Purportedly higher sepsis mortality in safety-net hospitals reflects less a difference in acute care than opportunities to discharge to hospice.
By extending the measure of sepsis-related mortality from in-hospital events to occurrences within 30 days after the diagnosis, the purported higher mortality rate of sepsis treated in safety-net hospitals decreased to parity with non-safety-net hospitals, in a retrospective national cohort study.1
The investigators note the particular challenges of safety-net hospitals, which care for a disproportionately high share of low-income and underinsured patients, include fewer resources and narrower operating margins, as well as patient populations with decreased access to preventative care and more complex disease presentations.
In addition to these distinctions, Anica Law, MD, MS, The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA and colleagues found these hospitals have less opportunity than non-safety-net hospitals to discharge patients to hospice care.
"Differences in in-hospital mortality between safety-net hospitals and non-safety-net hospitals may partially be explained by greater use of hospice at non-safety-net hospitals, which shifts attribution of death from the index hospitalization to hospice," Law and colleagues report.
Although in-hospital events can be accessed in large databases such as the National Inpatient Sample, Law and colleagues used Medicare records to obtain both inpatient and post-hospitalization data.Their national cohort comprised patients 66 years and older admitted with sepsis to intensive care units from January 2011 to December 2019.
They did find higher in-hospital mortality in safety-net hospitals (odds ratio [OR] 1.09; 95% CI, 1.06-1.13), but that was not the case for 30-day mortality (OR 1.01; 0.99-1.04).In addition, admission to safety–net hospitals was associated with lower do-not-resuscitate rates (OR 0.86; 0.81-0.91); palliative care delivery rates (OR 0.66; 0.60-0.73); and hospice discharge (OR 0.82; 0.78-0.87).
The investigators note that the factors contributing to the lower utilization of hospice after discharge from safety-net hospitals remain to be elucidated, and characterize this as an important area for further study.
"It remains unclear to what degree our observed differences in palliative care receipt and hospice use are culturally and goal-concordant, vs reflective of inadequate implementation of inpatient palliative care—and/or outpatient advanced care planning—at safety-net hospitals," Law and colleagues observe.
In accompanying, invited commentary, Jeremy Kahn, MD, MS, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh PA, underscored the finding, "patients in safety-net hospitals were dying at the same rates as patients in other hospitals...".2
Kahn calls for several measures to remediate the status of sepsis as "among the most costly and deadly conditions for hospitalized patients", and that "only a minority of patients with sepsis receive guideline adherent care."
First, Kahn recommends that sepsis quality programs should now be based on time-delineated mortality rates such as 30-day mortality, rather than on in-hospital occurrences.Second, he calls on government regulatory agencies to add policies that broaden access to high-quality end-of-life care.He also recommends that the agencies provide performance improvement toolkits and promote multi-hospital collaborations that support under-resourced hospitals.
Law and colleagues also call for using the measure of 30-day mortality, not only as a more accurate measure of sepsis management and outcome than in-hospital, but because metrics chosen for public reporting should "fairly represent patient-centered outcomes," and "to avoid further penalizing safety-net hospitals."
