In the Journals

Sepsis care differs for minority patients

The New York State Sepsis Initiative has improved sepsis care overall in New York, but implementation of the protocol appears to vary by race and ethnicity, according to recently published data.

During the first 27 months of the study, results demonstrated no significant differences in unadjusted rates of 3-hour protocol completion among white (60.8%), black (59.7%), Hispanic (62.6%) and Asian (58.8%) patients with sepsis who were admitted to the ED.

During the 2.25-year study period, though, increases in 3-hour protocol completion increased more among white patients (14 percentage points), as compared with black patients (5.3 percentage points). However, the magnitude of improvement among Hispanic (6.7 percentage points) and Asian patients (8.4 percentage points) did not differ significantly from that among white patients at the 95% CI level, the researchers noted.

Similar results were noted regarding rates of 6-hour protocol completion, which improved by 14.7 percentage points among white patients vs. 6.8 percentage points among black patients.

Additionally, in a sensitivity analysis that included all patients irrespective of where they received a sepsis diagnosis, improvements in 3-hour protocol completion remained higher among white patients (13.7 percentage points) throughout the study than among black patients (5.7 percentage points; P = .037). The findings were similar in other sensitivity analyses that randomly selected one observation among patients with multiple sepsis episodes and adjustment for a hospital’s Medicaid or self-pay status.

The magnitude of change in hospital mortality was not significantly different among racial/ethnic groups throughout the study.

“If our study findings extend beyond New York, it raises concerns about the possibility of these quality improvement initiatives for sepsis exacerbating racial disparities in care,” Amal N. Trivedi, MD, professor in the department of health services, policy and practice at Brown University School of Public Health and a research investigator at the Providence Veterans Affairs Medical Center, said in a press release.

Hospital differences

In addition to differences among racial and ethnic groups, the researchers found that hospitals treating a higher proportion of black patients vs. white patients demonstrated less improvement in completion of the 3-hour protocol, as compared with hospitals treating a higher proportion of white patients.

Specifically, whereas protocol completion improved by 9 percentage points in hospitals whose patient population with sepsis was 10% black, it improved by only 2.2 percentage points in hospitals whose patient population with sepsis was 50% black (difference, 6.8 percentage points; P = .027). A mixed-effects regression model also showed that hospitals with greater proportions of black patients among patients with sepsis demonstrated smaller magnitudes of improvement in 3-hour protocol completion for both black and white patients. However, the level of improvement among black and white patients with sepsis was comparable within individual hospitals.

“Minority-serving institutions have been shown to operate with fewer resources, less quality improvement infrastructure, more ED overcrowding and unfavorable nurse-to-patient ratios. These factors may explain why performance gains lagged in these facilities,” Trivedi and colleagues wrote.

Important implications

The New York State Sepsis Initiative, also known as “Rory’s Regulations,” was launched in 2013 by the New York State Department of Health and the New York State Executive Office. The initiative requires all 185 of New York’s nonfederal hospitals to implement 3- and 6-hour evidence-based protocols for the early detection and treatment of patients with sepsis and report on in-hospital mortality and their initiation and implementation of the protocols.

The 3-hour protocol, which applied to patients with sepsis or septic shock, included the measurement of blood lactate, collection of blood cultures before administering antibiotics and the administration of broad-spectrum antibiotics. The 6-hour protocol, which only applied to patients with septic shock, included the administration of 30 mL/kg IV fluids to patients with hypotension or at least 4 mmol/L of a serum lactate, initiation of vasopressors if patients had refractory hypotension after administration of IV fluids and remeasurement of blood lactate. Failing 3-hour protocol completion in a patient meant that the 6-hour protocol completion failed as well.

The researchers only included sepsis cases presenting to the ED and excluded sepsis cases that developed after hospital admission.

“Our work highlights the need for state and federal policymakers to anticipate and monitor the effects that quality improvement projects, such as the New York State Sepsis Initiative have on racial and ethnic minority groups,” Keith Corl, MD, assistant professor of medicine in the division of pulmonary, critical care and sleep medicine at Warren Alpert Medical School, Brown University, said in the release. “Racial and ethnic minority groups can get left behind. Knowing this, it is our job to better design and monitor these programs to ensure racial and ethnic minority patients realize the same benefits as white patients.” – by Melissa Foster

Disclosures: Healio Pulmonology could not confirm the authors’ relevant financial disclosures at the time of publication.

