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IIR 11-109 – HSR&D Study

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IIR 11-109
Longterm Consequences for Veterans with Sepsis
Anne E. Sales PhD MSN RN
VA Ann Arbor Healthcare System, Ann Arbor, MI
Ann Arbor, MI
Funding Period: September 2011 - May 2015

BACKGROUND/RATIONALE:
The Veterans Health Administration (VHA) has been an international leader in the scientific measurement and management of inpatient quality, from an early system-wide electronic medical record to the careful benchmarking of the Inpatient Evaluation Center (IPEC). Substantial expertise and infrastructure have been developed for the measurement of short-term outcomes for inpatient care. Although hospitals devote considerable energy to improving long-term outcomes for patients, there is little research linking hospitals to long-term outcomes -- nor are there operational systems to provide feedback to hospitals on their results.

The fundamental goal of this proposal was to use severe sepsis as a model condition in which to develop a process for linking acute inpatient care to long-term outcomes and to develop a strategy for identifying individual hospitals that are high performers and those in need of improvement.

OBJECTIVE(S):
The objectives of this proposal were to: (1) ascertain the timing of onset of severe sepsis during hospitalizations, and refine the automated definition of severe sepsis; (2) identify patient-level factors associated with an elevated risk for adverse long-term outcomes; and (3) measure the extent of variation between hospitals in risk-adjusted long-term outcomes after severe sepsis.

METHODS:
This project was performed as a retrospective cohort study using existing data on all Veterans hospitalized with severe sepsis. To meet the first objective, data from the IPEC were combined with structured medical record review to define the measurement characteristics of the administrative data. For the second and third objectives, these data were further augmented by VHA and Medicare administrative data which provided data on 1-year long-term outcomes: mortality, healthcare resource utilization, and nursing home use. Multi-level statistical modeling was used to examine the associations between patient characteristics, hospital characteristics, and long-term outcomes.

FINDINGS/RESULTS:
We have completed the following analyses.

Refining an Automated Definition of Sepsis: During the time period of this project, an international consensus conference was convened to redefine sepsis. For the first time, this process actually involved using data to compare alternative potential definitions and incorporate their relative performance into the definition. We participated in the conceptualization of the data and the determination that different definitions were necessary for intensive care unit (ICU) and non-ICU patients, and validated that the proposed definitions perform as well for Veterans as they do in an array of other populations. These new definitions of sepsis will be released publicly in February 2016; the manuscript demonstrating their performance in the VA and elsewhere is under review for possible synchronous release.

Hospital-level and Veterans Integrated Service Network (VISN)-level Variation in Short-Term Outcomes: 43,733 patients with severe sepsis in 2012 were compared to 33,095 such patients in 2008 at 114 hospitals in 21 VISNs. The median hospital in the worst quintile of performers had a risk-adjusted 30-day mortality of 16.7% in 2012 compared with the best quintile, which had a risk-adjusted mortality of 12.8% (95% CI, 10.7%, 15.3%). Hospitals and regions explained a statistically and clinically significant proportion of the variation in patient outcomes. Thirty-day mortality after severe sepsis declined from 18.3% in 2008 to 14.7% in 2012 despite very similar severity of illness between years. This work has been published as PMID: 25803652.

Understanding the Relationship between Patient and Hospital Effects on Short-Term Mortality and Subsequent Morbidity: We examined all patients hospitalized with severe sepsis in Veterans Affairs hospitals in 2009, using detailed laboratory, diagnostic and administrative data. We used multi-level sample selection models for both survival and subsequent number of independent living days (defined as days alive not in a hospital, skilled nursing facility or a nursing home), adjusting for presentation severity of illness, hospital effects and selection effects. These are new statistical methods developed for the purposes of this project, published as (doi:10. 1007/ s10742-015-0139-z).

