Search

Objectives: In developed countries, public health systems have become adept at rapidly identifying the etiology and impact of public health emergencies. However, within the time course of clinical responses, shortfalls in readily analyzable patient-level data limit capabilities to understand clinical course, predict outcomes, ensure resource availability, and evaluate the effectiveness of diagnostic and therapeutic strategies for seriously ill and injured patients. To be useful in the timeline of a public health emergency, multi-institutional clinical investigation systems must be in place to rapidly collect, analyze, and disseminate detailed clinical information regarding patients across prehospital, emergency department, and acute care hospital settings, including ICUs. As an initial step to near real-time clinical learning during public health emergencies, we sought to develop an "all-hazards" core dataset to characterize serious illness and injuries and the resource requirements for acute medical response across the care continuum.Subjects: A multidisciplinary panel of clinicians, public health professionals, and researchers with expertise in public health emergencies.Design: Group consensus process.Interventions: The consensus process included regularly scheduled conference calls, electronic communications, and an in-person meeting to generate candidate variables. Candidate variables were then reviewed by the group to meet the competing criteria of utility and feasibility resulting in the core dataset.Measurements and Main Results: The 40-member panel generated 215 candidate variables for potential dataset inclusion. The final dataset includes 140 patient-level variables in the domains of demographics and anthropometrics (7), prehospital (11), emergency department (13), diagnosis (8), severity of illness (54), medications and interventions (38), and outcomes (9).Conclusions: The resulting all-hazard core dataset for seriously ill and injured persons provides a foundation to facilitate rapid collection, analyses, and dissemination of information necessary for clinicians, public health officials, and policymakers to optimize public health emergency response. Further work is needed to validate the effectiveness of the dataset in a variety of emergency settings. [ABSTRACT FROM AUTHOR]

Competing Interests: Dr. Szumita received funding from Trevena. Dr. Barletta received funding from Wolters Kluwer and Lexicomp. Dr. DePriest received funding from Baxter Channel One. Dr. Wischmeyer received funding from Abbott, Baxter, Fresenius Kabi Deutschland GmbH, Danone and Nutricia, Musclesound, Dutch State Mines, and Nestle. Dr. Argetsinger disclosed that she is an employee of the University of Michigan Health West and Bronson Methodist Hospital and Georgetown University School of Nursing. Dr. Dionne received funding from the Canadian Institutes of Health Research. Dr. Granholm received funding from Sygeforsikringen “Danmark.” The remaining authors have disclosed that they do not have any potential conflicts of interest.

