Is sepsis mortality rate driven by differences in Brazilian healthcare systems?

Introduction

The sepsis mortality rate is higher in Brazilian public hospitals with no clear differences in risk factors. We aim to identify risk factors that could explain why the mortality rate is different in public and private hospitals.

Methods

All severe sepsis and septic shock patients over 18 years old admitted to two private ICUs (Group 1) and one public ICU (Group 2) were prospectively included. Demographic, clinical and outcome features, including compliance to the 6-hour Surviving Sepsis Campaign bundle (SSC-6 h), were collected in an electronic CRF. Duration of organ dysfunction was defined as the time elapsed between the installation of the dysfunction and its diagnosis by the healthcare provider. Results were expressed as a percentage or as median and interquartiles, and P < 0.05 was considered significant.

Results

Three hundred and eighty-six patients were included (Group 1 - 210, Group 2 - 176). Patients from Group 1 were older (69.5 (53.0 to 81.0) years vs 59.0 (43.5 to 73.5) years, P < 0.000), had a higher APACHE II score (19.0 (15.0 to 23.0) vs 17.0 (13.0 to 23.0), P = 0.01), had more organ dysfunctions (3.0 (2.0 to 4.0) vs 2.0 (2.0 to 4.00), P = 0.08), and more septic shock episodes (74.3% vs 60.8%, P = 0.006). No difference was found regarding gender, site of infection, and day 1 or day 3 delta SOFA score. However, the mortality rate was higher in Group 2 than in Group 1, 60.8 and 38.3, respectively. Compliance to the SSC-6 h bundle did not explain this difference as they were better in Group 2 for lactate (70.5% vs 49.8%), blood culture (61.4% vs 52.4%), achieving MAP >65 mmHg (98.8% vs 90.5%), and completion of the bundle (15.9% vs 4.8%). Only antibiotics (63.3% vs 54.5%, P = 0.10) and CVP had a better performance in Group 1 (49.4% vs 33.3%, P = 0.01). SOFA score at admission was slightly higher on Group 2 (7.0 (4.0 to 9.0) vs 8.0 (5.5 to 10.0), P = 0.004). However, duration of organ dysfunction was clearly longer in Group 2 (150.0 (0.0 to 650) minutes vs 360.0 (0.0 to 1008.0) minutes, P = 0.02). In all patients, we have identified some variables associated with mortality, including being in the public hospital (OR 2.46 (1.63 to 3.72), P = 0.00002), as well as the median duration of organ dysfunction, SOFA at admission, age, APACHE II score and number of organ dysfunctions.

Conclusions

The mortality rate was higher in the public hospital despite better SSC bundle adherence. A delay in initiating those interventions may negatively impact the outcome in patients treated in public hospital.