Most Sepsis-Associated Deaths Could be Caused by Severe Coexisting Conditions

New research contradicts the perception that better sepsis care alone can reduce mortality.

Most sepsis-associated deaths are linked to other underlying causes and are not preventable with better sepsis care alone, research published today indicates.

On an annual basis, sepsis affects about 1.7 million American adults and the infection is linked to more than 250,000 deaths.

The research published today in the Journal of the American Medical Association focused on sepsis-associated deaths at six academic medical centers and community hospitals, where sepsis was the most common immediate cause of death.

"However, most underlying causes of death were related to severe chronic comorbidities and most sepsis-associated deaths were unlikely to be preventable through better hospital-based care. Further innovations in the prevention and care of underlying conditions may be necessary before a major reduction in sepsis-associated deaths can be achieved," the researchers wrote.

The researchers reviewed the case histories of more than 500 randomly selected patients who either died in the hospital or were discharged to hospice care. The case history reviews generated several key findings.

• 300 of the patients were afflicted with sepsis and the infection was the immediate cause of death in 198 of those patients, or 34.9% of the total study cohort
   
• The second most common immediate cause of death was cancer, which claimed 92 patients, or 16.2% of the total study cohort
   
• The third most common immediate cause of death was heart failure, which claimed 39 patients, or 6.9%
   
• For the 300 patients with sepsis, the top underlying causes of death were solid cancer (63 patients), chronic heart disease (46 patients), hematologic cancer (31 patients), dementia (29 patients), and chronic lung disease (27 patients)
   
• Suboptimal care such as delayed administration of antibiotics was found in 22.7% of the 300 sepsis cases, but only 12% of sepsis-associated deaths were deemed potentially preventable

Gauging the preventability of sepsis-associated deaths

These findings call into question prior views of sepsis care, the researchers wrote.

"The high burden of sepsis and the perception that most sepsis-associated deaths are preventable with better care has catalyzed numerous sepsis performance improvement initiatives in hospitals around the world. The extent to which sepsis-associated deaths in adults might be preventable, however, is unknown."

Sepsis-associated mortality may not be as preventable as previously considered, they wrote.

"Sepsis disproportionately affects patients who are elderly, have severe comorbidities, and have impaired functional status. Some of these patients may receive optimal, guideline-compliant care yet still die due to overwhelming sepsis or from their underlying disease."

The researchers acknowledge that their conclusions are at odds with earlier studies that have shown positive outcomes from efforts to improve sepsis care.

"Our findings are notable in light of many sepsis quality improvement initiatives that reported substantial decreases in mortality rates after implementation of sepsis care improvement initiatives. These studies imply that many sepsis-associated deaths are preventable," the researchers wrote.

They say there are two possible explanations for the discrepancy.

• The hospitals in the JAMA study had already improved sepsis care, impacting the preventability of sepsis-associated deaths.
   
• Sepsis-care improvement initiatives have over-estimated their impact on mortality. A common element of these improvement initiatives is better recognition of sepsis, which leads to identification of more subtle cases of the infection and the impression of lower mortality rates.

To decrease sepsis-associated deaths, hospitals may have to expand the scope of care for patients afflicted with the infection, the researchers wrote.

"Our findings do not diminish the importance of trying to prevent as many sepsis-associated deaths as possible, but rather underscore that most fatalities occur in medically complex patients with severe comorbid conditions."