Risk Factors at Index Hospitalization Associated With Longer-term Mortality in Adult Sepsis Survivors
Authors: Manu Shankar-Hari, David A. Harrison, Paloma Ferrando-Vivas, Gordon D. Rubenfeld, Kathryn Rowan
Journal: JAMA Network Open (2019)

<h3>Importance</h3> Sepsis survivors, defined as adult patients who survived to hospital discharge following a critical care unit admission for sepsis, are at increased risk of long-term mortality. Identifying factors independently associated with long-term mortality, known during critical care admission for sepsis, could inform targeted strategies to reduce this risk. <h3>Objective</h3> To assess, in adult sepsis survivors, factors independently associated with long-term mortality, known during their index critical care admission for sepsis, meeting Third International Consensus Definitions for Sepsis and Septic Shock criteria. <h3>Design, Setting, and Participants</h3> This cohort study included a nationally representative sample of 94 748 adult sepsis survivors from 192 critical care units in England. Participants were identified from consecutive critical care admissions between April 1, 2009, and March 31, 2014, with survival status ascertained as of March 31, 2015. Statistical analyses were completed in June 2017. <h3>Exposures</h3> Generic patient characteristics (age, sex, ethnicity, severe comorbidities [defined using the Acute Physiology and Chronic Health Evaluation II method], dependency, surgical status, and acute illness severity [scored using the Acute Physiology and Chronic Health Evaluation II acute physiology component]) and sepsis-specific patient characteristics (site of infection, number of organ dysfunctions, and septic shock status) known during index critical care admission for sepsis. <h3>Main Outcomes and Measures</h3> Long-term mortality in adult sepsis survivors with maximum follow-up of 6 years. Adjusted hazard ratios (HRs) were estimated using Cox regression for both generic and sepsis-specific patient characteristics. <h3>Results</h3> Sepsis survivors had a mean (SD) age of 61.3 (17.0) years, 43 584 (46.0%) were female, and 86 056 (90.8%) were white. A total of 46.3% had respiratory site of infection. By 1 year from hospital discharge, 15% of sepsis survivors had died, with 6% to 8% dying per year over the subsequent 5 years. Age, sex, race/ethnicity, severe comorbidities, dependency, nonsurgical status, and site of infection were independently associated with long-term mortality. Compared with single-organ dysfunction, having 2 or 3 organ dysfunctions was associated with increased risk of long-term mortality (adjusted HR, 1.07; 95% CI, 1.01-1.13; and adjusted HR, 1.18; 95% CI, 1.03-1.14, respectively), while having 4 organ dysfunctions or more was not associated with increased risk. Unexpectedly, the Acute Physiology and Chronic Health Evaluation acute physiology component score had an incremental association with long-term mortality (adjusted HR, 1.11 for every 5-point increase; 95% CI, 1.08-1.13). The adjusted HR for septic shock was 0.89 (95% CI, 0.85-0.92). <h3>Conclusions and Relevance</h3> This study suggests that generic and sepsis-specific risk factors, known during index critical care admission for sepsis, could identify a high-risk sepsis survivor population for biological characterization and designing interventions to reduce long-term mortality.