Implementation of a multifaceted sepsis education program in an emerging country setting: clinical outcomes and cost-effectiveness in a long-term follow-up study

Purpose: To evaluate whether a multifaceted, centrally coordinated quality improvement program in a network of hospitals can increase compliance with the resuscitation bundle and improve clinical and economic outcomes in an emerging country setting. Methods: This was a pre- and post-intervention study in ten private hospitals (1,650 beds) in Brazil (from May 2010 to January 2012), enrolling 2,120 patients with severe sepsis or septic shock. the program used a multifaceted approach: screening strategies, multidisciplinary educational sessions, case management, and continuous performance assessment. the network administration and an external consultant provided performance feedback and benchmarking within the network. the primary outcome was compliance with the resuscitation bundle. the secondary outcomes were hospital mortality, hospital and ICU length of stay, quality-adjusted life year (QALY) gain, and cost-effectiveness. Results: the proportion of patients who received all the required items for the resuscitation bundle improved from 13 % [95 % confidence interval (CI) 8-18 %] at baseline to 62 % (95 % CI 54-69 %) in the last trimester (p < 0.001). Hospital mortality decreased from 55 % (95 % CI 48-62 %) to 26 % (95 % CI 19-32 %, p < 0.001). Full compliance with the resuscitation bundle was associated with lower risk of hospital mortality (propensity weighted corrected risk ratio 0.74; 95 % CI 0.56-0.94, p = 0.02). There was a reduction in the total cost per patient from 29.3 (95 % CI 23.9-35.4) to 17.5 (95 % CI 14.3-21.1) thousand US dollars from baseline to the last 3 months (mean difference -11,815; 95 % CI -18,604 to -5,338). the mean QALY increased from 2.63 (95 % CI 2.15-3.14) to 4.06 (95 % CI 3.58-4.57). for each QALY, the full compliance saves US$5,383. Conclusions: A multifaceted approach to severe sepsis and septic shock patients in an emerging country setting led to high compliance with the resuscitation bundle. the intervention was cost-effective and associated with a reduction in mortality.Hosp Paulistano, Unidade Terapia Intens, BR-01321001 São Paulo, BrazilUniv São Paulo, Unidade Terapia Intens, Hosp Clin, Disciplina Emergencias Clin, BR-05403000 São Paulo, BrazilLatin Amer Sepsis Inst, BR-04039002 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, Disciplina Anestesiol, BR-04024900 São Paulo, BrazilUniversidade Federal de São Paulo, Escola Paulista Med, Disciplina Anestesiol, BR-04024900 São Paulo, BrazilWeb of Scienc

Assessment of Cardiovascular Disease Risk and Therapeutic Patterns among Urban Black Rheumatoid Arthritis Patients

Rheumatoid arthritis (RA) patients have nearly twice the risk of cardiovascular disease (CVD) compared to the general population. We aimed to assess, in a predominantly Black population, the prevalence of traditional and RA-specific CVD risk factors and therapeutic patterns. Utilizing ICD codes, we identified 503 RA patients &#8805;18 years old who were seen from 2010 to 2017. Of them, 88.5% were Black, 87.9% were women and 29.4% were smokers. CVD risk factors (obesity, diabetes, hypertension, dyslipidemia) were higher than in previously reported White RA cohorts. Eighty-seven percent of the patients had at least one traditional CVD risk factor, 37% had three or more traditional CVD risk factors and 58% had RA-specific risk factors (seropositive RA, &gt;10 years of disease, joint erosions, elevated inflammatory markers, extra-articular disease, body mass index (BMI) &lt; 20). CV outcomes (coronary artery disease/myocardial infarction, heart failure, atrial fibrillation and stroke) were comparable to published reports. Higher steroid use, which increases CVD risk, and lesser utilization of biologics (decrease CV risk) were also observed. Our Black RA cohort had higher rates of traditional CVD risk factors, in addition to chronic inflammation from aggressive RA, which places our patients at a higher risk for CVD outcomes, calling for revised risk stratification strategies and effective interventions to address comorbidities in this vulnerable population