[Source: Journal of American Medical Association, full page: (LINK). Abstract, edited.]
Original Investigation / Caring for the Critically Ill Patient / October 3, 2017
Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014
Chanu Rhee, MD, MPH1,2; Raymund Dantes, MD, MPH3,4; Lauren Epstein, MD, MS3; et alDavid J. Murphy, MD, PhD5; Christopher W. Seymour, MD, MSc6; Theodore J. Iwashyna, MD, PhD7,8; Sameer S. Kadri, MD, MS9; Derek C. Angus, MD, MPH6,10; Robert L. Danner, MD9; Anthony E. Fiore, MD, MPH3; John A. Jernigan, MD, MS3; Greg S. Martin, MD, MSc5; Edward Septimus, MD11,12; David K. Warren, MD, MPH13; Anita Karcz, MD, MBA14; Christina Chan, MPH1; John T. Menchaca, BA1; Rui Wang, PhD1; Susan Gruber, PhD1; Michael Klompas, MD, MPH1,2; for the CDC Prevention Epicenter Program
Author Affiliations: 1 Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts; 2 Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts; 3 Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia; 4 Division of Hospital Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; 5 Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, and Emory Critical Care Center, Atlanta, Georgia; 6 Clinical Research, Investigation and Systems Modeling of Acute illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; 7 Department of Internal Medicine, University of Michigan, Ann Arbor; 8 VA Center for Clinical Management Research, VA Ann Arbor Health System, Ann Arbor, Michigan; 9 Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland; 10 Associate Editor, JAMA; 11 Hospital Corporation of America, Nashville, Tennessee; 12 Texas A&M Health Science Center College of Medicine, Houston; 13 Department of Medicine, Washington University School of Medicine, St Louis, Missouri; 14 Institute for Health Metrics, Burlington, Massachusetts
JAMA. 2017;318(13):1241-1249. doi:10.1001/jama.2017.13836
- Question – Is the incidence of sepsis in the United States increasing and mortality decreasing, as suggested by estimates from claims-based analyses?
- Findings – In this retrospective cohort study that included detailed clinical data from 7 801 624 adult hospitalizations, sepsis incidence did not change significantly between 2009 and 2014 (+0.6%/y). While in-hospital mortality decreased during the study period, the combined outcome of death or discharge to hospice did not change significantly (−1.3%/y).
- Meaning – Based on clinical data, the incidence of sepsis, and related mortality or discharge to hospice, has remained stable between 2009-2014. The findings also suggest that clinical data provide more objective estimates than claims-based data for sepsis surveillance.
Estimates from claims-based analyses suggest that the incidence of sepsis is increasing and mortality rates from sepsis are decreasing. However, estimates from claims data may lack clinical fidelity and can be affected by changing diagnosis and coding practices over time.
To estimate the US national incidence of sepsis and trends using detailed clinical data from the electronic health record (EHR) systems of diverse hospitals.
Design, Setting, and Population
Retrospective cohort study of adult patients admitted to 409 academic, community, and federal hospitals from 2009-2014.
Sepsis was identified using clinical indicators of presumed infection and concurrent acute organ dysfunction, adapting Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria for objective and consistent EHR-based surveillance.
Main Outcomes and Measures
Sepsis incidence, outcomes, and trends from 2009-2014 were calculated using regression models and compared with claims-based estimates using International Classification of Diseases, Ninth Revision, Clinical Modification codes for severe sepsis or septic shock. Case-finding criteria were validated against Sepsis-3 criteria using medical record reviews.
A total of 173 690 sepsis cases (mean age, 66.5 [SD, 15.5] y; 77 660 [42.4%] women) were identified using clinical criteria among 2 901 019 adults admitted to study hospitals in 2014 (6.0% incidence). Of these, 26 061 (15.0%) died in the hospital and 10 731 (6.2%) were discharged to hospice. From 2009-2014, sepsis incidence using clinical criteria was stable (+0.6% relative change/y [95% CI, −2.3% to 3.5%], P = .67) whereas incidence per claims increased (+10.3%/y [95% CI, 7.2% to 13.3%], P < .001). In-hospital mortality using clinical criteria declined (−3.3%/y [95% CI, −5.6% to −1.0%], P = .004), but there was no significant change in the combined outcome of death or discharge to hospice (−1.3%/y [95% CI, −3.2% to 0.6%], P = .19). In contrast, mortality using claims declined significantly (−7.0%/y [95% CI, −8.8% to −5.2%], P < .001), as did death or discharge to hospice (−4.5%/y [95% CI, −6.1% to −2.8%], P < .001). Clinical criteria were more sensitive in identifying sepsis than claims (69.7% [95% CI, 52.9% to 92.0%] vs 32.3% [95% CI, 24.4% to 43.0%], P < .001), with comparable positive predictive value (70.4% [95% CI, 64.0% to 76.8%] vs 75.2% [95% CI, 69.8% to 80.6%], P = .23).
Conclusions and Relevance
In clinical data from 409 hospitals, sepsis was present in 6% of adult hospitalizations, and in contrast to claims-based analyses, neither the incidence of sepsis nor the combined outcome of death or discharge to hospice changed significantly between 2009-2014. The findings also suggest that EHR-based clinical data provide more objective estimates than claims-based data for sepsis surveillance.
Keywords: Sepsis; USA.