Dombrovskiy VY, Martin AA, Sunderram J, et al. Facing the challenge: Decreasing case fatality rates in severe sepsis despite increasing hospitalizations

Division of Pulmonary and Critical Care Medicine, Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ 08903-0019, USA.
Critical Care Medicine (Impact Factor: 6.31). 12/2005; 33(11):2555-62. DOI: 10.1097/01.CCM.0000186748.64438.7B
Source: PubMed


To determine recent trends in severe sepsis-related rates of hospitalization, mortality, and hospital case fatality in a large geographic area and to determine the impact of age, race, and gender on these outcomes.
Trend analysis for the period of 1995 to 2002.
Acute care hospitals in New Jersey.
Subjects > or = 18 yrs of age with severe sepsis who were hospitalized in New Jersey during the period of 1995 to 2002.
We analyzed data from the 1995-2002 New Jersey State Inpatient Databases (SID) developed as part of the Healthcare Cost and Utilization Project (HCUP), covering all acute care hospitals in the state. On the basis of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for septicemia and organ dysfunction, we identified 87,675 patients with severe sepsis. The percentage of patients with severe sepsis among all hospitalized patients with sepsis grew steadily, from 32.7% to 44.7% (p < .0001), during these years. The crude rate of hospitalization with severe sepsis increased 54.2%, from 135.0/100,000 population in 1995 to 208.2/100,000 population in 2002 (p < .0001). Over time, the crude mortality rate rose by 35.8% (p < .0001), whereas the crude case fatality rate (number of deaths/number of cases) fell from 51.0% to 45.0% (p < .0001). For any given year, the rates of hospitalization and mortality were greater among older patients. After adjustment by age, the rates among blacks were greater than among whites, and they were greater among males than females. At the same time, there was no significant difference in the age-adjusted hospital case fatality rates with regard to gender and race. There was a significant increase in age-adjusted gender- and race-specific rates for hospitalization and mortality from 1995 to 2002. Blacks were more likely than whites to be admitted to the intensive care unit: for males, odds ratio = 1.19 (95% confidence interval, 1.13-1.26), and for females, odds ratio = 1.35 (95% confidence interval, 1.29-1.42). However, although case fatality rate was increased among patients admitted to the intensive care unit, this was not reflected in an increased case fatality among blacks. In addition, age-adjusted gender- and race-specific case fatality rates declined during 1995-2002.
In spite of increasing rates of hospitalization and mortality, there is a decreasing case fatality rate for severe sepsis. These data suggest that advances in critical care practice before and during the study period have resulted in improved outcomes for this population.

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Available from: Viktor Y Dombrovskiy, Jun 18, 2014
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    • "Sepsis as the primary diagnosis increased 3.6-fold during the study period, while primary pneumonia diagnosis decreased 1.4-fold, despite stable total annual admissions and decreasing sepsis-associated mortality, suggesting preferential exchange of other infection diagnoses for sepsis diagnoses. Other studies have shown changes in coding of primary infectious illnesses, in which sepsis coding increases occurred concurrently with a decline in coding of other infectious illnesses[4,9,10,14,15,21]. The possibility of up-capture may be further supported by the notable decreases in sepsis mortality reported here and elsewhere[9,22]. "
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    ABSTRACT: Background: Sepsis hospitalizations have increased dramatically in the last decade. It is unclear whether this represents an actual rise in sepsis illness or improved capture by coding. We evaluated the impact of Centers of Medicare and Medicaid Services (CMS) guidance after newly introduced sepsis codes and medical severity diagnosis-related group (MS-DRG) systems on sepsis trends. Methods: In this retrospective cohort study of California hospitalizations from January 2000 to December 2010, sepsis was identified by International Classification of Diseases, Ninth Revision (ICD-9) coding (Dombrovskiy method). Sepsis-associated mortality rates were calculated. Logistic regression models evaluated variables associated with sepsis and mortality. Segmented regression time series analysis assessed changes in sepsis frequency for (1) baseline (January 2000 to September 2003); (2) post-CMS guidelines on sepsis coding (October 2003 to September 2007); and (3) after the introduction of MS-DRG (October 2007 to December 2010). Results: Annual hospitalizations with sepsis diagnoses tripled within a decade, from 21.1 to 59.9 cases per 1000 admissions, with a 2.8- and 2.0-fold increase in severe and nonsevere sepsis, respectively, whereas annual admissions remained unchanged and sepsis-associated mortality decreased. Greatest increases were seen for severe sepsis present on admission (3.8-fold increase). Increases in sepsis were temporally correlated with CMS coding guidance and MS-DRG introduction after adjustment for comorbidity and other factors. Conclusions: Sepsis rate increases were associated with introduction of CMS-issued guidance for new sepsis ICD-9 coding and MS-DRGs. Coding artifact ("up-capture" of less severely ill septic patients) may be contributing to the apparent rise in sepsis incidence and decline in mortality. Epidemiologic trends based on administrative data should account for policy-related effects.
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    • "Third, it could reflect true variation in the underlying rates of critical illness. Though this is suggested by the large variations in reported rates of severe sepsis [27-30], and the adult respiratory distress syndrome [31,32], divergent disease definitions and administrative data coding likely account for much of those differences. Also, it seems unlikely that Manitobans experience critical illness at a rate double or half that of people living within 1,300 km in Alberta or Minnesota. "
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    • "There has been an inconsistency regarding gender-mortality relationships in clinical sepsis studies. Women have better prognosis in some studies (25, 26), whereas other studies found no gender differences (2, 4). In contrast, in a large cohort study of ICU patients published recently, women with severe sepsis or septic shock have a higher risk of in-hospital mortality than men after multivariable adjustment. "
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