SCCMPod-574 CCM: Socioeconomic Factors in Sepsis Survival

Dr. McLaughlin: Hello and welcome to the Society of Critical Care Medicine podcast. I'm your host, Diane McLaughlin. Today I'm speaking with Dr. Syed Almoosawy about the article, The Association Between Socioeconomic Position and Mortality in Patients with Sepsis and Septic Shock, a Systematic Review and Meta-Analysis, published in the April 2026 issue of Critical Care Medicine. To access the full article, visit ccmjournal.org. Dr. Al Moussaoui is Chief Medical Resident at Ottawa Hospital in Ottawa, Ontario, Canada. Welcome.

Before we start, do you have any disclosures to report?

Dr. Almoosawy: Thank you for having me and I don't have any disclosures to report.

Dr. McLaughlin: All right, excellent. Well, I read the article in preparation of this podcast and it seems like this paper really challenges us to think beyond lactate, pressers, antibiotics, and source control and more into the patient's insurance status, income, education, and neighborhood and what critical care teams can do with that information. For listeners who haven't read the paper yet, what was the central question you were trying to answer and why does it matter now?

Dr. Almoosawy: So really the main question that we wanted to discern from this paper is, is there an association between factors other than medical illness or acuity of illness that influence outcomes in patients with sepsis and septic shock? And with the emerging role of structural health inequities and the increasing attention that they've gained over the past few years in critical care research, our main aim was to really study and evaluate whether such an association exists between sepsis and septic shock because it can represent a modifiable factor that helps us improve morbidity and mortality and address healthcare costs that are associated with sepsis and septic shock.

And as we know, this is quite an expensive affliction.

Dr. McLaughlin: I noticed you used the term socioeconomic position rather than socioeconomic status. Why did you choose that?

Dr. Almoosawy: Yeah, so that's a good question because most often we're used to hearing or reading socioeconomic status rather than socioeconomic position. So socioeconomic status, if we're to define this as a term, it refers to an individual social and economic resources that is often measured using metrics such as income or education, but it does not capture someone's situational deprivation and that includes things like transportation barriers or limited access to care and therefore it's not a complete term. What socioeconomic position does is that it provides a broader construct.

It's more of a broader term that encompasses both socioeconomic status as well as deprivation and therefore it is a more comprehensive reflection of a person's social and economic resources.

Dr. McLaughlin: So how should clinicians think about the difference between individual level socioeconomic factors like income or education and area level measures like neighborhood deprivation? Because I've never thought about these things in critical care before.

Dr. Almoosawy: Yeah, that's a good question actually because we know that measurement of these factors or these metrics can actually be quite challenging in the critical care setting because patients may not be able to provide you with this information. Their families are under acute stress and they may also not be able to provide you with these specific bits of information and routine datasets don't necessarily tend to collect those factors. We often find ourselves in the critical care setting that we are focused on the here and now and what factors are that could be modifiable at that moment, but we tend to lose sight of outcomes beyond critical illness and this is really what this paper is trying to prompt in the sense that there are factors besides medical illness, besides acuity, besides things like their lactate factors, et cetera, like you mentioned that should be looked at and may potentially be modifiable in the sense that we could design targeted interventions and we can address these factors to improve outcomes for their patients.

How these things should be done and what should be looked at and what should be thought of is I guess a question that is raised really by this paper.

Dr. McLaughlin: It'll be exciting to see what people do with this over the next 10 years because outside of sepsis, people are starting to look at longitudinal follow-up and how it affects critical care admissions and readmissions as well, but let's get into the study a little bit. So you included 13 observational studies in nearly 4 million patients. What types of studies make up the evidence-based?

Dr. Almoosawy: So in all honesty, it was 13 studies that were all observational, either perspective or retrospective in nature and the amount of patients that you've included is quite a large amount, but there were no case series or randomized controlled trials, I guess, evaluating this question.

Dr. McLaughlin: And then you focused on short-term mortality, such as in-hospital or 30-day mortality. Why did you choose those metrics?