There were 35,786 Veterans with severe sepsis in 114 hospitals, with a median age of 69.3 years. 4,687 (13.1%) Veterans died during their inpatient stay. The median surviving Veteran experienced 334 independent living days in the year after discharge alive from severe sepsis; approximately 60% had at least 270 independent living days in that period. There was a moderate correlation (r=0.54) in the strength with which patient characteristics were associated with survival and independent living. In initial analyses, the following patient-level associations were present. Diagnosis, age, and albumin were strongly associated with both. Admission pH was associated disproportionately with hospital survival; living in a nursing home prior to admission, and sodium and hematocrit on admission were primarily associated with independent living among survivors. Hospitals where more patients survived were not consistently the same hospitals as those whose patients had more independent living days. The manuscript has been drafted, and analyses refining the patient-level associations are being completed.


IMPACT:
We have demonstrated substantial heterogeneity in VA progress in improving sepsis, have briefed the Center for Analytics and Research and our VISN on this, and are working with our VISN on approaches to improve sepsis care. We have developed new statistical methods to measure hospital effects on morbidity in the presence of substantial mortality, and are discussing with IPEC their suitability for wide-spread implementation.

PUBLICATIONS:

Journal Articles

  1. Sjoding MW, Cooke CR, Iwashyna TJ, Hofer TP. Acute Respiratory Distress Syndrome Measurement Error. Potential Effect on Clinical Study Results. Annals of the American Thoracic Society. 2016 Jul 1; 13(7):1123-8.
  2. Sjoding MW, Prescott HC, Wunsch H, Iwashyna TJ, Cooke CR. Longitudinal Changes in ICU Admissions Among Elderly Patients in the United States. Critical care medicine. 2016 Jul 1; 44(7):1353-60.
  3. Prescott HC, Osterholzer JJ, Langa KM, Angus DC, Iwashyna TJ. Late mortality after sepsis: propensity matched cohort study. BMJ (Clinical research ed.). 2016 May 17; 353:i2375.
  4. Seymour CW, Liu VX, Iwashyna TJ, Brunkhorst FM, Rea TD, Scherag A, Rubenfeld G, Kahn JM, Shankar-Hari M, Singer M, Deutschman CS, Escobar GJ, Angus DC. Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA : the journal of the American Medical Association. 2016 Feb 23; 315(8):762-74.
  5. Sjoding MW, Valley TS, Prescott HC, Wunsch H, Iwashyna TJ, Cooke CR. Rising Billing for Intermediate Intensive Care among Hospitalized Medicare Beneficiaries between 1996 and 2010. American journal of respiratory and critical care medicine. 2016 Jan 15; 193(2):163-70.
  6. Iwashyna TJ, Burke JF, Sussman JB, Prescott HC, Hayward RA, Angus DC. Implications of Heterogeneity of Treatment Effect for Reporting and Analysis of Randomized Trials in Critical Care. American journal of respiratory and critical care medicine. 2015 Nov 1; 192(9):1045-51.
  7. Iwashyna TJ, Hodgson CL, Pilcher D, Bailey M, Bellomo R. Persistent critical illness characterised by Australian and New Zealand ICU clinicians. Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine. 2015 Sep 1; 17(3):153-8.
  8. Iwashyna TJ, Hodgson CL, Pilcher D, Orford N, Santamaria JD, Bailey M, Bellomo R. Towards defining persistent critical illness and other varieties of chronic critical illness. Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine. 2015 Sep 1; 17(3):215-8.
  9. Prescott HC, Kepreos KM, Wiitala WL, Iwashyna TJ. Temporal Changes in the Influence of Hospitals and Regional Healthcare Networks on Severe Sepsis Mortality. Critical care medicine. 2015 Jul 1; 43(7):1368-74.
