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Defining pediatric sepsis by different criteria: discrepancies in populations and implications for clinical practice
Scott L Weiss1, Brandon Parker, Maria E Bullock
1Divisions of Critical Care, Department of Pediatrics, Children's Memorial Hospital, Chicago, IL, USA.
Insights
Pediatric severe sepsis/septic shock criteria show moderate agreement, impacting data extrapolation. Clinically diagnosed sepsis patients may not meet research or administrative criteria, highlighting selection differences.
Area of Science:
- Pediatric critical care medicine
- Epidemiology
- Health services research
Background:
- Pediatric severe sepsis and septic shock are identified using distinct clinical, research, and administrative criteria.
- The varying definitions can affect the comparability of data across different healthcare settings and studies.
- Understanding the agreement and discrepancies between these criteria is crucial for accurate patient cohort identification.
Purpose of the Study:
- To quantify the agreement among different criteria used for identifying pediatric severe sepsis/septic shock.
- To detect systematic differences in patient characteristics between cohorts identified by distinct criteria.
- To assess the implications of criterion overlap for data extrapolation in pediatric sepsis research.
Main Methods:
- An observational cohort study was conducted in a 42-bed pediatric intensive care unit.
- 1,729 patients aged 18 years or younger were analyzed.
- Agreement was assessed using Cohen's kappa (κ) for research, clinical, and administrative criteria; patient characteristics were compared between groups.
Main Results:
- The incidence of pediatric severe sepsis/septic shock was similar across criteria (5.2% research, 5.6% clinical, 6.0% administrative).
- Moderate agreement was observed between criteria (κ values ranging from 0.52 to 0.67).
- The research cohort had higher severity scores and greater need for vasoactive infusions compared to clinical and administrative cohorts.
Conclusions:
- Despite similar incidence rates, there is only moderate agreement in patient identification across research, clinical, and administrative criteria for pediatric severe sepsis/septic shock.
- A significant proportion of clinically diagnosed sepsis patients did not meet research or administrative criteria, impacting study validity.
- Differences in patient selection necessitate careful consideration when extrapolating pediatric sepsis data across settings.
Objective:
Pediatric patients with sepsis are identified using related but distinct criteria for clinical, research, and administrative purposes. The overlap between these criteria will affect the validity of extrapolating data across settings. We sought to quantify the extent of agreement among different criteria for pediatric severe sepsis/septic shock and to detect systematic differences between these cohorts.
Design:
Observational cohort study.
Setting:
Forty-two bed pediatric intensive care unit at an academic medical center.
Patients:
A total of 1,729 patients ≤ 18 yrs-old.
Interventions:
None.
Measurements And Main Results:
All patients were screened for severe sepsis or septic shock using consensus guidelines (research criteria), diagnosis by healthcare professionals (clinical criteria), and International Classification of Diseases, Ninth Revision, Clinical Modification codes (administrative criteria). Cohen's κ determined the level of agreement among criteria, and patient characteristics were compared between cohorts. Ninety (5.2%) patients were identified by research, 96 (5.6%) by clinical, and 103 (6.0%) by administrative criteria. The κ ± standard error for pair-wise comparisons was 0.67 ± 0.04 for research-clinical, 0.52 ± 0.05 for research-administrative, and 0.55 ± 0.04 for clinical-administrative. Of the patients in the clinical cohort, 67% met research and 58% met administrative criteria. The research cohort exhibited a higher Pediatric Index of Mortality-2 score (median, interquartile range 5.2, 1.6-13.3) than the clinical (3.6, 1.1-6.2) and administrative (3.9, 1.0-6.0) cohorts (p = .005), an increased requirement for vasoactive infusions (74%, 57%, and 45%, p < .001), and a potential bias toward an increased proportion with respiratory dysfunction compared with clinical practice.
Conclusions:
Although research, clinical, and administrative criteria yielded a similar incidence (5%-6%) for pediatric severe sepsis/septic shock, there was only a moderate level of agreement in the patients identified by different criteria. One third of patients diagnosed clinically with sepsis would not have been included in studies based on consensus guidelines or International Classification of Diseases, Ninth Revision, Clinical Modification codes. Differences in patient selection need to be considered when extrapolating data across settings.
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