Higher rates of all-cause mortality and resource utilization during episodes-of-care for diabetic foot ulceration.

AIMS: Our primary objective was to determine whether all-cause rates of mortality and resource utilization were higher during periods of diabetic foot ulceration. In support of this objective, a secondary objective was to develop and validate an episode-of-care model for diabetic foot ulceration. METHODS: We evaluated data from the Medicare Limited Data Set between 2013 and 2019. We defined episodes-of-care by clustering diabetic foot ulcer related claims such that the longest time interval between consecutive claims in any cluster did not exceed a duration which was adjusted to match two aspects of foot ulcer episodes that are well-established in the literature: healing rate at 12 weeks, and reulceration rate following healing. We compared rates of outcomes during periods of ulceration to rates immediately following healing to estimate incidence ratios. RESULTS: The episode-of-care model had a minimum mean relative error of 4.2% in the two validation criteria using a clustering duration of seven weeks. Compared to periods after healing, all-cause inpatient admissions were 2.8 times more likely during foot ulcer episodes and death was 1.5 times more likely. CONCLUSIONS: A newly-validated episode-of-care model for diabetic foot ulcers suggests an underappreciated association between foot ulcer episodes and all-cause resource utilization and mortality.

Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database.

PURPOSE: The optimal strategy of fluid resuscitation in the early hours of severe sepsis and septic shock is controversial, with both an aggressive and conservative approach being recommended. METHODS: We used the 2013 Premier Hospital Discharge database to analyse the administration of fluids on the first ICU day, in 23,513 patients with severe sepsis and septic shock, who were admitted to an ICU from the emergency department. Day 1 fluid was grouped into categories 1 L wide, starting with 1-1.99 L up to ≥9 L, to examine the effect of day 1 fluids on patient mortality. We built binary response models for hospital mortality and the propensity for receiving more than 5 L of fluids on day 1, using patient age and acute conditions present on admission. Patients were grouped by the requirement for mechanical ventilation and the presence or absence of shock. We assessed trends in the difference between actual and expected mortality, in the low fluid range (1-5 L day 1 fluids) and the high fluid range (5 to ≥9 L day 1 fluids) categories, using weighted linear regression controlling for the effects of sample size and variation within the day 1 fluid category. RESULTS: Day 1 fluid administration averaged 4.4 L being lowest in the group with no mechanical ventilation and no shock (3.6 L) and highest (5.4 L) in the group receiving mechanical ventilation and in shock. The administration of day 1 fluids was remarkably consistent on the basis of hospital size, teaching status, rural/urban location, and region of the country. The hospital mortality in the entire cohort was 25.8%, with a mean ICU and hospital length of stay of 5.1 and 9.1 days, respectively. In the entire cohort, low volume resuscitation (1-4.99 L) was associated with a small but significant reduction in mortality, of -0.7% per litre (95% CI -1.0%, -0.4%; p = 0.02). However, in patients receiving high volume resuscitation (5 to ≥9 L), the mortality increased by 2.3% (95% CI 2.0, 2.5%; p = 0.0003) for each additional litre above 5 L. Total hospital cost increased by $999 for each litre of fluid above 5 L (adjusted R 2 = 92.7%, p = 0.005). CONCLUSION: The mean amount of fluid administered to patients with severe sepsis and septic shock in the USA during the first ICU day is less than that recommended by the Surviving Sepsis Campaign guidelines. The administration of more than 5 L of fluid during the first ICU day is associated with a significantly increased risk of death and significantly higher hospital costs.

Relationship Between ICU Length of Stay and Long-Term Mortality for Elderly ICU Survivors.

