Nicholas M Mohr1, Karisa K Harland, Dan M Shane, Azeemuddin Ahmed, Brian M Fuller, Marcia M Ward, James C Torner. 1. 1Department of Emergency Medicine, University of Iowa College of Medicine, Iowa City, IA. 2Division of Critical Care, Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA. 3Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA. 4Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO. 5Division of Critical Care, Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO. 6Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA.
Abstract
OBJECTIVE: To identify factors associated with rural sepsis patients' bypassing rural emergency departments to seek emergency care in larger hospitals, and to measure the association between rural hospital bypass and sepsis survival. DESIGN: Observational cohort study. SETTING: Emergency departments of a rural Midwestern state. PATIENTS: All adults treated with severe sepsis or septic shock between 2005 and 2014, using administrative claims data. INTERVENTIONS: Patients bypassing local rural hospitals to seek care in larger hospitals. MEASUREMENTS AND MAIN RESULTS: A total of 13,461 patients were included, and only 5.4% (n = 731) bypassed a rural hospital for their emergency department care. Patients who initially chose a top-decile sepsis volume hospital were younger (64.7 vs 72.7 yr; p < 0.001) and were more likely to have commercial insurance (19.6% vs 10.6%; p < 0.001) than those who were seen initially at a local rural hospital. They were also more likely to have significant medical comorbidities, such as liver failure (9.9% vs 4.2%; p < 0.001), metastatic cancer (5.9% vs 3.2%; p < 0.001), and diabetes with complications (25.2% vs 21.6%; p = 0.024). Using an instrumental variables approach, rural hospital bypass was associated with a 5.6% increase (95% CI, 2.2-8.9%) in mortality. CONCLUSIONS: Most rural patients with sepsis seek care in local emergency departments, but demographic and disease-oriented factors are associated with rural hospital bypass. Rural hospital bypass is independently associated with increased mortality.
OBJECTIVE: To identify factors associated with rural sepsispatients' bypassing rural emergency departments to seek emergency care in larger hospitals, and to measure the association between rural hospital bypass and sepsis survival. DESIGN: Observational cohort study. SETTING: Emergency departments of a rural Midwestern state. PATIENTS: All adults treated with severe sepsis or septic shock between 2005 and 2014, using administrative claims data. INTERVENTIONS:Patients bypassing local rural hospitals to seek care in larger hospitals. MEASUREMENTS AND MAIN RESULTS: A total of 13,461 patients were included, and only 5.4% (n = 731) bypassed a rural hospital for their emergency department care. Patients who initially chose a top-decile sepsis volume hospital were younger (64.7 vs 72.7 yr; p < 0.001) and were more likely to have commercial insurance (19.6% vs 10.6%; p < 0.001) than those who were seen initially at a local rural hospital. They were also more likely to have significant medical comorbidities, such as liver failure (9.9% vs 4.2%; p < 0.001), metastatic cancer (5.9% vs 3.2%; p < 0.001), and diabetes with complications (25.2% vs 21.6%; p = 0.024). Using an instrumental variables approach, rural hospital bypass was associated with a 5.6% increase (95% CI, 2.2-8.9%) in mortality. CONCLUSIONS: Most rural patients with sepsis seek care in local emergency departments, but demographic and disease-oriented factors are associated with rural hospital bypass. Rural hospital bypass is independently associated with increased mortality.
Authors: Nicholas M Mohr; Terrence S Wong; Brett Faine; Adam Schlichting; Joseph Noack; Azeemuddin Ahmed Journal: J Rural Health Date: 2015-07-14 Impact factor: 4.333
Authors: M Kit Delgado; Michael A Yokell; Kristan L Staudenmayer; David A Spain; Tina Hernandez-Boussard; N Ewen Wang Journal: JAMA Surg Date: 2014-05 Impact factor: 14.766
Authors: Brett A Faine; Joseph M Noack; Terrance Wong; Jeffrey T Messerly; Azeemuddin Ahmed; Brian M Fuller; Nicholas M Mohr Journal: Crit Care Med Date: 2015-12 Impact factor: 7.598
Authors: Donald B Chalfin; Stephen Trzeciak; Antonios Likourezos; Brigitte M Baumann; R Phillip Dellinger Journal: Crit Care Med Date: 2007-06 Impact factor: 7.598
Authors: Steven A Ilko; J Priyanka Vakkalanka; Azeemuddin Ahmed; Karisa K Harland; Nicholas M Mohr Journal: Crit Care Med Date: 2019-05 Impact factor: 7.598
Authors: Margaret Greenwood-Ericksen; Neil Kamdar; Paul Lin; Naomi George; Larissa Myaskovsky; Cameron Crandall; Nicholas M Mohr; Keith E Kocher Journal: JAMA Netw Open Date: 2021-11-01
Authors: Nicholas M Mohr; Karisa K Harland; Uche E Okoro; Brian M Fuller; Kalyn Campbell; Morgan B Swanson; Stephen Q Simpson; Edith A Parker; Luke J Mack; Amanda Bell; Katie DeJong; Brett Faine; Anne Zepeski; Keith Mueller; Elizabeth Chrischilles; Christopher R Carpenter; Michael P Jones; Marcia M Ward Journal: J Comp Eff Res Date: 2021-01-20 Impact factor: 1.744
Authors: Nicholas M Mohr; Kalyn D Campbell; Morgan B Swanson; Fred Ullrich; Kimberly A Merchant; Marcia M Ward Journal: J Telemed Telecare Date: 2020-01-05 Impact factor: 6.344