Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014

• Type of Material: Article
• Authors: C Rhee, Harvard Med Sch; Raymund B. Dantes, Emory University; L Epstein, Ctr Dis Control & Prevent; David J Murphy, Emory University; CW Seymour, University of Pittsburgh; TJ Iwashyna, University of Michigan; SS Kadri, NIH; DC Angus, University of Pittsburgh; RL Danner, NIH; AE Fiore, Ctr Dis Control & Prevent; John A Jernigan, Emory University; Greg Martin, Emory University; E Septimus, Hosp Corp Amer; DK Warren, Washington Univ; A Karcz, Inst Hlth Metr; C Chan, Harvard Med Sch; JT Menchaca, Harvard Med Sch; R Wang, Harvard Med Sch; S Gruber, Harvard Med Sch; M Klompas, Harvard Med Sch
• Language: English
• Date: 2017-10-03
• Publisher: American Medical Association (AMA): JAMA
• Publication Version: Final Published Version
• Copyright Statement: © 2017 American Medical Association. All rights reserved.
• Final Published Version (URL): http://dx.doi.org/10.1001/jama.2017.13836
• Title of Journal or Parent Work: Journal of the American Medical Association
• ISSN: 0098-7484
• Volume: 318
• Issue: 13
• Start Page: 1241
• End Page: 1249
• Grant/Funding Information: This work was funded by the Centers for Disease Control and Prevention (3U54CK000172-05S2) and in part by the Agency for Healthcare Research and Quality (1K08HS025008-01A1), National Institutes of Health (R35GM119519), Department of Veterans Affairs (HSR&D 11-109), and intramural funding from the National Institutes of Health Clinical Center and National Institute of Allergy and Infectious Diseases.
• Keywords: SEPTIC SHOCK SEPSIS-3; DOCUMENTATION; UNITED-STATES; INTERNATIONAL CONSENSUS DEFINITIONS; Science & Technology; Life Sciences & Biomedicine; General & Internal Medicine; IMPACT; CENTERS; CRITERIA; MORTALITY-RATES; FAILURE; Medicine, General & Internal; CARE
• Research Categories: Health Sciences, Medicine and Surgery

Abstract

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. OBJECTIVE: 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. EXPOSURES: 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. RESULTS: 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.