Health and Care Needs of Young Adults Exiting Jail.

Reentry is a difficult juncture for young adults (ages 18-24 years), who simultaneously face challenges of emerging adulthood. Although their health-related needs may be substantial, little is reported on young adults' reentry health care and social service needs. Furthermore, empirical measurements of factors affecting their engagement in reentry services after jail are lacking. We sought to describe health needs and predictors of linkages to reentry services for the 2,525 young adult participants in the Whole Person Care-LA Reentry program (WPC Reentry). Descriptive statistics were calculated and chi-square tests, t tests, and logistic regression were performed to identify factors associated with linkage to WPC Reentry postrelease compared with only engaging with WPC Reentry prerelease. Most participants (72.6%) were male, 80.2% were Hispanic or Black, and 60.9% had been unhoused. Mental health (57.2%) and substance use disorders (45.8%) were common, physical health was overall good (mean Charlson Comorbidity Index score 0.53), and social needs, especially housing, were high (40.7%). Older age (i.e., closer to 25 years) and history of being unhoused were associated with higher postrelease engagement in WPC Reentry (age: odds ratio [OR] = 1.06, p = .01; history of being unhoused: OR = 1.18, p = .05). Attentiveness to younger clients and to addressing housing needs may be key for successful reentry care linkages.

Factors inhibiting institutional responses to domestic violence in Kyrgyzstan.

The study identifies factors that limit effective institutional responses to domestic violence (DV) in Kyrgyzstan, in the context of recent legislative actions aimed at reducing DV through improvements in law enforcement, judicial processes, and provision of social services. The study uses qualitative, grounded theory methods to analyze interviews and focus groups with 83 professionals working in these sectors. Two major themes emerge from the analysis: (1) barriers to effective institutional responses from internal challenges and constraints, and (2) social resources and challenges identified as important to provide a better collective response. The study highlights the need for capacity development within institutions and broader social learning to overcome existing barriers and better align outcomes with the intentions of recent legislation. Standardized training, awareness-raising, enhanced roles for educators and religious leaders, better coordinated social service provision, rehabilitation for victims and perpetrators, and family-centered school-based interventions are identified as targets for improving responsiveness.

Adolescent Cannabis Misuse Scale: Longitudinal Associations with Substance Use, Mental Health, and Social Determinants of Health in Early Adulthood.

BACKGROUND: Some patterns of cannabis use may presage risk for long-term negative effects. We examined associations between a novel adolescent cannabis misuse scale and early-adult life course outcomes. METHODS: We performed a secondary data analysis of a cohort of Los Angeles, CA high school students from grade 9 through age 21. Participants reported baseline individual demographic and family characteristics at grade 9, adolescent cannabis misuse (8-items) and alcohol misuse (12-items) at grade 10, and outcomes at age 21. We used multivariable regression to model the associations of cannabis misuse scale score with problem substance use (defined as any of: 30-day illegal drug use, 30-day use of another's prescription to get high, hazardous drinking) and several secondary outcomes (behavioral, mental health, academic, social determinants of health), adjusting for covariates. Parallel analyses were conducted for alcohol misuse. RESULTS: The 1,148 participants (86% retention) were 47% male, 90% Latinx, 87% US born, and 40% native English speakers. Approximately 11.4% and 15.9% of participants reported at least one item on the cannabis and alcohol misuse scales, respectively. At age 21, approximately 6.7% of participants reported problem substance use, which was associated with both Cannabis and Alcohol Misuse Scales (OR 1.31, 95%CI[1.16, 1.49] and OR 1.33, 95%CI[1.18, 1.49], respectively). Both scales were similarly associated with outcomes in all four categories. CONCLUSIONS: The Adolescent Cannabis Misuse Scale is a promising tool for identifying early patterns of substance use that predict future negative outcomes and enabling early intervention at a critical period in youth development.

Perceptions of School Climate Shape Adolescent Health Behavior: A Longitudinal Multischool Study.

