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Schwarzkopf D, Rose N, Fleischmann-Struzek C, Boden B, Dorow H, Edel A, Friedrich M, Gonnert FA, Götz J, Gründling M, Heim M, Holbeck K, Jaschinski U, Koch C, Künzer C, Le Ngoc K, Lindau S, Mehlmann NB, Meschede J, Meybohm P, Ouart D, Putensen C, Sander M, Schewe JC, Schlattmann P, Schmidt G, Schneider G, Spies C, Steinsberger F, Zacharowski K, Zinn S, Reinhart K. Understanding the biases to sepsis surveillance and quality assurance caused by inaccurate coding in administrative health data. Infection 2024; 52:413-427. [PMID: 37684496 PMCID: PMC10954942 DOI: 10.1007/s15010-023-02091-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023]
Abstract
PURPOSE Timely and accurate data on the epidemiology of sepsis are essential to inform policy decisions and research priorities. We aimed to investigate the validity of inpatient administrative health data (IAHD) for surveillance and quality assurance of sepsis care. METHODS We conducted a retrospective validation study in a disproportional stratified random sample of 10,334 inpatient cases of age ≥ 15 years treated in 2015-2017 in ten German hospitals. The accuracy of coding of sepsis and risk factors for mortality in IAHD was assessed compared to reference standard diagnoses obtained by a chart review. Hospital-level risk-adjusted mortality of sepsis as calculated from IAHD information was compared to mortality calculated from chart review information. RESULTS ICD-coding of sepsis in IAHD showed high positive predictive value (76.9-85.7% depending on sepsis definition), but low sensitivity (26.8-38%), which led to an underestimation of sepsis incidence (1.4% vs. 3.3% for severe sepsis-1). Not naming sepsis in the chart was strongly associated with under-coding of sepsis. The frequency of correctly naming sepsis and ICD-coding of sepsis varied strongly between hospitals (range of sensitivity of naming: 29-71.7%, of ICD-diagnosis: 10.7-58.5%). Risk-adjusted mortality of sepsis per hospital calculated from coding in IAHD showed no substantial correlation to reference standard risk-adjusted mortality (r = 0.09). CONCLUSION Due to the under-coding of sepsis in IAHD, previous epidemiological studies underestimated the burden of sepsis in Germany. There is a large variability between hospitals in accuracy of diagnosing and coding of sepsis. Therefore, IAHD alone is not suited to assess quality of sepsis care.
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Affiliation(s)
- Daniel Schwarzkopf
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
| | - Norman Rose
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Erlanger Allee 103, 07747, Jena, Germany
| | - Carolin Fleischmann-Struzek
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Erlanger Allee 103, 07747, Jena, Germany
| | - Beate Boden
- Department of Internal Medicine II-Intensive Care, Klinikum Lippe GmbH, Röntgenstraße 18, 32756, Detmold, Germany
| | - Heike Dorow
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Andreas Edel
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Marcus Friedrich
- Berlin Institute of Health, Visiting Professor for the Stiftung Charité, Anna-Louisa-Karsch-Str. 2, 10178, Berlin, Germany
| | - Falk A Gonnert
- Department of Anaesthesiology and Intensive Care Medicine, SRH Wald-Klinikum, Straße des Friedens 122, 07548, Gera, Germany
| | - Jürgen Götz
- Department of Internal Medicine II-Intensive Care, Klinikum Lippe GmbH, Röntgenstraße 18, 32756, Detmold, Germany
| | - Matthias Gründling
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Markus Heim
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Ismaninger Straße 22, 81675, Munich, Germany
| | - Kirill Holbeck
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Ismaninger Straße 22, 81675, Munich, Germany
| | - Ulrich Jaschinski
- Department of Anaesthesiology and Surgical Intensive Care Medicine, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Christian Koch
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Gießen, UKGM, Justus-Liebig University Gießen, Rudolf-Buchheim-Straße 7, 35392, Giessen, Germany
| | - Christian Künzer
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Khanh Le Ngoc
- Department of Anaesthesiology and Intensive Care Medicine, SRH Wald-Klinikum, Straße des Friedens 122, 07548, Gera, Germany
| | - Simone Lindau
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Ngoc B Mehlmann
- Department of Anaesthesiology and Surgical Intensive Care Medicine, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Germany
| | - Jan Meschede
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Ismaninger Straße 22, 81675, Munich, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Oberduerrbacher Straße 6, 97080, Würzburg, Germany
| | - Dominique Ouart
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Christian Putensen
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Gießen, UKGM, Justus-Liebig University Gießen, Rudolf-Buchheim-Straße 7, 35392, Giessen, Germany
| | - Jens-Christian Schewe
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Medicine, University Medical Centre Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Peter Schlattmann
- Institute for Medical Statistics, Computer Science and Data Science, Jena University Hospital, Bachstraße 18, 07743, Jena, Germany
| | - Götz Schmidt
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Gießen, UKGM, Justus-Liebig University Gießen, Rudolf-Buchheim-Straße 7, 35392, Giessen, Germany
| | - Gerhard Schneider
