• Sarah Seelye, Jennifer Cano, Cainnear K Hogan, Hallie C Prescott, and Jeremy B Sussman.
• VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA. sarah.seelye@va.gov.
• J Gen Intern Med. 2024 Oct 7.

ImportanceTraditional risk prediction and risk adjustment models have focused on clinical characteristics, but accounting for social determinants of health (SDOH) and complex health conditions could improve understanding of sepsis outcomes and our ability to predict outcomes, treat patients, and assess quality of care.ObjectiveTo evaluate the impact of SDOH and health scales in sepsis mortality risk prediction and hospital performance assessment.DesignObservational cohort study.SettingOne hundred twenty-nine hospitals in the nationwide Veterans Affairs (VA) Healthcare System between 2017 and 2021.ParticipantsVeterans admitted through emergency departments with community-acquired sepsis.ExposuresIndividual- and community-level SDOH (race, housing instability, marital status, Area Deprivation Index [ADI], and rural residence) and two health scales (the Care Assessment Need [CAN] score and Claims-Based Frailty Index [CFI]).Main Outcomes And MeasuresThe primary outcome was 90-day mortality from emergency department arrival; secondary outcomes included 30-day mortality and in-hospital mortality.ResultsAmong 144,889 patients admitted to the hospital with community-acquired sepsis, 139,080 were men (96.0%), median (IQR) age was 71 (64-77) years, and median (IQR) ADI was 60 (38-81). Multivariable regression models had good calibration and discrimination across models that adjusted for different sets of variables (e.g., AUROC, 0.782; Brier score, 1.33; and standardized mortality rate, 1.00). Risk-adjusted hospital performance was similar across all models. Among 129 VA hospitals, three hospitals shifted from the lowest or highest quintile of performance when comparing models that excluded SDOH to models that adjusted for all variables. Models that adjusted for ADI reported odds ratios (CI) of 1.00 (1.00-1.00), indicating that ADI does not significantly predict sepsis mortality in this cohort of patients.Conclusion And RelevanceIn patients with community-acquired sepsis, adjusting for community SDOH variables such as ADI did not improve 90-day sepsis mortality predictions in mortality models and did not substantively alter hospital performance within the VA Healthcare System. Understanding the role of SDOH in risk prediction and risk adjustment models is vital because it could prevent hospitals from being negatively evaluated for treating less advantaged patients. However, we found that in VA hospitals, the potential impact of SDOH on 90-day sepsis mortality was minimal.© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.

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