BACKGROUND: Adolescent behaviors and academic outcomes are thought to be shaped by school climate. We sought to identify longitudinal associations between school climate measures and downstream health and academic outcomes. METHODS: Data from a longitudinal survey of public high school students in Los Angeles were analyzed. Eleventh-grade health and academic outcomes (dependent variables, eg, substance use, delinquency, risky sex, bullying, standardized exams, college matriculation), were modeled as a function of 10th-grade school climate measures (independent variables: institutional environment, student-teacher relationships, disciplinary style), controlling for baseline outcome measures and student/parental covariates. RESULTS: The 1114 student respondents (87.8% retention), were 46% male, 90% Latinx, 87% born in the United States, and 40% native English speakers. Greater school order and teacher respect for students were associated with lower odds of multiple high risk behaviors including 30-day alcohol use (odds ratio [OR] 0.81; 95% confidence interval [CI] [0.72, 0.92] and OR 0.73; [0.62, 0.85]) and 30-day cannabis use (OR 0.74; [0.59, 0.91] and OR 0.76; [0.63, 0.92]). Neglectful disciplinary style was associated with multiple poor health and academic outcomes while permissive disciplinary style was associated with favorable academic outcomes. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: School health practitioners may prospectively leverage school environment, teacher-student relationships, and disciplinary style to promote health and learning. CONCLUSIONS: Our findings identify specific modifiable aspects of the school environment with critical implications for life course health.

Outcome of the AVID College Preparatory Program on Adolescent Health: A Randomized Trial.

BACKGROUND AND OBJECTIVES: Academic tracking is a widespread practice, separating students by prior academic performance. Clustering lower performing students together may unintentionally reinforce risky peer social networks, school disengagement, and risky behaviors. If so, mixing lower performing with high performing youth ("untracking") may be protective, leading to better adolescent health. METHODS: Advancement via Individual Determination (AVID), a nationally-disseminated college preparatory program, supports placing middle-performing students in rigorous college-preparatory classes alongside high-performing peers. We conducted the first randomized, controlled trial of AVID in the United States, randomizing 270 students within 5 large public high schools to receive AVID (AVID group) versus usual school programming (control group). Participants completed surveys at the transition to high school (end of eighth grade/ beginning of ninth grade) and the end of ninth grade. Intent-to-treat analyses tested whether AVID resulted in healthier social networks (primary outcome), health behaviors, and psychosocial wellbeing. RESULTS: At follow-up, AVID students had lower odds of using any substance (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.48-0.89) and associating with a substance-using peer (OR 0.74, 95% CI 0.45-0.98), and higher odds of associating with a peer engaged in school (OR 1.73, 95% CI 1.11-2.70). Male AVID students had lower stress and higher self-efficacy, grit, and school engagement than control students (P < .05 for all). No adverse health effects among high-performing peers were observed. CONCLUSIONS: AVID positively impacts social networks, health behaviors, and psychosocial outcomes suggesting academic untracking may have substantial beneficial spillover effects on adolescent health.

Association of Attending a High-Performing High School With Substance Use Disorder Rate and Health Outcomes in Young Adults.

Importance: Interventions directly targeting social factors, such as education, may have the potential to greatly improve health. Objective: To examine the association of attending a high-performing public charter high school with rates of substance use disorder and physical and mental health. Design, Setting, and Participants: This cohort study used the random school admissions lottery system of high-performing public charter high schools in low-income neighborhoods of Los Angeles, California, to examine the health outcomes of students who applied to at least 1 of 5 of these high schools. Participants attended 147 different high schools and were randomly selected from those who won the admissions lottery (intervention group) and those who were placed on a waiting list (control group). Participants were surveyed at the end of grade 8 through transition into grade 9 and then from grade 10 through 3 years after high school completion (at age 21 years). Surveys were conducted from March 2013 through November 2021. Intervention: Attendance at a high-performing public charter high school. Main Outcomes and Measures: Self-reported alcohol use disorder and cannabis misuse, delinquent behaviors, physical and mental health, and body mass index. Results: Of the 1270 participants at baseline (mean [SD] age, 14.2 [0.47] years; 668 female individuals [52.6%]). The control group included 576 individuals (45.4%), and 694 individuals (54.6%) were in the intervention group. Both groups were similar in almost all characteristics at baseline, and the median (IQR) follow-up was 6.4 (6.0-6.7) years. Participants attending a high-performing public charter high school had a 53.33% lower rate of hazardous or dependent alcohol use disorder compared with those in the control group (5.43% vs 11.64%; difference, -6.21% [95% CI, -11.87% to -0.55%]; P = .03). Among male participants, the intervention group had a 42.05% lower rate of self-reported fair or poor physical health (13.33% vs 23.01%; difference, -9.67% [95% CI, -18.30% to -1.05%]; P = .03) and a 32.94% lower rate of obesity or overweight (29.28% vs 43.67%; difference, -14.38% [95% CI, -25.74% to -3.02%]; P = .02) compared with the control group. Among female participants, attending a high-performing public charter high school was associated with worse physical health outcomes (30.29% vs 13.47% reporting fair or poor health; difference, 16.82% [95% CI, 0.36% to 33.28%]; P = .045) and higher rates of overweight or obesity (52.20% vs 32.91%; difference, 19.30% [95% CI, 3.37% to 35.22%]; P = .02) at age 21 years. Few differences in mental health outcomes were observed. Adjusting for educational outcomes did not significantly change these findings. Conclusions and Relevance: Results of this study suggest that attending a high-performing public charter high school was associated with lower rates of substance use disorder independent of academic achievement. Physical health and obesity outcomes were also better but only for young men; the intervention group had worse physical health outcomes among young women for unclear reasons. Schools are a potent social determinant of health and an important target for future health interventions.

