Wednesday, May 11, 2016
Should we track sepsis trends using administrative data?
A: Maybe, but only with extreme caution after adjusting for the influence of policy changes.
One of the topics that our group at the University of Iowa is very interested in is the use of administrative databases for tracking the epidemiology of health care-associated infections, including those caused by resistant pathogens. Marin Schweitzer reported (open access) in 2011 that the ICD-9 code V09, which was commonly used for tracking MRSA trends, was a poor predictor of actual MRSA infection. More recently, Michi Goto completed a systematic review (free full text) that determined the accuracy of administrative data for surveillance of catheter-associated urinary tract infections (CAUTI), Clostridium difficile infection (CDI), central line associated blood stream infections (CLABSI), ventilator associated pneumonia (VAP/VAE), postprocedure pneumonia, methicillin-resistant Staphylococcus aureus (MRSA), and surgical site infections (SSIs). He found that administrative data detected CDI and SSI with moderate sensitivity and high specificity. For all other conditions, ICD-9 based algorithms had limited accuracy and utility.
Which brings us to a condition that we haven't much explored, sepsis. Sepsis has been in the news lately, since the Third International Consensus Definitions of Sepsis and Septic Shock (Sepsis-3) were published in February. I've included an image of a monument to a different Third International above for historical purposes. We would expect that these new definition might alter the incidence of sepsis as measured using administrative databases, but only time will tell.
Fortunately, Shruti Gohil and colleagues working with the CDC Prevention Epicenter program just published (free text in CID) an important evaluation of how previous changes in sepsis coding criteria, definitions and reimbursement might have altered sepsis rates. Using retrospective data (2000-2010) from California they determine the association between the release of CMS guidelines of sepsis coding in October 2003 along with the introduction in the MS-DRG reimbursement changes for sepsis care in October 2007 and sepsis incidence. In that article, 2 figures that showed (A) the change in incidence after each CMS change and (D) mortality per 1000 cases over the same period.
As appears obvious in figures in the article, the marked increase in sepsis incidence, 3.6 fold over the study period, is temporally associated changes in CMS coding guidance and reimbursement. And fortunately, mortality appears to be decreasing. The authors suggest that some up-capture of less severely ill septic patients may be driving these findings. They also posit that background increases in sepsis, separate from those associated with CMS changes, could be driven by early recognition programs, such as Surviving Sepsis Campaign (2004), and improved diagnosis.
The most important conclusion is this, “It is imperative that reported sepsis rates based on administrative data account for policy-related effects … interpretation of recent epidemiologic trends in sepsis based on administrative data should be approached with caution.”
Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.
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Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
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Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
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