Hospital Variation in Renal Replacement Therapy for Sepsis in the United States

Objectives: Acute renal replacement therapy in patients with sepsis has increased dramatically with substantial costs. However, the extent of variability in use across hospitals—and whether greater use is associated with better outcomes—is unknown. Design: Retrospective cohort study. Setting: Nationwide Inpatient Sample in 2011. Patients: Eighteen years old and older with sepsis and acute kidney injury admitted to hospitals sampled by the Nationwide Inpatient Sample in 2011. Interventions: We estimated the risk- and reliability-adjusted rate of acute renal replacement therapy use for patients with sepsis and acute kidney injury at each hospital. We examined the association between hospital-specific renal replacement therapy rate and in-hospital mortality and hospital costs after adjusting for patient and hospital characteristics. Measurements and Main Results: We identified 293,899 hospitalizations with sepsis and acute kidney injury at 440 hospitals, of which 6.4% (n = 18,885) received renal replacement therapy. After risk and reliability adjustment, the median hospital renal replacement therapy rate for patients with sepsis and acute kidney injury was 3.6% (interquartile range, 2.9–4.5%). However, hospitals in the top quintile of renal replacement therapy use had rates ranging from 4.8% to 13.4%. There was no significant association between hospital-specific renal replacement therapy rate and in-hospital mortality (odds ratio per 1% increase in renal replacement therapy rate: 1.03; 95% CI, 0.99–1.07; p = 0.10). Hospital costs were significantly higher with increasing renal replacement therapy rates (absolute cost increase per 1% increase in renal replacement therapy rate: $1,316; 95% CI, $157–$2,475; p = 0.03). Conclusions: Use of renal replacement therapy in sepsis varied widely among nationally sampled hospitals without associated differences in mortality. Improving renal replacement standards for the initiation of therapy for sepsis may reduce healthcare costs without increasing mortality. This article does not necessarily represent the views of the U.S. Government or the Department of Veterans Affairs. Dr. Valley had full access to all of the data in the study and takes full responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Valley and Cooke contributed in study concept and design. Dr. Valley contributed in acquisition of data. Drs. Valley, Nallamothu, Heung, Iwashyna, and Cooke contributed in analysis and interpretation of data. Drs. Valley and Cooke contributed in drafting of the article. Drs. Valley, Nallamothu, Heung, Iwashyna, and Cooke contributed in critical revision of the article for important intellectual content. Drs. Valley and Cooke contributed in statistical analysis. Dr. Cooke obtained funding. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (http://ift.tt/29S62lw). Supported, in part, by National Institutes of Health T32HL007749 (to Dr. Valley), the Department of Veterans Affairs Health Services Research and Development Service grant 13–079 (to Dr. Iwashyna), and the Agency for Healthcare Research and Quality K08HS020672 (to Dr. Cooke). Dr. Valley received support for article research from the National Institutes of Health. Dr. Nallamothu received funding from United Healthcare and the American Heart Association. Dr. Iwashyna disclosed government work. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: valleyt@umich.edu Copyright © by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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