Sepsis tends to be more common and lethal in US racial and ethnic minority populations. Is it the patient, the care they receive, or both? Historically, excess mortality from acute illnesses in racial and ethnic minority populations was often simplistically thought to be linked to unchecked chronic illnesses and lower access to care. Other social determinants of health as well as factors such as who is caring for these patients (eg, implicit bias and triage) and where (eg, hospital infrastructure and care quality) have garnered more attention in recent years. Exacerbation of health disparities during the COVID-19 pandemic poignantly demonstrated that there was more to the story. While some of these factors might arguably be modifiable, identifying these factors and isolating their individual impact is difficult. Available data sources are not all encompassing. They often lack the granularity and interoperability needed to isolate and counter modifiable factors associated with disparities in sepsis outcomes. As sepsis is a leading cause of hospital death, the magnitude of this lingering disparity is catapulted on a population scale, warranting urgent action to advance research on mitigation strategies.
The role of hospital performance in sepsis care might be further highlighted by understanding the difference in sepsis outcomes on what is considered a good day vs a bad day at the hospital. Hospital surge strain, conceptualized as the resource burden an overcrowded hospital faces relative to its baseline, is a time-varying hospital-level factor that might help evince such bad days. Many hospitals encountered caseload surges during the pandemic that stressed resources and capacity, and more than 80% of pandemic studies found surge strain to lead to higher mortality. The association between hospital strain and health disparity-related outcomes among patients with sepsis has yet to be fully explored. The COVID-19 pandemic allows for a natural experiment putting sepsis quality of care to the test at hospitals that were overcrowded with patients with COVID-19.
The study by Glance et al uses the Medicare database to examine whether hospital strain was worse for older adults hospitalized for severe sepsis and whether racial and ethnic minority groups within this population had worse outcomes based on hospital strain. Their primary outcome was a composite of all-cause 30-day mortality and major morbidity. The authors used the burden of patients with COVID-19 that a hospital was experiencing at any week as a proxy for surge strain and assessed whether patients had worse outcomes at different degrees of strain. Glance et al went a step further to compare outcomes among racial and ethnic minority populations compared with White individuals during these varying levels of hospital strain.
There were several notable findings. First, there was no significant difference in mortality between racial and ethnic groups before the pandemic. Second, the risk of death and major morbidity increased as the proportion of COVID-19 hospitalizations increased, suggesting that higher levels of hospital strain led to worse outcomes. Third, the authors found that patients who identified as Asian, Black, and Hispanic had worse outcomes compared with White individuals at nearly every degree of strain. Disparities in COVID-19 outcomes by race and ethnicity have been observed in earlier studies. However, the findings by Glance et al persisted even after excluding patients with COVID-19. The differences also were present in Asian and Hispanic populations, albeit to a lower magnitude, when excluding patients during the first 5 months of the pandemic, suggesting that these observed inequities extend beyond the virus or the initial period of the pandemic. In fact, when hospitals faced a COVID-19 burden greater than 40% (their highest surge stratum), Asian, Black, and Hispanic individuals experienced a nearly 50% greater risk of death compared with White individuals, suggesting that there might be a dose-dependent effect of surge strain in observed disparities.
Research on racial and ethnic disparities in sepsis is divided into 2 groups: one showing worse outcomes and the other showing no major differences. Glance et al provide an important nuance that begins to unpack the conflicting evidence by successfully observing differences in sepsis outcomes among racial and ethnic minority populations that did not exist before a period of intense surge. Their analysis among patients with sepsis not due to COVID-19, combined with the finding of worse outcomes among patients of racial and ethnic minority status at every degree of strain, reminds us that hospital determinants can be key factors associated with health disparities.
The findings from Glance et al present the question: What is the basis of these disparities? Perhaps the competition for resources and diminished capacity among frontline workers were factors associated with worse sepsis outcomes. The authors missed an opportunity to evaluate this further. Their model could have explored outcome variations within and across hospital types, as well as how health care system affiliation with more baseline resources affected outcomes. While COVID-19 case burden is an interesting metric of surge, it is an imperfect proxy for resource allocation or intensity. For example, a patient with COVID-19 requiring extracorporeal membrane oxygenation stresses the system differently than a patient only requiring 2 L of oxygen. The lack of information about the source of infection, as well as the severity of illness on presentation and during the hospitalization, are additional unmeasured confounders not uncommon to analyses from administrative data.
As a community, we need to innovate better methods for examining the complex multifaceted association between racial and ethnic health disparities and sepsis. We need improved impartial tools to recognize and diagnose sepsis. Studies show that even basic tests measuring organ failure, such as pulse oximetry and calculating the glomerular filtration rate, have been shown to be biased against minoritized groups, which, compounded by implicit bias from health care professionals, can affect our assessments for acute illness severity. Objective operational definitions of sepsis embedded in electronic health records show promise but still only capture treated sepsis. Prospective cohort studies that encompass standardized measurements and systematic collection of granular qualitative data and causal inference techniques might help decrease noise and elucidate whether and why differences exist in sepsis outcomes among racial and ethnic minority populations. We also need to do a better job drawing from the experiences of patients and families to identify implicit bias among health care professionals and structural bias encoded in health systems that contribute to sepsis inequities. The path forward also requires us to better evaluate long-term outcomes of minoritized populations who survive sepsis and counter a potentially hidden longitudinal component to the health disparities uncovered by Glance and colleagues.
It is essential that we better understand why variations still exist in sepsis outcomes between hospitals. As the business of health care continues to move toward a value-based care model, there is a risk that financial penalties for poor performance can exacerbate the preexisting health disparities. In an earlier study, safety-net hospitals serving primarily populations of racial and ethnic minority and low socioeconomic status have been reported to have lower performance on the sepsis quality measure Severe Sepsis and Septic Shock Management Bundle. Root-cause analyses that identify vulnerabilities in care models and settings might prompt solutions for policymakers, payers, and health system leaders to safeguard against inequities introduced by reforming policies applied uniformly across the spectrum of health care.
Glance et al should be commended for their work. It serves as a launching point for future research that leverages surge strain to reveal mechanisms of disparity. While the pandemic strain has improved, we continue to have ongoing staffing shortages and can anticipate future strain during respiratory viral seasons -- not to mention other unforeseen events. It is vital that we explore these issues now to prepare for the future. We eagerly anticipate future work that will identify novel ways to tackle disparities in sepsis outcomes.
Corresponding Author: Sameer S. Kadri, MD, MS, Critical Care Medicine Department, National Institutes of Health Clinical Center, 10 Center Dr B10, 2C145, Bethesda, MD 20892 ([email protected]).
Conflict of Interest Disclosures: None reported.
Disclaimer: The thoughts expressed in this commentary are solely those of the authors and do not represent the views of the National Institutes of Health or the US government.