Thread by @PulmCrit

Currently there is a debate raging in the US about the role of government to mandate sepsis protocols. Given the current state of our government, this is probably a bad idea… (#rantorial 1/9)

A fresh study in JAMA attempts to associate the implementation of mandated sepsis protocols in New York State in 2013 with reduced mortality. The key word being *associate,* which I suppose sounds better than “correlate” (#rantorial 2/9) jamanetwork.com/journals/jama/…

The study compares sepsis mortality in New York with three other states before/after the mandates. In all cases, mortality decreased over time in a similar fashion. This suggests mortality reductions have *nothing* to do with the mandates… (#rantorial 3/9)

Notice that the New York mortality is considerably higher? That’s could reflect substantial differences between New York and the other states, which makes this entire study a bit of exercise in extrapolating between apples and oranges (#rantorial 4/9)

If at first you don’t succeed, adjust adjust again. Using an adjusted model, regression lines were generated for mortality trends before the mandates. Mortality was dropping in NY *slower* than in other states - see left half of this graph (#rantorial 5/9)

These regressions were then projected forwards in time and compared with the adjusted mortality. As shown on the right half of this graph, mortality in NY decreased parallel to other states (but *faster* than it had been falling previously) (#rantorial 6/9)

So their argument essentially amounts to saying NY started out as the slow kid in the class who was lagging way behind. By applying mandates, NY was able to achieve the same growth rate as the other kids (yet still never caught up!) (#rantorial 7/9).

This is a genuinely weird argument for mandated care: it helps underperforming states lag behind less. Rather than emulating NY (which remained behind, *years* after the mandates), it might make sense to emulate the control states (including, dare I say, Florida!) (8/9)

Finally, note that the 2013 mandate 3- & 6-hour bundles (and didn’t force docs to give 30 cc/kg fluid). So however you interpret this data, it can’t be misconstrued to support the current 1-hour bundles. (9/9).