Correction: Gender stigma awareness is associated with adolescent risky health behaviors.

[This corrects the article DOI: 10.1371/journal.pone.0251332.].

Turning Vicious Cycles Into Virtuous Ones: the Potential for Schools to Improve the Life Course.

Adolescence is a critical transition period that sets the stage for adulthood and future health outcomes. Marked by key developmental milestones in brain maturation, increasing independence from parents, and greater connections to peers, adolescence is also a time of heightened risk for behavioral health problems, including substance use, violence, delinquency, and mental health issues. High school completion is a significant life course event and a powerful social determinant of health and health disparities. Jessor's Theory of Problem Behavior suggests that adolescent health behaviors and mental health problems are closely tied to poor educational outcomes and peer network formation in a reinforcing feedback loop, or vicious cycle, often leading to school failure, school disengagement, and drop-out. Schools are a novel platform through which vicious cycles can be disrupted and replaced with virtuous ones, simultaneously improving education and health. This article describes the potential for schools to transform health trajectories through interventions creating positive and supportive school climates. In addition, new models such as the Whole School Whole Community Whole Child Model promote whole child well-being, including cognitive, social, emotional, psychological, and physical development. Full-service community schools can serve as a hub coordinating and integrating all available resources to better respond to the needs of children and families. Present in every neighborhood, schools are a way to reach every school-age child and improve their health trajectories, providing an important platform for life course intervention research.

A symphony within: Frequent participation in performing arts predicts higher positive mental health in young adults.

RATIONALE: Positive mental health is a critical component of overall mental health, but our understanding of the potential drivers of positive mental health is lacking. Participation in the arts may contribute to positive mental health through the mechanism of flow, a mental state of becoming completely engrossed in an enjoyable activity. Participation in performing arts specifically may be especially predictive of positive mental health due to its collective nature. OBJECTIVE AND METHODS: This study uses the Population Study of Income Dynamics (PSID) Transition to Adulthood Sample (N = 5657 person-years) to investigate whether participation in performing arts predicts positive mental health in young adults in the US through adjusted least squares and individual-level fixed-effects linear regression models across three waves of data per individual. Additionally, the study investigates different levels of participation to establish a dose response and employs stratified analyses by race/ethnicity, income, and gender. RESULTS: Results show that, compared to no participation, participating in the performing arts every day is associated with an increase in positive mental health of a 0.315 effect size [p < 0.001]. White and higher income individuals are more likely to participate in the arts than people of color and lower income individuals. Yet, the association between performing arts and positive mental health is similar, if not greater, for people of color than it is for white individuals. CONCLUSION: This study shows strong associations between frequent performing arts participation and positive mental health and suggests that more resources should be allocated to performing arts access for young adults from diverse backgrounds.

Gender stigma awareness is associated with adolescent risky health behaviors.

