Mitigating structural racism to reduce inequities in sepsis outcomes: a mixed methods, longitudinal intervention study

Linnander, Erika; Ayedun, Adeola; Boatright, Dowin; Ackerman-Barger, Kupiri; Morgenthaler, Timothy I.; Ray, Natasha; Roy, Brita; Simpson, Steven Q.; Curry, Leslie

doi:10.1186/s12913-022-08331-5

Cited by 8 publications

(5 citation statements)

References 91 publications

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“…Declaratively labeling a patient as "septic" may create an "upward spiral" of care team learning and expertise, creating shared experiences and expectations (31). Order sets are a structural element of quality that could be used to decrease disparities in processes of care and health outcomes (32). In our study, order set usage was associated with improved outcomes in all race/ethnicity categories.…”

Section: Observational Studymentioning

confidence: 64%

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Order Set Usage is Associated With Lower Hospital Mortality in Patients With Sepsis

Dale,

Schoepflin Sanders,

Chang

et al. 2023

Critical Care Explorations

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IMPORTANCE: The Surviving Sepsis Campaign recommends standard operating procedures for patients with sepsis. Real-world evidence about sepsis order set implementation is limited. OBJECTIVES: To estimate the effect of sepsis order set usage on hospital mortality. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Fifty-four acute care hospitals in the United States from December 1, 2020 to November 30, 2022 involving 104,662 patients hospitalized for sepsis. MAIN OUTCOMES AND MEASURES: Hospital mortality. RESULTS: The sepsis order set was used in 58,091 (55.5%) patients with sepsis. Initial mean sequential organ failure assessment score was 0.3 lower in patients for whom the order set was used than in those for whom it was not used (2.9 sd [2.8] vs 3.2 [3.1], p < 0.01). In bivariate analysis, hospital mortality was 6.3% lower in patients for whom the sepsis order set was used (9.7% vs 16.0%, p < 0.01), median time from emergency department triage to antibiotics was 54 minutes less (125 interquartile range [IQR, 68–221] vs 179 [98–379], p < 0.01), and median total time hypotensive was 2.1 hours less (5.5 IQR [2.0–15.0] vs 7.6 [2.5–21.8], p < 0.01) and septic shock was 3.2% less common (22.0% vs 25.4%, p < 0.01). Order set use was associated with 1.1 fewer median days of hospitalization (4.9 [2.8–9.0] vs 6.0 [3.2–12.1], p < 0.01), and 6.6% more patients discharged to home (61.4% vs 54.8%, p < 0.01). In the multivariable model, sepsis order set use was independently associated with lower hospital mortality (odds ratio 0.70; 95% CI, 0.66–0.73). CONCLUSIONS AND RELEVANCE: In a cohort of patients hospitalized with sepsis, order set use was independently associated with lower hospital mortality. Order sets can impact large-scale quality improvement efforts.

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Section: Observational Studymentioning

confidence: 64%

“…Order sets are a structural element of quality that could be used to decrease disparities in processes of care and health outcomes ( 32 ). In our study, order set usage was associated with improved outcomes in all race/ethnicity categories.…”

Section: Discussionmentioning

confidence: 99%

Order Set Usage is Associated With Lower Hospital Mortality in Patients With Sepsis

Dale,

Schoepflin Sanders,

Chang

et al. 2023

Critical Care Explorations

View full text Add to dashboard Cite

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“…This is particularly pertinent in light of our identification of implicit bias and structural racism as underlying factors contributing to non-adherence, which are critical to address in the pursuit of equitable healthcare. 31,32 While our study's EHR-based nature significantly enhances its applicability, there are several limitations. First, this study employed qualitative analysis of EHR data, which does not yield detailed descriptive statistics regarding instances of non-adherence to clinical guideline at our institution.…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Barriers to Optimal Clinician Guideline Adherence in the Management of Markedly Elevated Blood Pressure: A Qualitative Content Analysis of Electronic Health Records

