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Reporting of Sepsis Cases for Performance Measurement Versus for Reimbursement in New York State*

Prescott, Hallie, C., MD, MSc1,2; Cope, Tara, M., MS3; Gesten, Foster, C., MD3; Ledneva, Tatiana, A., MS3; Friedrich, Marcus, E., MD3; Iwashyna, Theodore, J., MD, PhD1,2; Osborn, Tiffany, M., MD, MPH4; Seymour, Christopher, W., MD, MSc5,6; Levy, Mitchell, M., MD7

doi: 10.1097/CCM.0000000000003005
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Objectives: Under “Rory’s Regulations,” New York State Article 28 acute care hospitals were mandated to implement sepsis protocols and report patient-level data. This study sought to determine how well cases reported under state mandate align with discharge records in a statewide administrative database.

Design: Observational cohort study.

Setting: First 27 months of mandated sepsis reporting (April 1, 2014, to June 30, 2016).

Patients: Hospitalizations with sepsis at New York State Article 28 acute care hospitals.

Intervention: Sepsis regulations with mandated reporting.

Measurements and Main Results: We compared cases reported to the New York State Department of Health Sepsis Clinical Database with discharge records in the Statewide Planning and Research Cooperative System database. We classified discharges as 1) “coded sepsis discharges”—a diagnosis code for severe sepsis or septic shock and 2) “possible sepsis discharges,” using Dombrovskiy and Angus criteria. Of 111,816 sepsis cases reported to the New York State Department of Health Sepsis Clinical Database, 105,722 (94.5%) were matched to discharge records in Statewide Planning and Research Cooperative System. The percentage of coded sepsis discharges reported increased from 67.5% in the first quarter to 81.3% in the final quarter of the study period (mean, 77.7%). Accounting for unmatched cases, as many as 82.7% of coded sepsis discharges were potentially reported, whereas at least 17.3% were unreported. Compared with unreported discharges, reported discharges had higher rates of acute organ dysfunction (e.g., cardiovascular dysfunction 63.0% vs 51.8%; p < 0.001) and higher in-hospital mortality (30.2% vs 26.1%; p < 0.001). Hospital characteristics (e.g., number of beds, teaching status, volume of sepsis cases) were similar between hospitals with a higher versus lower percent of discharges reported, p values greater than 0.05 for all. Hospitals’ percent of discharges reported was not correlated with risk-adjusted mortality of their submitted cases (Pearson correlation coefficient 0.11; p = 0.17).

Conclusions: Approximately four of five discharges with a diagnosis code of severe sepsis or septic shock in the Statewide Planning and Research Cooperative System data were reported in the New York State Department of Health Sepsis Clinical Database. Incomplete reporting appears to be driven more by underrecognition than attempts to game the system, with minimal bias to risk-adjusted hospital performance measurement.

1Department of Internal Medicine, University of Michigan, Ann Arbor, MI.

2VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI.

3Former affiliation: New York State Department of Health, Albany, NY.

4Departments of Surgery and Emergency Medicine, Washington University, St. Louis, MO.

5Departments of Critical Care and Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

6Clinical Research, Investigation, and Systems Modeling of Acute illness (CRISMA) Center, Pittsburgh, PA.

7Department of Medicine, Brown University, Providence, RI.

*See also p. 809.

Current affiliation for Ms. Cope: Siena College, Loudonville, NY.

Current affiliation for Dr. Gesten: Greater New York Hospital Association, New York, NY.

The views expressed here do not necessarily represent the views of the U.S. government or the Department of Veterans Affairs.

Drs. Prescott, Gesten, Friedrich, Iwashyna, Osborn, Seymour, and Levy designed the study. Ms. Cope and Dr. Ledneva designed the deterministic matching algorithm, applied the matching algorithm, and completed the analyses. Dr. Prescott drafted the article. All authors revised the article critically for intellectual content, approved the final version, and accept responsibility for all aspects of the work.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Drs. Prescott (K08 GM115859) and Seymour (R35GM119519) were supported, in part, by grants from the National Institutes of Health. Dr. Iwashyna is supported, in part, by grants from the Department of Veterans Affairs Health Services Research & Development IIR (11-109 13-079). Statewide Planning and Research Cooperative System and the New York State Department of Health Sepsis Clinical Database are sponsored by New York State.

Dr. Prescott’s institution received funding from the National Institutes of Health (NIH)/National Institute of General Medical Sciences. Drs. Prescott and Seymour received funding from the NIH. Drs. Prescott, Gesten, and Iwashyna disclosed government work. Dr. Cope disclosed work for hire. Dr. Iwashyna received support for article research from the VA. Dr. Osborn received funding from Cheetah, ImaCor, and Viven ATLEE HALL Legal Provisional utility patent pending, software development. Dr. Seymour’s institution received funding from a NIH grant, and he received funding from Beckman Coulter. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: hprescot@med.umich.edu

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