Association Between State-Mandated Protocolized Sepsis Care and In-hospital Mortality Among Adults With Sepsis

IMPORTANCE: Beginning in 2013, New York State implemented regulations mandating that hospitals implement evidence-based protocols for sepsis management, as well as report data on protocol adherence and clinical outcomes to the state government. The association between these mandates and sepsis outco...

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Bibliographic Details
Published in:JAMA : the journal of the American Medical Association 2019-07, Vol.322 (3), p.240-250
Main Authors: Kahn, Jeremy M, Davis, Billie S, Yabes, Jonathan G, Chang, Chung-Chou H, Chong, David H, Hershey, Tina Batra, Martsolf, Grant R, Angus, Derek C
Format: Article
Language:English
Subjects:
Adult
Aged
Central Venous Catheters - statistics & numerical data
Clostridium Infections - epidemiology
Female
Government Regulation
Hospital Mortality
Hospitalization
Hospitals
Humans
Infections
Intensive care
Intensive Care Units - statistics & numerical data
Interrupted Time Series Analysis
Length of Stay
Male
Medical instruments
Middle Aged
Mortality
New York - epidemiology
Original Investigation
Patients
Practice Guidelines as Topic
Regulations
Retrospective Studies
Sepsis
Sepsis - mortality
Sepsis - therapy
Time series
United States - epidemiology
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Summary:IMPORTANCE: Beginning in 2013, New York State implemented regulations mandating that hospitals implement evidence-based protocols for sepsis management, as well as report data on protocol adherence and clinical outcomes to the state government. The association between these mandates and sepsis outcomes is unknown. OBJECTIVE: To evaluate the association between New York State sepsis regulations and the outcomes of patients hospitalized with sepsis. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of adult patients hospitalized with sepsis in New York State and in 4 control states (Florida, Maryland, Massachusetts, and New Jersey) using all-payer hospital discharge data (January 1, 2011-September 30, 2015) and a comparative interrupted time series analytic approach. EXPOSURES: Hospitalization for sepsis before (January 1, 2011-March 31, 2013) vs after (April 1, 2013-September 30, 2015) implementation of the 2013 New York State sepsis regulations. MAIN OUTCOMES AND MEASURES: The primary outcome was 30-day in-hospital mortality. Secondary outcomes were intensive care unit admission rates, central venous catheter use, Clostridium difficile infection rates, and hospital length of stay. RESULTS: The final analysis included 1 012 410 sepsis admissions to 509 hospitals. The mean age was 69.5 years (SD, 16.4 years) and 47.9% were female. In New York State and in the control states, 139 019 and 289 225 patients, respectively, were admitted before implementation of the sepsis regulations and 186 767 and 397 399 patients, respectively, were admitted after implementation of the sepsis regulations. Unadjusted 30-day in-hospital mortality was 26.3% in New York State and 22.0% in the control states before the regulations, and was 22.0% in New York State and 19.1% in the control states after the regulations. Adjusting for patient and hospital characteristics as well as preregulation temporal trends and season, mortality after implementation of the regulations decreased significantly in New York State relative to the control states (P = .02 for the joint test of the comparative interrupted time series estimates). For example, by the 10th quarter after implementation of the regulations, adjusted absolute mortality was 3.2% (95% CI, 1.0% to 5.4%) lower than expected in New York State relative to the control states (P = .004). The regulations were associated with no significant differences in intensive care unit admission rates (P = .09) (10th quarter adjusted diff
ISSN:0098-7484
1538-3598
DOI:10.1001/jama.2019.9021