Original Investigation
Critical Care Medicine
May 31, 2024
In-Hospital vs 30-Day Sepsis Mortality at US Safety-Net and Non–Safety-Net Hospitals
Anica C. Law, Nicholas A. Bosch, Yang Song, et al
JAMA Netw Open. 2024;7(5):e2412873. doi:10.1001/jamanetworkopen.2024.12873
Question Among patients with sepsis, is admission to a safety-net hospital associated with increased 30-day mortality and differences in discharge practices?
Findings In this cohort study of more than 2 million patients with sepsis, admission to safety-net hospitals was associated with higher in-hospital mortality, but not 30-day mortality. Admission to safety-net hospitals was associated with decreased discharge to hospice.
Meaning These findings suggest in-hospital mortality rates are associated with differences in discharge practices (eg, by shifting attribution of death from the index hospitalization to hospice), raising concern that current sepsis quality measures using in-hospital mortality could unfairly penalize safety-net hospitals.
Abstract
Importance In-hospital mortality of patients with sepsis is frequently measured for benchmarking, both by researchers and policymakers. Prior studies have reported higher in-hospital mortality among patients with sepsis at safety-net hospitals compared with non–safety-net hospitals; however, in critically ill patients, in-hospital mortality rates are known to be associated with hospital discharge practices, which may differ between safety-net hospitals and non–safety-net hospitals.
Objective To assess how admission to safety-net hospitals is associated with 2 metrics of short-term mortality (in-hospital mortality and 30-day mortality) and discharge practices among patients with sepsis.
Design, Setting, and Participants Retrospective, national cohort study of Medicare fee-for-service beneficiaries aged 66 years and older, admitted with sepsis to an intensive care unit from January 2011 to December 2019 based on information from the Medicare Provider Analysis and Review File. Data were analyzed from October 2022 to September 2023.
Exposure Admission to a safety-net hospital (hospitals with a Medicare disproportionate share index in the top quartile per US region).
Main Outcomes and Measures Coprimary outcomes: in-hospital mortality and 30-day mortality. Secondary outcomes: (1) in-hospital do-not-resuscitate orders, (2) in-hospital palliative care delivery, (3) discharge to a postacute facility (skilled nursing facility, inpatient rehabilitation facility, or long-term acute care hospital), and (4) discharge to hospice.
Results Between 2011 and 2019, 2 551 743 patients with sepsis (mean [SD] age, 78.8 [8.2] years; 1 324 109 [51.9%] female; 262 496 [10.3%] Black, 2 137 493 [83.8%] White, and 151 754 [5.9%] other) were admitted to 666 safety-net hospitals and 1924 non–safety-net hospitals. Admission to safety-net hospitals was associated with higher in-hospital mortality (odds ratio [OR], 1.09; 95% CI, 1.06-1.13) but not 30-day mortality (OR, 1.01; 95% CI, 0.99-1.04). Admission to safety-net hospitals was associated with lower do-not-resuscitate rates (OR, 0.86; 95% CI, 0.81-0.91), palliative care delivery rates (OR, 0.66; 95% CI, 0.60-0.73), and hospice discharge (OR, 0.82; 95% CI, 0.78-0.87) but not with discharge to postacute facilities (OR, 0.98; 95% CI, 0.95-1.01).
Conclusions and Relevance In this cohort study, among patients with sepsis, admission to safety-net hospitals was associated with higher in-hospital mortality but not with 30-day mortality. Differences in in-hospital mortality may partially be explained by greater use of hospice at non–safety-net hospitals, which shifts attribution of death from the index hospitalization to hospice. Future investigations and publicly reported quality measures should consider time-delimited rather than hospital-delimited measures of short-term mortality to avoid undue penalty to safety-net hospitals with similar short-term mortality.
