PIONEER, HDR-UK Health Data Research Hub in Acute Care, Institute of Inflammation and Ageing, University Hospitals Birmingham NHS Foundation Trust, University of Birmingham, Edgbaston, Birmingham, B15 2GW, UK.
Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, UK.
BMC Med Inform Decis Mak. 2022 Aug 1;22(1):204. doi: 10.1186/s12911-022-01947-x.
NHS Digital issued new guidance on sepsis coding in April 2017 which was further modified in April 2018. During these timeframes some centres reported increased sepsis associated mortality, whilst others reported reduced mortality, in some cases coincident with specific quality improvement programmes. We hypothesised that changes in reported mortality could not be separated from changes in coding practice.
Hospital Episode Statistics from the Admitted Patient Care dataset for NHS hospitals in England, from April 2016 to March 2020 were analysed. Admissions of adults with sepsis: an International Classification of Diseases 10 (ICD-10) code associated with the Agency for Healthcare Research and Quality Clinical Classifications Software class 'Septicaemia (except in labour)', were assessed. Patient comorbidities were defined by other ICD-10 codes recorded within the admission episode.
1,081,565 hospital episodes with a coded diagnosis of sepsis were studied. After April 2017 there was a significant increase in admission episodes with sepsis coded as the primary reason for admission. There were significant changes in the case-mix of patients with a primary diagnosis of sepsis after April 2017. An analysis of case-mix, hospital and year treated as random effects, defined a small reduction in sepsis associated mortality across England following the first change in coding guidance. No centre specific improvement in outcome could be separated from these random-effects.
Changes in sepsis coding practice altered case-mix and case selection, in ways that varied between centres. This was associated with changes in centre-specific sepsis associated mortality, over time. According to the direction of change these may be interpreted either as requiring local investigation for cause or as supporting coincident changes in clinical practice. A whole system analysis showed that centre specific changes in mortality cannot be separated from system-wide changes. Caution is therefore required when interpreting sepsis outcomes in England, particularly when using single centre studies to inform or support guidance or policy.
NHS Digital 于 2017 年 4 月发布了新的脓毒症编码指南，该指南于 2018 年 4 月进一步修改。在此期间，一些中心报告说脓毒症相关死亡率增加，而其他中心报告说死亡率降低，在某些情况下，这与特定的质量改进计划同时发生。我们假设报告的死亡率变化不能与编码实践的变化分开。
分析了英格兰 NHS 医院 2016 年 4 月至 2020 年 3 月期间的住院患者护理数据集（Admitted Patient Care dataset）中的医院入院记录。评估了与 Agency for Healthcare Research and Quality Clinical Classifications Software 类“败血症（分娩除外）”（ICD-10 代码）相关的成人脓毒症的入院记录。患者合并症由入院期间记录的其他 ICD-10 代码定义。
研究了 1081565 例编码诊断为脓毒症的住院记录。2017 年 4 月后，以脓毒症为主要入院原因的入院记录显著增加。2017 年 4 月后，主要诊断为脓毒症的患者的病例组合发生了显著变化。在分析病例组合、医院和年份作为随机效应后，确定在英格兰，在首次改变编码指南后，脓毒症相关死亡率略有下降。在没有特定中心改进的情况下，无法将这些随机效应与结果分开。
脓毒症编码实践的变化改变了病例组合和病例选择，而且在不同中心之间存在差异。这与各中心特定时间的脓毒症相关死亡率的变化有关。根据变化的方向，这些变化可能被解释为需要对病因进行局部调查，或者支持同时发生的临床实践变化。全系统分析表明，死亡率的中心特异性变化不能与全系统变化分开。因此，在解释英格兰的脓毒症结果时，特别是在使用单中心研究为指导或政策提供信息或支持时，需要谨慎。
