Variation in Identifying Sepsis and Organ Dysfunction Using Administrative Versus Electronic Clinical Data and Impact on Hospital Outcome Comparisons*

Abstract

Objectives: Administrative claims data are commonly used for sepsis surveillance, research, and quality improvement. However, variations in diagnosis, documentation, and coding practices for sepsis and organ dysfunction may confound efforts to estimate sepsis rates, compare outcomes, and perform risk adjustment. We evaluated hospital variation in the sensitivity of claims data relative to clinical data from electronic health records and its impact on outcome comparisons. Design, Setting, and Patients: Retrospective cohort study of 4.3 million adult encounters at 193 U.S. hospitals in 2013–2014. Interventions: None. Measurements and Main Results: Sepsis was defined using electronic health record–derived clinical indicators of presumed infection (blood culture draws and antibiotic administrations) and concurrent organ dysfunction (vasopressors, mechanical ventilation, doubling in creatinine, doubling in bilirubin to ≥ 2.0 mg/dL, decrease in platelets to < 100 cells/µL, or lactate ≥ 2.0 mmol/L). We compared claims for sepsis prevalence and mortality rates between both methods. All estimates were reliability adjusted to account for random variation using hierarchical logistic regression modeling. The sensitivity of hospitals’ claims data was low and variable: median 30% (range, 5–54%) for sepsis, 66% (range, 26–84%) for acute kidney injury, 39% (range, 16–60%) for thrombocytopenia, 36% (range, 29–44%) for hepatic injury, and 66% (range, 29–84%) for shock. Correlation between claims and clinical data was moderate for sepsis prevalence (Pearson coefficient, 0.64) and mortality (0.61). Among hospitals in the lowest sepsis mortality quartile by claims, 46% shifted to higher mortality quartiles using clinical data. Using implicit sepsis criteria based on infection and organ dysfunction codes also yielded major differences versus clinical data. Conclusions: Variation in the accuracy of claims data for identifying sepsis and organ dysfunction limits their use for comparing hospitals’ sepsis rates and outcomes. Using objective clinical data may facilitate more meaningful hospital comparisons.

Sepsis Among Medicare Beneficiaries: 1. The Burdens of Sepsis, 2012–2018*

“…Plausible alternatives may also contribute to the rise in counts and percentages of sepsis inpatient admissions. Those alternatives note that a) although the shock aspect of septic shock is arguably objective, the sepsis part of septic shock is certainly not given that up to half of septic shock is culture negative; b) the estimated sensitivity of coding for septic shock relative to clinical markers of shock (i.e., vasopressors) has been reported by others to be only 66% and therefore codes are an imperfect proxy for true disease incidence; c) other investigators have reported substantial differences in the trajectories of septic shock incidence and mortality when using claims data compared with data in the electronic health record; and d) more sensitive and complete coding could be occurring at all levels of sepsis severity (1,(44)(45)(46). We further note that the accuracy of POA coding has been reported as only moderate; however, this assessment is based on data now a decade and half old (47).…”

Validation of automated sepsis surveillance based on the Sepsis-3 clinical criteria against physician record review in a general hospital population: observational study using electronic health records data

“…Initiatives to monitor sepsis incidence have often focussed on using administrative hospital data, such as discharge diagnosis, trigger based audits or reporting to clinical databases, all carrying risk of bias and making comparisons between hospitals difficult 28–30. The use of ICD-codes for sepsis surveillance is associated with considerable uncertainty31 32 and studies indicate that some of the increased incidence of sepsis during the last decade can be explained by changes in coding practices 33–37.…”

Sepsis and septic shock in France: incidences, outcomes and costs of care

“…Our study has several limitations, mostly related to the nature of the database: the specificity of the coding, the rise in coding due to better recognition and coding, missing data due to billing reasons, and the lack of detailed clinical, paraclinical and drug exposure data. Thus, it was not possible to compare our inclusion criteria with those based on clinical data using the sepsis 3.0 definitions as done elsewhere [28,29] to determine whether our increase was related to coding and to assess the number of misdiagnosed patients. Nor was it possible to differentiate primary infections from nosocomial infections, to know whether limitations of care were achieved or to take into account discharges to a hospice.…”