  10. Casalino LP, Pesko MF, Ryan AM, Nyweide DJ, Iwashyna TJ, Sun X, Mendelsohn J, Moody J. Physician Networks and Ambulatory Care-sensitive Admissions. Medical care. 2015 Jun 1; 53(6):534-41.
  11. Sjoding MW, Prescott HC, Wunsch H, Iwashyna TJ, Cooke CR. Hospitals with the highest intensive care utilization provide lower quality pneumonia care to the elderly. Critical care medicine. 2015 Jun 1; 43(6):1178-86.
  12. Sjoding MW, Iwashyna TJ, Dimick JB, Cooke CR. Gaming hospital-level pneumonia 30-day mortality and readmission measures by legitimate changes to diagnostic coding. Critical care medicine. 2015 May 1; 43(5):989-95.
  13. Govindan S, Iwashyna TJ, Odden A, Flanders SA, Chopra V. Mobilization in severe sepsis: an integrative review. Journal of hospital medicine (Online). 2015 Jan 1; 10(1):54-9.
  14. Jones M, Nielson C, Gupta K, Khader K, Evans M. Collateral benefit of screening patients for methicillin-resistant Staphylococcus aureus at hospital admission: isolation of patients with multidrug-resistant gram-negative bacteria. American journal of infection control. 2015 Jan 1; 43(1):31-4.
  15. Patterson OV, Jones M, Yao Y, Viernes B, Alba PR, Iwashyna TJ, DuVall SL. Extraction of Vital Signs from Clinical Notes. Studies in health technology and informatics. 2015 Jan 1; 216:1035.
  16. Madaras-Kelly K, Jones M, Remington R, Hill N, Huttner B, Samore M. Development of an antibiotic spectrum score based on veterans affairs culture and susceptibility data for the purpose of measuring antibiotic de-escalation: a modified Delphi approach. Infection control and hospital epidemiology : the official journal of the Society of Hospital Epidemiologists of America. 2014 Sep 1; 35(9):1103-13.
  17. Liu V, Lei X, Prescott HC, Kipnis P, Iwashyna TJ, Escobar GJ. Hospital readmission and healthcare utilization following sepsis in community settings. Journal of hospital medicine (Online). 2014 Aug 1; 9(8):502-7.
  18. Prescott HC, Chang VW, O'Brien JM, Langa KM, Iwashyna TJ. Obesity and 1-year outcomes in older Americans with severe sepsis. Critical care medicine. 2014 Aug 1; 42(8):1766-74.
  19. Liu V, Escobar GJ, Greene JD, Soule J, Whippy A, Angus DC, Iwashyna TJ. Hospital deaths in patients with sepsis from 2 independent cohorts. JAMA : the journal of the American Medical Association. 2014 Jul 2; 312(1):90-2.
  20. Govindan S, Iwashyna TJ, Watson SR, Hyzy RC, Miller MA. Issues of survivorship are rarely addressed during intensive care unit stays. Baseline results from a statewide quality improvement collaborative. Annals of the American Thoracic Society. 2014 May 1; 11(4):587-91.
  21. Cooke CR, Kennedy EH, Wiitala WL, Almenoff PL, Sales AE, Iwashyna TJ. Despite variation in volume, Veterans Affairs hospitals show consistent outcomes among patients with non-postoperative mechanical ventilation. Critical care medicine. 2012 Sep 1; 40(9):2569-75.
  22. Davydow DS, Hough CL, Langa KM, Iwashyna TJ. Depressive symptoms in spouses of older patients with severe sepsis. Critical care medicine. 2012 Aug 1; 40(8):2335-41.
Journal Other

  1. Hodgson CL, Iwashyna TJ, Schweickert WD. All That Work and No Gain: What Should We Do to Restore Physical Function in Our Survivors? [Editorial]. American journal of respiratory and critical care medicine. 2016 May 15; 193(10):1071-2.
  2. Odden AJ, Govindan S, Sheth J, Iwashyna TJ. A Systematic Assessment of the Surviving Sepsis Campaign's Evidence Supporting the Care of Patients with Severe Sepsis on the Wards. [Letter to the Editor]. Annals of the American Thoracic Society. 2015 Jun 1; 12(6):956-8.
  3. Iwashyna TJ, Govindan S. Did they just prove that a diagnosis of "septic shock" is meaningless? American journal of respiratory and critical care medicine. 2014 May 15; 189(10):1156-7.
OART

