This study explored predictors of hospital mortality, length of stay (LOS) and costs in patients with severe sepsis at high risk of death who received drotrecogin alfa (activated) [DrotAA].
We examined Solucient ® database records for 1,179 adult ICU patients receiving DrotAA from November 2001–June 2003. Evident severe sepsis (ESS) was defined as concurrent antibiotic plus ventilator and/or vasopressor use. The interval between ESS and DrotAA initiation was characterized as Same-day, Next-day, or ≥ 2 days later. Groups were compared on patient characteristics and hospital outcomes. Multivariate models of hospital mortality, LOS, and costs were created to control for confounding.
Forty-three percent of patients received Same-day DrotAA, 30% Next-day, and 27% Day2+. At ICU admission, Day2+ patients had fewer organ dysfunctions (1.0±0.8) than Same-day (1.1±0.9; p=0.021) and Next-day (1.2±0.8; p<0.001) patients; but between ICU admission and DrotAA initiation, organ dysfunctions increased more among Day2+ patients than Next-day and Same-day patients (+0.6, +0.4, +0.0 respectively; all p<0.0001). Hospital mortality was predicted by Day2+ DrotAA initiation (OR 1.7, 95% CI 1.3–2.3), hospital size ≥ 300 beds (OR 1.9, 95% CI 1.4–2.6), age 65-69 (OR 2.2, 95% CI 1.6–3.0), vasopressor use (OR 2.6, 95% CI 1.5–4.3), ventilator use (OR 5.1, 95% CI 3.2–8.0), hematologic dysfunction (OR 1.4, 95% CI 1.0–1.8), renal dysfunction (OR 1.5, 95% CI 1.2–2.0), malignancy (OR 1.7, 95% CI 1.2–2.5), and shock (OR 1.3, 95% CI 1.0–1.7). Among survivors, 7% shorter LOS (p=0.044) and 10% lower adjusted post-DrotAA costs (p=0.012) were predicted by Same-day or Next-day initiation. Baseline adjusted post-DrotAA costs were predicted to be $8,685; later DrotAA initiation added $6,400 (p<0.01). Ventilator use added $6,000 (p<0.01), renal replacement therapy $8,100 (p<0.0001), prior non-GI surgery $5,900 (p=0.01), each ICU day $2,500 (p<0.0001), and each non-ICU day $1,300 (p<0.0001).
Multiple factors, including later DrotAA initiation, predicted hospital mortality. Earlier DrotAA initiation predicted lower hospital costs and shorter LOS among survivors.
Improved understanding of the predictors of hospital mortality, LOS, and costs may help clinicians efficiently improve patient outcomes.
F.R. Ernst, Eli Lilly and Company, Solucient LLC