title: Temporal Changes in the Influence of Hospitals and Regional Healthcare Networks on Severe Sepsis Mortality.
abstract: OBJECTIVE
  There is systematic variation between hospitals in their care of severe sepsis, but little information on whether this variation impacts sepsis-related mortality, or how hospitals' and health-systems' impacts have changed over time. We examined whether hospital and regional organization of severe sepsis care is associated with meaningful differences in 30-day mortality in a large integrated health care system, and the extent to which those effects are stable over time.
  
  
  METHODS
  In this retrospective cohort study, we used risk- and reliability-adjusted hierarchical logistic regression to estimate hospital- and region-level random effects after controlling for severity of illness using a rich mix of administrative and clinical laboratory data.
  
  
  METHODS
  One hundred fourteen U.S. Department of Veterans Affairs hospitals in 21 geographic regions.
  
  
  METHODS
  Forty-three thousand seven hundred thirty-three patients with severe sepsis in 2012, compared to 33,095 such patients in 2008.
  
  
  METHODS
  None.
  
  
  RESULTS
  The median hospital in the worst quintile of performers had a risk-adjusted 30-day mortality of 16.7% (95% CI, 13.5%, 20.5%) in 2012 compared with the best quintile, which had a risk-adjusted mortality of 12.8% (95% CI, 10.7%, 15.3%). Hospitals and regions explained a statistically and clinically significant proportion of the variation in patient outcomes. Thirty-day mortality after severe sepsis declined from 18.3% in 2008 to 14.7% in 2012 despite very similar severity of illness between years. The proportion of the variance in sepsis-related mortality explained by hospitals and regions was stable between 2008 and 2012.
  
  
  CONCLUSIONS
  In this large integrated healthcare system, there is clinically significant variation in sepsis-related mortality associated with hospitals and regions. The proportion of variance explained by hospitals and regions has been stable over time, although sepsis-related mortality has declined.
authors: 1Division of Pulmonary and Critical Care Medicine and Institute of Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI. 2VA Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, MI.
authors: Hallie C
authors: HC
authors: Prescott
authors: Kyle M
authors: KM
authors: Kepreos
authors: Wyndy L
authors: WL
authors: Wiitala
authors: Theodore J
authors: TJ
authors: Iwashyna
mesh_terms: D000368:Aged; D015331:Cohort Studies; D003695:Delivery of Health Care; D005260:Female; D006761:Hospitals; D006801:Humans; D008297:Male; D063868:Patient Outcome Assessment; D012189:Retrospective Studies; D018805:Sepsis / Q000401:mortality* / Q000628:therapy*; D013997:Time Factors; D014481:United States; D014493:United States Department of Veterans Affairs