OBJECTIVES: To evaluate the association between length of ICU stay and 1-year mortality for elderly patients who survived to hospital discharge in the United States. DESIGN: Retrospective cohort study of a random sample of Medicare beneficiaries who survived to hospital discharge, with 1- and 3-year follow-up, stratified by the number of days of intensive care and with additional stratification based on receipt of mechanical ventilation. INTERVENTIONS: None. PATIENTS: The cohort included 34,696 Medicare beneficiaries older than 65 years who received intensive care and survived to hospital discharge in 2005. MEASUREMENTS AND MAIN RESULTS: Among 34,696 patients who survived to hospital discharge, the mean ICU length of stay was 3.4 days (± 4.5 d). Patients (88.9%) were in the ICU for 1-6 days, representing 58.6% of ICU bed-days. Patients (1.3%) were in the ICU for 21 or more days, but these patients used 11.6% of bed-days. The percentage of mechanically ventilated patients increased with increasing length of stay (6.3% for 1-6 d in the ICU and 71.3% for ≥ 21 d). One-year mortality was 26.6%, ranging from 19.4% for patients in the ICU for 1 day, up to 57.8% for patients in the ICU for 21 or more days. For each day beyond 7 days in the ICU, there was an increased odds of death by 1 year of 1.04 (95% CI, 1.03-1.05) irrespective of the need for mechanical ventilation. CONCLUSIONS: Increasing ICU length of stay is associated with higher 1-year mortality for both mechanically ventilated and non-mechanically ventilated patients. No specific cutoff was associated with a clear plateau or sharp increase in long-term risk.

Incidence, outcome, and attributable resource use associated with pulmonary and cardiac complications after major small and large bowel procedures.

BACKGROUND: Complications increase the costs of care of surgical patients. We studied the Premier database to determine the incidence and direct medical costs related to pulmonary complications and compared it to cardiac complications in the same cohort. METHODS: We identified 45,969 discharges in patients undergoing major bowel procedures. Postoperative pulmonary and cardiac complications were identified through the use of International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes and through the use of daily resource use data. Pulmonary complications included pneumonia, tracheobronchitis, pleural effusion, pulmonary failure, and mechanical ventilation more than 48 h after surgery. Cardiac complications included ventricular fibrillation, acute myocardial infarction, cardiogenic shock, cardiopulmonary arrest, transient ischemia, premature ventricular contraction, and acute congestive heart failure. RESULTS: Postoperative pulmonary complications (PPC) or postoperative cardiac complications (PCC) were present in 22% of cases; PPC alone was most common (19.0%), followed by PPC and PCC (1.8%) and PCC alone (1.2%). The incremental cost of PPC is large ($25,498). In comparison, PCC alone only added $7,307 to the total cost. CONCLUSIONS: The current study demonstrates that postoperative pulmonary complications represent a significant source of morbidity and incremental cost after major small intestinal and colon surgery and have greater incidence and costs than cardiac complications alone. Therefore, strategies to reduce the incidence of these complications should be targeted as means of improving health and bending the cost curve in health care.

Intensive care unit readmission during childhood after preterm birth with respiratory failure.

OBJECTIVE: To determine the incidence and risk factors for readmission to the intensive care unit (ICU) among preterm infants who required mechanical ventilation at birth. STUDY DESIGN: We studied preterm newborns (birth weight 500-1250 g) who required mechanical ventilation at birth and were enrolled in a multicenter trial of inhaled nitric oxide therapy. Patients were assessed up to 4.5 years of age via annual in-person evaluations and structured telephone interviews. Univariate and multivariable analyses of baseline and birth hospitalization predictors of ICU readmission were performed. RESULTS: Of 512 subjects providing follow-up data, 58% were readmitted to the hospital (51% of these had multiple readmissions, averaging 3.9 readmissions per subject), 19% were readmitted to an ICU, and 12% required additional mechanical ventilation support. In univariate analyses, ICU readmission was more common among male subjects (OR 2.01; 95% CI 1.27-3.18), infants with grade 3-4 intracranial hemorrhage (OR 2.13; 95% CI 1.23-3.69), increasing duration of birth hospitalization (OR 1.01 per day; 95% CI 1.00-1.02), and prolonged oxygen therapy (OR 1.01 per day; 95% CI 1.00-1.01). In the first year after birth hospitalization, children readmitted to an ICU incurred greater health care costs (median $69,700 vs $30,200 for subjects admitted to the ward and $9600 for subjects never admitted). CONCLUSIONS: Small preterm infants who were mechanically ventilated at birth have substantial risk for readmission to an ICU and late mechanical ventilation, require extensive health care resources, and incur high treatment costs.

Epidemiology of ophthalmologic disease associated with erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis in hospitalized children in the United States.

