Healthcare Utilization and Infection in the Week Prior to Sepsis Hospitalization

Abstract

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.

Figure 1. Figure panels show the total number of encounters or antibiotics (lines) and the percentage of encounters with infection or antibiotics (bars) in the week prior to sepsis hospitalization drawn from a total sample of 14,658 KP and 31,369 VA sepsis patients

Panels display changes over time in: primary care and specialty care (Figure 1a); emergency department and urgent care (Figure 1b); hospitalization and nursing facility (Figure 1c); and in antibiotic usage relative to outpatient visits. On the x-axis, day 0 represents the day of sepsis admission while day −7 represents 7 days prior to admission.

Figure 1. Figure panels show the total number of encounters or antibiotics (lines) and the percentage of encounters with infection or antibiotics (bars) in the week prior to sepsis hospitalization drawn from a total sample of 14,658 KP and 31,369 VA sepsis patients

Panels display changes over time in: primary care and specialty care (Figure 1a); emergency department and urgent care (Figure 1b); hospitalization and nursing facility (Figure 1c); and in antibiotic usage relative to outpatient visits. On the x-axis, day 0 represents the day of sepsis admission while day −7 represents 7 days prior to admission.

Figure 1. Figure panels show the total number of encounters or antibiotics (lines) and the percentage of encounters with infection or antibiotics (bars) in the week prior to sepsis hospitalization drawn from a total sample of 14,658 KP and 31,369 VA sepsis patients

Panels display changes over time in: primary care and specialty care (Figure 1a); emergency department and urgent care (Figure 1b); hospitalization and nursing facility (Figure 1c); and in antibiotic usage relative to outpatient visits. On the x-axis, day 0 represents the day of sepsis admission while day −7 represents 7 days prior to admission.

Figure 1. Figure panels show the total number of encounters or antibiotics (lines) and the percentage of encounters with infection or antibiotics (bars) in the week prior to sepsis hospitalization drawn from a total sample of 14,658 KP and 31,369 VA sepsis patients

Panels display changes over time in: primary care and specialty care (Figure 1a); emergency department and urgent care (Figure 1b); hospitalization and nursing facility (Figure 1c); and in antibiotic usage relative to outpatient visits. On the x-axis, day 0 represents the day of sepsis admission while day −7 represents 7 days prior to admission.