Dr. Almoosawy: Yeah, that's a good question because this was something that we had to think about in terms of trying to obtain quantitative synthesis of the evidence. Firstly, it's because short-term mortality in terms of 30-day or in-hospital mortality was the most commonly measured metric in the included studies or in the studies that looked at the association of socio-clinical physician with outcomes in sepsis and hematologic shock. And studies that looked at longer-term outcomes tend to be a bit more heterogeneous.

So it essentially enabled a more meaningful quantitative synthesis of our main outcome and the fact that longer-term outcomes are less frequently reported for this specific question.

Dr. McLaughlin: Yeah. I think it's interesting whenever you do a systematic review or a meta-analysis, you see how many different factors can affect your sample and create a lot of heterogeneity. And so one of the things that I would imagine was a challenge for you was that our new sepsis guidelines just came out.

So sepsis definitions and then socioeconomic measures varied a lot between the studies. So how did you handle that?

Dr. Almoosawy: Certainly. And this was essentially a limitation that we have to acknowledge. And that is the differences in definitions of sepsis and septic shock.

What we did was include the studies as they were with their definitions of sepsis and septic shock. And we outlined the definitions of those studies in our supplementary materials so that readers are aware of those differences. And with regards to differences in the specific socioeconomic position metrics, we essentially included studies that looked at those different metrics in the way that they had measured.

So this was incorporated in our grade approach when we pulled the evidence together to understand how it affects the predictions or our discernment of to what degree of certainty these outcomes could be linked to those socioeconomic metrics. And I guess what we found is that the differences between the studies and how they measured things were something that has to be taken into consideration when thinking about the interpretability of our findings.

Dr. McLaughlin: So talking about the results of this, it seems like the strongest association was lack of private insurance and increased mortality. What does that finding tell us? And what does it not tell us?

Dr. Almoosawy: So what it does tell us is that there are several mechanisms that could explain why lack of insurance specifically was the factor that had the highest association with mortality. And I think this really boils down to the fact that it limits access to timely care or delays hospital presentation. And we know that delays in hospital presentation also potentially means that there's delay in investigation and treatment.

And therefore that is a plausible way of it affecting mortality. However, that is one mechanism. And there are other potential mechanisms by which lack of private insurance may or may not affect mortality or other mechanisms that could be explained by other factors, which not show that strong association, such as the ones that we've demonstrated in our study.

And this includes things that lack of private insurance does not explain things like transportation barriers or lack of healthcare infrastructure in certain areas or neighborhood deprivation itself. But it may indirectly reflect the fact that people with no private insurance may be sort of individuals that are affected by those factors, but not so directly by just lack of private insurance itself, if that makes sense.

Dr. McLaughlin: Yeah, it was also interesting to me because education and unemployment showed lower certainty associations. And I guess I typically, I mean, no, I've always gotten my insurance through employment. And so for me, those two factors go together.

When you have something like that, that shows that lower certainty association, should we just view this as a weaker signal or an understudied domain or both?

Dr. Almoosawy: I think given the lack of an extensive number of studies evaluating those factors, it would be more reasonable to think that the lack of evidence assessing those specific factors could be more of a plausible explanation for why there is a lack of association or a weaker association between those specific factors and mortality and sepsis and septic shock. Because a lot of the mechanisms that underpin why certain socioeconomic position factors may be associated with higher mortality and septic shock can be both socially and biologically plausible.

Dr. McLaughlin: Were there any of the findings that surprised you?

Dr. Almoosawy: I think really that was the main finding in terms of lower education and unemployment, not being associated, not being strongly associated, I should say, with higher mortality. But one could think of multiple mechanisms and ways that they could be, because they could be interlinked with lower neighborhood socioeconomic status, or as you've mentioned, not having a private insurance. But more so than ever, I think this was probably just because of the lack of studies and potentially the adjudicating findings that could have affected the results, rather than these factors not having a stronger association with this.

