Effects of Compliance with the Early Management Bundle (SEP-1) on Mortality Changes among Medicare Beneficiaries with Sepsis: A Propensity Score Matched Cohort Study.

Abstract

BACKGROUND\nU.S. hospitals have reported compliance with the SEP-1 quality measure to Medicare since 2015. Finding an association between compliance and outcomes is essential to gauge measure effectiveness.\n\n\nRESEARCH QUESTION\nWhat is the association between compliance with SEP-1 and 30-day mortality among Medicare beneficiaries?\n\n\nSTUDY DESIGN AND METHODS\nStudying patient-level data reported to Medicare by 3,241 hospitals from October 1, 2015 to March 31, 2017, we used propensity score matching and a hierarchical general linear model (HGLM) to estimate the treatment effects associated with compliance with SEP-1. Compliance was defined as completion of all qualifying SEP-1 elements including lactate measurements, blood culture collection, broad-spectrum antibiotic administration, 30 ml/kg crystalloid fluid administration, application of vasopressors, and patient reassessment. The primary outcome was a change in 30-day mortality. Secondary outcomes included changes in length-of-stay.\n\n\nRESULTS\nWe completed two matches to evaluate population-level treatment effects. In Standard-match 122,870 patients whose care was compliant were matched with the same number whose care was non-compliant. Compliance was associated with a reduction in 30-day mortality: 21.81% versus 27.48% yielding an ARR of 5.67% (95% confidence interval [CI]: 5.33-6.00; P < 0.001). In Stringent-match 107,016 patients whose care was compliant were matched with the same number whose care was non-compliant. Compliance was associated with a reduction in 30-day mortality: 22.22% versus 26.28% yielding an ARR of 4.06% (95% CI: 3.70-4.41; P < 0.001). At the subject-level, our HGLM model found compliance associated with lower 30-day risk-adjusted mortality (adjusted conditional odds ratio = 0.829; 95% CI: 0.812-0.846; P < 0001). Multiple elements correlated with lower mortality. Median length-of-stay was shorter among cases whose care was compliant (5 vs. 6 days; IQR: 3-9 vs. 4-10; P < 0.001).\n\n\nINTERPRETATION\nCompliance with SEP-1 was associated with lower 30-day mortality. Rendering SEP-1 compliant care may reduce the incidence of avoidable deaths.