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Compliance With the National SEP-1 Quality Measure and Association With Sepsis Outcomes: A Multicenter Retrospective Cohort Study*

Rhee, Chanu, MD, MPH1,2; Filbin, Michael R., MD, MSc3; Massaro, Anthony F., MD2; Bulger, Amy L., RN, MPH4; McEachern, Donna, RN, ALM4; Tobin, Kathleen A., RN5; Kitch, Barrett T., MD6; Thurlo-Walsh, Bert, RN, MM7; Kadar, Aran, MD8; Koffman, Alexandra, RN9; Pande, Anupam, MD, MPH10; Hamad, Yasir, MD10; Warren, David K., MD, MPH10; Jones, Travis M., PharmD11; O’Brien, Cara, MD12; Anderson, Deverick J., MD, MPH11; Wang, Rui, PhD1; Klompas, Michael, MD, MPH1,2 for the Centers for Disease Control and Prevention (CDC) Prevention Epicenters Program

doi: 10.1097/CCM.0000000000003261
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Objectives: Many septic patients receive care that fails the Centers for Medicare and Medicaid Services’ SEP-1 measure, but it is unclear whether this reflects meaningful lapses in care, differences in clinical characteristics, or excessive rigidity of the “all-or-nothing” measure. We compared outcomes in cases that passed versus failed SEP-1 during the first 2 years after the measure was implemented.

Design: Retrospective cohort study.

Setting: Seven U.S. hospitals.

Patients: Adult patients included in SEP-1 reporting between October 2015 and September 2017.

Interventions: None.

Measurements and Main Results: Of 851 sepsis cases in the cohort, 281 (33%) passed SEP-1 and 570 (67%) failed. SEP-1 failures had higher rates of septic shock (20% vs 9%; p < 0.001), hospital-onset sepsis (11% vs 4%; p = 0.001), and vague presenting symptoms (46% vs 30%; p < 0.001). The most common reasons for failure were omission of 3- and 6-hour lactate measurements (228/570 failures, 40%). Only 86 of 570 failures (15.1%) had greater than 3-hour delays until broad-spectrum antibiotics. Cases that failed SEP-1 had higher in-hospital mortality rates (18.4% vs 11.0%; odds ratio, 1.82; 95% CI, 1.19–2.80; p = 0.006), but this association was no longer significant after adjusting for differences in clinical characteristics and severity of illness (adjusted odds ratio, 1.36; 95% CI, 0.85–2.18; p = 0.205). Delays of greater than 3 hours until antibiotics were significantly associated with death (adjusted odds ratio, 1.94; 95% CI, 1.04–3.62; p = 0.038), whereas failing SEP-1 for any other reason was not (adjusted odds ratio, 1.10; 95% CI, 0.70–1.72; p = 0.674).

Conclusions: Crude mortality rates were higher in sepsis cases that failed versus passed SEP-1, but there was no difference after adjusting for clinical characteristics and severity of illness. Delays in antibiotic administration were associated with higher mortality but only accounted for a small fraction of SEP-1 failures. SEP-1 may not clearly differentiate between high- and low-quality care, and detailed risk adjustment is necessary to properly interpret associations between SEP-1 compliance and mortality.

1Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA.

2Department of Medicine, Brigham and Women’s Hospital, Boston, MA.

3Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.

4Department of Quality and Safety, Brigham and Women’s Hospital, Boston, MA.

5Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, MA.

6Department of Medicine, North Shore Medical Center, Salem, MA.

7Office of Quality, Patient Safety & Experience, Newton-Wellesley Hospital, Newton, MA.

8Department of Medicine, Newton-Wellesley Hospital, Newton, MA.

9Department of Quality, Brigham and Women’s Faulkner Hospital, Boston, MA.

10Department of Medicine, Washington University School of Medicine, St. Louis, MO.

11Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, NC.

12Department of Medicine, Duke University Medical Center, Durham, NC.

*See also p. 1689.

The content is solely the responsibility of the authors and does not necessarily represent the official views of the Centers for Disease Control and Prevention or the Agency for Healthcare Research and Quality.

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://journals.lww.com/ccmjournal).

Supported, in part, by the Prevention Epicenters Program of the Centers for Disease Control and Prevention (grant number: U54CK000484) and the Agency for Healthcare Research and Quality (grant number: K08HS025008 to Dr. Rhee).

Dr. Rhee’s institution received funding from the Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality. Dr. Pande’s institution received funding from the CDC/National Institute for Communicable Diseases (NICD), and he received support for article research from the CDC/NICD. Dr. Hamad’s institution received a National Institutes of Health (NIH) grant for CDC center of excellence, and he received support for article research from the NIH. Dr. Warren received funding from consulting Worrell, Pursuit Vascular, and CareFusion/Becton Dickinson, as well as serving as a site subinvestigator for a vaccine trial sponsored by Pfizer. He received support for article research from the CDC Prevention Epicenters Program (U54CK000484). Dr. Jones’ institution received funding from the CDC Prevention Epicenters Program (U54CK000164). Drs. Anderson’s and Wang’s institutions received funding from the CDC. Dr. Anderson disclosed government work. Dr. Klompas’s institution received funding from the CDC and the Massachusetts Department of Public Health. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Presented in abstract form at the 2018 Society of Critical Care Medicine Conference (Abstract #1), San Antonio, TX, February 25, 2018.

For information regarding this article, E-mail: crhee@bwh.harvard.edu

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