Mortality Measures to Profile Hospital Performance for Patients With Septic Shock

Objectives: Sepsis care is becoming a more common target for hospital performance measurement, but few studies have evaluated the acceptability of sepsis or septic shock mortality as a potential performance measure. In the absence of a gold standard to identify septic shock in claims data, we assessed agreement and stability of hospital mortality performance under different case definitions. Design: Retrospective cohort study. Setting: U.S. acute care hospitals. Patients: Hospitalized with septic shock at admission, identified by either implicit diagnosis criteria (charges for antibiotics, cultures, and vasopressors) or by explicit International Classification of Diseases, 9th revision, codes. Interventions: None. Measurements and Main Results: We used hierarchical logistic regression models to determine hospital risk–standardized mortality rates and hospital performance outliers. We assessed agreement in hospital mortality rankings when septic shock cases were identified by either explicit International Classification of Diseases, 9th revision, codes or implicit diagnosis criteria. Kappa statistics and intraclass correlation coefficients were used to assess agreement in hospital risk–standardized mortality and hospital outlier status, respectively. Fifty-six thousand six-hundred seventy-three patients in 308 hospitals fulfilled at least one case definition for septic shock, whereas 19,136 (33.8%) met both the explicit International Classification of Diseases, 9th revision, and implicit septic shock definition. Hospitals varied widely in risk-standardized septic shock mortality (interquartile range of implicit diagnosis mortality: 25.4–33.5%; International Classification of Diseases, 9th revision, diagnosis: 30.2–38.0%). The median absolute difference in hospital ranking between septic shock cohorts defined by International Classification of Diseases, 9th revision, versus implicit criteria was 37 places (interquartile range, 16–70), with an intraclass correlation coefficient of 0.72, p value of less than 0.001; agreement between case definitions for identification of outlier hospitals was moderate (kappa, 0.44 [95% CI, 0.30–0.58]). Conclusions: Risk-standardized septic shock mortality rates varied considerably between hospitals, suggesting that septic shock is an important performance target. However, efforts to profile hospital performance were sensitive to septic shock case definitions, suggesting that septic shock mortality is not currently ready for widespread use as a hospital quality measure. Drs. Walkey, Liu, and Lindenauer contributed to conception and design. Drs. Walkey, Shieh, and Lindenauer contributed to data acquisition and analysis. All authors contributed in interpretation of data for the work and drafting the work and revising for important intellectual content. 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 (https://ift.tt/29S62lw). Dr. Walkey received support from National Institutes of Health (NIH)/National Heart Lung and Blood Institute K01HL116768 and R01 HL136660. Dr. Liu was supported by K23GM112018. Dr. Liu's institution received funding from the NIH/National Institute of General Medicine Sciences. Dr. Lindenauer received support from NIH K24HL 132008. Dr. Lindenauer disclosed that he receives salary support to develop and maintain hospital outcome measures through a subcontract with the Center for Outcomes Research and Evaluation and the Centers for Medicare and Medicaid Services. Dr. Shieh has disclosed that she does not have any potential conflicts of interest. For information regarding this article, E-mail: alwalkey@bu.edu Copyright © by 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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