OBJECTIVES: Although racial stigma in school is associated with adolescent risky health behaviors, there are no studies investigating how gender stigma relates to adolescent risky health behaviors among low-income, minority youth. We sought to determine whether gender stigma awareness is associated with adolescent risky health behaviors (delinquency, fighting, and substance use) and whether this association is mediated by school disengagement (low perceived teacher support, low school engagement, cutting classes, and breaking school rules) among low-income, minority students. METHODS: We analyzed cross-sectional survey data, collected from 2017 to 2019, from 412 high school students. Multi-level logistic regressions tested whether gender stigma awareness was associated with delinquency, fighting, and substance use, controlling for covariates, baseline behaviors, and clustering within schools. Mediation analyses tested whether school disengagement (low school engagement, perceived teacher support, cutting class, and breaking school rules) mediated these associations. Secondary analyses explored whether associations differed for male versus female, high-performing versus low-performing, and Latinx versus non-Latinx students. RESULTS: In this predominantly Latinx (83%) sample, gender stigma awareness was associated with delinquency (AOR = 1.48, P< 0.001) and fighting (AOR = 1.15, P< 0.001). School engagement, perceived teacher support, breaking school rules, and cutting classes mediated 42.7% of the association between gender stigma awareness and delinquency and 65.42% of the association between gender stigma awareness and fighting. Gender stigma awareness was also associated with substance use for low-performing (AOR = 1.68, P = 0.003) and non-Latinx adolescents (AOR = 3.80, P = 0.03). School disengagement did not mediate the association between gender stigma awareness and substance use for non-Latinx students but mediated 50% of this association for low-performing students. CONCLUSIONS: Gender stigma awareness is associated with adolescent risky health behaviors. A decreased sense of acceptance in the school community and increased school misbehavior may mediate these associations. School environments that value and accept all students may better support adolescent health.

The longitudinal relationship of school climate with adolescent social and emotional health.

BACKGROUND: Schools and school climate are thought to influence academic outcomes as well as child and adolescent development, health and well-being. We sought to examine the relationship between several aspects of the school climate with adolescent social-emotional health outcomes. METHODS: We analysed data from the Reducing Inequities through Social and Educational change Follow-up (RISE UP) Study, a longitudinal natural experimental study of Los Angeles high school students collected from 2013 to 2018. We analysed data on the portion of the sample that completed the baseline, 10th grade and 11th grade surveys (n=1114). Students reported their perceptions of school climate at 10th grade and social-emotional outcomes including grit, self-efficacy, depression, hopelessness, and stress at baseline (9th grade) and at 11th grade. Multivariable regressions adjusted for student and parental demographics and baseline social-emotional states tested associations between school climate and each outcome. RESULTS: Students who reported being in authoritative school environments in 10th grade, one that is highly supportive and highly structured, had subsequently higher levels of self-efficacy (p< 0.001) and grit (p=0.01). They also had fewer depressive symptoms (p=0.008), and less hopelessness (p = 0.01), stress at school (p=0.002) and stress about the future (p=0.03) reported in 11th grade. CONCLUSIONS: School climate, and particularly an authoritative school environment, is strongly associated with better social-emotional health among adolescents. Relationship with teachers and their disciplinary style may be a focus for future interventions to improve the social-emotional health of children.

Mechanobiological conditioning of mesenchymal stem cells for enhanced vascular regeneration.

Using endogenous mesenchymal stem cells for treating myocardial infarction and other cardiovascular conditions typically results in poor efficacy, in part owing to the heterogeneity of the harvested cells and of the patient responses. Here, by means of high-throughput screening of the combinatorial space of mechanical-strain level and of the presence of particular kinase inhibitors, we show that human mesenchymal stem cells can be mechanically and pharmacologically conditioned to enhance vascular regeneration in vivo. Mesenchymal stem cells conditioned to increase the activation of signalling pathways mediated by Smad2/3 (mothers against decapentaplegic homolog 2/3) and YAP (Yes-associated protein) expressed markers that are associated with pericytes and endothelial cells, displayed increased angiogenic activity in vitro, and enhanced the formation of vasculature in mice after subcutaneous implantation and after implantation in ischaemic hindlimbs. These effects were mediated by the crosstalk of endothelial-growth-factor receptors, transforming-growth-factor-beta receptor type 1 and vascular-endothelial-growth-factor receptor 2. Mechanical and pharmacological conditioning can significantly enhance the regenerative properties of mesenchymal stem cells.

Evaluation of antibiotic escalation in response to nurse-driven inpatient sepsis screen.