  1. Iwashyna T, Prescott HC. What are septic shock and sepsis? The facts behind these deadly conditions. The Conversation [Internet]. 2016 Jun 6. Available from: https://theconversation.com/what-are-septic-shock-and-sepsis-the-facts-behind-these-deadly-conditions-60599.
  2. Prescott HC, Iwashyna T. The infection that killed Muhammad Ali accounts for one-third of US hospital deaths. Business Insider [Internet]. 2016 Jun 6. Available from: http://www.businessinsider.com/what-are-septic-shock-and-sepsis-2016-6?r=UK&IR=T.
CYBR

  1. Iwashyna T. Survivorship of Severe Sepsis. Keystone: Sepsis Monthly Webinar, Michigan Health & Hospital Association (MHA). [Cyberseminar]. 2014 Aug 6.
Conference Presentations

  1. Iwashyna T. Survivorship After Sepsis: A Population Perspective with particular relevance to the Brain. Paper presented at: American Thoracic Society Annual International Conference; 2016 May 13; San Francisco, CA.
  2. Iwashyna T. Cognitive Decline After Sepsis: Knowledge Gained & Mistakes Made. Paper presented at: Universitatsklinikum Bonn Klinik und Polikinik fur Neurologie Heneka Lab Grand Rounds; 2016 Mar 17; Bonn, Germany.
  3. Iwashyna T. Increasing ICU Access Can Improve Outcomes for Pneumonia. Paper presented at: Intensive Care and Emergency Medicine International Symposium; 2016 Mar 16; Brussels, Belgium.
  4. Iwashyna T. 4 Mistakes I Have Made Thinking About Cognitive Dysfunction, Mood Disorders, and Long Term Psychiatric Morbidity (including Sexual Dysfunction) So You Don’t Have To. Paper presented at: Intensive Care and Emergency Medicine International Symposium; 2016 Mar 13; Brussels, Belgium.
  5. Prescott HC, Iwashyna T. Obesity paradox in Critical Illness-Pro. Paper presented at: American Society for Parenteral and Enteral Nutrition's Clinical Nutrition Week; 2016 Jan 16; Austin, TX.
  6. Iwashyna T. Recovery & Challenges after Severe Sepsis: New Data & More Questions. Paper presented at: Monash University Grand Rounds; 2015 Feb 16; Melbourne, Australia.
  7. Iwashyna T. Recovery & Challenges after Severe Sepsis: New Data & More Questions. Paper presented at: George Institute for Global Health Seminar; 2015 Feb 12; Sydney, Australia.
  8. Iwashyna T. Trajectories Models of Recovery and Dysfunction After Acute Illness. Paper presented at: Argentine Congress on Intensive Care; 2014 Sep 19; Mar del Plata, Argentina.
  9. Iwashyna T. Sepsis Outcomes: How Much is Due to the Patient, the Hospital or the Health System? Paper presented at: Argentine Congress on Intensive Care; 2014 Sep 19; Mar del Plata, Argentina.
  10. Iwashyna T. The Burdens of Survivorship: An Approach To thinking About Long-Term Outcomes After Critical Illness. Paper presented at: Argentine Congress on Intensive Care; 2014 Sep 18; Mar del Plata, Argentina.
  11. Iwashyna T. Sepsis: Care Models and Outcomes. Poster session presented at: American Thoracic Society Annual International Conference; 2014 May 17; San Diego, CA.
  12. Iwashyna T. Sepsis Outcomes: How much is due to the hospital or the Health System? Paper presented at: International Symposium on Intensive Care and Emergency Medicine; 2014 Mar 20; Brussels, Belgium.
  13. Iwashyna T. Why does Higher Patient Volume Not Necessarily Yield Better Outcomes in Severe Sepsis? Paper presented at: International Symposium on Intensive Care and Emergency Medicine; 2014 Mar 20; Brussels, Belgium.
