Area Deprivation Index and Trauma Status Associate with Increased Mortality in Transferred Surgical Patients with Sepsis
Author(s):
Anahita Jalilvand; Courtney Collins; Whitney Kellett; Megan Ireland; Emily Daron; Wendy Wahl; Jon Wisler
Background:
Within our quaternary surgical ICU, approximately 50% of patients are transfers from outlying facilities. We have previously shown that transfer status associate with increased 90-day mortality for surgical patients with sepsis. Given their increased mortality and high prevalence of transfers into the ICU, the primary objective of this study was to identify predictors of mortality within this cohort.
Hypothesis:
We hypothesized that mortality in the transfer cohort would be associated with higher disease severity and baseline comorbidity status.
Methods:
A single-institution retrospective analysis of transferred patients admitted to the SICU with sepsis was performed (2014-2019, n=660). Baseline comorbidities, area deprivation index (ADI), antecedent trauma status, sepsis presentation, and outcomes were compared between those who survived (n=410) and died within 90 days (n=250). A multiple logistic regression was performed to determine independent predictors of cumulative 90-day mortality within the transfer cohort. A p <0.05 was considered statistically significant.
Results:
Compared to those who survived, transfer patients who died were older (67.5 ± 14.0 vs 59.0 ± 14.8, p<0.005), more likely to be African American (8.4% vs 3.7%, p =0.002), experience antecedent trauma
(9% vs 4%, p=0.01), and present with higher Charlson Comorbidity Index (CCI) (5 (3-7) vs 2.5 (1-4), p<0.05). Socioeconomic distress (high ADI) was more prevalent in those who died (37.5% vs 29%, p=0.03). Median SOFA score, vasopressor use, and admission lactate were significantly elevated within the cohort that died. Compared to survivors, mortalities were more likely to present with intra-abdominal catastrophes (78% vs 58%, p<0.05) necessitating exploratory laparotomies (66% vs 51%, p=0.001). Notable independent predictors of cumulative 90-day mortality included high ADI (OR 2.4, 95th 1.4-3.9), trauma status (OR 6.7, 95th CI:3-20), and intra-abdominal sepsis (OR 9.4, 95th CI:1-70), after adjusting for age, race, CCI, SOFA, and serum lactate.
Conclusions:
While mortality within the transfer cohort was partly due to higher sepsis severity and comorbidity status, socioeconomic distress and antecedent trauma were also independent predictors. Further studies should elucidate how these variables impart their mortality risk and whether there are actionable events that can be taken to reduce the disparity in outcomes.