The objective of the current study was to characterize the epidemiology and resource use of U.S. children hospitalized with ophthalmologic disease secondary to erythema multiforme (EM), Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis (TEN). We studied children ages 5 to 19 years hospitalized in 2005 in 11 states, encompassing 38% of the U.S. pediatric population. Using International Classification of Diseases, Ninth Revision, Clinical Modification codes, we identified admissions of children with EM, SJS, or TEN and the presence of concurrent ophthalmologic disease, analyzed patient and hospitalization characteristics, and generated age- and sex-adjusted national estimates. We identified 460 children admitted with EM, SJS, or TEN, corresponding to 1,229 U.S. hospitalizations in 2005. Of the children with EM, SJS, or TEN, 60 (13.0%) had ophthalmologic disease, primarily (90.0%) disorders of the conjunctiva. Children with the highest proportions of ophthalmologic disease included those with mycoplasma pneumonia (26.7%), herpes simplex virus (15.6%), upper respiratory infection (13.9%), and lower respiratory infection (13.7%). Individuals with EM, SJS, or TEN and ophthalmologic disease were more likely than those without ophthalmologic disease to receive intensive care unit care (28.3% vs 17.0%, p = 0.03) and to be admitted to a children's hospital (63.3% vs 48.8%, p = 0.03). Ophthalmologic disease was also associated with a significantly longer median length of stay (6.0 days, interquartile range [IQR] 3-9 days vs 3.0 days, IQR 2-6 days, p < 0.001) and median hospital cost ($7,868, IQR $3,539-$17,440 vs $2,969, IQR $1,603-$8,656, p < 0.001). In children with EM, SJS, or TEN, ophthalmologic disease was most common in those with concurrent Mycoplasma pneumoniae and herpes simplex virus infections. Ophthalmologic disease was associated with considerably higher inpatient resource use in this population. Children with EM, SJS, or TEN should be screened and treated early for ophthalmologic disease to prevent morbidity and minimize long-term sequellae.

Trends in the epidemiology of pediatric severe sepsis*.

OBJECTIVES: In the past decade, guidelines have been developed for the early detection and management of severe sepsis in children and neonates. However, severe sepsis continues to be a significant U.S. healthcare problem, accounting for over 720,000 annual hospitalizations. Large-scale epidemiologic studies of severe sepsis continue to be limited, particularly in children. We present data from 1995, 2000, and 2005 in seven U.S. states, examining how case mix, outcome, and resource use for pediatric severe sepsis have changed over time. DESIGN: We constructed a database including all acute-care hospitalizations for children in the seven states. For each case, we extracted data on demographic characteristics; the principal diagnosis, up to six secondary diagnoses, and six procedures as classified by the International Classification of Diseases, 9th Revision, Clinical Modification codes; and in-hospital fatality. We identified patients with severe sepsis using International Classification of Diseases, 9th Revision, Clinical Modification codes for both infection and acute organ failure. SETTING: Retrospective observational cohort dataset from seven U.S. states from 1995, 2000, and 2005. SUBJECTS: Children in the U.S. 0-19 years old. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In 2005, 17,542 children were hospitalized with severe sepsis in the seven states; there was an 81% increase in pediatric severe sepsis cases since 1995 and a 45% increase since 2000. This corresponded to an increase in prevalence from 0.56 to 0.89 cases per 1,000 pediatric population. Between 1995 and 2005, the prevalence of severe sepsis in newborns more than doubled, from 4.5 to 9.7 cases per 1,000 births. The most common infecting organisms in all 3 years were Staphylococcus species. From 1995 to 2005, the case-fatality rate decreased from 10.3% to 8.9%. Case fatality associated with Staphylococcus aureus increased, whereas fatality associated with Streptococcus pneumoniae decreased by 75%. Nationally, there were 75,255 pediatric hospitalizations in 2005 involving severe sepsis, with an associated cost of $4.8 billion. CONCLUSIONS: Between 1995 and 2005, the prevalence of severe sepsis in U.S. children steadily rose, due to a significant increase in the prevalence of severe sepsis in newborns.

Hospitalizations of children with neurologic disorders in the United States.