Objective: To determine the frequency and predictors of antibiotic escalation in response to the inpatient sepsis screen at our institution. Design: Retrospective cohort study. Setting: Two affiliated academic medical centers in Los Angeles, California. Patients: Hospitalized patients aged 18 years and older who had their first positive sepsis screen between January 1, 2019, and December 31, 2019, on acute-care wards. Methods: We described the rate and etiology of antibiotic escalation, and we conducted multivariable regression analyses of predictors of antibiotic escalation. Results: Of the 576 cases with a positive sepsis screen, antibiotic escalation occurred in 131 cases (22.7%). New infection was the most documented etiology of escalation, with 76 cases (13.2%), followed by known pre-existing infection, with 26 cases (4.5%). Antibiotics were continued past 3 days in 17 cases (3.0%) in which new or existing infection was not apparent. Abnormal temperature (adjusted odds ratio [aOR], 3.00; 95% confidence interval [CI], 1.91-4.70) and abnormal lactate (aOR, 2.04; 95% CI, 1.28-3.27) were significant predictors of antibiotic escalation. The patient already being on antibiotics (aOR, 0.54; 95% CI, 0.34-0.89) and the positive screen occurred during a nursing shift change (aOR, 0.36; 95% CI, 0.22-0.57) were negative predictors. Pneumonia was the most documented new infection, but only 19 (50%) of 38 pneumonia cases met full clinical diagnostic criteria. Conclusions: Inpatient sepsis screening led to a new infectious diagnosis in 13.2% of all positive sepsis screens, and the risk of prolonged antibiotic exposure without a clear infectious source was low. Pneumonia diagnostics and lactate testing are potential targets for future stewardship efforts.

Chaos in Schools and Its Relationship to Adolescent Risk Behaviors.

OBJECTIVE: Chaos in the home is associated with worse childhood behaviors. We hypothesize chaos in the school environment might also be associated with teen risk behaviors. METHODS: We analyzed data from the Reducing Inequities through Social and Educational change Follow-Up study, a natural experiment designed to examine the impact of high-performing schools on adolescent outcomes. Students reported the amount of noise, order, and control in their school environment and whether they engaged in substance use, fighting, school absenteeism, and delinquent behaviors. We conducted cross-lagged panel structural equation modeling to examine the relationship between school chaos at 10th grade with risk behaviors at 11th grade while simultaneously examining the relationship between behaviors at 10th grade with chaos at 11th grade. RESULTS: Among a sample of 1114 teens, 90% were Latinx and 40% were native English speakers. Students reporting more school chaos in 10th grade were more likely in 11th grade to report recent alcohol and cannabis use, physical fighting, school absenteeism, and delinquent behaviors in the last year. Cross-lagged structural equation model analyses indicate school chaos at 10th grade is linked to alcohol use and absenteeism at 11th grade, while fighting, absenteeism, and any delinquent behaviors at 10th grade are associated with more chaos at 11th grade. School engagement was not a mediating factor. CONCLUSIONS: Although causal relationships cannot be assumed, school chaos may be an important predictor of adolescent risk behaviors. Future studies should examine whether reducing school chaos leads to lower rates of adolescent risk behaviors.

A high throughput screening system for studying the effects of applied mechanical forces on reprogramming factor expression.

Mechanical forces are important in the regulation of physiological homeostasis and the development of disease. The application of mechanical forces to cultured cells is often performed using specialized systems that lack the flexibility and throughput of other biological techniques. In this study, we developed a high throughput platform for applying complex dynamic mechanical forces to cultured cells. We validated the system for its ability to accurately apply parallel mechanical stretch in a 96 well plate format in 576 well simultaneously. Using this system, we screened for optimized conditions to stimulate increases in Oct-4 and other transcription factor expression in mouse fibroblasts. Using high throughput mechanobiological screening assays, we identified small molecules that can synergistically enhance the increase in reprograming-related gene expression in mouse fibroblasts when combined with mechanical loading. Taken together, our findings demonstrate a new powerful tool for investigating the mechanobiological mechanisms of disease and performing drug screening in the presence of applied mechanical load.

Association of a Care Bundle for Early Sepsis Management With Mortality Among Patients With Hospital-Onset or Community-Onset Sepsis.