Lu,

Arowojolu,

Qiu

et al. 2024

Preprint

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IMPORTANCE: Hypertension poses a significant public health challenge. Despite clinical practice guidelines for hypertension management, clinician adherence to these guidelines remains suboptimal. OBJECTIVE: This study aims to develop a taxonomy of suboptimal adherence scenarios for severe hypertension and identify barriers to guideline adherence. DESIGN: We conducted a qualitative content analysis using electronic health records (EHRs) of Yale New Haven Health System who had at least two consecutive visits between January 1, 2013, and October 31, 2018. SETTING: This was a thematic analysis of EHR data to generate a real-world taxonomy of scenarios of suboptimal clinician guideline adherence in the management of severe hypertension. PARTICIPANTS: We identified patients with markedly elevated blood pressure ([BP]; defined as at least 2 consecutive readings of BP ≥160/100 mmHg) and no prescription for antihypertensive medication within a 90-day of the 2nd BP elevation (n=4,828). We randomly selected 100 records from the group of all eligible patients for qualitative analysis. MAIN OUTCOMES AND MEASURES: The scenarios and influencing factors contributing to clinician non-adherence to the guidelines for hypertension management. RESULTS: Thematic saturation was reached after analyzing 100 patient records. Three content domains emerged: clinician-related scenarios (neglect and diffusion of responsibility), patient-related scenarios (patient non-adherence and patient preference), and clinical complexity-related scenarios (diagnostic uncertainty, maintenance of current intervention and competing medical priorities). Through a metareview of literature, we identified several plausible influencing factors, including a lack of protocols and processes that clearly define the roles within the institution to implement guidelines, infrastructure limitations, and clinicians lack of autonomy and authority, excessive workload, time constraints, clinician belief that intervention was not part of their role, or perception that guidelines restrict clinical judgment. CONCLUSIONS AND RELEVANCE: This study illuminates reasons for suboptimal adherence to guidelines for managing markedly elevated BP. The taxonomy of suboptimal adherence scenarios, derived from real-world EHR data, is pragmatic and provides a basis for developing targeted interventions to improve clinician guideline adherence and patient outcomes.

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“…32,33 JAMA Network Open | CardiologyBarriers to Clinician Guideline Adherence in Management of Severe Hypertension…”

mentioning

confidence: 99%

Barriers to Optimal Clinician Guideline Adherence in Management of Markedly Elevated Blood Pressure

Lu,

Arowojolu,

Qiu

et al. 2024

JAMA Netw Open

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IMPORTANCEHypertension poses a substantial public health challenge. Despite clinical practice guidelines for hypertension management, clinician adherence to these guidelines remains suboptimal.OBJECTIVETo develop a taxonomy of suboptimal adherence scenarios for severe hypertension and identify barriers to guideline adherence.DESIGN, SETTING, and PARTICIPANTSThis qualitative content analysis using electronic health records (EHRs) of Yale New Haven Health System included participants who had at least 2 consecutive visits with markedly elevated blood pressure (BP; defined as at least 2 consecutive readings of systolic BP ≥160 mm Hg and diastolic BP ≥100 mm Hg) between January 1, 2013, and December 31, 2021, and no prescription for antihypertensive medication within a 90 days of the second BP measurement. Data analysis was conducted from January to December 2023.MAIN OUTCOMES AND MEASURESThe primary outcome was scenarios and influencing factors contributing to clinician nonadherence to the guidelines for hypertension management. A thematic analysis of EHR data was conducted to generate a pragmatic taxonomy of scenarios of suboptimal clinician guideline adherence in the management of severe hypertension.RESULTSOf the 20 654 patients who met criteria, 200 were randomly selected and thematic saturation was reached after analyzing 100 patients (mean [SD] age at index visit, 66.5 [12.8] years; 50 female [50%]; 8 Black [8%]; 5 Hispanic or Latino [5%]; 85 White [85%]). Three content domains emerged: (1) clinician-related scenarios (defined as noninitiation or nonintensification of treatment due to issues relating to clinician intention, capability, or scope), which included 2 subcategories (did not address and diffusion of responsibility); (2) patient-related scenarios (defined as noninitiation or nonintensification of treatment due to patient behavioral considerations), which included 2 subcategories (patient nonadherence and patient preference); and (3) clinical complexity–related scenarios (defined as noninitiation or nonintensification of treatment due to clinical situational complexities), which included 3 subcategories (diagnostic uncertainty, maintenance of current intervention, and competing medical priorities).CONCLUSIONS AND RELEVANCEIn this qualitative study of EHR data, a taxonomy of suboptimal adherence scenarios for severe hypertension was developed and barriers to guideline adherence were identified. This pragmatic taxonomy lays the foundation for developing targeted interventions to improve clinician adherence to guidelines and patient outcomes.

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Mitigating structural racism to reduce inequities in sepsis outcomes: a mixed methods, longitudinal intervention study

Cited by 8 publications

References 91 publications

Order Set Usage is Associated With Lower Hospital Mortality in Patients With Sepsis

Order Set Usage is Associated With Lower Hospital Mortality in Patients With Sepsis

Barriers to Optimal Clinician Guideline Adherence in the Management of Markedly Elevated Blood Pressure: A Qualitative Content Analysis of Electronic Health Records

Barriers to Optimal Clinician Guideline Adherence in Management of Markedly Elevated Blood Pressure

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