Variation in Corticosteroid Prescribing Practices for Patients With Septic Shock.

objectivesUnderstanding sources of variation in acute care delivery may inform targeted strategies to promote evidence-uptake. We sought to characterize physician-level and ICU-level variation in corticosteroid prescribing for patients with septic shock.

designWe performed a retrospective cohort study using the electronic health record of a multihospital health system. We identified ICU patients with septic shock admitted between 2018 and 2020. Using medication administration data, we determined which patients received corticosteroids within 2 days of vasopressor initiation. We linked each patient to their attending physician of record using digital signatures from clinical documentation. We then fit a hierarchical mixed-effects logistic regression model to identify factors associated with corticosteroid use and quantify variation in corticosteroid administration across physicians and ICUs.

settingTwenty-six ICUs across nine hospitals in the United States. PATIENTS: ICU patients with septic shock. MEASUREMENTS AND MAIN

resultsOf 5322 patients with vasopressor dependent septic shock, 1294 (24.3%) were treated with corticosteroids within 2 days of vasopressor initiation. We linked these patients to 174 unique attending physicians across 26 ICUs. At the ICU-level, median corticosteroid use was 21.8% (interquartile range [IQR], 18.5-25.7%). At the physician-level, median corticosteroid use was 22.0% (IQR, 11.9-32.7%). In the mixed-effects regression controlling for patient and physician characteristics, 16.5% of the variation in corticosteroid administration was attributable to the ICUs and 10.1% was attributable to the physicians.

conclusionsBoth ICUs and physicians contribute to observed variation in the use of corticosteroids for vasopressor dependent septic shock. These findings underscore the need for multilevel interventions to standardize evidence-based practices in critical care.