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Methodology

24 May 2022

An economic and health outcome evaluation of telehealth in rural sepsis care: a comparative effectiveness study

Publication: Journal of Comparative Effectiveness Research

Volume 11, Number 10

https://doi.org/10.2217/cer-2022-0019

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Abstract

Aim: Sepsis is a top contributor to in-hospital mortality and, healthcare expenditures and telehealth have been shown to improve short-term sepsis care in rural hospitals. This study will evaluate the effect of provider-to-provider video telehealth in rural emergency departments (EDs) on healthcare costs and long-term outcomes for sepsis patients. Materials & methods: We will use Medicare administrative claims to compare total healthcare expenditures, mortality, length-of-stay, readmissions, and category-specific costs between telehealth-subscribing and control hospitals. Results: The results of this work will demonstrate the extent to which telehealth use is associated with total healthcare expenditures for sepsis care. Conclusion: These findings will be important to inform future policy initiatives to improve sepsis care in rural EDs.

Clinical Trial Registration: NCT05072145 (ClinicalTrials.gov)

Plain language summary

Sepsis is a severe condition that results from infection. In addition to costly care, sepsis is a leading cause of death and disability. When comparing outcomes, those treated for sepsis in lower volume emergency departments fare worse and rural emergency departments often have lower patient volumes. While telehealth has been shown to improve sepsis care, the effect of telehealth on costs and long-term outcomes for patients is unclear. This study will use Medicare claims data to compare outcomes for people with sepsis in rural emergency departments who had video telehealth used with those who did not have video telehealth used, with the goal of measuring how telehealth affects healthcare costs, hospital readmissions and deaths after hospital discharge.

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References

Papers of special note have been highlighted as: • of interest; •• of considerable interest

1.

Rhee C, Dantes R, Epstein L et al. Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009–2014. JAMA 318(13), 1241–1249 (2017).

2.

Iwashyna TJ, Ely EW, Smith DM, Langa KM. Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 304(16), 1787–1794 (2010).

3.

Prescott HC, Osterholzer JJ, Langa KM, Angus DC, Iwashyna TJ. Late mortality after sepsis: propensity matched cohort study. BMJ 353, i2375 (2016).

4.

Buchman TG, Simpson SQ, Sciarretta KL et al. Sepsis Among Medicare Beneficiaries: 1. The Burdens of Sepsis, 2012–2018. Crit. Care Med. 48(3), 276–288 (2020).

5.

Mcdermott KW, Roemer M. Most Frequent Principal Diagnoses for Inpatient Stays in U.S. Hospitals, 2018: Statistical Brief #277. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Agency for Healthcare Research and Quality (US), MD, USA (2006).

6.

Rhodes A, Evans LE, Alhazzani W et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 43(3), 304–377 (2017).

7.

Rivers E, Nguyen B, Havstad S et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N. Engl. J. Med. 345(19), 1368–1377 (2001).

8.

Kent N, Fields W. Early recognition of sepsis in the emergency department: an evidence-based project. J. Emerg. Nurs. 38(2), 139–143 (2012).

9.

Kumar A, Roberts D, Wood KE et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit. Care Med. 34(6), 1589–1596 (2006).

10.

Yealy DM, Kellum JA, Huang DT et al. A randomized trial of protocol-based care for early septic shock. N. Engl. J. Med. 370(18), 1683–1693 (2014).

11.

Rhee C, Jones TM, Hamad Y et al. Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals. JAMA Network Open 2(2), e187571–e187571 (2019).

12.

Wang HE, Jones AR, Donnelly JP. Revised National Estimates of Emergency Department Visits for Sepsis in the United States. Crit. Care Med. 45(9), 1443–1449 (2017).

13.

US Census Bureau. One in Five Americans Live in Rural Areas. www.census.gov/library/stories/2017/08/rural-america.html

14.

Feazel L, Schlichting AB, Bell GR et al. Achieving regionalization through rural interhospital transfer. Am. J. Emerg. Med. 33(9), 1288–1296 (2015).

15.

Williams JM, Ehrlich PF, Prescott JE. Emergency medical care in rural America. Ann. Emerg. Med. 38(3), 323–327 (2001).

