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Key Points Question How has timing of antibiotics for sepsis changed over time in US Department of Veterans Affairs Hospitals? Findings In this cohort of 111 385 veterans hospitalized with sepsis from 2013 to 2018, median time to antibiotics declined by 9 minutes per year. However, there was significant variation in time to antibiotics across hospitals, even after adjustment for patient characteristics. Meaning These findings suggest that there is potential for performance improvement for sepsis hospitalizations, but efforts to further accelerate time-to-antibiotics must be weighed against the risks of overtreatment., This cohort study examines temporal trends and variations in time-to-antibiotics for sepsis in the US Department of Veterans Affairs health care system., Importance It is unclear whether antimicrobial timing for sepsis has changed outside of performance incentive initiatives. Objective To examine temporal trends and variation in time-to-antibiotics for sepsis in the US Department of Veterans Affairs (VA) health care system. Design, Setting, and Participants This observational cohort study included 130 VA hospitals from 2013 to 2018. Participants included all patients admitted to the hospital via the emergency department with sepsis from 2013 to 2018, using a definition adapted from the Centers for Disease Control and Prevention Adult Sepsis Event definition, which requires evidence of suspected infection, acute organ dysfunction, and systemic antimicrobial therapy within 12 hours of presentation. Data were analyzed from October 6, 2020, to July 1, 2021. Exposures Time from presentation to antibiotic administration. Main Outcomes and Measures The main outcome was differences in time-to-antibiotics across study periods, hospitals, and patient subgroups defined by presenting temperature and blood pressure. Temporal trends in time-to-antibiotics were measured overall and by subgroups. Hospital-level variation in time-to-antibiotics was quantified after adjusting for differences in patient characteristics using multilevel linear regression models. Results A total of 111 385 hospitalizations for sepsis were identified, including 107 547 men (96.6%) men and 3838 women (3.4%) with a median (interquartile range [IQR]) age of 68 (62-77) years. A total of 7574 patients (6.8%) died in the hospital, and 13 855 patients (12.4%) died within 30 days. Median (IQR) time-to-antibiotics was 3.9 (2.4-6.5) hours but differed by presenting characteristics. Unadjusted median (IQR) time-to-antibiotics decreased over time, from 4.5 (2.7-7.1) hours during 2013 to 2014 to 3.5 (2.2-5.9) hours during 2017 to 2018 (P

IMPORTANCE: Some experts have cautioned that national and health system emphasis on rapid administration of antimicrobials for sepsis may increase overall antimicrobial use even among patients without sepsis. OBJECTIVE: To assess whether temporal changes in antimicrobial timing for sepsis are associated with increasing antimicrobial use, days of therapy, or broadness of antimicrobial coverage among all hospitalized patients at risk for sepsis. DESIGN, SETTING, AND PARTICIPANTS: This is an observational cohort study of hospitalized patients at 152 hospitals in 2 health care systems during 2013 to 2018, admitted via the emergency department with 2 or more systemic inflammatory response syndrome (SIRS) criteria. Data analysis was performed from June 10, 2021, to March 22, 2022. EXPOSURES: Hospital-level temporal trends in time to first antimicrobial administration. OUTCOMES: Antimicrobial outcomes included antimicrobial use, days of therapy, and broadness of antibacterial coverage. Clinical outcomes included in-hospital mortality, 30-day mortality, length of hospitalization, and new multidrug-resistant (MDR) organism culture positivity. RESULTS: Among 1 559 523 patients admitted to the hospital via the emergency department with 2 or more SIRS criteria (1 269 998 male patients [81.4%]; median [IQR] age, 67 [59-77] years), 273 255 (17.5%) met objective criteria for sepsis. In multivariable models adjusted for patient characteristics, the adjusted median (IQR) time to first antimicrobial administration to patients with sepsis decreased by 37 minutes, from 4.7 (4.1-5.3) hours in 2013 to 3.9 (3.6-4.4) hours in 2018, although the slope of decrease varied across hospitals. During the same period, antimicrobial use within 48 hours, days of antimicrobial therapy, and receipt of broad-spectrum coverage decreased among the broader cohort of patients with SIRS. In-hospital mortality, 30-day mortality, length of hospitalization, new MDR culture positivity, and new MDR blood culture positivity decreased over the study period among both patients with sepsis and those with SIRS. When examining hospital-specific trends, decreases in antimicrobial use, days of therapy, and broadness of antibacterial coverage for patients with SIRS did not differ by hospital antimicrobial timing trend for sepsis. Overall, there was no evidence that accelerating antimicrobial timing for sepsis was associated with increasing antimicrobial use or impaired antimicrobial stewardship. CONCLUSIONS AND RELEVANCE: In this multihospital cohort study, the time to first antimicrobial for sepsis decreased over time, but this trend was not associated with increasing antimicrobial use, days of therapy, or broadness of antimicrobial coverage among the broader population at-risk for sepsis, which suggests that shortening the time to antibiotics for sepsis is feasible without leading to indiscriminate antimicrobial use.

