Aggressive diagnoses and care spark big rise in Medicare sepsis discharges

The number of Medicare inpatient discharges for sepsis has been on a steady rise, and in 2015 it beat out major joint replacements as the most common discharge for the first time.

On first glance, the results are jarring considering how the federal government and providers have made concentrated efforts in recent years to curb sepsis. But patient safety experts claim that the rise likely stems from changes in clinical practice over the last 15 years to diagnosis more patients with infections as septic sooner so they can treat the infection quickly before it develops into severe sepsis and becomes life-threatening.

Sepsis accounted for 521,358 discharges in 2015, an 82,761 increase from 2014 to 2015, according to a Modern Healthcare analysis of CMS Medicare claims data released last week. At the same time, the cost of sepsis for Medicare jumped from $5.3 billion in 2014 to $6 billion in 2015, also making it the most costly discharge.

Providers now commonly diagnosis patients with sepsis if they have an infection like pneumonia along with other conditions that are considered warning signs for sepsis, such as organ dysfunction or high blood pressure. This allows providers to initiate a treatment plan that includes giving patients antibiotics, liquids and blood cultures known to stop sepsis in its tracks, said Dr. Tara Lagu, research scientist and hospitalist at Baystate Medical Center in Springfield, Mass., who has studied sepsis diagnosis.

Before these clinical practice changes, patients were diagnosed as septic too late or they weren't diagnosed as septic at all, according to Dr. Dave Gaieski, a professor of emergency medicine at Thomas Jefferson University. "If we find it early, we can treat it when it's reversible. What has come from all of this is we are diagnosing it sooner," he said.

The more aggressive sepsis diagnoses was part of a nationwide campaign that began in 2002 by the Society of Critical Care Medicine to reduce mortality from sepsis. The campaign called for clinicians to diagnose sepsis sooner in order to quickly stop it from getting worse. Sepsis is notoriously hard to identify and treat. Once patients show clear sepsis warning signs like organ failure, it becomes difficult to reverse the infection's course and the mortality rate increases. An estimated 250,000 people die from sepsis each year in the U.S.

"Identifying more cases (of sepsis) is a good thing. It allows us to intervene on the cases that would have progressed to severe sepsis, septic shock or death," Lagu said.

Another driving force for the high sepsis discharge numbers in 2015 could be a CMS quality measure that went into effect that same year. The CMS Sepsis Core Measure defines sepsis and requires providers to follow a multi-step process to treat the infection.

Providers are likely using the measure more for conditions they wouldn't have previously labeled as sepsis, like urinary tract infections, so they can initiate the treatment plan outlined in the measure and be reimbursed, said Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins.

"It is likely that we are just using the term sepsis more," he said.

Reimbursement for sepsis is also higher than the treatment of other infections like pneumonia or UTIs, and that may encourage providers to use the sepsis DRG more, Lagu said.

As providers increasingly call more infections sepsis, standardization is forming around the condition that didn't previously exist, Pronovost said.

"We have a more consistent way of labeling sepsis and a standard therapy for sepsis," he said. This allows providers and patient safety experts to better understand how many people suffer from sepsis and what treatments work best.

But both Pronovost and Lagu caution that because more people who survive sepsis are diagnosed as such, the mortality rate might appear lower for the condition.

"We have to be cautious about interpreting changes in mortality," Pronovost said.