OBJECTIVES: Although neurologic disorders are among the most serious acute pediatric illnesses, epidemiologic data are scarce. We sought to determine the scope and outcomes of children with these disorders in the United States. DESIGN: Retrospective cohort study. SETTING: All nonfederal hospitals in 11 states encompassing 38% of the U.S. pediatric population. PATIENTS: Children 29 days to 19 years old hospitalized in 2005. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Using International Classification of Diseases, 9th Revision, Clinical Modification, codes, we identified admissions with neurologic diagnoses, analyzed patient and hospitalization characteristics, and generated age- and sex-adjusted national estimates. Of 960,020 admissions in the 11 states, 10.7% (103,140) included a neurologic diagnosis, which yields a national estimate of 273,900 admissions of children with neurologic diagnoses. The most common were seizures (53.9%) and traumatic brain injury (17.3%). Children with neurologic diagnoses had nearly three times greater ICU use than other hospitalized children (30.6% vs 10.6%, p < 0.001). Neurologic diagnoses were associated with nearly half of deaths (46.2%, n = 1,790). Among ICU patients, children with neurologic diagnoses had more than three times the mortality of other patients (4.8% vs1.5%, p < 0.001). Children with neurologic diagnoses had a significantly longer median hospital length of stay than other children (3 d [1, 5] vs 2 d [2, 4], p < 0.001) and greater median hospital costs ($4,630 [$2,380, $9,730] vs $2,840 [$1,520, $5,550], p < 0.001). CONCLUSIONS: Children with neurologic diagnoses account for a disproportionate amount of ICU stays and deaths compared with children hospitalized for other reasons.

Risk factors for dementia after critical illness in elderly Medicare beneficiaries.

INTRODUCTION: Hospitalization increases the risk of a subsequent diagnosis of dementia. We aimed to identify diagnoses or events during a hospitalization requiring critical care that are associated with a subsequent dementia diagnosis in the elderly. METHODS: A cohort study of a random 5% sample of Medicare beneficiaries who received intensive care in 2005 and survived to hospital discharge, with three years of follow-up (through 2008) was conducted using Medicare claims files. We defined dementia using the International Classification of Diseases, 9th edition, clinical modification (ICD-9-CM) codes and excluded patients with any prior diagnosis of dementia or cognitive impairment in the year prior to admission. We used an extended Cox model to examine the association between diagnoses and events associated with the critical illness and a subsequent diagnosis of dementia, adjusting for known risk factors for dementia. RESULTS: Over the three years of follow-up, dementia was newly diagnosed in 4,519 (17.8%) of 25,368 patients who received intensive care and survived to hospital discharge. After accounting for known risk factors, having an infection (adjusted hazard ratio (AHR) = 1.25; 95% CI, 1.17 to 1.35), or a diagnosis of severe sepsis (AHR = 1.40; 95% CI, 1.28 to 1.53), acute neurologic dysfunction (AHR = 2.06; 95% CI, 1.72 to 2.46), and acute dialysis (AHR = 1.70; 95% CI, 1.30 to 2.23) were all independently associated with a subsequent diagnosis of dementia. No other measured ICU factors, such as need for mechanical ventilation, were independently associated. CONCLUSIONS: Among ICU events, infection or severe sepsis, neurologic dysfunction, and acute dialysis were independently associated with a subsequent diagnosis of dementia. Patient prognostication, as well as future research into post-ICU cognitive decline, should focus on these higher-risk subgroups.

A comparison of critical care research funding and the financial burden of critical illness in the United States.

OBJECTIVES: To estimate federal dollars spent on critical care research, the cost of providing critical care, and to determine whether the percentage of federal research dollars spent on critical care research is commensurate with the financial burden of critical care. DESIGN AND DATA SOURCES: The National Institutes of Health Computer Retrieval of Information on Scientific Projects database was queried to identify funded grants whose title or abstract contained a key word potentially related to critical care. Each grant identified was analyzed by two reviewers (three if the analysis was discordant) to subjectively determine whether it was definitely, possibly, or definitely not related to critical care. Hospital and total costs of critical care were estimated from the Premier Database, state discharge data, and Medicare data. To estimate healthcare expenditures associated with caring for critically ill patients, total costs were calculated as the combination of hospitalization costs that included critical illness as well as additional costs in the year after hospital discharge. MEASUREMENTS AND MAIN RESULTS: Of 19,257 grants funded by the National Institutes of Health, 332 (1.7%) were definitely related to critical care and a maximum of 1212 (6.3%) grants were possibly related to critical care. Between 17.4% and 39.0% of total hospital costs were spent on critical care, and a total of between $121 and $263 billion was estimated to be spent on patients who required intensive care. This represents 5.2% to 11.2%, respectively, of total U.S. healthcare spending. CONCLUSIONS: The proportion of research dollars spent on critical care is lower than the percentage of healthcare expenditures related to critical illness.

Comparison of medical admissions to intensive care units in the United States and United Kingdom.

