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Sepsis surveillance limited by variations in claims data
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SAN FRANCISCO — An analysis of records from nearly 200 hospitals showed that variations in the completeness and accuracy of claims data makes it difficult to compare sepsis rates and outcomes, according to findings presented at IDWeek.
Researchers said meaningful comparisons may require the use of objective clinical data to facilitate improved sepsis surveillance.
“Sepsis is a major cause of death in U.S. hospitals, yet timely and effective sepsis care can reduce the risk of death,” Chanu Rhee, MD, MPH, assistant professor of population medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute, said during a presentation.
Previously, Infectious Disease News spoke with Konrad Reinhart, MD, chair of the Global Sepsis Alliance, about the global rise of sepsis. Although he said there have been improvements in coding standards in the last 5 years, before that “the medical system was not doing a good job of accounting for cases of sepsis.”
Rhee and colleagues found that the reliance on claims data may be hindering sepsis surveillance, research and quality improvement. Likewise, Rhee said variations in hospital diagnosis, documentation and coding practices may make it difficult to benchmark hospital sepsis outcomes using claims data.
“Administrative claims data have important limitations,” Rhee said. “We know they have low-to-moderate sensitivity when identifying sepsis and, more importantly, recent analyses have suggested that claims-based trends are biased by changing diagnosis and coding practices over time.”
Rhee and colleagues used the electronic health records of 193 hospitals in the United States — which included data on 4.3 million adult hospitalizations in 2013 or 2014 — to evaluate the sensitivity of claims data for sepsis and organ dysfunction. They defined clinical cases of sepsis using presumed infection and concurrent organ dysfunction as markers and tracked ICD-9-CM codes for severe sepsis or septic shock to determine sepsis incidence and mortality via hospital claims data.
According to Rhee and colleagues, hospitals’ claims data for sepsis and organ dysfunction exhibited low and variable sensitivity. For sepsis, the median sensitivity was 30%. According to Rhee’s presentation, median sensitivity for both acute kidney injury and shock was 66%. The median sensitivity for thrombocytopenia and hepatic injury was 39% and 36%, respectively.
The researchers observed only a moderate correlation between claims and clinical data for sepsis incidence and mortality rates and a substantial difference in the relative hospital rankings for sepsis mortality. Furthermore, Rhee and colleagues said 46% of hospitals ranked as having the lowest rate of sepsis mortality using claims data saw an increase in mortality rates when clinical data was used.
Rhee explained that varying claims data between hospitals limits its use when comparing sepsis rates and outcomes.
“I would be the first to acknowledge that there is no true gold standard for sepsis,” Rhee said. “However, the EHR clinical criteria, I believe, are more objective and consistent.” – Marley Ghizzone
Reference:
Rhee C, et al. Abstract 1659. Presented at: IDWeek; Oct. 3-7, 2018; San Francisco.
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Konrad Reinhart, MD
There are several limitations in using administrative claims data for sepsis surveillance.
As already demonstrated, using this data set for the assessment of the incidence of sepsis results in an underestimation of sepsis incidence by more than 50%. In the year 2014, hospital incidence using EHRs was 6% compared with only 2.5% using explicit ICD-9-CM codes.
Based on explicit ICD-9-CM codes between 2010 and 2014, there was an annual increase of sepsis incidence by 10.4%, whereas the trend analysis based on EHRs showed a stable trend of sepsis incidence. The additional analyses of this data set confirm that the absolute sepsis mortality rates in patients with explicit sepsis codes on average are 7% to 8% higher, compared with clinical data, and 10% to 12% higher in comparison to patients with implicit sepsis codes. Furthermore, these data also showed that there is considerable variation of the reliability of adjusted mortality rates between individual hospitals and that these differences are similarly reflected by both coding strategies and by the clinical criteria. However, the standard deviations in the mortality rates defined by clinical criteria are smaller.
The current estimates of sepsis incidence and its trends result in a considerable underestimation of the incidence and overestimation of its increase because currently they are mostly based on explicit sepsis codes. The big variation in hospital mortality rates demonstrates the huge potential to reduce sepsis mortality rates by quality improvement efforts. Hospitals should increase their efforts to educate physicians and coders to improve the quality of coding and base quality improvement efforts whenever it is possible on clinical criteria, although differences in quality of sepsis care are reflected also in claims data. The research on sepsis epidemiology and surveillance should be based more on prospectively collected clinical data.
Antimicrobials are the only cure for sepsis, although about 30% of patients may require surgery in addition to antimicrobials to control the source of the infection. For example, if you have gallstones and kidney stones with an infected gallbladder or kidney or an infected heart valve or hip prosthesis, you will need to undergo surgery. As antimicrobials become less effective, we may increasingly fail to effectively treat infections and prevent their progress to sepsis, and if we have patients whose sepsis is caused by multidrug-resistant pathogens, the chance of survival becomes even worse. This is why I joined the “I’m a resistance fighter” campaign created by Becton, Dickinson and Company, because sepsis awareness and education is so critical. Collectively, we are driving global, concentrated efforts to raise awareness of the need to combat antimicrobial resistance and the necessary actions being taken. By getting involved, we aim to encourage others to share their stories of survival, remembrance or commitment, and to inspire others to act because we all need to be resistance fighters. (To learn more about the campaign and share a story, visit www.antimicrobialresistancefighters.org.)
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