JC: The IHME study on the global burden of sepsis. St Emlyn's

Editors note: This blog is based on the presentation of this trial at the Critical Care Reviews conference in Belfast. We will add more data, and be able to add a more detailed critical appraisal when the full paper is published in the Lancet soon. Since we have not seen the full paper yet you should add a little bit of extra scepticism to the findings described below.

Live stream of presentation

We couldn’t find out much about this trial in advance of the #CCR20 conference. An earlier publication states that the aim is to assess the global impact of sepsis​1​.

It comes from the The Institute for Health Metrics and Evaluation (IHME) which is an independent population health research centre at the University of Washington. In their own words, the IHME aims to publish in open access so that policymakers have the evidence they need to make informed decisions about how to allocate resources to best improve population health.

The Global Burden of Disease projects are epidemiological studies to assess where and how much disease there is across the globe, in this case with a focus on sepsis. This is important as we should understand where and what is going on across the planet in an increasingly connected and mobile world. It’s also important for those of us in high income countries to appreciate the burden of diseases such as sepsis in low and middle income countries. It’s easy to think that sepsis has an excessive focus here in #Virchester, especially when we see how much greater the burden is in other, less fortunate, health economies.

The full paper can be found here​2​ and the abstract below. As we always say please read the full paper, it’s quite complex and nuanced.

If we are to improve the care of patients with sepsis and to work out where to resesarch and intervene then it’s important that we have good data. previous studies have not taken a global perspective and importantly have not consistently involved low income countries or paediatric patients. They are often snap shots of disease and therefore we struggle to follow trends across the world.

The paper will be published in the Lancet later today.

Previously the best work suggested that there were 19 million cases worldwide with 5 million deaths​[NO_PRINTED_FORM]​ but we know that to be inaccurate.

The Global Burden of Disease looks at 195 countries and 80,000 data sources and over 1 Billion data points to look at epidemiological data. In this study they looked at death certification data (amongst other things) as this is pretty good data. They needed good quality data on this and so that limited the countries they could use.

They found 109 Million cause of death certificates that could be included in the analysis. This gave 282 causes of sepsis across 195 locations worldwide. This gave mortality data.

For sepsis incidence they looked at hospital records. They looked at over 9 Million hospital records and modelled that to estimate a global incidence of disease.

The headline figures are that they estimate that there are 78.9 Million sepsis cases and 11 Million sepsis related deaths. Interestingly the time trends in this data suggest that the incidence of sepsis and sepsis deaths is falling over time.

There are huge variations across the globe, with an excess of sepsis burden in sub saharan Africa. There is an excess of sepsis deaths in neonates, and then a second peak in later life. I suspect that the excess of deaths from sepsis in low income countries may also be related to the neonatal death rate, though that was not described in the presentation.

Make sure that you read the full paper when it comes out. We will try and update the blog when it does.

In the editorial section Prof. Kath Maitland pointed out that the study relies on accurate records. This is a real problem as there is quite a lot of evidence to show that sepsis is often overdiagnosed, especially in low income countries. That’s potentially a big problem as it these methods may over-estimate the burden of sepsis. How sure can we be that the increase in global burden estimates is real, or simply because we have applied a different, albeit probably better, method?

Lastly we need to be careful about how this trial is interpreted outside of the world of #FOAMed and critical appraisal. We talked earlier today about how social media, and indeed media can be sensationalist. It’s interesting then to see how this trial has been reported today. I’ll leave you to make your own mind up on this….. My twitter feed is full of comments from the usual suspects of this being evidence that sepsis is being missed and also that all these deaths are preventable, which of course they cannot be.

Final thoughts

An incredible piece of work and a realisation of big data research in medicine. It changes our view of sepsis across the world and that should help. Importantly, the burden of sepsis appears to be four times as large as previously thought. However, in high income countries the incidence and burden may be lower than previously thought (certainly in the US).

What this study cannot tell us is what the number of sepsis deaths (and morbidity) that is either preventable or treatable, but it does tell us where to look to make those interventions.

vb

S

References

  1. 1.
    Rudd KE, Kissoon N, Limmathurotsakul D, et al. The global burden of sepsis: barriers and potential solutions. Crit Care. September 2018. doi:10.1186/s13054-018-2157-z
  2. 2.
    Rudd KE, Johnson SC, Agesa KM, et al. Global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the Global Burden of Disease Study. The Lancet. January 2020. doi:10.1016/s0140-6736(19)32989-7


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Posted by Simon Carley

Professor Simon Carley MB ChB, PGDip, DipIMC (RCS Ed), FRCS (Ed)(1998), FHEA, FAcadMed, FRCEM, MPhil, MD, PhD is Creator, Webmaster, owner and Editor in Chief of the St Emlyn’s blog and podcast. He is Professor of Emergency Medicine at Manchester Metropolitan University and a Consultant in adult and paediatric Emergency Medicine at Manchester Foundation Trust. He is co-founder of BestBets, St.Emlyns and the MSc in emergency medicine at Manchester Metropolitan University. He is an Education Associate with the General Medical Council and is an Associate Editor for the Emergency Medicine Journal. His research interests include diagnostics, MedEd, Major incidents & Evidence based Emergency Medicine. He is verified on twitter as @EMManchester

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