Research

Severe sepsis: variation in resource and therapeutic modality use among academic centers

D Tony Yu¹, Edgar Black², Kenneth E Sands³, J Sanford Schwartz⁴, Patricia L Hibberd⁵, Paul S Graman⁶, Paul N Lanken⁷, Katherine L Kahn⁸, David R Snydman⁹, Jeffrey Parsonnet¹⁰, Richard Moore¹¹, Richard Platt¹² and David W Bates¹³ for for the Academic Medical Center Consortium Sepsis Project Working Group

¹Research Fellow, Brigham and Women's Hospital, Partners HealthCare System, Wellesley, Massachusetts, USA

²Associate Medical Director, Finger Lakes Blue Cross Blue Shield, Rochester, New York, USA

³VP and Medical Director, Healthcare Quality, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA

⁴L. Davis Institute, University of Pennsylvania Health System, Philadelphia, USA

⁵Director, Clinical Research Institute, Tufts-New England Medical Center, Boston, Massachusetts, USA

⁶Professor of Medicine, University of Rochester Medical Center, Rochester, New York, USA

⁷Professor of Medicine, Pulmonary, Allergy and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, USA

⁸Professor of Medicine, UCLA, Department of Medicine, Division of GIM and HSR, Los Angeles, California, USA

⁹Chief, Geographic Medicine and Infectious Diseases and Hospital Epidemiologist, Tufts-New England Medical Center, Boston, Massachusetts, USA

¹⁰Infectious Diseases Section Staff, Infectious Disease, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA

¹¹Professor, Medicine and Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA

¹²Interim Director, Ambulatory Care and Prevention, Harvard Pilgrim Health Care, Boston, Massachusetts, USA

¹³Chief, General Medicine Division, Brigham and Women's Hospital, Boston, Massachusetts, USA

author email corresponding author email

Critical Care 2003, 7:R24-R34doi:10.1186/cc2171

Published:	17 March 2003

See related Commentary http://ccforum.com/content/7/3/211

Abstract

Background

Treatment of severe sepsis is expensive, often encompassing a number of discretionary modalities. The objective of the present study was to assess intercenter variation in resource and therapeutic modality use in patients with severe sepsis.

Methods

We conducted a prospective cohort study of 1028 adult admissions with severe sepsis from a stratified random sample of patients admitted to eight academic tertiary care centers. The main outcome measures were length of stay (LOS; total LOS and LOS after onset of severe sepsis) and total hospital charges.

Results

The adjusted mean total hospital charges varied from $69 429 to US$237 898 across centers, whereas the adjusted LOS after onset varied from 15.9 days to 24.2 days per admission. Treatments used frequently after the first onset of sepsis among patients with severe sepsis were pulmonary artery catheters (19.4%), ventilator support (21.8%), pressor support (45.8%) and albumin infusion (14.4%). Pulmonary artery catheter use, ventilator support and albumin infusion had moderate variation profiles, varying 3.2-fold to 4.9-fold, whereas the rate of pressor support varied only 1.92-fold across centers. Even after adjusting for age, sex, Charlson comorbidity score, discharge diagnosis-relative group weight, organ dysfunction and service at onset, the odds for using these therapeutic modalities still varied significantly across centers. Failure to start antibiotics within 24 hours was strongly correlated with a higher probability of 28-day mortality (r² = 0.72).

Conclusion

These data demonstrate moderate but significant variation in resource use and use of technologies in treatment of severe sepsis among academic centers. Delay in antibiotic therapy was associated with worse outcome at the center level.