Objectives: To provide updated information on the burdens of sepsis during acute inpatient admissions for Medicare beneficiaries., Design: Analysis of paid Medicare claims via the Centers for Medicare and Medicaid Services DataLink Project., Setting: All U.S. acute-care hospitals, excluding federally operated hospitals (Veterans Administration and Defense Health Agency)., Patients: All Medicare beneficiaries, January 2012-February 2020, with an explicit sepsis diagnostic code assigned during an inpatient admission., Interventions: None., Measurements and Main Results: The count of Medicare Part A/B (fee-for-service) plus Medicare Advantage inpatient sepsis admissions rose from 981,027 (CY2012) to 1,700,433 (CY 2019). The proportion of total admissions with sepsis in the Medicare Advantage population rose from 21.43% to 35.39%, reflecting the increasing beneficiary proportion enrolled in Medicare Advantage. In CY2019, 6-month mortality rates in Medicare fee-for-service beneficiaries for sepsis continued to decline, but remained high: 59.9% for septic shock, 35.5% for severe sepsis, 30.8% for sepsis attributed to a specific organism, and 26.5% for unspecified sepsis. Total fee-for-service-only inpatient hospital costs rose from $17.79B (CY2012) to $22.98B (CY2019). We estimated that the aggregate cost of sepsis hospital care for the entire U.S. population was at least $57.47B in 2019. Inclusion of 14 months' (January 2019-February 2020) newer data exposed new trends: the cost per patient, number of admissions, and fraction of patients with sepsis labeled as present on admission inflected around November 2015, coincident with the change to International Classification of Diseases, 10th Edition, and introduction of the Severe Sepsis and Septic Shock Management Bundle (SEP-1) metric., Conclusions: Sepsis among Medicare beneficiaries precoronavirus disease 2019 imposed immense burdens upon patients, their families, and the taxpayers., Competing Interests: Drs. Frank, Buchman, Sciarretta, Sowers, Collier, Chavan, Lin, Oke, Rhodes, Santhosh, Chu, Patel, Disbrow, and Kelman disclosed government work. Dr. Buchman’s institution received funding from United States government Biomedical Advanced Research and Development Authority (BARDA)/Division of Research, Innovation, and Ventures and the Society of Critical Care Medicine (Editor in Chief of Critical Care Medicine). Dr. Simpson disclosed he is the President of the American College of Chest Physicians. Dr. Sowers’s institution received funding from BARDA, Office of the Assistant Secretary for Preparedness and Response. Drs. Collier, Chavan, Lin, Oke, Rhodes, and Santhosh disclosed that this work was performed by Acumen, LLC under contract with the Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services (Contract No. HHSM-500-2014-00027I; Task Order No. HHSM-500-T0004), with funding from U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. Dr. MaCurdy’s institution received funding from Centers for Medicare & Medicaid Services, he received support for article research from Centers for Medicare & Medicaid Services; and he disclosed work for hire. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Objectives: To provide contemporary estimates of the burdens (costs and mortality) associated with acute inpatient Medicare beneficiary admissions for sepsis., Design: Analysis of paid Medicare claims via the Centers for Medicare & Medicaid Services DataLink Project., Setting: All U.S. acute care hospitals, excluding federally operated hospitals (Veterans Administration and Defense Health Agency)., Patients: All Medicare beneficiaries, 2012-2018, with an inpatient admission including one or more explicit sepsis codes., Interventions: None., Measurements and Main Results: Total inpatient hospital and skilled nursing facility admission counts, costs, and mortality over time. From calendar year (CY)2012-CY2018, the total number of Medicare Part A/B (fee-for-service) beneficiaries with an inpatient hospital admission associated with an explicit sepsis code rose from 811,644 to 1,136,889. The total cost of inpatient hospital admission including an explicit sepsis code for those beneficiaries in those calendar years rose from $17,792,657,303 to $22,439,794,212. The total cost of skilled nursing facility care in the 90 days subsequent to an inpatient hospital discharge that included an explicit sepsis code for Medicare Part A/B rose from $3,931,616,160 to $5,623,862,486 over that same interval. Precise costs are not available for Medicare Part C (Medicare Advantage) patients. Using available federal data sources, we estimated the aggregate cost of inpatient admissions and skilled nursing facility admissions for Medicare Advantage patients to have risen from $6.0 to $13.4 billion over the CY2012-CY2018 interval. Combining data for fee-for-service beneficiaries and estimates for Medicare Advantage beneficiaries, we estimate the total inpatient admission sepsis cost and any subsequent skilled nursing facility admission for all (fee-for-service and Medicare Advantage) Medicare patients to have risen from $27.7 to $41.5 billion. Contemporary 6-month mortality rates for Medicare fee-for-service beneficiaries with a sepsis inpatient admission remain high: for septic shock, approximately 60%; for severe sepsis, approximately 36%; for sepsis attributed to a specific organism, approximately 31%; and for unspecified sepsis, approximately 27%., Conclusion: Sepsis remains common, costly to treat, and presages significant mortality for Medicare beneficiaries.

