Sepsis improvement program widened disparities between white and black patients

An analysis of New York State's sepsis reporting initiative found overall improved rates of compliance with three-hour sepsis protocols, but significantly lower rates among hospitals that served more black patients.

An initiative to improve sepsis response in New York State improved care overall but was associated with widened disparities in care between white and black patients, a recent study found.

The retrospective study included 50,029 ED encounters for severe sepsis or septic shock in New York State hospitals from April 1, 2014, to June 30, 2016. A 2013 state regulation required all nonfederal hospitals in New York to report in-hospital mortality and initiation and implementation of three- and six-hour protocols for the early detection and treatment of sepsis or septic shock. Results were published in the July Health Affairs.

The studied patients were 66.6% white, 17.3% black, 11.0% Hispanic, and 5.1% Asian. Black, Hispanic, and Asian patients were more likely than white patients to receive care at hospitals with more certified beds and at teaching hospitals; they were also more likely to live within New York City. In the first quarter of the studied period, there were no significant differences in unadjusted rates of three-hour protocol completion by racial group: white (60.8%), black (59.7%), Hispanic (62.6%), and Asian (58.8%). However, during follow-up, rates of three-hour protocol completion increased by 14.0 percentage points among white patients compared to 5.3 percentage points among black patients.

Improvements were 6.7 and 8.4 percentage points for Hispanic and Asian patients, respectively, but that did not represent a significant difference compared with white patients. White patients also experienced greater improvement in six-hour protocol completion than black patients (14.7 vs. 6.8 percentage points).

Sensitivity analyses showed that the disparity in use of three-hour protocols between white and black patients existed irrespective of where sepsis was first diagnosed (ED, ICU, or ward). However, the disparities were not found between patients of the two races treated in the same hospitals. Instead, the study found the disparities could be attributed to an inverse relationship in which hospitals with a higher proportion of black sepsis patients showed less improvement in use of the three-hour protocol.

“Our study suggests an urgent need to understand why improvements in sepsis care lagged in hospitals in New York that care for higher proportions of minority patients,” said the study authors. The findings also “raise concerns about the potential for broadly targeted quality improvement initiatives to exacerbate inequities in care,” they added. They noted that possible explanations for the findings include previous observations that minority-serving hospitals have fewer resources, less quality improvement infrastructure, more ED overcrowding, and worse nurse-to-patient ratios. The authors called for stratified reporting on quality improvement initiatives, attention to the potential negative effects of related financial incentives on minority-serving hospitals, and investigation into the causes of these disparities in order to potentially undertake efforts to remedy them.

ACP Hospitalist covered current controversies in sepsis care, including the New York State regulations, in a January 2019 article.