Importance: The Early Management Bundle for Severe Sepsis/Septic Shock (SEP-1) is a quality metric based on a care bundle for early sepsis management. Published evidence on the association of SEP-1 with mortality is mixed and largely excludes cases of hospital-onset sepsis. Objective: To assess the association of the SEP-1 bundle with mortality and organ dysfunction in cohorts with hospital-onset or community-onset sepsis. Design, Setting, and Participants: This retrospective cohort study used data from 4 University of California hospitals from October 1, 2014, to October 1, 2017. Adult inpatients with a diagnosis consistent with sepsis or disseminated infection and laboratory or vital signs meeting the Sepsis-3 (Third International Consensus Definitions for Sepsis and Septic Shock) criteria were divided into community-onset sepsis and hospital-onset sepsis cohorts based on whether time 0 of sepsis occurred after arrival in the emergency department or an inpatient area. Data were analyzed from April to October 2019. Additional analyses were performed from December 2019 to January 2020. Exposures: Administration of SEP-1 and 4 individual bundle components (serum lactate level testing, blood culture, broad-spectrum intravenous antibiotic treatment, and intravenous fluid treatment). Main Outcomes and Measures: The primary outcome was in-hospital mortality. The secondary outcome was days requiring vasopressor support, measured as vasopressor days. Results: Among the 6404 patient encounters identified (3535 men [55.2%]; mean [SD] age, 64.0 [18.2] years), 2296 patients (35.9%) had hospital-onset sepsis. Among 4108 patients (64.1%) with community-onset sepsis, serum lactate level testing within 3 hours of time 0 was associated with reduced mortality (absolute difference, -7.61%; 95% CI, -14.70% to -0.54%). Blood culture (absolute difference, -1.10 days; 95% CI, -1.85 to -0.34 days) and broad-spectrum intravenous antibiotic treatment (absolute difference, -0.62 days; 95% CI, -1.02 to -0.22 days) were associated with fewer vasopressor days. Among patients with hospital-onset sepsis, broad-spectrum intravenous antibiotic treatment was the only bundle component significantly associated with any improved outcome (mortality difference, -5.20%; 95% CI, -9.84% to -0.56%). Care that was adherent to the complete SEP-1 bundle was associated with increased vasopressor days in patients with community-onset sepsis (absolute difference, 0.31 days; 95% CI, 0.11-0.51 days) but was not significantly associated with reduced mortality in either cohort (absolute difference, -0.07%; 95% CI, -3.02% to 2.88% in community-onset; absolute difference, -0.42%; 95% CI, -6.77% to 5.93% in hospital-onset). Conclusions and Relevance: SEP-1-adherent care was not associated with improved outcomes of sepsis. Although multiple components of SEP-1 were associated with reduced mortality or decreased days of vasopressor therapy for patients who presented with sepsis in the emergency department, only broad-spectrum intravenous antibiotic treatment was associated with reduced mortality when time 0 occurred in an inpatient unit. Current sepsis quality metrics may need refinement.

Adherence to the SEP-1 Sepsis Bundle in Hospital-Onset v. Community-Onset Sepsis: a Multicenter Retrospective Cohort Study.

BACKGROUND: Sepsis is the leading cause of in-hospital death. The SEP-1 sepsis bundle is a protocol for early sepsis care that requires providers to diagnose and treat sepsis quickly. Limited evidence suggests that adherence to the sepsis bundle is lower in cases of hospital-onset sepsis. OBJECTIVE: To compare sepsis bundle adherence in hospital-onset vs. community-onset sepsis. DESIGN: Retrospective cohort study using multivariable analysis of clinical data. PARTICIPANTS: A total of 4658 inpatients age 18 or older were identified by diagnosis codes consistent with sepsis or disseminated infection. SETTING: Four university hospitals in California between 2014 and 2016. MAIN OUTCOMES AND MEASURES: The primary outcome was adherence to key components of the sepsis bundle defined by the Centers for Medicare and Medicaid Services in their core measure, SEP-1. Covariates included clinical characteristics related to the patient, infection, and pathogen. KEY RESULTS: Compared with community-onset, cases of hospital-onset sepsis were less likely to receive SEP-1 adherent care (relative risk 0.33, 95% confidence interval 0.29-0.38, p < 0.001). With the exception of vasopressors (RR 1.11, p = 0.002), each component of SEP-1 evaluated-blood cultures (RR 0.76, p < 0.001), serum lactate (RR 0.51, p < 0001), broad-spectrum antibiotics (RR 0.62, p < 0.001), intravenous fluids (0.47, p < 0.001), and follow-up lactate (RR 0.71, p < 0.001)-was less likely to be performed within the recommended time frame in hospital-onset sepsis. Within the hospital, cases of hospital-onset sepsis arising on the ward were less likely to receive SEP-1-adherent care than were cases arising in the intensive care unit (RR 0.68, p = 0.004). CONCLUSIONS: Inpatients with hospital-onset sepsis receive different management than individuals with community-onset sepsis. It remains to be determined whether system-level factors, provider-level factors, or factors related to measurement explain the observed variation in care or whether variation in care affects outcomes.