Let’s start with a non-trivial trivia question: What disease kills an American every two minutes, is implicated in as many as 50% of hospital deaths and is the most expensive condition treated in US hospitals?
For many of our healthcare savvy readers, you likely identified sepsis as the correct answer. But for the general public this is a largely unknown condition, despite accounting for nearly $24 billion in hospital costs per year and more deaths than prostate cancer, breast cancer and AIDS combined.1,3 Somewhat bewilderingly, a recent Sepsis Alliance survey found that fewer than half of Americans were familiar with this devastating and costly disease.
With Sepsis Awareness Month right around the corner, we wanted to shine a light on the condition and, particularly, the unique role care variation plays in the high cost and poor outcomes that are all too common. Of course, we also want to share some success stories.
Regional variation in sepsis mortality has been reported since 2010 when Wang et al. were among the first to identify a sepsis mortality “belt” of 11 adjacent states in the Southeastern and mid-Atlantic US with a 30% higher sepsis mortality incident rate ratio. Wang and other authors have attempted to explain the regional variation, but have fallen short of identifying a single cause. However, new data is suggesting that variation in care practices between facilities and between individual providers is likely playing a role.
In 2011, Lagu, et al published national data showing wide variation in sepsis spending and adjusted mortality rates between hospitals, but no correlation between the two. That means that spending more money on sepsis care didn’t lead to better survival. Peltan et al.’s article this summer in Critical Care Medicine drilled even more specifically into variation in sepsis care at the individual provider level. The authors identified wide variation between individual providers at a given facility in, among other things, how quickly sepsis patients were started on an antibiotic (a strong predictor of improved outcomes). Peltan’s results present an excellent view into unwarranted variation, which we define as deviations from the most effective and/or efficient care paths without a compelling patient-specific reason for that variation.
Reducing this unwarranted variation, between providers and facilities, would go a long way to saving lives and money. It is easy to think clinical variation is uncontrollable, but in our performance improvement work with health systems around the country, we’ve found variation can be successfully addressed. One of the keys to reducing unwarranted variation is to create a safe, fair and transparent space to engage providers in meaningful discussions of unwarranted variation, that does not trigger defensiveness or claims that “my patients are sicker.” One of the keys to creating this space, we’ve found, is to remove patient variability by having all providers care for consistent clinical simulations, allowing everyone to focus exclusively on variation in clinician decisions made by them and their peers in the same situations. This makes variation in a group more tangible and apparent to providers, helping them truly acknowledge, accept, and address it. While this is not a simple task, it is precisely the work we’ve shown drives real and sustainable improvements in care quality and cost effectiveness.
As the studies above show, sepsis care is a huge opportunity to improve survival and reduce the total cost of care through improved care standardization and adherence to evidence-based guidelines. Current research continues to strongly support the claim that increased compliance with guidelines is associated with reduced mortality in patients with sepsis, severe sepsis or septic shock., The focus of recent sepsis guidelines has been on early identification and treatment, before the disease increases in severity. Practice standards in sepsis care have advanced greatly in recent years with development of the Surviving Sepsis Campaign’s Bundles, the quick sepsis-related organ failure assessment (qSOFA), and the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). Focus on clinician practice adherence to these internationally recognized standards should be core to every sepsis performance improvement program.
Helping physicians recognize and reduce their sepsis care variation can play a big role in improving outcomes in this silent killer. Sepsis Awareness Month is coming up. We encourage you to take steps and find out how many of your docs are consistently following the guidelines and offer tools and solutions to help them more consistently apply them in practice.
 Sepsis Alliance Launches New Tools and Resources for Sepsis Awareness Month 2017, June 1, 2017. http://www.sepsis.org/sepsis-alliance-news/new-tools-resources-sepsis-awareness-month-2017/
 Liu, et al. Hospital Deaths in Patients With Sepsis From 2 Independent Cohorts, JAMA. 2014;312(1):90-92. doi:10.1001/jama.2014.5804, http://jamanetwork.com/journals/jama/fullarticle/1873131
 HCUP Statistical Brief #20, May 2016. National Inpatient Hospital Costs: The Most Expensive Conditions by Payer, 2013, https://www.hcup-us.ahrq.gov/reports/statbriefs/sb204-Most-Expensive-Hospital-Conditions.jsp
 Sepsis Awareness Month: Fewer than Half of Americans Have Heard of this Devastating Illness, https://www.cdc.gov/media/releases/2014/s0903-sepsis-awareness.html
Damiani E, Donati A, Serafini G, Rinaldi L, Adrario E, Pelaia P, et al. (2015) Effect of Performance Improvement Programs on Compliance with Sepsis Bundles and Mortality: A Systematic Review and Meta-Analysis of Observational Studies. PLoS ONE 10(5): e0125827. https://doi.org/10.1371/journal.pone.0125827
 Guo et al, Compliance with severe sepsis bundles and its effect on patient outcomes of severe community-acquired pneumonia in a limited resources, Arch Med Sci. 2014 Oct 27; 10(5): 970–978. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4223141/