The number of sepsis cases is on the rise, and the Centers for Medicare and Medicaid Services (CMS) continues to promote a sense of urgency for hospitals to address sepsis, a deadly condition that claims some 270,000 lives each year. One way CMS is focusing on sepsis is through publicly reporting sepsis hospital performance on its public portal called Hospital Compare, which was introduced in July 2018. Soon after, Hospital Compare reported that the national average percentage of patients who received appropriate care based on CMS sepsis core measures for severe sepsis and septic shock was 49 percent.
The effort to make hospitals’ sepsis care public follows the introduction of CMS’s hospital reporting on Core Measure SEP-1: Early Management Bundle, Severe Sepsis/Septic Shock—in its Inpatient Quality Reporting program, which began in October 2015. Since then, the measure has undergone modifications, requiring hospitals to make corresponding changes to the way they document and report their adherence to the measure. At least for now, failure to complete any aspect of the bundle in the given time period earns hospitals a zero score for those patients.
No second guessing
As most hospitals know all too well, there is a range of issues involved in sepsis management – from complexity of diagnosis to siloed data and documentation issues. Then there is the CMS sepsis bundle itself. SEP-1 requires completion of multiple components within a short window of time and involves a multidisciplinary team beyond front-line clinicians.
Due to the complexity in diagnosing it, sepsis often goes underreported and underdiagnosed. There is no single test for the condition; rather, a diagnosis requires experienced clinical judgment based on a complex set of clinical factors. Speed in diagnosis and treatment is essential to avoid lengthy hospital stays and increased morbidity and mortality, yet over-reporting can pose a problem too. Today many hospitals rely on systems that vendors build into Electronic Health Record systems (EHRs) to scan for abnormal systemic inflammatory-response-syndrome (SIRS) criteria, which can serve as an early warning system for sepsis. Such systems tend to be sensitive—they capture nearly all possible sepsis cases—but they’re also imprecise, generating false-positives and corresponding alert fatigue among clinicians who tend to tune out alerts that constantly fire off. Because these systems oftentimes falsely identify patients as being septic, they may be incorrectly counted in the denominator of the SEP-1 measure.
Even if a hospital team has all of the right tools, the appropriate change management, and strong internal protocols, the sepsis measure can still be challenging. Successful reporting of sepsis not only requires abstracting the measure quickly to deliver feedback to leadership about daily performance; it also involves improving that performance. And once a health system or hospital has found a way of effectively adopting evidence-based practices, they must hard-wire those processes into care delivery so the results are sustainable.
Unfortunately, the answer on how to improve performance is not a simple one.
Taking a lesson from those hospitals that have seen some of the best outcomes, organizations must consider a multidisciplinary approach backed by sophisticated clinical surveillance solutions that draw on vast clinical content, proven practices and change management specifically aimed at compliance with the CMS sepsis bundles. There also needs to be transparency so clinicians can see what interventions were the most effective, and so they can track progress on outcomes and how their actions are impacting compliance and performance.
The upside: financial opportunity
Beyond the obvious, positive impact on patient health is a financial implication for more-effective sepsis management. According to The Advisory Board, the average direct cost borne by hospitals per case for a primary sepsis diagnosis is $18,700, yet the typical Medicare reimbursement for sepsis and sepsis with complications is only $7,100 to $12,000.
Sepsis is clearly in the financial crosshairs—and with good reason. It’s second on the list in clinical variability, which is one of the five most-worrisome issues for CEOs identified by The Advisory Board, along with identifying innovative approaches to expense reduction and controlling unavoidable utilization.
Sepsis volume has more than doubled and inpatient mortality rates have grown by 20% in the past decade. And, at 48%, it is the inpatient service with the highest growth projection from 2020 to 2025.
Given the dangers and costs of sepsis, it seems unlikely that CMS will stop at public displays of hospital sepsis scores. It’s more likely that over time, the SEP-1 measure will become part of a Medicare value-based reimbursement program for hospitals. If that happens, poor scores will further negatively affect revenue, making the incentives to improve sepsis management even stronger. Hospitals must have access to tools that help identify patients early and accurately, that deliver rapid treatment that is in full compliance with CMS bundles, and that carefully monitor how clinicians respond within their workflow to deliver the necessary clinical support to save both lives and money.
Facts about hospital compare
As part of the public reporting, CMS posts a rolling-years’ worth of data on Medicare’s public portal Hospital Compare. The data reflects SEP-1 scores and is updated quarterly in January, April, July and October each year. At the start of each new quarter, another quarter’s worth of information is released, and the oldest quarter will be removed. According to CMS, SEP-1 is grouped with other clinical process-of-care measures under the Timely and Effective Care tab. Other measures appearing under that tab include flu immunization, emergency department time to admit and volume, blood clot acquired in the hospital and perinatal care.
Individual hospital performance is displayed as a percentage derived from the numerator/denominator calculation reported. For example, a hospital that reports 78 of 100 patients were properly treated in accordance with the sepsis measure bundle would be 78%. For a hospital reporting fewer than 11 cases total, no data is reported.
On the Hospital Compare display page, an individual hospital’s performance is also compared with (1) the performance of the top 10% of hospitals reporting on SEP-1, (2) the average performance of the hospitals reporting in that hospital’s state, and (3) the national average which is 58% currently.