Objectives: To distinguish characteristics of Medicare beneficiaries who will have an acute inpatient admission for sepsis from those who have an inpatient admission without sepsis, and to describe their further trajectories during and subsequent to those inpatient admissions., Design: Analysis of paid Medicare claims via the Centers for Medicare and Medicaid Services DataLink Project., Setting: All U.S. acute care hospitals, excepting federal hospitals (Veterans Administration and Defense Health Agency)., Patients: Medicare beneficiaries, 2012-2018, with an inpatient hospital admission including one or more explicit sepsis codes., Interventions: None., Measurements and Main Results: Prevalent diagnoses in the year prior to the inpatient admission; healthcare contacts in the week prior to the inpatient admission; discharges, transfers, readmissions, and deaths (trajectories) for 6 months following discharge from the inpatient admission. Beneficiaries with no sepsis inpatient hospital admission for a year prior to an index hospital admission for sepsis were nearly indistinguishable by accumulated diagnostic codes from beneficiaries who had an index hospital admission without sepsis. Although the timing of healthcare services in the week prior to inpatient hospital admission was similar among beneficiaries who would be admitted for sepsis versus those whose inpatient admission did not include a sepsis code, the setting differed: beneficiaries destined for a sepsis admission were more likely to have received skilled nursing or unskilled nursing (e.g., nursing aide for activities of daily living) care. In contrast, comparing beneficiaries who had been free of any inpatient admission for an entire year and then required an inpatient admission, acute inpatient stays that included a sepsis code led to more than three times as many deaths within 1 week of discharge, with more admissions to skilled nursing facilities and fewer discharges to home. Comparing all beneficiaries who were admitted to a skilled nursing facility after an inpatient hospital admission, those who had sepsis coded during the index admission were more likely to die in the skilled nursing facility; more likely to be readmitted to an acute inpatient hospital and subsequently die in that setting; or if they survive to discharge from the skilled nursing facility, they are more likely to go next to a custodial nursing home., Conclusions: Although Medicare beneficiaries destined for an inpatient hospital admission with a sepsis code are nearly indistinguishable by other diagnostic codes from those whose admissions will not have a sepsis code, their healthcare trajectories following the admission are worse. This suggests that an inpatient stay that included a sepsis code not only identifies beneficiaries who were less resilient to infection but also signals increased risk for worsening health, for mortality, and for increased use of advanced healthcare services during and postdischarge along with an increased likelihood of an inpatient hospital readmission.

Objective: To evaluate the impact of sepsis, age, and comorbidities on death following an acute inpatient admission and to model and forecast inpatient and skilled nursing facility costs for Medicare beneficiaries during and subsequent to an acute inpatient sepsis admission., Design: Analysis of paid Medicare claims via the Centers for Medicare & Medicaid Services DataLink Project (CMS) and leveraging the CMS-Hierarchical Condition Category risk adjustment model., Setting: All U.S. acute care hospitals, excepting federal hospitals (Veterans Administration and Defense Health Agency)., Patients: All Part A/B (fee-for-service) Medicare beneficiaries with an acute inpatient admission in 2017 and who had no inpatient sepsis admission in the prior year., Interventions: None., Measurements and Main Results: Logistic regression models to determine covariate risk contribution to death following an acute inpatient admission; conventional regression to predict Medicare beneficiary sepsis costs. Using the Hierarchical Condition Category risk adjustment model to illuminate influence of illness on outcome of inpatient admissions, representative odds ratios (with 95% CIs) for death within 6 months of an admission (referenced to beneficiaries admitted but without the characteristic) are as follows: septic shock, 7.27 (7.19-7.35); metastatic cancer and acute leukemia (Hierarchical Condition Category 8), 6.76 (6.71-6.82); all sepsis, 2.63 (2.62-2.65); respiratory arrest (Hierarchical Condition Category 83), 2.55 (2.35-2.77); end-stage liver disease (Hierarchical Condition Category 27), 2.53 (2.49-2.56); and severe sepsis without shock, 2.48 (2.45-2.51). Models of the cost of sepsis care for Medicare beneficiaries forecast arise approximately 13% over 2 years owing the rising enrollments in Medicare offset by the cost of care per admission., Conclusions: A sepsis inpatient admission is associated with marked increase in risk of death that is comparable to the risks associated with inpatient admissions for other common and serious chronic illnesses. The aggregate costs of sepsis care for Medicare beneficiaries will continue to increase.