Letter
Rhee and colleagues conclude in their recent study [1] that a substantial fraction of the administrative data-based rise in the incidence of severe sepsis is due to a decreasing threshold of documentation/coding of several types of organ dysfunction (OD). The conclusion was based mostly on diverging rates of rise in code-based OD versus that based on conservative clinical criteria, being faster among the former, coupled with a slower drop in hospital mortality among the latter.
However, these findings do not preclude an actual rise in the incidence of severe sepsis as a key driver of the observed trends, with reduced peak severity of sepsis-associated OD over time, possibly related to increasingly timely and effective resuscitative interventions. Indeed, the investigators reported a clinical criteria-based rising incidence of shock (+29 %) versus concomitant drop (−27 %) of acute renal failure. The latter finding may indicate that evolving renal failure has become increasingly less severe than the study’s definition threshold, despite the marked rise in shock.
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Finally, the slower decrease in hospital mortality among clinical criteria-based OD may alternatively represent a higher likelihood of in-hospital death among patients with more severe OD, while those with relatively less severe OD may be more likely to be discharged to a long-term care facility or hospice, shifting in part their location of death. The later proposition is supported by prior reports [2] and a recent study by Kumar et al. [3] showing that the absolute drop in severe sepsis-associated hospital mortality (12.3 %) was matched by a similar rise (11.6 %) in discharge to a long-term care facility or hospice.
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Competing interests
The author declares that he has no competing interests.