RATIONALE: The United States has seven times as many intensive care unit (ICU) beds per capita as the United Kingdom; the effect on care of critically ill patients is unknown. OBJECTIVES: To compare medical ICU admissions in the United States and United Kingdom. METHODS: Retrospective (2002-2004) cohort study of 172,785 ICU admissions (137 United States ICUs, Project IMPACT database; 160 United Kingdom ICUs, Case Mix Program) with patients followed until initial hospital discharge. MEASUREMENT AND MAIN RESULTS: United Kingdom (vs. United States) admissions were less likely to be admitted directly from the emergency room (ER) (33.4% vs. 58%); had longer hospital stays before ICU admission (mean days 2.6 ± 8.2 vs. 1 ± 3.6); and fewer were greater than or equal to 85 years (3.2% vs. 7.8%). United Kingdom patients were more frequently mechanically ventilated within 24 hours after ICU admission (68% vs. 27.4%); were sicker (mean Acute Physiology Score 16.7 ± 7.6 vs. 10.6 ± 6.8); and had higher primary hospital mortality (38% vs. 15.9%; adjusted odds ratio, 1.73; 95% confidence interval, 1.50-1.99). There was no mortality difference for mechanically ventilated patients admitted from the ER (adjusted odds ratio, 1.09; 95% confidence interval, 0.89-1.33). Comparisons of hospital mortality were confounded by differences in case mix; hospital length of stay (United Kingdom median 10 d [interquartile range {IQR}, 3-24] vs. United States 6 d [IQR, 3-11]; and discharge practices (more United States patients were discharged to skilled care facilities [29% of survivors vs. 6% in the United Kingdom]). CONCLUSIONS: Lower United Kingdom ICU bed availability is associated with fewer direct admissions from the ER, longer hospital stays before ICU admission, and higher severity of illness. Interpretation of between-country hospital outcomes is confounded by differences in case mix, processes of care, and discharge practices.

Trends in admissions for pediatric status asthmaticus in New Jersey over a 15-year period.

OBJECTIVE: Status asthmaticus accounts for a large portion of the morbidity and mortality associated with asthma, but we know little about its epidemiology. We describe here the hospitalization characteristics of children with status asthmaticus, how they changed over time, and how they differed between hospitals with and without PICUs. PATIENTS AND METHODS: We used administrative data from New Jersey that included all hospitalizations in the state from 1992, 1995, and 1999-2006. We identified children with status asthmaticus by using International Classification of Diseases, Ninth Revision, diagnosis codes that indicate status asthmaticus and the use of mechanical ventilation by using procedure codes. We designated hospitals with a PICU as "PICU hospitals" and those without as "adult hospitals." RESULTS: We identified 28 309 admissions of children with status asthmaticus (22.8% of all asthma hospitalizations). From 1992 to 2006, the rate of hospital admissions decreased by half (from 1.98 in 1000 to 0.93 in 1000 children), and there was a 70% decrease in the number of children admitted to adult hospitals. The rate of ICU care in PICU hospitals more than tripled. However, the rate of mechanical ventilation remained low, and the number of deaths was small and unchanged (n=14 total). Hospital costs climbed from $6.6 million to $9.5 million. CONCLUSIONS: Although fewer children are being admitted with status asthmaticus, the proportion of patients managed in PICUs is climbing. There has been no substantial change in rates of mechanical ventilation or death. Additional research is needed to better understand how patients and physicians decide on the appropriate site for hospital care and how that choice affects outcome.

Antipsychotic adherence, switching, and health care service utilization among Medicaid recipients with schizophrenia.

OBJECTIVE: To evaluate health care resource utilization in patients with schizophrenia who continued newly prescribed antipsychotic medications, compared with those switching to different treatments. METHODS: Adults with schizophrenia in the California Medicaid (MediCal) database who initiated treatment with index medications in 1998-2001, were classified as having: 1) abandoned antipsychotic medications; 2) switched to another medication; or 3) continued with the index antipsychotic, for up to 6 months after the index date. RESULTS: Of 2300 patients meeting eligibility criteria, 1382 (60.1%) continued index medications, 480 (20.9%) switched, and 438 (19.0%) abandoned antipsychotic treatment. Utilization in several resource categories occurred significantly more frequently among patients whose regimens were switched (vs those continuing index medications). These included using psychiatric (24.2% vs 14.5%; P < 0.001) or nonpsychiatric (31.5% vs 24.3%; P < 0.05) emergency services; being admitted to a hospital (10.6% vs 7.4%; P < 0.05); making nonpsychiatric outpatient hospital visits (43.3% vs 36.4%; P < 0.05) or nonpsychiatric physician visits (62.7% vs 56.4%; P < 0.05); and using other outpatient psychiatric (53.3% vs 40.7%; P < 0.001) or nonpsychiatric (82.7% vs 74.6%; P < 0.001) services. CONCLUSIONS: Switching antipsychotic medications is associated with significantly increased health care resource utilization (vs continuing treatment).