  14. Iwashyna T. Survival & Life After Critical Illness: How Well are We Doing? Paper presented at: International Symposium on Intensive Care and Emergency Medicine; 2014 Mar 19; Brussels, Belgium.
  15. Iwashyna T. eRecords for Benchmarking and Performance Assessment. Paper presented at: International Symposium on Intensive Care and Emergency Medicine; 2014 Mar 19; Brussels, Belgium.
  16. Iwashyna T. Recovery and Challenges after Severe Sepsis: New Data. Paper presented at: University Medical Center Utrecht Grand Rounds; 2014 Mar 14; Utrecht, Netherlands.
  17. Iwashyna T. Long Term Outcomes from Sepsis in the Developed World. Paper presented at: University Medical Center Utrecht Grand Rounds; 2014 Mar 14; Utrecht, Netherlands.
  18. Iwashyna T. Is there a Morbidity/Mortality Trade-off in Hospital Care for Severe Sepsis? Very Preliminary Results. Paper presented at: University of Manitoba Critical Care Conference; 2014 Feb 25; Winnipeg, Canada.
  19. Iwashyna T. The Old Man's Friend No More: Disability and Cognitive Decline After Infection. Paper presented at: University of Manitoba Grand Rounds; 2014 Feb 25; Winnipeg, Canada.
  20. Iwashyna T. Costs of PICS to Families & Societies. Paper presented at: Society of Critical Care Medicine Annual Congress; 2014 Jan 10; San Francisco, CA.
  21. Iwashyna T. The Old Man’s Friend No More: Disability and Cognitive Decline After Infection. Paper presented at: Kaiser Permanente Division of Research Annual Meeting; 2014 Jan 9; Oakland, CA.
  22. Iwashyna T. Predicting Outcome: Is There Any Evidence to Guide Resource Rationing? Paper presented at: Australian and New Zealand Intensive Care Society Annual Scientific Meeting; 2013 Oct 19; Hobart, Australia.
  23. Iwashyna T. Long Term Outcomes from Sepsis in the Developed World. Paper presented at: Australian and New Zealand Intensive Care Society Annual Scientific Meeting; 2013 Oct 17; Hobart, Australia.
  24. Iwashyna T. The Impact of Early Mobilization: The Story So Far. Paper presented at: Australian and New Zealand Intensive Care Society Annual Scientific Meeting; 2013 Oct 17; Hobart, Australia.
  25. Iwashyna T. Life Post-Intensive Care: Our Patients. Paper presented at: Society of Critical Care Medicine Annual Congress; 2013 Jan 20; San Juan, Puerto Rico.
  26. Iwashyna T. Avoiding an Epidemic of Post-ICU Disability. Paper presented at: American Thoracic Society Annual International Conference; 2012 May 23; San Francisco, CA.
  27. Iwashyna T. Less Mean, More Variance: Understanding the Mechanisms Generating Variability in Disability After Critical Illness. Paper presented at: International Physical and Rehabilitation in the Critically Ill Meeting; 2012 May 19; San Francisco, CA.
  28. Iwashyna T. Disparities in Resuscitation. Paper presented at: American Heart Association Annual Scientific Sessions; 2011 Nov 17; Orlando, FL.
  29. Iwashyna T. Disparities Across Social Lines. Paper presented at: Critical Care Canada Forum; 2011 Nov 15; Toronto, Canada.
  30. Iwashyna T. Improving Patient Outcomes by Improving Interhospital Transfer. Paper presented at: Critical Care Canada Forum; 2011 Nov 14; Toronto, Canada.


DRA: Health Systems, Infectious Diseases
DRE: Epidemiology, Pathology
Keywords: Clinical Performance Measures, Guideline Development and Implementation, Quality of Care, System Performance Measures
MeSH Terms: none