A recent review evaluated the association between socioeconomic position (SEP) and mortality among adults with sepsis and septic shock. Sepsis remains a leading cause of morbidity, mortality, and healthcare expenditure worldwide, and there is increasing recognition that social and economic factors may significantly influence patient outcomes. While previous research has explored health inequities broadly, this study specifically focused on SEP as a multidimensional construct encompassing income, education, occupation, and deprivation.
The authors conducted a comprehensive search and included observational studies and trials involving adult patients with sepsis or septic shock that examined SEP indicators in relation to short-term mortality, defined as in-hospital or 30-day mortality. SEP measures included income, education, occupation, insurance status, neighbourhood socioeconomic status, and composite deprivation indices. Studies using race alone as a proxy for SEP were excluded, as race does not fully capture socioeconomic conditions.
A total of 13 observational cohort studies comprising 3,951,677 patients were included. Most studies were conducted in North America and varied in clinical settings, including emergency departments, hospital wards, intensive care units, and national registries. SEP was measured heterogeneously, with area-level deprivation and socioeconomic indices being the most common approaches. Other measures included income, education, and insurance status.
The findings indicate that several SEP indicators are associated with increased short-term mortality in patients with sepsis. The most robust association was observed for lack of private insurance, which was linked to a 34% increase in mortality. Lower neighbourhood socioeconomic status was also associated with increased mortality. Similarly, lower income demonstrated a probable association with higher mortality, with both odds ratios (aOR 1.06) and hazard ratios (aHR 1.51) suggesting increased risk, although with some limitations in precision and consistency.
Other SEP indicators, including lower education and unemployment, showed potential associations with increased mortality, but the certainty of evidence was low. For example, unemployment was associated with nearly double the odds, though confidence intervals were wide and included borderline significance. Similarly, lower education was associated with increased mortality, but findings were limited by inconsistency across studies.
The authors highlight several mechanisms that may explain these associations. Individuals with lower SEP may face barriers to accessing timely and high-quality healthcare, leading to delayed diagnosis and treatment. Lower income and education may also be linked to poorer baseline health, reduced health literacy, and higher prevalence of undiagnosed comorbidities. Neighbourhood deprivation may reflect limited healthcare infrastructure, transportation challenges, and reduced access to primary care, all of which can contribute to worse outcomes. Insurance status, particularly lack of private insurance, may further exacerbate disparities in care delivery.
The study emphasises that SEP represents a broader construct than traditional socioeconomic status, incorporating both individual-level and contextual factors. However, inconsistency in how SEP is defined and measured across studies contributed to heterogeneity in the findings. Additionally, differences in healthcare systems may influence observed associations; for example, in settings with universal healthcare, insurance status may not vary and therefore cannot explain outcome differences.
The review also identifies gaps in current research. SEP variables are not routinely collected or reported in sepsis studies, limiting the ability to fully understand and address health inequities. The authors advocate for the routine inclusion of equity-relevant data, such as income, education, and housing stability, in clinical research and practice. Frameworks such as PROGRESS-Plus may help capture the complex and intersecting dimensions of social determinants of health.
Overall, this review demonstrates that lower socioeconomic position is associated with increased short-term mortality in patients with sepsis and septic shock. Key indicators such as lack of private insurance, lower income, and neighbourhood deprivation show moderate- to high-certainty associations with worse outcomes. These findings underscore the importance of integrating socioeconomic factors into sepsis research, clinical care, and policy-making. Addressing modifiable social determinants may offer opportunities to reduce disparities and improve outcomes for vulnerable populations.
Source: Critical Care Medicine
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