Sepsis Care Discrepancy Found Between United States, Europe

Patients with sepsis or septic shock admitted to European intensive care units (ICUs) were more severely ill and had a 10% higher raw mortality rate compared with patients admitted to US ICUs, according to results from a comparison study published onlineOctober 26 in the Lancet Infectious Diseases. After adjusting for organ dysfunction and severity of illness, however, the mortality rates were comparable.

Mitchell M. Levy, MD, from the Division of Pulmonary and Critical Care Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, and international colleagues analyzed the records of 25,375 patients in US (18,766 patients) and European (6609 patients) hospitals who were admitted to 107 US hospital ICUs and 79 ICUs in Europe between January 2005 and January 2010.

Their primary goal was to assess whether hospitals were complying with international, evidence-based guidelines for resuscitation and management under the Surviving Sepsis Campaign (SSC). "Rates of compliance with sepsis care measures differed significantly between regions," the researchers write. For all applicable elements of SSC, US hospitals were more compliant (difference, 3.2%; 95% confidence interval [CI], 2.2% - 4.4%), whereas European hospitals were more compliant with the management elements of SSC (difference, 8.4%; 95% CI, 7.2% - 9.7%).

However, it was the difference in raw mortality rates, the researchers write, that "raises important questions." In unadjusted results, the odds of hospital death were 51% to 65% higher in Europe (P < .0001). Overall unadjusted hospital mortality was higher in Europe than in the United States (41.1% vs 28.3%; difference, 12.8%, 95% CI, 11.5% - 14.7%).

Pneumonia was the primary cause of sepsis in all patients, and on ICU admission, most patients had multiple organ failure and required mechanical ventilation. A higher percentage of US patients had more single-organ failures than patients in European hospitals. Overall, 8032 deaths (32%) occurred among 25,375 patients.

Most patients admitted to US ICUs came directly from emergency departments, whereas most European patients were admitted to ICUs from regular hospital wards. The researchers found that median lengths of stay were longer in Europe (difference, 3.6 days [95% CI, 3.3 - 3.7 days] for ICU stays; difference, 12.3 days [95% CI, 11.9 - 12.8 days] for hospital stays).

"These results raise important questions about the effect of the approach to critical care in Europe compared with that in the USA," Dr. Levy said in a news release. "Given the higher number of ICU beds per head in the USA than in Europe, more patients with less serious cases of sepsis might be admitted to the ICU. However, this is not at all clear from existing research, and further investigation is urgently needed if we are to be able to accurately monitor, and ultimately improve, sepsis care."

"The investigators identified important international differences in processes and outcomes of care, which, taken together, provide a convincing argument for the need to address variation in structure and process to reduce mortality from this lethal and complex disease," Julian Bion, MBBS, from the Queen Elizabeth Hospital and University of Birmingham, United Kingdom, writes in an accompanying commentary.

Limitations of the study include the fact that it was not a randomized study and that only patients admitted to ICUs were included, the researchers write. Data on patients just admitted to wards who were either treated and released or died were unavailable. In addition, the number of available ICU beds can vary among European countries and the United States.

Nevertheless, the researchers conclude, "[P]atients admitted to the ICU with severe sepsis and septic shock in Europe were more severely ill than those in the USA and had a 10% higher unadjusted mortality rate. This difference disappeared after adjustment for severity of illness and organ dysfunction. Patients admitted to ICUs with severe sepsis in Europe were also more frequently admitted from hospital wards, whereas those in the USA were more likely to be admitted directly to ICUs. This study raises questions about the effect of the different models of ICU resourcing and use."

This research was supported by Eli Lilly, Baxter Lifesciences, Philips Medical Systems, the Society of Critical Care Medicine, and the European Society of Intensive Care Medicine. One coauthor has reported receiving reimbursement for steering committee work by Eli Lilly and by Orion Pharma, has been a member of the advisory board of LiDCO and bioMérieux, and has received lecture fees from LiDCO and Edwards Lifesciences. One coauthor's department and institution have received payment for research support and honoraria from Eli Lilly and Philips Medical Systems. The other authors and the editorialist have disclosed no relevant financial relationships.