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      Racial and Geographic Disparities in Interhospital ICU Transfers* :

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          Abstract

          <div class="section"> <a class="named-anchor" id="S1"> <!-- named anchor --> </a> <h5 class="section-title" id="d680793e187">Objective</h5> <p id="P1">Inter-hospital transfer (IHT), a common intervention, may be subject to healthcare disparities. In mechanically ventilated patients with sepsis, we hypothesize that disparities not disease-related would be found between patients who were and were not transferred. </p> </div><div class="section"> <a class="named-anchor" id="S2"> <!-- named anchor --> </a> <h5 class="section-title" id="d680793e192">Design</h5> <p id="P2">Retrospective cohort study.</p> </div><div class="section"> <a class="named-anchor" id="S3"> <!-- named anchor --> </a> <h5 class="section-title" id="d680793e197">Setting</h5> <p id="P3">Nationwide Inpatient Sample, 2006–2012.</p> </div><div class="section"> <a class="named-anchor" id="S4"> <!-- named anchor --> </a> <h5 class="section-title" id="d680793e202">Patients</h5> <p id="P4">Patients over 18 years of age with a primary diagnosis of sepsis who underwent mechanical ventilation. </p> </div><div class="section"> <a class="named-anchor" id="S5"> <!-- named anchor --> </a> <h5 class="section-title" id="d680793e207">Interventions</h5> <p id="P5">none</p> </div><div class="section"> <a class="named-anchor" id="S6"> <!-- named anchor --> </a> <h5 class="section-title" id="d680793e212">Measurements and Main Results</h5> <p id="P6">We obtained age, gender, length of stay, race, insurance coverage, do not resuscitate status, and Elixhauser co-morbidities. The outcome used was inter-hospital transfer from a small- or medium-sized hospital to a larger acute care hospital. Of 55,208,382 hospitalizations, 46,406 patients met inclusion criteria. In the multivariate model, patients were less likely to be transferred if the following were present: older age (OR 0.98, 95% CI 0.978–0.982), black race (OR 0.79, 95% CI 0.70–0.89), Hispanic race (OR 0.79, 95% CI 0.69–0.90), South region hospital (OR 0.79, 0.72–0.88), teaching hospital (OR 0.31, 95% CI 0.28–0.33), and DNR status (OR 0.19, 95% CI 0.15–0.25). </p> </div><div class="section"> <a class="named-anchor" id="S7"> <!-- named anchor --> </a> <h5 class="section-title" id="d680793e217">Conclusions</h5> <p id="P7">In mechanically ventilated patients with sepsis, we found significant disparities in race and geographic location not explained by medical diagnoses or illness severity. </p> </div>

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          Identifying patients with severe sepsis using administrative claims: patient-level validation of the angus implementation of the international consensus conference definition of severe sepsis.

          Severe sepsis is a common and costly problem. Although consistently defined clinically by consensus conference since 1991, there have been several different implementations of the severe sepsis definition using ICD-9-CM codes for research. We conducted a single center, patient-level validation of 1 common implementation of the severe sepsis definition, the so-called "Angus" implementation. Administrative claims for all hospitalizations for patients initially admitted to general medical services from an academic medical center in 2009-2010 were reviewed. On the basis of ICD-9-CM codes, hospitalizations were sampled for review by 3 internal medicine-trained hospitalists. Chart reviews were conducted with a structured instrument, and the gold standard was the hospitalists' summary clinical judgment on whether the patient had severe sepsis. Three thousand one hundred forty-six (13.5%) hospitalizations met ICD-9-CM criteria for severe sepsis by the Angus implementation (Angus-positive) and 20,142 (86.5%) were Angus-negative. Chart reviews were performed for 92 randomly selected Angus-positive and 19 randomly-selected Angus-negative hospitalizations. Reviewers had a κ of 0.70. The Angus implementation's positive predictive value was 70.7% [95% confidence interval (CI): 51.2%, 90.5%]. The negative predictive value was 91.5% (95% CI: 79.0%, 100%). The sensitivity was 50.4% (95% CI: 14.8%, 85.7%). Specificity was 96.3% (95% CI: 92.4%, 100%). Two alternative ICD-9-CM implementations had high positive predictive values but sensitivities of <20%. The Angus implementation of the international consensus conference definition of severe sepsis offers a reasonable but imperfect approach to identifying patients with severe sepsis when compared with a gold standard of structured review of the medical chart by trained hospitalists.
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            Racial variation in the incidence, care, and outcomes of severe sepsis: analysis of population, patient, and hospital characteristics.

            Higher rates of sepsis have been reported in minorities. To explore racial differences in the incidence and associated case fatality of severe sepsis, accounting for clinical, social, health care service delivery, and geographic characteristics. Retrospective population-based cohort study using hospital discharge and U.S. Census data for all persons (n = 71,102,655) living in 68 hospital referral regions in six states. Age-, sex- and race-standardized severe sepsis incidence and inpatient case fatality rates, adjusted incidence rate ratios, and adjusted intensive care unit (ICU) admission and case fatality rate differences. Of 8,938,111 nonfederal hospitalizations, 282,292 had severe sepsis. Overall, blacks had the highest age- and sex-standardized population-based incidence (6.08/1,000 vs. 4.06/1,000 for Hispanics and 3.58/1,000 for whites) and ICU case fatality (32.1 vs. 30.4% for Hispanics and 29.3% for whites, P < 0.0001). Adjusting for differences in poverty in their region of residence, blacks still had a higher population-based incidence of severe sepsis (adjusted rate ratio, 1.44 [95% CI, 1.42-1.46]) than whites, but Hispanics had a lower incidence (adjusted rate ratio, 0.91 [0.90-0.92]). Among patients with severe sepsis admitted to the ICU, adjustments for clinical characteristics and the treating hospital fully explained blacks' higher ICU case fatality. Higher adjusted black incidence and the lower Hispanic incidence may reflect residual confounding, or it could signal biologic differences in susceptibility. Focused interventions to improve processes and outcomes of care at the hospitals that disproportionately treat blacks could narrow disparities in overall mortality from severe sepsis.
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              Black-White health disparities in the United States and Chicago: a 15-year progress analysis.

              In an effort to examine national and Chicago, Illinois, progress in meeting the Healthy People 2010 goal of eliminating health disparities, we examined whether disparities between non-Hispanic Black and non-Hispanic White persons widened, narrowed, or stayed the same between 1990 and 2005. We examined 15 health status indicators. We determined whether a disparity widened, narrowed, or remained unchanged between 1990 and 2005 by examining the percentage difference in rates between non-Hispanic Black and non-Hispanic White populations at both time points and at each location. We calculated P values to determine whether changes in percentage difference over time were statistically significant. Disparities between non-Hispanic Black and non-Hispanic White populations widened for 6 of 15 health status indicators examined for the United States (5 significantly), whereas in Chicago the majority of disparities widened (11 of 15, 5 significantly). Overall, progress toward meeting the Healthy People 2010 goal of eliminating health disparities in the United States and in Chicago remains bleak. With more than 15 years of time and effort spent at the national and local level to reduce disparities, the impact remains negligible.
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                Author and article information

                Journal
                Critical Care Medicine
                Critical Care Medicine
                Ovid Technologies (Wolters Kluwer Health)
                0090-3493
                2018
                January 2018
                : 46
                : 1
                : e76-e80
                Article
                10.1097/CCM.0000000000002776
                5743219
                29068859
                28271636-a7e1-44a9-ad35-24720cb9f6c7
                © 2018
                History

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