Dr. McLaughlin: So even if it did surprise you, there was actually an explanation that made it reasonable. Did the results suggest that one socioeconomic measure is more useful than the others for future sepsis research?

Dr. Almoosawy: If we see that lack of private insurance has demonstrated the strongest association with mortality and sepsis and septic shock, it may potentially make us think that this is something that we should investigate to see if we can, first of all, replicate the finding. And second of all, is this something that we could potentially target for our patients who may not have insurance or may not have a full insurance in order to try to improve their outcomes? And if we look at lower neighborhood socioeconomic status and lower income, which demonstrated a moderate certain association, that moderate certain association may well be just because of the number of studies or because of statistical differences, rather than the lack of a mechanism or the lack of strength of them, or like the lower strength of a mechanism that explains the association between those specific factors and socioeconomic position. It may also be something that policymakers can target or address for patients who come from these backgrounds or are at disadvantage in terms of those factors so we may be able to help them and potentially improve their outcomes in the future.

Dr. McLaughlin: So I love this whole thought process because it does get into what do we do with these results? What comes next? And so we start to think about the mechanisms and the interpretation.

And one of the first things that come up is how much of this relationship do you think happens before hospital arrival? So things like delayed presentation, untreated comorbidities, and access barriers versus after admission, where we really do have the largest realm of influence on patient outcomes.

Dr. Almoosawy: Truly. And I think that these factors that tend to present themselves before hospital also introduce another question on that is there's a lot of heterogeneity in how they affect patients and their families and therefore how these could affect their outcomes as well.

Dr. McLaughlin: Do you think the current sepsis risk models, the sepsis alerts that pop up everywhere, do you think these at all adequately account for social risk?

Dr. Almoosawy: It's a good question because I'm personally not aware of any scoring systems that account for these specific factors. So maybe it is something that could be looked at in terms of seeing whether it would be worthwhile alerting clinicians and healthcare providers in terms of patients who may be more vulnerable and maybe more disadvantaged and therefore prompting them to think about their situation and ways to potentially influence their outcomes by, first of all, recognizing that they are from disadvantaged backgrounds and perhaps speaking to the right people in terms of things like social workers or even policymakers to try and move things forward for them and hopefully improve future outcomes.

Dr. McLaughlin: So I agree with you. I am not aware of any type of sepsis triaging that includes any of these factors. And I think in terms of how do you apply this clinically or what the clinical practice implications are is we don't really know what to do with this yet or how to incorporate it, but we know that there's something important here with this signal for the association.

So I think the one question that pops up in regards to that is how do we collect this socioeconomic data without increasing stigma bias or documentation burden?

Dr. Almoosawy: That's a good question as well because we have identified that these data points are not routinely collected as part of data sets that collect data in the critical care setting. I think that this study shows us that there may be potential clinical relevance of socioeconomic position because we know that the surviving sepsis campaign both in 2021 and carried through in 2026 acknowledges this gap by putting a best practice statement that recommends that patients are screened for their social and economic needs or social and economic factors as well.

Dr. McLaughlin: It's just hard to collect this data is the truth.

Dr. Almoosawy: It is and it's because of things like the data may be difficult to collect in the critical care setting and both patients and their families may not be able to provide this as well as the fact that there may be a degree of cultural sensitivity. But I think that with this study showing that there is an association between these metrics and a hard outcome that matters for patients and their families and that is mortality or short-term mortality to be specific that first of all we should collect the data and second of all ways to collect the data should be looked at or should be investigated in order for us to make this less burdensome as you said or less rigorous so that it can be easily captured or captured in a more straightforward manner in routine data sets. And I think one way that this could be done one way that this was proposed in the literature was through something called the progress plus framework which tends to consider these factors and how they intersect with each other including things like place of residence, education, occupation as well as social capital that could be collected and captured within data sets.

So it is one way of looking at these things but I agree that there needs to be a way to look at how these factors could be captured.

