Hospital Variation in Risk-Adjusted Pediatric Sepsis Mortality

Objectives: With continued attention to pediatric sepsis at both the clinical and policy levels, it is important to understand the quality of hospitals in terms of their pediatric sepsis mortality. We sought to develop a method to evaluate hospital pediatric sepsis performance using 30-day risk-adjusted mortality and to assess hospital variation in risk-adjusted sepsis mortality in a large state-wide sample. Design: Retrospective cohort study using administrative claims data. Settings: Acute care hospitals in the state of Pennsylvania from 2011 to 2013. Patients: Patients between the ages of 0–19 years admitted to a hospital with sepsis defined using validated International Classification of Diseases, Ninth revision, Clinical Modification, diagnosis and procedure codes. Interventions: None. Measurements and Main Results: During the study period, there were 9,013 pediatric sepsis encounters in 153 hospitals. After excluding repeat visits and hospitals with annual patient volumes too small to reliably assess hospital performance, there were 6,468 unique encounters in 24 hospitals. The overall unadjusted mortality rate was 6.5% (range across all hospitals: 1.5–11.9%). The median number of pediatric sepsis cases per hospital was 67 (range across all hospitals: 30–1,858). A hierarchical logistic regression model for 30-day risk-adjusted mortality controlling for patient age, gender, emergency department admission, infection source, presence of organ dysfunction at admission, and presence of chronic complex conditions showed good discrimination (C-statistic = 0.80) and calibration (slope and intercept of calibration plot: 0.95 and –0.01, respectively). The hospital-specific risk-adjusted mortality rates calculated from this model varied minimally, ranging from 6.0% to 7.4%. Conclusions: Although a risk-adjustment model for 30-day pediatric sepsis mortality had good performance characteristics, the use of risk-adjusted mortality rates as a hospital quality measure in pediatric sepsis is not useful due to the low volume of cases at most hospitals. Novel metrics to evaluate the quality of pediatric sepsis care are needed. Supported, in part, by United States National Institutes of Health (R01HL126694 and K24HL133444). Drs. Davis and Kahn received support for article research from the National Institutes of Health (NIH). Dr. Davis’ institution received funding from the NIH, and she disclosed work for hire. Dr. Kahn’s institution received funding from the NIH. The remaining authors have disclosed that they do not have any potential conflicts of interest ©2018The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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