key: cord-0023237-t3bia8bd authors: Fleischmann-Struzek, Carolin; Rose, Norman; Freytag, Antje; Spoden, Melissa; Prescott, Hallie C.; Schettler, Anna; Wedekind, Lisa; Ditscheid, Bianka; Storch, Josephine; Born, Sebastian; Schlattmann, Peter; Günster, Christian; Reinhart, Konrad; Hartog, Christiane S. title: Epidemiology and Costs of Postsepsis Morbidity, Nursing Care Dependency, and Mortality in Germany, 2013 to 2017 date: 2021-11-12 journal: JAMA Netw Open DOI: 10.1001/jamanetworkopen.2021.34290 sha: 2ff9dfb7f3c10290476a0fccc02db0e4a0fc4649 doc_id: 23237 cord_uid: t3bia8bd IMPORTANCE: Sepsis survivorship is associated with postsepsis morbidity, but epidemiological data from population-based cohorts are lacking. OBJECTIVE: To quantify the frequency and co-occurrence of new diagnoses consistent with postsepsis morbidity and mortality as well as new nursing care dependency and total health care costs after sepsis. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study based on nationwide health claims data included a population-based cohort of 23.0 million beneficiaries of a large German health insurance provider. Patients aged 15 years and older with incident hospital-treated sepsis in 2013 to 2014 were included. Data were analyzed from January 2009 to December 2017. EXPOSURES: Sepsis, identified by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) hospital discharge codes. MAIN OUTCOMES AND MEASURES: New medical, psychological, and cognitive diagnoses; long-term mortality; dependency on nursing care; and overall health care costs in survivors at 1 to 12, 13 to 24, and 25 to 36 months after hospital discharge. RESULTS: Among 23.0 million eligible individuals, we identified 159 684 patients hospitalized with sepsis in 2013 to 2014. The mean (SD) age was 73.8 (12.8) years, and 75 809 (47.5%; 95% CI, 47.2%-47.7%) were female patients. In-hospital mortality was 27.0% (43 177 patients; 95% CI, 26.8%-27.3%). Among 116 507 hospital survivors, 86 578 (74.3%; 95% CI, 74.1%-74.6%) had a new diagnosis in the first year post sepsis; 28 405 (24.4%; 95% CI, 24.1%-24.6%) had diagnoses co-occurring in medical, psychological, or cognitive domains; and 23 572 of 74 878 survivors (31.5%; 95% CI, 31.1%-31.8%) without prior nursing care dependency were newly dependent on nursing care. In total, 35 765 survivors (30.7%; 95% CI, 30.4%-31.0%) died within the first year. In the second and third year, 53 089 (65.8%; 95% CI, 65.4%-66.1%) and 40 959 (59.4%; 95% CI, 59.0%-59.8%) had new diagnoses, respectively. Health care costs for sepsis hospital survivors for 3 years post sepsis totaled a mean of €29 088/patient ($32 868/patient) (SD, €44 195 [$49 938]). New postsepsis morbidity (>1 new diagnosis) was more common in survivors of severe sepsis (75.6% [95% CI, 75.1%-76.0%]) than nonsevere sepsis (73.7% [95% CI, 73.4%-74.0%]; P < .001) and more common in survivors treated in the intensive care unit (78.3% [95% CI, 77.8%-78.7%]) than in those not treated in the intensive care unit (72.8% [95% CI, 72.5%-73.1%]; P < .001). Postsepsis morbidity was 68.5% (95% CI, 67.5%-69.5%) among survivors without prior morbidity and 56.1% (95% CI, 54.2%-57.9%) in survivors younger than 40 years. CONCLUSIONS AND RELEVANCE: In this study, new medical, psychological, and cognitive diagnoses consistent with postsepsis morbidity were common after sepsis, including among patients with less severe sepsis, no prior diagnoses, and younger age. This calls for more efforts to elucidate the underlying mechanisms, define optimal screening for common new diagnoses, and test interventions to prevent and treat postsepsis morbidity. To identify diagnoses associated with postsepsis morbidity, we conducted a comprehensive literature review on reviews, round table/position papers, and large cohort studies investigating impairments following acute care treatment with sepsis or intensive care treatment. 