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Healthcare Utilization and Infection in the Week Prior to Sepsis Hospitalization*

Liu, Vincent X. MD, MS1,2; Escobar, Gabriel J. MD1; Chaudhary, Rakesh MD2; Prescott, Hallie C. MD, MSc3,4

doi: 10.1097/CCM.0000000000002960
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Objectives: To quantify healthcare utilization in the week preceding sepsis hospitalization to identify potential opportunities to improve the recognition and treatment of sepsis prior to admission.

Design: Retrospective study.

Setting: Two large integrated healthcare delivery systems in the United States.

Participants: Hospitalized sepsis patients.

Interventions: None.

Measurements and Main Results: We quantified clinician-based encounters in each of the 7 days preceding sepsis admission, as well as on the day of admission, and categorized them as: hospitalization, subacute nursing facility, emergency department, urgent care, primary care, and specialty care. We identified the proportion of encounters with diagnoses for acute infection based on 28 single-level Clinical Classification Software categories. We also quantified the use of antibiotics over the same interval and used linear regression to evaluate time trends. We included a total of 14,658 Kaiser Permanente Northern California sepsis hospitalizations and 31,369 Veterans Health Administration sepsis hospitalizations. Over 40% of patients in both cohorts required intensive care. A total of 7,747 Kaiser Permanente Northern California patients (52.9%) and 14,280 Veterans Health Administration patients (45.5%) were seen by a clinician in the week before sepsis. Prior to sepsis, utilization of subacute nursing facilities remained steady, whereas hospital utilization declined. Primary care, specialty care, and emergency department visits increased, particularly at admission day. Among those with a presepsis encounter, 2,648 Kaiser Permanente Northern California patients (34.2%) and 3,858 Veterans Health Administration patients (27.0%) had at least one acute infection diagnosis. An increasing percentage of outpatient encounters also had infectious diagnoses (3.3%/d; 95% CI, 1.5%–5.1%; p < 0.01), particularly in primary and specialty care settings. Prior to sepsis hospitalization, the use of antibiotics also increased steadily (2.1%/d; 95% CI, 1.1%–3.1%; p < 0.01).

Conclusions: Over 45% of sepsis patients had clinician-based encounters in the week prior to hospitalization with an increasing frequency of diagnoses for acute infection and antibiotic use in the outpatient setting. These presepsis encounters offer several potential opportunities to improve the recognition, risk stratification, and treatment prior to sepsis hospitalization.

1Kaiser Permanente Division of Research, Oakland, CA.

2Kaiser Permanente Santa Clara Medical Center, Santa Clara, CA.

3VA Center for Clinical Management Research, Health Services Research & Development Center of Innovation, Ann Arbor, MI.

4Department of Internal Medicine, University of Michigan, Ann Arbor, MI.

*See also p. 644.

Supported, in part, by funding from The Permanente Medical Group, IIR 11–109 from the U.S. Department of Veterans Affairs Health Services Research and Development Service, National Institutes of Health (NIH) K23GM112018 (to Dr. Liu), and NIH K08GM115859 (to Dr. Prescott).

Drs. Liu, Escobar, and Prescott received support for article research from the National Institutes of Health (NIH). Dr. Liu’s institution received funding from the National Institute of General Medical Sciences. Dr. Escobar’s institution received funding from Gordon and Betty Moore Foundation (grants to develop predictive models for in-hospital deterioration and rehospitalization) and Merck (grant to develop predictive model for recurrent Clostridium difficile infection). Dr. Prescott’s institution received funding from the NIH, and she disclosed government work. Dr. Chaudhary disclosed that he does not have any potential conflicts of interest.

For information regarding this article, E-mail: Vincent.X.Liu@kp.org

Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.