The New York State Sepsis Initiative has improved sepsis care overall in New York, but implementation of the protocol appears to vary by race and ethnicity, according to recently published data.

During the first 27 months of the study, results demonstrated no significant differences in unadjusted rates of 3-hour protocol completion among white (60.8%), black (59.7%), Hispanic (62.6%) and Asian (58.8%) patients with sepsis who were admitted to the ED.

During the 2.25-year study period, though, increases in 3-hour protocol completion increased more among white patients (14 percentage points), as compared with black patients (5.3 percentage points). However, the magnitude of improvement among Hispanic (6.7 percentage points) and Asian patients (8.4 percentage points) did not differ significantly from that among white patients at the 95% CI level, the researchers noted.

Similar results were noted regarding rates of 6-hour protocol completion, which improved by 14.7 percentage points among white patients vs. 6.8 percentage points among black patients.

Additionally, in a sensitivity analysis that included all patients irrespective of where they received a sepsis diagnosis, improvements in 3-hour protocol completion remained higher among white patients (13.7 percentage points) throughout the study than among black patients (5.7 percentage points; P = .037). The findings were similar in other sensitivity analyses that randomly selected one observation among patients with multiple sepsis episodes and adjustment for a hospital’s Medicaid or self-pay status.

The magnitude of change in hospital mortality was not significantly different among racial/ethnic groups throughout the study.

“If our study findings extend beyond New York, it raises concerns about the possibility of these quality improvement initiatives for sepsis exacerbating racial disparities in care,” Amal N. Trivedi, MD, professor in the department of health services, policy and practice at Brown University School of Public Health and a research investigator at the Providence Veterans Affairs Medical Center, said in a press release.

Hospital differences

In addition to differences among racial and ethnic groups, the researchers found that hospitals treating a higher proportion of black patients vs. white patients demonstrated less improvement in completion of the 3-hour protocol, as compared with hospitals treating a higher proportion of white patients.

Specifically, whereas protocol completion improved by 9 percentage points in hospitals whose patient population with sepsis was 10% black, it improved by only 2.2 percentage points in hospitals whose patient population with sepsis was 50% black (difference, 6.8 percentage points; P = .027). A mixed-effects regression model also showed that hospitals with greater proportions of black patients among patients with sepsis demonstrated smaller magnitudes of improvement in 3-hour protocol completion for both black and white patients. However, the level of improvement among black and white patients with sepsis was comparable within individual hospitals.

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“Minority-serving institutions have been shown to operate with fewer resources, less quality improvement infrastructure, more ED overcrowding and unfavorable nurse-to-patient ratios. These factors may explain why performance gains lagged in these facilities,” Trivedi and colleagues wrote.

Important implications

The New York State Sepsis Initiative, also known as “Rory’s Regulations,” was launched in 2013 by the New York State Department of Health and the New York State Executive Office. The initiative requires all 185 of New York’s nonfederal hospitals to implement 3- and 6-hour evidence-based protocols for the early detection and treatment of patients with sepsis and report on in-hospital mortality and their initiation and implementation of the protocols.

The 3-hour protocol, which applied to patients with sepsis or septic shock, included the measurement of blood lactate, collection of blood cultures before administering antibiotics and the administration of broad-spectrum antibiotics. The 6-hour protocol, which only applied to patients with septic shock, included the administration of 30 mL/kg IV fluids to patients with hypotension or at least 4 mmol/L of a serum lactate, initiation of vasopressors if patients had refractory hypotension after administration of IV fluids and remeasurement of blood lactate. Failing 3-hour protocol completion in a patient meant that the 6-hour protocol completion failed as well.

The researchers only included sepsis cases presenting to the ED and excluded sepsis cases that developed after hospital admission.

“Our work highlights the need for state and federal policymakers to anticipate and monitor the effects that quality improvement projects, such as the New York State Sepsis Initiative have on racial and ethnic minority groups,” Keith Corl, MD, assistant professor of medicine in the division of pulmonary, critical care and sleep medicine at Warren Alpert Medical School, Brown University, said in the release. “Racial and ethnic minority groups can get left behind. Knowing this, it is our job to better design and monitor these programs to ensure racial and ethnic minority patients realize the same benefits as white patients.” – by Melissa Foster

Disclosures: Healio Pulmonology could not confirm the authors’ relevant financial disclosures at the time of publication.