1, 9, 11, 36, [39] [40] [41] We classified diagnoses as medical, psychological, or cognitive (Table S1 ). For the identification of each diagnosis in hospital discharge and outpatient data, relevant ICD-10 codes or procedural codes were identified (i) from prior literature, 42-45 or (ii) in the ICD-10-GM and list of procedural codes, to ensure completeness of definitions. The classification and ICD-10-GM definitions were reviewed in an iterative process by experts from the following fields: • for sepsis rehabilitation Klinik Bavaria, Kreischa (Prof. Oehmichen, Dr. Sauter) • from the SMOOTH 46 study group (Dr. Konrad Schmidt, A. Freytag) • from the REPAIR 47 study group (PD Dr. Rosendahl, Dr. Gawlytta) • for sepsis-related pain (Prof. Meißner) and neurology/geriatrics (PD Preul) • from the SEPFROK expert panel (Prof. Vollmar (general medicine), Prof. Janssens (intensive care), Dr. Hecker (patient safety), A. Trumann (sepsis survivor), Dr. Rosseau (pulmonology), L. Ullrich (intensive care nursing)). The identification of sepsis patients in our study was based on the following ICD-10-GM codes in health claims data. At least one of the codes had to be coded as primary and secondary discharge diagnosis. During the complete observation period, sepsis coding was based on the sepsis-1/2 criteria in Germany. Therefore, severity was classified as: sepsis -all forms; severe sepsis (including septic shock); septic shock; and non-severe sepsis. Sepsis ICD-10-GM Codes: A02.1 Salmonella sepsis A20.0 Bubonic plague A20.7 Septicaemic plague A21.7 Generalized tularaemia A22.7 Anthrax sepsis A24. (1) first sentence of the Hospital Funding Act; Internal transfer with a change between the DRG fee ranges according to section 17b (1)first sentence of the Hospital Funding Act; Relocation; Discharge before resumption with reclassification; Discharge before resumption with reclassification due to complication; Discharge or transfer with subsequent readmission; Case closure (internal transfer) when changing between full, day-care and ward-equivalent treatment; Start of an outside stay with an absence past midnight (BPflV area -for the specialist department for laying); Ending an outside stay with an absence past midnight (BPflV area -for pseudo specialist department 0003); Discharge at the end of the year if accepted in the previous year (for the purposes of Billing - § 4 PEPPV); Beginning of a period without direct patient contact (station equivalent treatment); Termination of a period without direct patient contact (ward equivalent treatment -for pseudo-specialist department 0004); As data on outpatient diagnoses, cases, case-related therapies and corresponding costs in Germany are available on only a quarterly basis, data from quarters 1-4 prior to hospital admission were included in the 12 months look-back, respectively. Both primary and secondary hospital discharge diagnoses as well as outpatient diagnoses labeled as confirmed diagnoses by the treating physicians 23 were included in the definition of pre-sepsis health impairments. Employed Mechanical ventilation and respiratory support in adults 8-712 Mechanical ventilation and respiratory support in children and adolescents Special procedure for mechanical ventilation in the case of severe respiratory failure 8-70 Access for mechanical ventilation and measures to maintain the airway Mechanical ventilation and respiratory support via a mask or tube and ventilation weaning Heart and heart-lung transplantation 5-555 Kidney transplantation 5-335 Lung transplantation 5-5281 Transplantation of a pancreas segment 5-5282 Transplantation of the pancreas (whole organ) 5-4676 Small intestine transplantation Prior major surgery OPS Codes: 5-32 Excision and resection of lung and bronchus 5-33 Other operations on lung and bronchus 5-34 Operations on the chest wall, pleura, mediastinum and diaphragm 5-35 Operations on the valves and septa of the heart and pericardial vessels 5-36 Operations on the coronary vessels Surgical treatment of arrhythmias and other operations on the heart and pericardium 8-851 Bypass surgery (using the heart-lung machine) 5-38 Incision excision and occlusion of blood vessels. Other operations on blood vessels 5-42 Surgery on the oesophagus 5-43 Incision, excision and resection of the stomach 5-44 Extended stomach resection and other operations on the stomach 5-45 Incision, excision, resection and anastomosis of the small and large intestine 5-46 Other operations on the small and large intestine 5-47 Operations on the appendix 5-48 Operations on the rectum 5-49 Operations on the anus 5-50 Operations on the liver 5-51 Operations on the gallbladder and bile ducts 5-52 Operations on the pancreas 5-53 Abdominal hernia repair 5-54 Other operations in the abdominal region 5-78 Operations on other bones 5-79 Reduction of fractures