Effectiveness of Treatments and Diagnostic Tools and Declining Mortality in Patients With Severe Sepsis: A 12-Year Population-Based Cohort Study

Abstract

Sepsis is a major cause of morbidity and mortality worldwide. With the advance of medical care, the mortality of sepsis has decreased in the past decades. Many treatments and diagnostic tools still lack supporting evidence. We conducted a retrospective population-based cohort study with propensity score matched subcohorts based on a prospectively collected national longitudinal health insurance database in Taiwan. Severe sepsis-associated hospital admissions from 2000 to 2011 based on International Classification of Diseases, Ninth Revision, Clinical Modification codes of infections and acute organ dysfunction were identified. To compare the effectiveness of treatment and diagnostic tool, propensity scores were generated to match the comparable control groups. During the 12-year period, 33 375 patients and 50 465 hospitalizations of severe sepsis were identified. The age-standardized 28-day in-hospital mortality decreased significantly from 21% in 2008 to 15% in 2011 with increasingly implemented treatment and diagnostic tool. After propensity score matching, procalcitonin (odds ratio [OR]: 0.70, 95% confidence interval [95% CI]: 0.61-0.81) and lactate testing (OR: 0.90, 95% CI: 0.84-0.97, respectively), transfusion of packed red blood cell (OR: 0.60, 95% CI: 0.52-0.69), albumin (OR: 0.72, 95% CI: 0.55-0.93), balanced crystalloid (OR: 0.29, 95% CI: 0.20-0.41), and use of dopamine (OR: 0.44, 95% CI: 0.39-0.49) were found to be significantly associated with lower mortality rate. However, inconsistent findings need to be further validated.

Keywords

propensity score matching sepsis procalcitonin lactate vasoactive agents blood transfusion albumin mortality balanced crystalloid cohort

Get full access to this article

View all access options for this article.

References

Dellinger

Levy

Rhodes

, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41(2):580–637.

Angus

Wax

. Epidemiology of sepsis: an update. Crit Care Med. 2001;29(7 Suppl):S109–S116.

Khwannimit

Bhurayanontachai

. The epidemiology of, and risk factors for, mortality from severe sepsis and septic shock in a tertiary-care university hospital setting. Epidemiol Infect. 2009;137(9):1333–1341.

Tanriover

Guven

Sen

Unal

Uzun

. Epidemiology and outcome of sepsis in a tertiary-care hospital in a developing country. Epidemiol Infect. 2006;134(2):315–322.

Yang

Hsann

Lim

Ong

. The effect of comorbidity and age on hospital mortality and length of stay in patients with sepsis. J Crit Care. 2010;25(3):398–405.

Chao

Liu

Lin

, et al. Association of in-hospital mortality and dysglycemia in septic patients. PLoS One. 2017;12(1):e0170408.

Angus

Linde-Zwirble

Lidicker

Clermont

Carcillo

Pinsky

. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29(7):1303–1310.

Rhodes

Evans

Alhazzani

, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Crit Care Med. 2017;45(3):486–552.

Silversides

Ferguson

McAuley

Blackwood

Marshall

Fan

. Fluid strategies and outcomes in patients with acute respiratory distress syndrome, systemic inflammatory response syndrome and sepsis: a protocol for a systematic review and meta-analysis. Syst Rev. 2015;4:162.

10.

Rochwerg

Alhazzani

Gibson

, et al. Fluid type and the use of renal replacement therapy in sepsis: a systematic review and network meta-analysis. Intensive Care Med. 2015;41(9):1561–1571.

11.

Alegria

Vera

Dreyse

, et al. A hypoperfusion context may aid to interpret hyperlactatemia in sepsis-3 septic shock patients: a proof-of-concept study. Ann Intensive Care. 2017;7(1):29.

12.

Haas

Lange

Saugel

, et al. Severe hyperlactatemia, lactate clearance and mortality in unselected critically ill patients. Intensive Care Med. 2016;42(2):202–210.

13.

Shen

Yang

. Epidemiologic trend of severe sepsis in Taiwan from 1997 through 2006. Chest. 2010;138(2):298–304.

14.

O’Malley

Cook

Price

Wildes

Hurdle

Ashton

. Measuring diagnoses: ICD code accuracy. Health Serv Res. 2005;40(5 Pt 2):1620–1639.

15.

Kajiwara

Zucoloto

Manco

Muccillo

Barbieri

. Accuracy of clinical diagnoses in a teaching hospital: a review of 997 autopsies. J Intern Med. 1993;234(2):181–187.

16.

Liu

Chuang

Chen

, et al. Incorporating development stratification of Taiwan townships into sampling design of large scale health interview survey. J Health Manag. 2006;4(1):1–22.

17.

Lai

Gau

Wang

Tsai

. Concordance between patient self-reports and claims data on clinical diagnoses, medication use, and health system utilization in Taiwan. PLoS One. 2014;9(12):e112257.

18.

Roffman

Buchanan

Allison

. Charlson comorbidities index. J Physiother. 2016;62(3):171.

19.

Chen

Chang

Tang

. The impact of nationwide education program on clinical practice in sepsis care and mortality of severe sepsis: a population-based study in Taiwan. PLoS One. 2013;8(10):e77414.

20.

Rosenbaum

Rubin

. Constructing a control group using multivariate matched sampling methods that incorporate the propensity score. Am Stat. 1985;39(1):33–38.

21.

Walkey

Wiener

Lindenauer

. Utilization patterns and outcomes associated with central venous catheter in septic shock: a population-based study. Crit Care Med. 2013;41(6):1450–1457.

22.

Sormani

. The Will Rogers phenomenon: the effect of different diagnostic criteria. J Neurol Sci. 2009;287(Suppl 1):S46–S49.

23.

Chung

. Are quality improvement methods a fashion for hospitals in Taiwan? Int J Qual Health Care. 2012;24(4):371–379.

24.

Ho Chan

. Taiwan’s healthcare report 2010. EPMA J. 2010;1(4):563–585.

25.

Huang

Chuang

Tsai

. High mortality in severe sepsis and septic shock patients with do-not-resuscitate orders in east Asia. PLoS One. 2016;11(7):e0159501.

26.

Andriolo

Salomao

Atallah

. Effectiveness and safety of procalcitonin evaluation for reducing mortality in adults with sepsis, severe sepsis or septic shock. Cochrane Database Syst Rev. 2017;1:CD010959.

27.

Zhang

Wang

Yang

Dong

. Procalcitonin-guided antibiotic therapy in critically ill adults: a meta-analysis. BMC Infect Dis. 2017;17(1):514.

28.

Park

Chun

Kwon

, et al. Red blood cell transfusions are associated with lower mortality in patients with severe sepsis and septic shock: a propensity-matched analysis*. Crit Care Med. 2012;40(12):3140–3145.

29.

Chan

Han

Chen

. Transfusion of red blood cells to patients with sepsis. Int J Mol Sci. 2017;18(9):pii: E1946.

30.

Gamper

Havel

Arrich

, et al. Vasopressors for hypotensive shock. Cochrane Database Syst Rev. 2016;2:CD003709.

31.

De Backer

Biston

Devriendt

, et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med. 2010;362(9):779–789.

32.

Ollendorf

Fendrick

Massey

Williams

Oster

. Is sepsis accurately coded on hospital bills? Value Health. 2002;5(2):79–81.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.55 MB

1.53 MB