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Mortality Measures to Profile Hospital Performance for Patients With Septic Shock.
Crit Care Med. 2018 08; 46(8):1247-1254.CC

Abstract

OBJECTIVES

Sepsis care is becoming a more common target for hospital performance measurement, but few studies have evaluated the acceptability of sepsis or septic shock mortality as a potential performance measure. In the absence of a gold standard to identify septic shock in claims data, we assessed agreement and stability of hospital mortality performance under different case definitions.

DESIGN

Retrospective cohort study.

SETTING

U.S. acute care hospitals.

PATIENTS

Hospitalized with septic shock at admission, identified by either implicit diagnosis criteria (charges for antibiotics, cultures, and vasopressors) or by explicit International Classification of Diseases, 9th revision, codes.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We used hierarchical logistic regression models to determine hospital risk-standardized mortality rates and hospital performance outliers. We assessed agreement in hospital mortality rankings when septic shock cases were identified by either explicit International Classification of Diseases, 9th revision, codes or implicit diagnosis criteria. Kappa statistics and intraclass correlation coefficients were used to assess agreement in hospital risk-standardized mortality and hospital outlier status, respectively. Fifty-six thousand six-hundred seventy-three patients in 308 hospitals fulfilled at least one case definition for septic shock, whereas 19,136 (33.8%) met both the explicit International Classification of Diseases, 9th revision, and implicit septic shock definition. Hospitals varied widely in risk-standardized septic shock mortality (interquartile range of implicit diagnosis mortality: 25.4-33.5%; International Classification of Diseases, 9th revision, diagnosis: 30.2-38.0%). The median absolute difference in hospital ranking between septic shock cohorts defined by International Classification of Diseases, 9th revision, versus implicit criteria was 37 places (interquartile range, 16-70), with an intraclass correlation coefficient of 0.72, p value of less than 0.001; agreement between case definitions for identification of outlier hospitals was moderate (kappa, 0.44 [95% CI, 0.30-0.58]).

CONCLUSIONS

Risk-standardized septic shock mortality rates varied considerably between hospitals, suggesting that septic shock is an important performance target. However, efforts to profile hospital performance were sensitive to septic shock case definitions, suggesting that septic shock mortality is not currently ready for widespread use as a hospital quality measure.

Authors+Show Affiliations

Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA.Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA. Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA.Kaiser Permanente Division of Research, Oakland, CA.Institute for Healthcare Delivery and Population Science and Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield, MA. Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA.

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

29727371

Citation

Walkey, Allan J., et al. "Mortality Measures to Profile Hospital Performance for Patients With Septic Shock." Critical Care Medicine, vol. 46, no. 8, 2018, pp. 1247-1254.
Walkey AJ, Shieh MS, Liu VX, et al. Mortality Measures to Profile Hospital Performance for Patients With Septic Shock. Crit Care Med. 2018;46(8):1247-1254.
Walkey, A. J., Shieh, M. S., Liu, V. X., & Lindenauer, P. K. (2018). Mortality Measures to Profile Hospital Performance for Patients With Septic Shock. Critical Care Medicine, 46(8), 1247-1254. https://doi.org/10.1097/CCM.0000000000003184
Walkey AJ, et al. Mortality Measures to Profile Hospital Performance for Patients With Septic Shock. Crit Care Med. 2018;46(8):1247-1254. PubMed PMID: 29727371.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Mortality Measures to Profile Hospital Performance for Patients With Septic Shock. AU - Walkey,Allan J, AU - Shieh,Meng-Shiou, AU - Liu,Vincent X, AU - Lindenauer,Peter K, PY - 2018/5/5/pubmed PY - 2019/9/26/medline PY - 2018/5/5/entrez SP - 1247 EP - 1254 JF - Critical care medicine JO - Crit Care Med VL - 46 IS - 8 N2 - OBJECTIVES: Sepsis care is becoming a more common target for hospital performance measurement, but few studies have evaluated the acceptability of sepsis or septic shock mortality as a potential performance measure. In the absence of a gold standard to identify septic shock in claims data, we assessed agreement and stability of hospital mortality performance under different case definitions. DESIGN: Retrospective cohort study. SETTING: U.S. acute care hospitals. PATIENTS: Hospitalized with septic shock at admission, identified by either implicit diagnosis criteria (charges for antibiotics, cultures, and vasopressors) or by explicit International Classification of Diseases, 9th revision, codes. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used hierarchical logistic regression models to determine hospital risk-standardized mortality rates and hospital performance outliers. We assessed agreement in hospital mortality rankings when septic shock cases were identified by either explicit International Classification of Diseases, 9th revision, codes or implicit diagnosis criteria. Kappa statistics and intraclass correlation coefficients were used to assess agreement in hospital risk-standardized mortality and hospital outlier status, respectively. Fifty-six thousand six-hundred seventy-three patients in 308 hospitals fulfilled at least one case definition for septic shock, whereas 19,136 (33.8%) met both the explicit International Classification of Diseases, 9th revision, and implicit septic shock definition. Hospitals varied widely in risk-standardized septic shock mortality (interquartile range of implicit diagnosis mortality: 25.4-33.5%; International Classification of Diseases, 9th revision, diagnosis: 30.2-38.0%). The median absolute difference in hospital ranking between septic shock cohorts defined by International Classification of Diseases, 9th revision, versus implicit criteria was 37 places (interquartile range, 16-70), with an intraclass correlation coefficient of 0.72, p value of less than 0.001; agreement between case definitions for identification of outlier hospitals was moderate (kappa, 0.44 [95% CI, 0.30-0.58]). CONCLUSIONS: Risk-standardized septic shock mortality rates varied considerably between hospitals, suggesting that septic shock is an important performance target. However, efforts to profile hospital performance were sensitive to septic shock case definitions, suggesting that septic shock mortality is not currently ready for widespread use as a hospital quality measure. SN - 1530-0293 UR - https://www.unboundmedicine.com/medline/citation/29727371/Mortality_Measures_to_Profile_Hospital_Performance_for_Patients_With_Septic_Shock_ L2 - https://dx.doi.org/10.1097/CCM.0000000000003184 DB - PRIME DP - Unbound Medicine ER -