The epidemiology of mechanical ventilation use in the United States.

OBJECTIVE: Few contemporary population-based data exist about the incidence, patient characteristics, and outcomes of mechanical ventilation in acute care hospitals. We sought to describe the epidemiology of mechanical ventilation use in the United States. DESIGN: Retrospective cohort study using year 2005 hospital discharge records from six states. National projections were generated from age-, race-, and sex-specific rates in the cohort. SETTING: Nonfederal acute care hospitals. PATIENTS: All discharges that included invasive mechanical ventilation identified using International Classification of Diseases, 9th Revision, Clinical Modification procedure codes (96.7x). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 6,469,674 hospitalizations in the six states, 180,326 (2.8%) received invasive mechanical ventilation. There was a wide age distribution with 52.2% of patients <65 yrs of age. A total of 44.6% had at least one major comorbid condition. The most common comorbidities included diabetes (13.2%) and pulmonary disease (13.2%). Inhospital mortality was 34.5%, and only 30.8% of patients were discharged home from the hospital. Almost all patients received care in urban (73.5%) or suburban (23.6%) hospitals vs. rural hospitals (2.9%). Patients in urban hospitals experienced a higher number of organ dysfunctions, more dialysis and tracheostomies, and higher mortality compared with patients in rural hospitals. Projecting to national estimates, there were 790,257 hospitalizations involving mechanical ventilation in 2005, representing 2.7 episodes of mechanical ventilation per 1000 population. Estimated national costs were $27 billion representing 12% of all hospital costs. Incidence, mortality, and cumulative population costs rose significantly with age. CONCLUSIONS: Mechanical ventilation use is common and accounts for a disproportionate amount of resource use, particularly in urban hospitals and in elderly patients. Mortality for mechanically ventilated patients is high. Quality improvement and cost-reduction strategies targeted at these patients are warranted.

Infection rate and acute organ dysfunction risk as explanations for racial differences in severe sepsis.

CONTEXT: Severe sepsis, defined as infection complicated by acute organ dysfunction, occurs more frequently and leads to more deaths in black than in white individuals. The optimal approach to minimize these disparities is unclear. OBJECTIVE: To determine the extent to which higher severe sepsis rates in black than in white patients are due to higher infection rates or to a higher risk of acute organ dysfunction. DESIGN, SETTING, AND PARTICIPANTS: Analysis of infection-related hospitalizations from the 2005 hospital discharge data of 7 US states and infection-related emergency department visits from the 2003-2007 National Hospital Ambulatory Care Survey. MAIN OUTCOME MEASURE: Age- and sex-standardized severe sepsis and infection hospitalization rates and the risk of acute organ dysfunction. RESULTS: Of 8,661,227 non-childbirth-related discharges, 2,261,857 were associated with an infection, and of these, 381,787 (16.8%) had severe sepsis. Black patients had a 67% higher age- and sex-standardized severe sepsis rate than did white patients (9.4; 95% confidence interval [CI], 9.3-9.5 vs 5.6; 95% CI, 5.6-5.6 per 1000 population; P < .001) and 80% higher standardized mortality (1.8, 95% CI, 1.8-1.9 vs 1.0, 95% CI, 1.0-1.1 per 1000 population; P < .001). The higher severe sepsis rate was explained by both a higher infection rate in black patients (47.3; 95% CI, 47.1-47.4 vs 34.0; 95% CI, 33.9-34.0 per 1000 population; incidence rate ratio, 1.39; P < .001) and a higher risk of developing acute organ dysfunction (age- and sex-adjusted odds ratio [OR], 1.29; 95% CI, 1.27-1.30; P < .001). Differences in infection presented broadly across different sites and etiology of infection and for community- and hospital-acquired infections and occurred despite a lower likelihood of being admitted for infection from the emergency department (adjusted OR, 0.70; 95% CI, 0.64-0.76; P < .001). The higher risk of organ dysfunction persisted but was attenuated after adjusting for age, sex, comorbid conditions, poverty, and hospital effect (OR, 1.14; 95% CI, 1.13-1.16; P < .001). Racial disparities in infection and severe sepsis incidence and mortality rates were largest among younger adults (eg, the proportion of invasive pneumococcal disease occurring in adults < 65 years was 73.9% among black patients vs 44.5% among white patients, P < .001). CONCLUSION: Racial differences in severe sepsis are explained by both a higher infection rate and a higher risk of acute organ dysfunction in black than in white individuals.

