Yoshida Shinichiro, Babazono Akira, Liu Ning, Yamao Reiko, Ishihara Reiko
Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
Department of Health Care Administration and Management, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.
JMA J. 2025 Jul 15;8(3):708-717. doi: 10.31662/jmaj.2024-0331. Epub 2025 Jun 6.
Variations in intensive care unit (ICU) policies and physician characteristics influence mortality, potentially leading to regional differences in mortality rates. Previous studies have not specifically focused on septic shock or older patients and have lacked consideration of the context effect. We hypothesized that regional variability in mortality exists among older patients with septic shock and investigated factors associated with mortality.
Administrative medical claims data were analyzed. Participants were enrolled from April 2015 to March 2020 in Fukuoka Prefecture, Japan. ICU physicians were classified based on board certification in intensive care medicine as either "intensivists" or "ICU-dedicated physicians". The primary outcome was 28-day mortality after ICU admission. Data from all ICUs in Fukuoka Prefecture and 9 secondary medical areas were analyzed. We calculated and compared the 28-day mortality rates across regions. Multilevel logistic regression analyses were conducted to adjust for the context effect.
Among the 1,238 participants, mortality across regions ranged from 18.3% to 41.4%. Based on multilevel logistic analyses, age, sex, postsurgical admission, and the number of ICU beds per intensivist were significantly associated with mortality. The adjusted odds ratio from the multilevel analysis for having no intensivists versus having ≥1 intensivist per 4 ICU beds was 1.99 (95% confidence interval 1.15-3.44, p = 0.01).
After accounting for the regional context effect, our analysis confirmed regional mortality variability in mortality among older patients with septic shock. Mortality was influenced by whether ICU physicians are board-certified in intensive care medicine. These findings suggest that sufficient commitment in terms of time, intensity, and knowledge is crucial to reducing mortality in older patients with septic shock.
重症监护病房（ICU）政策和医生特征的差异会影响死亡率，可能导致死亡率出现地区差异。以往研究并未特别关注感染性休克或老年患者，也未考虑背景效应。我们假设老年感染性休克患者存在地区死亡率差异，并调查了与死亡率相关的因素。
对行政医疗索赔数据进行分析。研究对象于2015年4月至2020年3月在日本福冈县入组。ICU医生根据重症医学委员会认证分为“重症医学专家”或“ICU专科医生”。主要结局是ICU入院后28天死亡率。对福冈县所有ICU和9个二级医疗区域的数据进行分析。我们计算并比较了各地区的28天死亡率。进行多水平逻辑回归分析以调整背景效应。
在1238名参与者中，各地区死亡率在18.3%至41.4%之间。基于多水平逻辑分析，年龄、性别、术后入院情况以及每位重症医学专家的ICU床位数与死亡率显著相关。多水平分析中，每4张ICU床位没有重症医学专家与有≥1名重症医学专家相比，调整后的优势比为1.99（95%置信区间1.15至3.44，p = 0.01）。
在考虑地区背景效应后，我们的分析证实了老年感染性休克患者存在地区死亡率差异。死亡率受ICU医生是否获得重症医学委员会认证的影响。这些发现表明，在时间、强度和知识方面做出充分投入对于降低老年感染性休克患者的死亡率至关重要。