Rationale: In 2017, the U.S. Centers for Disease Control and Prevention (CDC) developed a new surveillance definition of sepsis, the adult sepsis event (ASE), to better track sepsis epidemiology. The ASE requires evidence of acute organ dysfunction and defines baseline organ function pragmatically as the best in-hospital value. This approach may undercount sepsis if new organ dysfunction does not resolve by discharge. Objectives: To understand how sepsis identification and outcomes differ when using the best laboratory values during hospitalization versus methods that use historical lookbacks to define baseline organ function. Methods: We identified all patients hospitalized at 138 Veterans Affairs hospitals (2013–2018) admitted via the emergency department with two or more systemic inflammatory response criteria, were treated with antibiotics within 48 hours (i.e., had potential infection), and completed 4+ days of antibiotics (i.e., had suspected infection). We considered the following three approaches to defining baseline renal, hematologic, and liver function: the best values during hospitalization (as in the Centers for Disease Control and Prevention’s ASE), the best values during hospitalization plus the prior 90 days (3-mo baseline), and the best values during hospitalization plus the prior 180 days (6-mo baseline). We determined how many patients met the criteria for sepsis by each approach, and then compared characteristics and outcomes of sepsis hospitalizations between the three approaches. Results: Among 608,128 hospitalizations with potential infection, 72.1%, 68.5%, and 58.4% had creatinine, platelet, and total bilirubin measured, respectively, in the prior 3 months. A total of 86.0%, 82.6%, and 74.8%, respectively, had these labs in the prior 6 months. Using the hospital baseline, 100,568 hospitalizations met criteria for community-acquired sepsis. By contrast, 111,983 and 117,435 met criteria for sepsis using the 3- and 6-month baselines, for a relative increase of 11% and 17%, respectively. Patient characteristics were similar across the three approaches. In-hospital mortality was 7.2%, 7.0%, and 6.8% for sepsis hospitalizations identified using the hospital, 3-month baseline, and 6-month baseline. The 30-day mortality was 12.5%, 12.7%, and 12.5%, respectively. Conclusions: Among veterans hospitalized with potential infection, the majority had laboratory values in the prior 6 months. Using 3- and 6-month lookbacks to define baseline organ function resulted in an 11% and 17% relative increase, respectively, in the number of sepsis hospitalizations identified.

Heart disease is the leading cause of death in the United States. African Americans and people of low socioeconomic status suffer disproportionately from heart disease–related morbidity and mortality. In Detroit, Michigan, a primarily African American and low-income urban area, heart disease mortality is at twice the national rate. Despite evidence for the effectiveness of self-management support interventions in reducing chronic disease burden for older adults, few are adapted for communities most in need. This article describes the process of adapting Take PRIDE, an evidence-based heart disease self-management intervention, for older adults in Detroit via the Replicating Effective Programs (REP) framework. Working within a community–academic partnership, we found REP useful in facilitating the identification of diverse stakeholders, core versus adaptable elements of the intervention and barriers to implementation. We also made several modifications to the REP framework in order to better fit our project needs. Overall, we found REP to be an effective, flexible tool that allowed us to successfully adapt a disease-management intervention for this setting. Processes, lessons learned, and recommendations offered in this article may help researchers and practitioners working to expand access to self-management support for populations most affected by chronic disease.

BackgroundFew published studies report lessons learned for recruiting older adults from racial/ethnic minority, low SES communities for behavioral interventions. In this article, we describe recruitment processes and results for Take Heart, a randomized controlled trial testing the effectiveness of an adapted heart disease self-management program for primarily African American, urban, low SES adults 50 years or older living in Detroit.MethodsOlder adults were recruited via community-based (CB), electronic medical record (EMR), and in-person hospital clinic (HC) methods. Recruitment processes, demographic characteristics of enrolled participants, yield and cost, lessons learned, and best practices for each method are described.ResultsWithin 22 months, 1,478 potential participants were identified, 1,223 were contacted and 453 enrolled, resulting in an overall recruitment yield of 37%. The CB method had the highest yield at 49%, followed by HC at 36% and EMR at 16%. Of six CB approaches, information sessions and flyers had the highest yields at 60% and 59%, respectively. The average cost of recruiting and enrolling one participant was $142.ConclusionsCB, EMR, and HC methods each made important contributions to reaching our recruitment goal. The CB method resulted in the highest recruitment yield, while EMR had the lowest. Face-to-face interaction with community members and hiring a community health worker were particularly useful in engaging this population. Further research is needed to confirm these findings in urban, minority, low SES populations of older adults.

Supplemental material, HPP775740_Take_Heart_Health_Educator_Manual_Outline for Using the Replicating Effective Programs Framework to Adapt a Heart Health Intervention by Jessica E. Ramsay, Mary R. Janevic, Cainnear K. Hogan, Dominique L. Edwards, Cathleen M. Connell in Health Promotion Practice

Many older adults with heart disease, especially those from vulnerable populations, live with chronic pain. Self-management strategies for reducing cardiovascular risk (e.g., physical activity, stress reduction) are also recommended for management of chronic pain. It is not known, however, whether self-management education focused on heart health has a beneficial “side effect” on pain-related outcomes. We explored this possibility using data from a randomized controlled trial (n=405) of Take Heart, a group intervention adapted for low-income, African American adults 50 and over with heart disease or significant risk factors. We first assessed the sample prevalence of high-impact chronic pain; i.e., substantial pain-related disability in one or more life domains (National Pain Strategy, 2016). Next, we assessed whether participation in Take Heart resulted in decreased pain interference (PROMIS-29). One-third of participants (n=131) met criteria for high impact chronic pain. Mean pain interference T-score in the entire sample at baseline was 58.1 (SD=9.9), indicating a score one standard deviation greater than population average. Compared to controls, intervention participants had a greater, but non-significant, improvement in pain interference (0.7 vs. -0.8; p=.11). Overall, findings demonstrate that African American adults with cardiovascular conditions have a high burden of comorbid pain. This pain was not greatly improved by an intervention that taught key chronic disease self-management skills but did not address pain specifically. Future research can test whether incorporating pain-management content into heart disease education has a stronger impact on improving pain outcomes -- which may, in turn, promote adherence to behaviors to reduce cardiovascular risk.