Dr. McLaughlin: So now knowing that you poured over all of this data probably what weeks and months now I'm going to let you be a dreamer and tell me which equity relevant variables should future sepsis studies routinely collect if there was no obstacle in the way.

Dr. Almoosawy: It's a difficult question because there may be factors that we specifically looked at or factors that were looked at by different studies that did not show an association so it's difficult to know whether these factors should or should not should not be included but certainly based on the results that we've found from our study I think factors that may be easier to collect or may provide a more comprehensive assessment of someone's socioeconomic position includes things like insurance or benefit status because that is something that could be modifiable and could be targeted and the other thing as well is measures of area level deprivation because as we've seen that neighborhood level deprivation can be associated with worse outcomes in these patients but it may also be something that is easier to and quicker to collect because it may provide somewhat of a reflection of a patient's background including their income including their level of education including their access to care and therefore it potentially may be something that provides a broader assessment of someone's socioeconomic position rather than just looking at individual factors per se.

Dr. McLaughlin: What's the plan for your next study? Are you going to continue looking at these factors? Are you going to take a break for a little bit before diving into such another big...

Dr. Almoosawy: Yeah it's a good question. I'm just trying to think about this because we've thought about it it's quite difficult to sort of design or implement but I think from my perspective I think it's interesting to see this association but I also acknowledge that there are difficulties and challenges with designing a prospective study that looks at these metrics and how they relate to outcomes but one such thought that was being contemplated is trying to implement some of the progress plus frameworks into data that is being collected for patients with sepsis and septic shock in a prospective manner and seeing whether that affects outcomes. I think that would be quite interesting to look at.

Dr. McLaughlin: Well I look forward to when after a little break from all of this you're able to do that. I think if we're closing things up what's the single most important takeaway for frontline critical care clinicians and then I'm going to ask you the same question but for sepsis researchers so two very different groups.

Dr. Almoosawy: So let's take the first question. So for clinicians and healthcare workers I think the main take-home point that I want people to take from the study is that we looked at 13 observational studies. These included almost four million patients with sepsis and septic shock and we found that people with lower socio-economic position were more likely to die in the short term after sepsis and specific metrics including things like no private insurance, lower income, living in deprived areas among others were all linked with worse outcomes and the main finding is that socio-economic disadvantage is associated with worse sepsis outcomes and that it does highlight the need for us to collect equity relevant data and potentially think about policies to reduce gaps in care and hopefully improve survival for these patients. What I want clinicians to think about is that this wasn't a study to say or show that poor people die more. I think there may be other statistics or other ways that show that unfortunately this is the case but that this is a study that has shown that factors beyond medical illness beyond the routine things that we measure and try to see if there's an association with worse outcomes in sepsis that social factors can also influence outcomes and this is something that we need to look at first of all.

We need to try and see if those findings can be replicated and then also we need to collect the relevant data and think about interventions and ways to address this in order to improve outcomes for their patients. So that's what I want clinicians to take away from this study. In terms of what sepsis researchers may take away from the study that is it highlights the need for us to look at incorporating equity data into sepsis research and seeing whether that influences outcomes for our patients.

Dr. McLaughlin: Well I really applaud you for taking this on and it really does have quite significant implications for our patients and our day-to-day work. I'm excited to see what research comes out over the next 10 years from what you've been able to start. Thank you so much for joining us.

Any final words or thoughts?

Dr. Almoosawy: No thank you so much for having me it was a pleasure to be at this podcast.

Dr. McLaughlin: Well with that this will conclude another episode of the Society of Critical Care Medicine podcast. If you're listening on your favorite podcast app and you liked what you heard consider rating and leaving a review. For the Society of Critical Care Medicine podcast I'm Diane McLaughlin.

Announcer: Diane C. McLaughlin DNP AGA CNP BC CCRN FCCM is a Neuro Critical Care Nurse Practitioner at University of Florida Health Jacksonville. She is active within SCCM serving on both the APP resource and ultrasound committees and is a social media ambassador for SCCM.

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