Three-year outcomes for Medicare beneficiaries who survive intensive care.

CONTEXT: Although hospital mortality has decreased over time in the United States for patients who receive intensive care, little is known about subsequent outcomes for those discharged alive. OBJECTIVE: To assess 3-year outcomes for Medicare beneficiaries who survive intensive care. DESIGN, SETTING, AND PATIENTS: A matched, retrospective cohort study was conducted using a 5% sample of Medicare beneficiaries older than 65 years. A random half of all patients were selected who received intensive care and survived to hospital discharge in 2003 with 3-year follow-up through 2006. From the other half of the sample, 2 matched control groups were generated: hospitalized patients who survived to discharge (hospital controls) and the general population (general controls), individually matched on age, sex, race, and whether they had surgery (for hospital controls). MAIN OUTCOME MEASURE: Three-year mortality after hospital discharge. RESULTS: There were 35,308 intensive care unit (ICU) patients who survived to hospital discharge. The ICU survivors had a higher 3-year mortality (39.5%; n = 13,950) than hospital controls (34.5%; n = 12,173) (adjusted hazard ratio [AHR], 1.07 [95% confidence interval {CI}, 1.04-1.10]; P < .001) and general controls (14.9%; n = 5266) (AHR, 2.39 [95% CI, 2.31-2.48]; P < .001). The ICU survivors who did not receive mechanical ventilation had minimal increased risk compared with hospital controls (3-year mortality, 38.3% [n = 12,716] vs 34.6% [n=11,470], respectively; AHR, 1.04 [95% CI, 1.02-1.07]). Those receiving mechanical ventilation had substantially increased mortality (57.6% [1234 ICU survivors] vs 32.8% [703 hospital controls]; AHR, 1.56 [95% CI, 1.40-1.73]), with risk concentrated in the 6 months after the quarter of hospital discharge (6-month mortality, 30.1% (n = 645) for those receiving mechanical ventilation vs 9.6% (n = 206) for hospital controls; AHR, 2.26 [95% CI, 1.90-2.69]). Discharge to a skilled care facility for ICU survivors (33.0%; n = 11,634) and hospital controls (26.4%; n = 9328) also was associated with high 6-month mortality (24.1% for ICU survivors and hospital controls discharged to a skilled care facility vs 7.5% for ICU survivors and hospital controls discharged home; AHR, 2.62 [95% CI, 2.50-2.74]; P < .001 for ICU survivors and hospital controls combined). CONCLUSIONS: There is a large US population of elderly individuals who survived the ICU stay to hospital discharge but who have a high mortality over the subsequent years in excess of that seen in comparable controls. The risk is concentrated early after hospital discharge among those who require mechanical ventilation.

The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis.

OBJECTIVE: The Surviving Sepsis Campaign (SSC or "the Campaign") developed guidelines for management of severe sepsis and septic shock. A performance improvement initiative targeted changing clinical behavior (process improvement) via bundles based on key SSC guideline recommendations on process improvement and patient outcomes. DESIGN AND SETTING: A multifaceted intervention to facilitate compliance with selected guideline recommendations in the ICU, ED, and wards of individual hospitals and regional hospital networks was implemented voluntarily in the US, Europe, and South America. Elements of the guidelines were "bundled" into two sets of targets to be completed within 6 h and within 24 h. An analysis was conducted on data submitted from January 2005 through March 2008. MAIN RESULTS: Data from 15,022 subjects at 165 sites were analyzed to determine the compliance with bundle targets and association with hospital mortality. Compliance with the entire resuscitation bundle increased linearly from 10.9% in the first site quarter to 31.3% by the end of 2 years (P<0.0001). Compliance with the entire management bundle started at 18.4% in the first quarter and increased to 36.1% by the end of 2 years (P = 0.008). Compliance with all bundle elements increased significantly, except for inspiratory plateau pressure, which was high at baseline. Unadjusted hospital mortality decreased from 37 to 30.8% over 2 years (P = 0.001). The adjusted odds ratio for mortality improved the longer a site was in the Campaign, resulting in an adjusted absolute drop of 0.8% per quarter and 5.4% over 2 years (95% CI, 2.5-8.4%). CONCLUSIONS: The Campaign was associated with sustained, continuous quality improvement in sepsis care. Although not necessarily cause and effect, a reduction in reported hospital mortality rates was associated with participation. The implications of this study may serve as an impetus for similar improvement efforts.

