Two Decades of Mortality Trends Among Patients With Severe Sepsis: A Comparative Meta-Analysis.
ABSTRACT Trends in severe sepsis mortality derived from administrative data may be biased by changing International Classification of Diseases, 9th Revision, Clinical Modification, coding practices. We sought to determine temporal trends in severe sepsis mortality using clinical trial data that does not rely on International Classification of Diseases, Ninth Revision, Clinical Modification coding and compare mortality trends in trial data with those observed from administrative data.
We searched MEDLINE for multicenter randomized trials that enrolled patients with severe sepsis from 1991 to 2009. We calculated standardized mortality ratios for each trial from observed 28-day mortality of usual care participants and predicted mortality from severity-of-illness scores. To compare mortality trends from clinical trials to administrative data, we identified adult severe sepsis hospitalizations in the Nationwide Inpatient Sample, 1993-2009, using two previously validated algorithms.
Patients with severe sepsis or septic shock.
Of 3,244 potentially eligible articles, we included 36 multicenter severe sepsis trials, with a total of 14,418 participants in a usual care arm. Participants with severe sepsis receiving usual care had a 28-day mortality of 33.2%. Observed mortality decreased 3.0% annually (95% CI, 0.8%-5.0%; p = 0.009), decreasing from 46.9% (standardized mortality ratio 0.94; 95% CI, 0.86-1.03) during years 1991-1995 to 29% (standardized mortality ratio 0.53; 95% CI, 0.50-0.57) during years 2006-2009 (3.0% annual change). Trends in hospital mortality among patients with severe sepsis identified from administrative data (Angus definition, 4.7% annual change; 95% CI, 4.1%-5.3%; p = 0.69 and Martin definition, 3.5% annual change; 95% CI, 3.0%-4.1%; p = 0.97) were similar to trends identified from clinical trials.
Since 1991, patients with severe sepsis enrolled in usual care arms of multicenter randomized trials have experienced decreasing mortality. The mortality trends identified in clinical trial participants appear similar to those identified using administrative data and support the use of administrative data to monitor mortality trends in patients with severe sepsis.
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ABSTRACT: Infections are a well-known complication of pregnancy. However, pregnancy-associated severe sepsis (PASS) has not been as well-characterized, with limited population-level data reported to date. We performed a population-based study of the evolving patterns of the epidemiology, clinical characteristics, resource utilization, and outcomes of PASS in Texas over the past decade. The Texas Inpatient Public Use Data File was used to identify pregnancy-associated hospitalizations and PASS hospitalizations for the years 2001 - 2010. The Texas Center for Health Statistics reports of live births, abortions and fetal deaths, and a previously reported population-based, age-specific linkage study on miscarriage were used to derive the annual total estimated pregnancies (TEPs). The incidence, demographics, clinical characteristics, resource utilization and outcomes of PASS were examined. Logistic regression modeling was used to explore the predictors of PASS and its associated mortality. There were 4,060,201 pregnancy-associated hospitalizations and 1,007 PASS hospitalizations during study period. The incidence of PASS was increased by 236% over the past decade, rising from 11 to 26 hospitalizations per 100,000 TEPs. The key changes between 2001 - 2002 and 2009 - 2010 within PASS hospitalizations included: admission to ICU 78% vs. 90% (P = 0.002); development of ≥ 3 organ failures 9% vs. 35% (P < 0.0001); and inflation-adjusted median hospital charges (2,010 dollars) $64,034 vs. $89,895 (P = 0.0141). Hospital mortality (11%) remained unchanged during study period. Chronic liver disease (adjusted odds ratio (aOR) 41.4) and congestive heart failure (CHF) (aOR 20.5) were associated with the highest risk of PASS, in addition to black race, poverty, drug abuse, and lack of health insurance. The highest risk of death was among women with HIV infection (aOR 45.5), need for mechanical ventilation (aOR 4.5), drug abuse (aOR 3.0), and lacking health insurance (aOR 2.9). The incidence, severity, and fiscal burden of PASS rose substantially over the past decade. Case fatality was lower than that for severe sepsis in the general population. Chronic liver disease and CHF pose especially high risk of PASS. Pregnant women with history of drug abuse and lacking health insurance are at high risk of both developing and dying with PASS, requiring extra vigilance for early diagnosis and targeted intervention.Journal of Clinical Medicine Research 06/2015; 7(6):400-16. DOI:10.14740/jocmr2118w
- American Journal of Respiratory and Critical Care Medicine 11/2014; 190(9):970-1. DOI:10.1164/rccm.201409-1710ED · 11.99 Impact Factor
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ABSTRACT: Rationale: Stakeholders seek to monitor processes and outcomes of care among patients with sepsis, but use of administrative data for sepsis surveillance is controversial. Prior studies using only principal diagnoses from claims data have shown a trend of rising sepsis incidence with falling infection incidence, implying that administrative data are inaccurate for sepsis surveillance. Objectives: Because a sepsis diagnosis often modifies an infection site diagnosis, we sought to investigate trends in sepsis and infection using both principal and secondary diagnoses in administrative data. Methods: Retrospective cohort study. We used data from the Nationwide Inpatient Sample years 2003-2009 to identify age-standardized, population-based trends in sepsis and infection using all available diagnosis codes. Infections sites were defined as bacteremia, pneumonia, urinary tract, skin/soft tissue and gastrointestinal; codes for septicemia, sepsis, severe sepsis and septic shock were used to identify 'sepsis'. We identified patients with infection and mechanical ventilation to estimate incidence of severe sepsis without requiring specific claims for sepsis or acute organ failure. Measurements and Main Results: We identified 53.9 million adult infection hospitalizations during years 2003-2009; average age was 63 years, 61% of patients were female, and 70% reported white race, 14% black, and 11% Hispanic ethnicity. Incidence of hospitalizations with an infection claim increased from 3147/100,000 US residents in 2003 to 3480/100,000 in 2009 (11% increase) while hospitalizations with sepsis claims increased from 359/100,000 to 535/100,000 residents during the same time frame (49% increase), p=0.009 between infection and sepsis trends. The proportion of infection hospitalizations with a sepsis claim increased from 7.5% in 2003 to 11.5% in 2009 (54% increase). The incidence of hospitalizations with both an infection and mechanical ventilation claim during 2003 was 173/100,000 as compared with 251/100,000 in 2009 (45% increase), p=0.76 compared with sepsis trends. Conclusions: Sepsis claims are increasing at a greater rate than infection claims, but are not inversely related. Trends in sepsis are similar to trends in infection cases requiring mechanical ventilation. Further studies should seek to identify the optimal algorithms to identify sepsis within administrative data and explore potential mechanisms for the increasing incidence of infection and sepsis in the US.01/2015; 12(5). DOI:10.1513/AnnalsATS.201411-498BC