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Racial Variation in the Incidence, Care, and Outcomes of Severe Sepsis

Analysis of Population, Patient, and Hospital Characteristics

¹ Center for Research on Health Care, and ² Clinical Research, Investigation, and Systems Modeling of Acute Illness Laboratory, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; ³ Genentech, Inc., South San Francisco, California; and ⁴ ZD Associates, LLC, Perkasie, Pennsylvania

Correspondence and requests for reprints should be addressed to Amber E. Barnato, M.D., M.P.H., M.S., Center for Research on Health Care, 200 Meyran Ave., Suite 200, Pittsburgh, PA 15213. E-mail: aeb2{at}pitt.edu

Rationale: Higher rates of sepsis have been reported in minorities.

Objectives: To explore racial differences in the incidence and associated case fatality of severe sepsis, accounting for clinical, social, health care service delivery, and geographic characteristics.

Methods: Retrospective population-based cohort study using hospital discharge and U.S. Census data for all persons (n = 71,102,655) living in 68 hospital referral regions in six states.

Measurements and Main Results: Age-, sex- and race-standardized severe sepsis incidence and inpatient case fatality rates, adjusted incidence rate ratios, and adjusted intensive care unit (ICU) admission and case fatality rate differences. Of 8,938,111 nonfederal hospitalizations, 282,292 had severe sepsis. Overall, blacks had the highest age- and sex-standardized population-based incidence (6.08/1,000 vs. 4.06/1,000 for Hispanics and 3.58/1,000 for whites) and ICU case fatality (32.1 vs. 30.4% for Hispanics and 29.3% for whites, P < 0.0001). Adjusting for differences in poverty in their region of residence, blacks still had a higher population-based incidence of severe sepsis (adjusted rate ratio, 1.44 [95% CI, 1.42–1.46]) than whites, but Hispanics had a lower incidence (adjusted rate ratio, 0.91 [0.90–0.92]). Among patients with severe sepsis admitted to the ICU, adjustments for clinical characteristics and the treating hospital fully explained blacks' higher ICU case fatality.

Conclusions: Higher adjusted black incidence and the lower Hispanic incidence may reflect residual confounding, or it could signal biologic differences in susceptibility. Focused interventions to improve processes and outcomes of care at the hospitals that disproportionately treat blacks could narrow disparities in overall mortality from severe sepsis.

Key Words: severe sepsis • epidemiology • race • clinical practice variations

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject It has been reported that wide racial variation exists in the incidence of septicemia, with rates among nonwhites almost double those of whites. These observations persisted after adjusting for preexisting chronic illness and source of infection. What This Study Adds to the Field Higher adjusted black incidence and the lower Hispanic incidence in severe sepsis may reflect residual confounding, or could signal biologic differences in susceptibility.