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[JAMA在线发表]:2009-2014年美国医院全身性感染的发病率趋势
2017年09月25日 时讯速递, 进展交流 暂无评论

Original Investigation

Caring for the Critically Ill Patient

September 13, 2017

Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014

Chanu Rhee, Raymund Dantes, Lauren Epstein, et al.

JAMA. Published online September 13, 2017. doi:10.1001/jama.2017.13836

Importance 背景

Estimates from claims-based analyses suggest that the incidence of sepsis is increasing and mortality rates from sepsis are decreasing. However, estimates from claims data may lack clinical fidelity and can be affected by changing diagnosis and coding practices over time.

根据医疗报销分析所做出的估计表明,全身性感染的发病率增加,而病死率降低。然而,根据医疗报销数据所做的估计缺乏临床真实性,受到诊断及疾病编码改变的影响。

Objective 目的

To estimate the US national incidence of sepsis and trends using detailed clinical data from the electronic health record (EHR) systems of diverse hospitals.

采用不同医院电子病历(EHR)系统的详细临床数据估计美国全国全身性感染的发病率及其变化趋势。

Design, Setting, and Population 设计,场景及研究对象

Retrospective cohort study of adult patients admitted to 409 academic, community, and federal hospitals from 2009-2014.

2009-2014年409所学术型、社区和联邦医院收治的成年患者的回顾性队列研究

Exposures 暴露因素

Sepsis was identified using clinical indicators of presumed infection and concurrent acute organ dysfunction, adapting Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria for objective and consistent EHR-based surveillance.

采用感染及同时发生的急性器官功能障碍的临床指标鉴别全身性感染,并根据第三次全身性感染及感染性休克国际共识定义(Sepsis-3)标准对EHR进行客观一致的调查。

Main Outcomes and Measures 主要预后指标

Sepsis incidence, outcomes, and trends from 2009-2014 were calculated using regression models and compared with claims-based estimates using International Classification of Diseases, Ninth Revision, Clinical Modification codes for severe sepsis or septic shock. Case-finding criteria were validated against Sepsis-3 criteria using medical record reviews.

根据回归模型计算2009-2014年间全身性感染发病率、临床预后及变化趋势,并根据ICD-9-CM中严重全身性感染或感染性休克的相关编码得到医疗报销的估计数字,将两者进行比较。通过查阅病历记录将病例鉴别标准与Sepsis-3标准进行验证。

Results 结果

A total of 173 690 sepsis cases (mean age, 66.5 [SD, 15.5] y; 77 660 [42.4%] women) were identified using clinical criteria among 2 901 019 adults admitted to study hospitals in 2014 (6.0% incidence). Of these, 26 061 (15.0%) died in the hospital and 10 731 (6.2%) were discharged to hospice. From 2009-2014, sepsis incidence using clinical criteria was stable (+0.6% relative change/y [95% CI, −2.3% to 3.5%], P = .67) whereas incidence per claims increased (+10.3%/y [95% CI, 7.2% to 13.3%], P < .001). In-hospital mortality using clinical criteria declined (−3.3%/y [95% CI, −5.6% to −1.0%], P = .004), but there was no significant change in the combined outcome of death or discharge to hospice (−1.3%/y [95% CI, −3.2% to 0.6%], P = .19). In contrast, mortality using claims declined significantly (−7.0%/y [95% CI, −8.8% to −5.2%], P < .001), as did death or discharge to hospice (−4.5%/y [95% CI, −6.1% to −2.8%], P < .001). Clinical criteria were more sensitive in identifying sepsis than claims (69.7% [95% CI, 52.9% to 92.0%] vs 32.3% [95% CI, 24.4% to 43.0%], P < .001), with comparable positive predictive value (70.4% [95% CI, 64.0% to 76.8%] vs 75.2% [95% CI, 69.8% to 80.6%], P = .23).

在2014年参研医院收治的2901019名成年患者中,采用临床标准确定了173690名全身性感染病例(平均年龄,66.5 [SD, 15.5] y; 77 660名 [42.4%]女性)(发病率6.0%)。其中, 26 061名 (15.0%) 在住院期间死亡, 10 731名 (6.2%) 转入安养院。从2009至2014年,根据临床标准诊断的全身性感染发病率保持稳定(相对改变+0.6%/y [95% CI, −2.3% to 3.5%], P = .67),而根据医疗报销估计的发病率显著增加 (+10.3%/y [95% CI, 7.2% to 13.3%], P < .001)。根据临床标准诊断的住院病死率下降 (−3.3%/y [95% CI, −5.6% to −1.0%], P = .004),但死亡或转入安养院的综合预后没有显著改变(−1.3%/y [95% CI, −3.2% to 0.6%], P = .19)。相反,根据医疗报销估计的病死率显著降低 (−7.0%/y [95% CI, −8.8% to −5.2%], P < .001),死亡或转入安养院的综合预后也呈显著下降 (−4.5%/y [95% CI, −6.1% to −2.8%], P < .001)。与医疗报销数据相比,临床标准鉴别全身性感染更加敏感 (69.7% [95% CI, 52.9% to 92.0%] vs 32.3% [95% CI, 24.4% to 43.0%], P < .001),而阳性预期值相似 (70.4% [95% CI, 64.0% to 76.8%] vs 75.2% [95% CI, 69.8% to 80.6%], P = .23)。

Conclusions and Relevance 结论与意义

In clinical data from 409 hospitals, sepsis was present in 6% of adult hospitalizations, and in contrast to claims-based analyses, neither the incidence of sepsis nor the combined outcome of death or discharge to hospice changed significantly between 2009-2014. The findings also suggest that EHR-based clinical data provide more objective estimates than claims-based data for sepsis surveillance.

根据409所医院的临床数据,成年住院患者中约6%罹患全身性感染,与根据医疗报销数据分析结果相反,全身性感染的发病率以及死亡或转入安养院的综合预后指标在2009-2014年间并无显著改变。这些发现还提示,对于全身性感染监测而言,基于EHR的临床数据得到的预测数据较根据医疗报销得到的结果更加客观。

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