or Practice Makes Perfect) constructs. Likewise, diagnostic, and therapeutic capabilities are linked to ‘Access to specialists’ as an organizational factor, e.g. hospitals that perform large numbers of diagnostic imaging procedures or surgical procedures are those that are more likely to have round-the-clock access to radiologists (for interpretation) or surgeons. Literature search and review performed by UO (first author), SB, and EL (see acknowledgement section). Conceptual mapping performed by UO. ICU: Intensive Care Unit; ED: Emergency Department; QI: Quality Improvement.
Figure 2:
Figure 2:
In-hospital Mortality Odds for Sepsis Patients. Odds Ratios and 95% Confidence Intervals showing differences between high and low capability hospitals for (A) the derivation cohort, and (B) the validation cohort.
Figure 3:
Figure 3:
Adjusted Hospital Mortality, Hospital Capability Category, and Number of Organ Dysfunctions
See this image and copyright information in PMC

Comment in

References

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