Sepsis Diagnostic Excellence and its Association with Mortality in Adults with Potential Infection

BACKGROUND: Diagnostic uncertainty in sepsis contributes to both undertreatment (delayed antibiotics) and overtreatment (unnecessary early antibiotics in non-sepsis patients). We hypothesized hospitals with high relative performance on sepsis undertreatment and overtreatment measures have improved patient outcomes. METHODS: We conducted a retrospective cohort study of hospitalized adults at 20 hospitals (Advocate Health, Michigan Medicine) between 2022-2024. Patients met ≥2 systemic inflammatory response syndrome criteria within 6 hours of presentation. Hospital-level diagnostic performance was characterized using risk-standardized rates (RSR) for undertreatment and overtreatment. "Diagnostic Excellence" (DxEx) was prespecified as top-tertile performance in one measure without bottom-tertile performance in the other. The primary outcome was hospital mortality or hospice discharge. Secondary outcomes were hospital-free days alive at 28 days (HFD), length of stay (LOS), and total antibiotic days. RESULTS: Among 152,779 patients, 49,109 (32.1%) received antibiotics within 3 hours and 16,361 (10.7%) ultimately met sepsis criteria. Undertreatment RSRs ranged 29.3%-46.8%. Overtreatment RSRs ranged 21.5%-37.2%. There was negative correlation between performance ranks (τ=-0.51, p=0.01). Four hospitals met DxEx criteria. Receiving treatment at DxEx hospitals was associated with lower odds of hospital mortality or hospice discharge (adjusted OR=0.61, 95% Confidence Interval [95%CI]=0.41-0.90; p=0.01), greater HFD (adjusted difference=0.59, 95%CI=0.04-1.14; p=0.04), reduced LOS (adjusted difference=-1.20, 95%CI=-2.23- -0.17; p=0.02), and fewer antibiotic days (adjusted difference=-0.62, 95%CI=-1.28-0.05; p=0.07), versus non-DxEx hospitals. CONCLUSIONS: Hospital performance that jointly minimizes sepsis undertreatment and overtreatment was associated with improved patient outcomes, after adjustment for patient and hospital factors. These findings highlight the importance of reducing diagnostic error in efforts to improve sepsis outcomes.