16.

Kocher KE, Haggins AN, Sabbatini AK, Sauser K, Sharp AL. Emergency department hospitalization volume and mortality in the United States. Ann. Emerg. Med. 64(5), 446–457.e446 (2014).

17.

Mohr NM, Harland KK, Shane DM, Ahmed A, Fuller BM, Torner JC. Inter-hospital transfer is associated with increased mortality and costs in severe sepsis and septic shock: an instrumental variables approach. J. Crit. Care 36, 187–194 (2016).

18.

Gaieski DF, Edwards JM, Kallan MJ, Mikkelsen ME, Goyal M, Carr BG. The relationship between hospital volume and mortality in severe sepsis. Am. J. Respir. Crit. Care Med. 190(6), 665–674 (2014).

• Highlights the importance of hospital characteristics on sepsis outcomes, and it demonstrates that care in a low-volume hospital is a specific risk factor for poor outcomes.

19.

Miller AC, Ward MM, Ullrich F, Merchant KS, Swanson MB, Mohr NM. Emergency department telemedicine consults are associated with faster time-to-electrocardiogram and time-to-fibrinolysis for myocardial infarction patients. Telemed JE Health 26(12), 1440–1448 (2020).

20.

Mohr NM, Young T, Harland KK et al. Telemedicine is associated with faster diagnostic imaging in stroke patients: a cohort study. Telemed JE Health 25(2), 93–100 (2019).

21.

Mohr NM, Vakkalanka JP, Harland KK et al. Telemedicine use decreases rural emergency department length of stay for transferred North Dakota trauma patients. Telemed. J. E-health 24(3), 194–202 (2018).

22.

Heppner S, Mohr NM, Carter KD, Ullrich F, Merchant KaS, Ward MM. HRSA's evidence-based tele-emergency network grant program: multi-site prospective cohort analysis across six rural emergency department telemedicine networks. PLoS ONE 16(1), e0243211 (2021).

23.

Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Lancet 370(9596), 1453–1457 (2007).

24.

Husereau D, Drummond M, Petrou S et al. Consolidated Health Economic Evaluation Reporting Standards (CHEERS)--explanation and elaboration: a report of the ISPOR Health Economic Evaluation Publication Guidelines Good Reporting Practices Task Force. Value Health 16(2), 231–250 (2013).

25.

WWAMI Rural Health Research Center. Ruca Data: Zip Code RUCA Approximation. (2021). https://depts.washington.edu/uwruca/ruca-approx.php

26.

WWAMI Rural Health Research Center. RUCA Data Code Definitions. https://depts.washington.edu/uwruca/ruca-codes.php

27.

Rudd KE, Johnson SC, Agesa KM et al. Global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the Global Burden of Disease Study. Lancet 395(10219), 200–211 (2020).

28.

Mohr NM, Skow B, Wittrock A et al. Improving Access to High Quality Sepsis Care in a South Dakota Emergency Telemedicine Network. https://ruraltelehealth.org/briefs/2017-8-23_Access%20to%20Sepsis%20Care%20Emergency%20Telemedicine.pdf

29.

Zachrison KS, Boggs KM, Hayden EM, Espinola JA, Camargo CA. A national survey of telemedicine use by US emergency departments. J. Telemed. Telecare 26(5), 278–284 (2020).

30.

Sullivan AF, Richman IB, Ahn CJ et al. A profile of US emergency departments in 2001. Ann. Emerg. Med. 48(6), 694–701 (2006).

31.

American Hospitial Association. American Hospital Association Annual Survey. www.aha.org/

32.

United States Census Bureau. American Hospital Association Annual Survey. www.census.gov/en.html

33.

Environmental Systems Research Institute, Inc. (Esri). American Hospital Association Annual Survey. www.esri.com/en-us/home

34.

Mohr NM, Harland KK, Chrischilles EA, Bell A, Shane DM, Ward MM. Emergency department telemedicine is used for more severely injured rural trauma patients, but does not decrease transfer: a cohort study. Acad. Emerg. Med. 24(2), 177–185 (2017).

35.