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, School of Medicine, Ismaninger Straße 22, 81675, Munich, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Ferdinand Steinsberger
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Gießen, UKGM, Justus-Liebig University Gießen, Rudolf-Buchheim-Straße 7, 35392, Giessen, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Sebastian Zinn
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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Hechtman RK, Kipnis P, Cano J, Seelye S, Liu VX, Prescott HC. Heterogeneity of Benefit from Earlier Time-to-Antibiotics for Sepsis. Am J Respir Crit Care Med 2024; 209:852-860. [PMID: 38261986 PMCID: PMC10995570 DOI: 10.1164/rccm.202310-1800oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/23/2024] [Indexed: 01/25/2024] Open
Abstract
Rationale: Shorter time-to-antibiotics improves survival from sepsis, particularly among patients in shock. There may be other subgroups for whom faster antibiotics are particularly beneficial.Objectives: Identify patient characteristics associated with greater benefit from shorter time-to-antibiotics.Methods: Observational cohort study of patients hospitalized with community-onset sepsis at 173 hospitals and treated with antimicrobials within 12 hours. We used three approaches to evaluate heterogeneity of benefit from shorter time-to-antibiotics: 1) conditional average treatment effects of shorter (⩽3 h) versus longer (>3-12 h) time-to-antibiotics on 30-day mortality using multivariable Poisson regression; 2) causal forest to identify characteristics associated with greatest benefit from shorter time-to-antibiotics; and 3) logistic regression with time-to-antibiotics modeled as a spline.Measurements and Main Results: Among 273,255 patients with community-onset sepsis, 131,094 (48.0%) received antibiotics within 3 hours. In Poisson models, shorter time-to-antibiotics was associated with greater absolute mortality reduction among patients with metastatic cancer (5.0% [95% confidence interval; CI: 4.3-5.7] vs. 0.4% [95% CI: 0.2-0.6] for patients without cancer, P < 0.001); patients with shock (7.0% [95% CI: 5.8-8.2%] vs. 2.8% [95% CI: 2.7-3.5%] for patients without shock, P = 0.005); and patients with more acute organ dysfunctions (4.8% [95% CI: 3.9-5.6%] for three or more dysfunctions vs. 0.5% [95% CI: 0.3-0.8] for one dysfunction, P < 0.001). In causal forest, metastatic cancer and shock were associated with greatest benefit from shorter time-to-antibiotics. Spline analysis confirmed differential nonlinear associations of time-to-antibiotics with mortality in patients with metastatic cancer and shock.Conclusions: In patients with community-onset sepsis, the mortality benefit of shorter time-to-antibiotics varied by patient characteristics. These findings suggest that shorter time-to-antibiotics for sepsis is particularly important among patients with cancer and/or shock.
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Affiliation(s)
- Rachel K. Hechtman
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Patricia Kipnis
- Division of Research, Kaiser Permanente, Oakland, California; and
| | - Jennifer Cano
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Sarah Seelye
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California; and
| | - Hallie C. Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
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Taylor SP, Kowalkowski MA, Skewes S, Chou SH. Real-World Implications of Updated Surviving Sepsis Campaign Antibiotic Timing Recommendations. Crit Care Med 2024:00003246-990000000-00297. [PMID: 38385751 DOI: 10.1097/ccm.0000000000006240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVE To evaluate real-world implications of updated Surviving Sepsis Campaign (SSC) recommendations for antibiotic timing. DESIGN Retrospective cohort study. SETTING Twelve hospitals in the Southeastern United States between 2017 and 2021. PATIENTS One hundred sixty-six thousand five hundred fifty-nine adult hospitalized patients treated in the emergency department for suspected serious infection. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We determined the number and characteristics of patients affected by updated SSC recommendations for initiation of antibiotics that incorporate a risk- and probability-stratified approach. Using an infection prediction model with a cutoff of 0.5 to classify possible vs. probable infection, we found that 30% of the suspected infection cohort would be classified as shock absent, possible infection and thus eligible for the new 3-hour antibiotic recommendation. In real-world practice, this group had a conservative time to antibiotics (median, 5.5 hr; interquartile range [IQR], 3.2-9.8 hr) and low mortality (2%). Patients categorized as shock absent, probable infection had a median time to antibiotics of 3.2 hours (IQR, 2.1-5.1 hr) and mortality of 3%. Patients categorized as shock present, the probable infection had a median time to antibiotics 2.7 hours (IQR, 1.7-4.6 hr) and mortality of 17%, and patients categorized as shock present, the possible infection had a median time to antibiotics 6.9 hours (IQR, 3.5-16.3 hr) and mortality of 12%. CONCLUSIONS These data support recently updated SSC recommendations to align antibiotic timing targets with risk and probability stratifications. Our results provide empirical support that clinicians and hospitals should not be held to 1-hour targets for patients without shock and with only possible sepsis.
