Characteristics of Patients Hospitalized in Rural and Urban ICUs From 2010 to 2019.

OBJECTIVES: Rural hospitals are threatened by workforce shortages and financial strain. To optimize regional critical care delivery, it is essential to understand what types of patients receive intensive care in rural and urban hospitals. DESIGN: A retrospective cohort study. SETTING AND PATIENTS: All fee-for-service Medicare beneficiaries in the United States who were 65 years old or older hospitalized in an ICU between 2010 and 2019 were included. Rural and urban hospitals were classified according to the 2013 National Center For Health Statistics Urban-Rural Classification Scheme for Counties. Patient comorbidities, primary diagnoses, organ dysfunction, and procedures were measured using the International Classification of Diseases, 9th and 10th revisions diagnosis and procedure codes. Standardized differences were used to compare rural and urban patient admission characteristics. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 12,224,097 ICU admissions between 2010 and 2019, and 1,488,347 admissions (12.2%) were to rural hospitals. The most common diagnoses in rural hospitals were cardiac (30.3%), infectious (24.6%), and respiratory (10.9%). Patients in rural ICUs had similar organ dysfunction compared with urban hospitals (mean organ failures in rural ICUs 0.5, sd 0.8; mean organ failures in urban ICUs 0.6, sd 0.9, absolute standardized mean difference 0.096). Organ dysfunction among rural ICU admissions increased over time (0.4 mean organ failures in 2010 to 0.7 in 2019, p < 0.001). CONCLUSIONS: Rural hospitals care for an increasingly complex critically ill patient population with similar organ dysfunction as urban hospitals. There is a pressing need to develop policies at federal and regional healthcare system levels to support the continued provision of high-quality ICU care within rural hospitals.

Ethnic Disparities in Deep Sedation of Patients with Acute Respiratory Distress Syndrome in the United States: Secondary Analysis of a Multicenter Randomized Trial.

Rationale: Patients identified as Hispanic, the largest minority group in the United States, are more likely to die from acute respiratory distress syndrome (ARDS) than non-Hispanic patients. Mechanisms to explain this disparity remain unidentified. However, Hispanic patients may be at risk of overexposure to deep sedation because of language differences between patients and clinicians, and deep sedation is associated with higher ARDS mortality.Objective: We examined associations between Hispanic ethnicity and exposure to deep sedation among patients with ARDS.Methods: A secondary analysis was conducted of patients enrolled in the control arm of a randomized trial of neuromuscular blockade for ARDS across 48 U.S. hospitals. Exposure to deep sedation was measured over the first 5 days that a patient was alive and received mechanical ventilation. Multilevel mixed-effects models were used to evaluate associations between Hispanic ethnicity and exposure to deep sedation, controlling for patient characteristics.Results: Patients identified as Hispanic had approximately five times the odds of deep sedation (odds ratio, 4.98; 95% confidence interval, 2.02-12.28; P < 0.0001) on a given day, compared with non-Hispanic White patients. Hospitals with at least one enrolled Hispanic patient kept all enrolled patients deeply sedated longer than hospitals without any enrolled Hispanic patients (85.8% of ventilator-days vs. 65.5%; P < 0.001).Conclusions: Hispanic patients are at higher risk of exposure to deep sedation than non-Hispanic White patients. There is an urgent need to understand and address disparities in sedation delivery.

External Validation of a Widely Implemented Proprietary Sepsis Prediction Model in Hospitalized Patients.

Importance: The Epic Sepsis Model (ESM), a proprietary sepsis prediction model, is implemented at hundreds of US hospitals. The ESM's ability to identify patients with sepsis has not been adequately evaluated despite widespread use. Objective: To externally validate the ESM in the prediction of sepsis and evaluate its potential clinical value compared with usual care. Design, Setting, and Participants: This retrospective cohort study was conducted among 27 697 patients aged 18 years or older admitted to Michigan Medicine, the academic health system of the University of Michigan, Ann Arbor, with 38 455 hospitalizations between December 6, 2018, and October 20, 2019. Exposure: The ESM score, calculated every 15 minutes. Main Outcomes and Measures: Sepsis, as defined by a composite of (1) the Centers for Disease Control and Prevention surveillance criteria and (2) International Statistical Classification of Diseases and Related Health Problems, Tenth Revision diagnostic codes accompanied by 2 systemic inflammatory response syndrome criteria and 1 organ dysfunction criterion within 6 hours of one another. Model discrimination was assessed using the area under the receiver operating characteristic curve at the hospitalization level and with prediction horizons of 4, 8, 12, and 24 hours. Model calibration was evaluated with calibration plots. The potential clinical benefit associated with the ESM was assessed by evaluating the added benefit of the ESM score compared with contemporary clinical practice (based on timely administration of antibiotics). Alert fatigue was evaluated by comparing the clinical value of different alerting strategies. Results: We identified 27 697 patients who had 38 455 hospitalizations (21 904 women [57%]; median age, 56 years [interquartile range, 35-69 years]) meeting inclusion criteria, of whom sepsis occurred in 2552 (7%). The ESM had a hospitalization-level area under the receiver operating characteristic curve of 0.63 (95% CI, 0.62-0.64). The ESM identified 183 of 2552 patients with sepsis (7%) who did not receive timely administration of antibiotics, highlighting the low sensitivity of the ESM in comparison with contemporary clinical practice. The ESM also did not identify 1709 patients with sepsis (67%) despite generating alerts for an ESM score of 6 or higher for 6971 of all 38 455 hospitalized patients (18%), thus creating a large burden of alert fatigue. Conclusions and Relevance: This external validation cohort study suggests that the ESM has poor discrimination and calibration in predicting the onset of sepsis. The widespread adoption of the ESM despite its poor performance raises fundamental concerns about sepsis management on a national level.