Mohr NM, Young T, Harland KK et al. Emergency department telemedicine shortens rural time-to-provider and emergency department transfer times. Telemed. JE Health 24(8), 582–593 (2018).

36.

Vakkalanka JP, Harland KK, Wittrock A et al. Telemedicine is associated with rapid transfer and fewer involuntary holds among patients presenting with suicidal ideation in rural hospitals: a propensity matched cohort study. J. Epidemiol. Community Health 73(11), 1033–1039 (2019).

37.

US Bureau of Labor Statistics. Measuring the Price Change in the Consumer Price Index: Medical Care. www.bls.gov/cpi/factsheets/medical-care.htm

38.

Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med. Care 36(1), 8–27 (1998).

39.

Quan H, Sundararajan V, Halfon P et al. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med. Care 43(11), 1130–1139 (2005).

40.

Whiles BB, Deis AS, Simpson SQ. Increased time to initial antimicrobial administration is associated with progression to septic shock in severe sepsis patients. Crit. Care Med. 45(4), 623–629 (2017).

41.

Mohr N, Harland K, Chrischilles E, Bell A, Shane D, Ward M. Emergency department telemedicine is used for more severely injured rural trauma patients, but does not decrease transfer: a cohort study. Acad. Emerg. Med. 24(2), 177–185 (2017).

42.

Mohr NM, Harland KK, Shane DM et al. Rural patients with severe sepsis or septic shock who bypass rural hospitals have increased mortality: an instrumental variables approach. Crit. Care Med. 45(1), 85–93 (2017).

43.

Mohr NM, Harland KK, Okoro UE et al. TELEmedicine as an intervention for sepsis in emergency departments: a multicenter, comparative effectiveness study (TELEvISED Study). J Comp Eff Res 10(2), 77–91 (2021).

• The televised study is a related study using different methods, but upon which the current study methodology is based.

44.

Elixhauser A, Friedman B, Stranges E. Septicemia in U.S. Hospitals, 2009: Statistical Brief #122. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Agency for Healthcare Research and Quality (US), MD, USA (2006).

45.

Afshar M, Arain E, Ye C et al. Patient outcomes and cost-effectiveness of a sepsis care quality improvement program in a health system. Crit. Care Med. 47(10), 1371–1379 (2019).

46.

Huang DT, Angus DC, Dremsizov TT, Rivers EP, Clermont G. Cost-effectiveness of early goal-directed therapy in the treatment of severe sepsis and septic shock. Crit. Care 7(2), P232 (2003).

47.

Paoli CJ, Reynolds MA, Sinha M, Gitlin M, Crouser E. Epidemiology and costs of sepsis in the United States—an analysis based on timing of diagnosis and severity level*. Crit. Care Med. 46(12), 1889–1897 (2018).

48.

Mohr NM, Campbell KD, Swanson MB, Ullrich F, Merchant KA, Ward MM. Provider-to-provider telemedicine improves adherence to sepsis bundle care in community emergency departments. J Telemed Telecare 27(8), 518–526 (2021).

•• This study demonstrated that early telehealth for rural ED sepsis care was associated with improved compliance with Surviving Sepsis Campaign guideline adherence.

49.

Zhu X, Merchant KaS, Mohr NM, Wittrock AJ, Bell AL, Ward MM. Real-Time Learning Through Telemedicine Enhances Professional Training in Rural Emergency Departments. Telemed J E Health 27(4), 441–447 (2021).

• This qualitative study finds that the provider-to-provider telehealth has a benefit of providing ongoing professional education to rural providers through mentored patient interactions, which was a significant perceived reason to encourage its use.

50.

Moreno A, Schwamm LH, Siddiqui KA et al. Frequent hub-spoke contact is associated with improved spoke hospital performance: results from the Massachusetts General Hospital Telestroke Network. Telemed. JE Health 24(9), 678–683 (2018).

51.

Sharma R, Zachrison KS, Viswanathan A et al. Trends in telestroke care delivery: a 15-year experience of an academic hub and its network of spokes. Circ. Cardiovasc. Qual. Outcomes 13(3), e005903 (2020).

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