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Affiliation(s)
- Stephanie P Taylor
- Division of Hospital Medicine, Department of Internal Medicine, University of Michigan, Institute for Health Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Marc A Kowalkowski
- Department of Internal Medicine, Wake Forest University School of Medicine, Center for Health System Sciences, Atrium Health, Charlotte, NC
| | - Sable Skewes
- Division of Pulmonary and Critical Care, Wake Forest University, Winston-Salem, NC
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Donnelly JP, Seelye SM, Kipnis P, McGrath BM, Iwashyna TJ, Pogue J, Jones M, Liu VX, Prescott HC. Impact of Reducing Time-to-Antibiotics on Sepsis Mortality, Antibiotic Use, and Adverse Events. Ann Am Thorac Soc 2024; 21:94-101. [PMID: 37934602 PMCID: PMC10867916 DOI: 10.1513/annalsats.202306-505oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/31/2023] [Indexed: 11/09/2023] Open
Abstract
Rationale: Shorter time-to-antibiotics is lifesaving in sepsis, but programs to hasten antibiotic delivery may increase unnecessary antibiotic use and adverse events. Objectives: We sought to estimate both the benefits and harms of shortening time-to-antibiotics for sepsis. Methods: We conducted a simulation study using a cohort of 1,559,523 hospitalized patients admitted through the emergency department with meeting two or more systemic inflammatory response syndrome criteria (2013-2018). Reasons for hospitalization were classified as septic shock, sepsis, infection, antibiotics stopped early, and never treated (no antibiotics within 48 h). We simulated the impact of a 50% reduction in time-to-antibiotics for sepsis across 12 hospital scenarios defined by sepsis prevalence (low, medium, or high) and magnitude of "spillover" antibiotic prescribing to patients without infection (low, medium, high, or very high). Outcomes included mortality and adverse events potentially attributable to antibiotics (e.g., allergy, organ dysfunction, Clostridiodes difficile infection, and culture with multidrug-resistant organism). Results: A total of 933,458 (59.9%) hospitalized patients received antimicrobial therapy within 48 hours of presentation, including 38,572 (2.5%) with septic shock, 276,082 (17.7%) with sepsis, 370,705 (23.8%) with infection, and 248,099 (15.9%) with antibiotics stopped early. A total of 199,937 (12.8%) hospitalized patients experienced an adverse event; most commonly, acute liver injury (5.6%), new MDRO (3.5%), and Clostridiodes difficile infection (1.7%). Across the scenarios, a 50% reduction in time-to-antibiotics for sepsis was associated with a median of 1 to 180 additional antibiotic-treated patients and zero to seven additional adverse events per death averted from sepsis. Conclusions: The impacts of faster time-to-antibiotics for sepsis vary markedly across simulated hospital types. However, even in the worst-case scenario, new antibiotic-associated adverse events were rare.
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Affiliation(s)
- John P. Donnelly
- Department of Learning Health Sciences
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- VA Center for Implementation and Evaluation Resources, Ann Arbor, Michigan
| | - Sarah M. Seelye
- VA Center for Clinical Management Research, Ann Arbor, Michigan
| | - Patricia Kipnis
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Brenda M. McGrath
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- OCHIN Inc., Portland, Oregon
| | - Theodore J. Iwashyna
- Department of Internal Medicine, and
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- Department of Internal Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jason Pogue
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - Makoto Jones
- Salt Lake City VA Healthcare System, Salt Lake City, Utah; and
- Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Hallie C. Prescott
- Department of Internal Medicine, and
- VA Center for Clinical Management Research, Ann Arbor, Michigan
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