and dislocations 5-80 Open joint surgery 5-81 Arthroscopic joint surgery 5-82 Prosthetic joint and bone replacement 5-83 Operations on the spine 5-84 Operations on the hand 5-85 Operations on muscles, tendons, fasciae and bursae Replantation, exarticulation and amputation of extremities and other operations on the organs of locomotion 5-01 Incision (trepanation) and excision of the skull, brain and meninges 5-02 Other operations on the skull, brain and meninges 5-03 Operations on the spinal cord, spinal meninges and spinal canal 5-04 Operations on the nerves and nerve ganglia 5-05 Other operations on the nerves and nerve ganglia 5-55 Operations on the kidneys 5-56 Operations on the ureters 5-57 Operations on the bladder 5-58 Operations on the urethra 5-59 Other operations on the urinary organs 5-60 Operations on the prostate and seminal vesicles 5-61 Operations on the scrotum and tunica vaginalis testis 5-62 Operations on the testicles 5-63 Operations on the spermatic cord, epididymis and vas deferens 5-64 Operations on the penis 5-65 Operations on the ovary 5-66 Operations on the fallopian tubes 5-67 Operations for facial bone fractures 5-68 Incision, excision and removal of the uterus 5-69 Other operations on the uterus and operations on the parametria 5-70 Operations on the vagina and recto-uterine pouch 5-71 Operations on the vulva 5-72 Childbirth with breech presentation and instrumental delivery 5-73 Other operations to induce labour and during the birth 5-74 Caesarean section and child development 5-75 Other obstetric operations 5-87 Excision and resection of the breast 5-88 Other operations on the breast 8-989 Surgical complex treatment in cases of severe infection As data on outpatient diagnoses, cases, case-related therapies and corresponding costs in Germany are available on only a quarterly basis, data from quarters 1-4, 5-8 and 9-12 following the quarter of the index hospitalization discharge date were included in the 12, 24 and 36 month follow-up, respectively. Both primary and secondary hospital discharge diagnoses as well as outpatient diagnoses labeled as confirmed diagnoses by the treating physicians 23 were included in the definition of post-sepsis diagnoses. Unspecified organic mental disorder due to brain damage and dysfunction and to physical disease F07.8 Other organic personality and behavioural disorders due to brain disease, damage and dysfunction F07.9 Unspecified organic personality and behavioural disorder due to brain disease, damage and dysfunction G30 Alzheimer disease G31.0 Circumscribed brain atrophy G31.1 Senile degeneration of brain, not elsewhere classified G31.9 Degenerative disease of nervous system, unspecified G32* Other degenerative disorders of nervous system in diseases classified elsewhere All ICD-based definition for the baseline and index hospitalization characteristics can be found in Supplement 1. Abbreviations: CCI = Charlson Comorbidity Index, unweighted; IQR = Interquartile range; SD = Standard deviation * eligibility for long-term care benefits in line with the German Social Code, ranging from Grade 1: "Little impairment of independence" up to Grade 5: "Hardship cases" ** Total health care costs include cost for hospitalizations, outpatient consultations, medication, treatments (e.g. physical or occupational therapy) and rehabilitation. ***Defined by ICD code indicating an infectious source, as indicated in methods supplement. Note that multiple sites of infection were possible. 12,982 (19,255); 6,194 (2,066, 15,891) 13,192 (20,233); 6,495 (2,203, 16,114) 13,344 (21,175); 6,141 (1,992, 15,995) 12,935 (18,877); 6,423 (2,194, 15,985) 3,089 (9,001); 443 (70, 1,869) IQR = Interquartile range; SD = Standard deviation * any ICD-10 code for organ dysfunction, not necessarily linked to infection/sepsis, as the coding of organ dysfunction in sepsis patients is not mandatory in Germany ** eligibility for long-term care benefits in line with the German Social Code *** Total health care costs include cost for hospitalizations, outpatient consultations, medication and treatments (e.g. physical or occupational therapy) and rehabilitation. 278) Index hospitalization 116,507 Standard deviation; *Total health care costs include cost for hospitalizations, outpatient consultations, medication and treatments (e.g. physical or occupational therapy) and rehabilitation