The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis.

OBJECTIVE: The Surviving Sepsis Campaign (SSC or "the Campaign") developed guidelines for management of severe sepsis and septic shock. A performance improvement initiative targeted changing clinical behavior (process improvement) via bundles based on key SSC guideline recommendations. DESIGN AND SETTING: A multifaceted intervention to facilitate compliance with selected guideline recommendations in the intensive care unit, emergency department, and wards of individual hospitals and regional hospital networks was implemented voluntarily in the United States, Europe, and South America. Elements of the guidelines were "bundled" into two sets of targets to be completed within 6 hrs and within 24 hrs. An analysis was conducted on data submitted from January 2005 through March 2008. SUBJECTS: A total of 15,022 subjects. MEASUREMENTS AND MAIN RESULTS: Data from 15,022 subjects at 165 sites were analyzed to determine the compliance with bundle targets and association with hospital mortality. Compliance with the entire resuscitation bundle increased linearly from 10.9% in the first site quarter to 31.3% by the end of 2 yrs (p < .0001). Compliance with the entire management bundle started at 18.4% in the first quarter and increased to 36.1% by the end of 2 yrs (p = .008). Compliance with all bundle elements increased significantly, except for inspiratory plateau pressure, which was high at baseline. Unadjusted hospital mortality decreased from 37% to 30.8% over 2 yrs (p = .001). The adjusted odds ratio for mortality improved the longer a site was in the Campaign, resulting in an adjusted absolute drop of 0.8% per quarter and 5.4% over 2 yrs (95% confidence interval, 2.5-8.4). CONCLUSIONS: The Campaign was associated with sustained, continuous quality improvement in sepsis care. Although not necessarily cause and effect, a reduction in reported hospital mortality rates was associated with participation. The implications of this study may serve as an impetus for similar improvement efforts.

Clinical and economic effects of iNO in premature newborns with respiratory failure at 1 year.

BACKGROUND: The long-term consequences of inhaled nitric oxide (iNO) use in premature newborns with respiratory failure are unknown. We therefore studied the clinical and economic outcomes to 1 year of corrected age after a randomized controlled trial of prophylactic iNO. METHODS: Premature newborns (gestational age

Use of intensive care services during terminal hospitalizations in England and the United States.

RATIONALE: Despite broad concern regarding the provision and cost of health care at the end of life, country-specific patterns of care have rarely been compared. OBJECTIVES: To assess the use of hospital and intensive care services during terminal hospitalizations in England and the United States, two populations with similar socioeconomic backgrounds and life expectancies. METHODS: Retrospective cohort study over a 1-year period (2001) using national (England) Hospital Episode Statistics, and regional (seven U.S. states) administrative discharge data as well as English and U.S. census data. We measured hospitalization rates and death rates during hospitalization with and without intensive care. MEASUREMENTS AND MAIN RESULTS: Age-adjusted acute hospitalization rates were 110.5 per 1,000 population in England versus 105.3 in the seven U.S. states, with the same mortality rate (0.9 per 1,000 population) in both countries. Of all deaths, 50.3% occurred in hospital in England and 36.6% in the United States, yet only 5.1% of all deaths in England involved intensive care, versus 17.2% in the United States, representing 10.1% of hospital deaths in England versus 47.1% in the United States. Greater intensive care use in the U.S. was most notable with older age; among decedents 85+ years, intensive care was used for 31.5% of medical deaths and 61.0% of surgical deaths in the United States versus 1.9 and 8.5% of deaths in England. CONCLUSIONS: Despite similar overall hospitalization rates in England and the United States, there were marked differences in terminal hospitalizations, with far greater use of intensive care services in the United States, especially among medical patients and the elderly population.