Sepsis is an extremely common, and life threatening illness that occurs when the immune system initiates a vigorous inflammatory response to an infection. To assist with the fight against sepsis, the Centers for Medicare and Medicaid Services (CMS) established SEP-1, the nation's first quality measure on early sepsis intervention.
Starting October 1, 2015, CMS began requiring hospitals to keep track of how many septic patients they effectively treated. This has proved to be somewhat problematic because CMS has made defining sepsis much harder than what it used to be and physicians are often unsure of how to adhere with they myriad of treatment systems and definitions. CMS defines severe sepsis as “having a suspected source of clinical infection and two or more manifestations of systemic infection (SIRS criteria) plus one or more variable of organ dysfunction.” Sepsis can be diagnosed by using SIRS criteria or by using the newly released SOFA (Sequential Organ Failure Assessment) and qSOFA (Quick SOFA) scores, which have both been discussed in previous articles.
The two different definitions for sepsis present a problem because CMS guidelines require hospitals to make sure that sepsis is being documented, coded, and reported correctly. In order to do this correctly, hospitals need to figure out if they are going to follow the current SIRS definition or adopt the new SOFA criteria for coding and reporting. However, SOFA is stricter than SIRS which means that a lower fraction of patients are documented, and thus billed, with sepsis. Depending on which method to a hospital decided to use, there can be serious financial impact.
Hospitals report data to CMS in a ratio format. The numerator consists of patients that have been correctly and timely treated and the denominator consists of all patients that should have had the bundle applied to them.
Since CMS quality measures are federal regulations, hospitals are required to report their compliance with CMS measures. There are several potential consequences for poor scores, with the most serious one being the possibility of Medicare reimbursement being tied to rates of adherence in the future.
Hospital scores will be released starting July 25. CMS will start posting scores from the first, second, and third quarters of 2017. In October, a fourth quarter will be added. At the beginning of each new quarter, another quarter’s scores will be added and the oldest will be removed. Each individual hospital’s performance will be compared with:
- The performance of the top 10% compliant hospitals
- The average performance of the hospital’s reporting in that hospital’s state
- The national average of compliance
Essentially, the goal of this effort is to ensure that sepsis is being properly documented and treated in compliance with CMS SEP-1 core measure. There may be some kinks that need to be worked out before everything works properly, but it has the potential to reduce care variability and have positive impact on sepsis intervention. However, given the physiological diversity among patients with sepsis and the changing landscape of evidence for various interventions, it is important the the measure not become too rigid so as to impede with clinical gestalt and the practice of medicine.