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Ling L, Zhang JZ, Chang LC, Chiu LCS, Ho S, Ng PY, Dharmangadan M, Lau CH, Ling S, Man MY, Fong KM, Liong T, Yeung AWT, Au GKF, Chan JKH, Tang M, Liu YZ, Wu WKK, Wong WT, Wu P, Cowling BJ, Lee A, Rhee C. Population sepsis incidence, mortality, and trends in Hong Kong between 2009-2018 using clinical and administrative data. Clin Infect Dis 2023:ciad491. [PMID: 37596856 DOI: 10.1093/cid/ciad491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/26/2023] [Accepted: 08/16/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Sepsis surveillance using electronic health record (EHR)-based data may provide more accurate epidemiologic estimates than administrative data, but experience with this approach to estimate population-level sepsis burden is lacking. METHODS This was a retrospective cohort study including all adults admitted to publicly-funded hospitals in Hong Kong between 2009-2018. Sepsis was defined as clinical evidence of presumed infection (clinical cultures and treatment with antibiotics) and concurrent acute organ dysfunction (≥2 point increase in baseline SOFA score). Trends in incidence, mortality, and case fatality risk (CFR) were modelled by exponential regression. Performance of the EHR-based definition was compared with 4 administrative definitions using 500 medical record reviews. RESULTS Among 13,550,168 hospital episodes during the study period, 485,057 (3.6%) had sepsis by EHR-based criteria with 21.5% CFR. In 2018, age- and sex-adjusted standardized sepsis incidence was 759 per 100,000 (relative +2.9%/year [95%CI 2.0, 3.8%] between 2009-2018) and standardized sepsis mortality was 156 per 100,000 (relative +1.9%/year [95%CI 0.9,2.9%]). Despite decreasing CFR (relative -0.5%/year [95%CI -1.0, -0.1%]), sepsis accounted for an increasing proportion of all deaths (relative +3.9%/year [95%CI 2.9, 4.9%]). Medical record reviews demonstrated that the EHR-based definition more accurately identified sepsis than administrative definitions (AUC 0.91 vs 0.52-0.55, p < 0.001). CONCLUSIONS An objective EHR-based surveillance definition demonstrated an increase in population-level standardized sepsis incidence and mortality in Hong Kong between 2009-2018 and was much more accurate than administrative definitions. These findings demonstrate the feasibility and advantages of an EHR-based approach for widescale sepsis surveillance.
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Affiliation(s)
- Lowell Ling
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jack Zhenhe Zhang
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lok Ching Chang
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Lok Ching Sandra Chiu
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Samantha Ho
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Pauline Yeung Ng
- Critical Care Medicine Unit, The University of Hong Kong, Hong Kong SAR, China
- Department of Adult Intensive Care, Queen Mary Hospital, Hong Kong SAR, China
| | | | - Chi Ho Lau
- Department of Intensive Care, North District Hospital, Hong Kong SAR, China
| | - Steven Ling
- Department of Intensive Care, Tuen Mun Hospital, Hong Kong SAR, China
| | - Man Yee Man
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | - Ka Man Fong
- Department of Intensive Care, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Ting Liong
- Department of Intensive Care, United Christian Hospital, Hong Kong SAR, China
| | - Alwin Wai Tak Yeung
- Department of Medicine & Geriatrics, Ruttonjee and Tang Shiu Kin Hospitals, Hong Kong SAR, China
| | - Gary Ka Fai Au
- Department of Intensive Care, Kwong Wah Hospital, Hong Kong SAR, China
| | | | - Michele Tang
- Department of Medicine and Geriatrics, Caritas Medical Centre, Hong Kong SAR, China
| | - Ying Zhi Liu
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - William Ka Kei Wu
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
- State Key Laboratory of Digestive Diseases, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong SAR, China
- CUHK Shenzhen Research Institute, Shenzhen, China
- Peter Hung Pain Research Institute, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Wai Tat Wong
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Peng Wu
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health Limited, Hong Kong Science and Technology Park, New Territories, Hong Kong SAR, China
| | - Benjamin J Cowling
- WHO Collaborating Centre for Infectious Disease Epidemiology and Control, School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health Limited, Hong Kong Science and Technology Park, New Territories, Hong Kong SAR, China
| | - Anna Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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Chu RBH, Zhao S, Zhang JZ, Chan KCK, Ng PY, Chan C, Fong KM, Au SY, Yeung AWT, Chan JKH, Tsang HH, Law KI, Chow FL, Lam KN, Chan KM, Dharmangadan M, Wong WT, Joynt GM, Wang MH, Ling L. Comparison of COVID-19 with influenza A in the ICU: a territory-wide, retrospective, propensity matched cohort on mortality and length of stay. BMJ Open 2023; 13:e067101. [PMID: 37429680 DOI: 10.1136/bmjopen-2022-067101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Abstract
OBJECTIVES Direct comparisons between COVID-19 and influenza A in the critical care setting are limited. The objective of this study was to compare their outcomes and identify risk factors for hospital mortality. DESIGN AND SETTING This was a territory-wide, retrospective study on all adult (≥18 years old) patients admitted to public hospital intensive care units in Hong Kong. We compared COVID-19 patients admitted between 27 January 2020 and 26 January 2021 with a propensity-matched historical cohort of influenza A patients admitted between 27 January 2015 and 26 January 2020. We reported outcomes of hospital mortality and time to death or discharge. Multivariate analysis using Poisson regression and relative risk (RR) was used to identify risk factors for hospital mortality. RESULTS After propensity matching, 373 COVID-19 and 373 influenza A patients were evenly matched for baseline characteristics. COVID-19 patients had higher unadjusted hospital mortality than influenza A patients (17.5% vs 7.5%, p<0.001). The Acute Physiology and Chronic Health Evaluation IV (APACHE IV) adjusted standardised mortality ratio was also higher for COVID-19 than influenza A patients ((0.79 (95% CI 0.61 to 1.00) vs 0.42 (95% CI 0.28 to 0.60)), p<0.001). Adjusting for age, PaO2/FiO2, Charlson Comorbidity Index and APACHE IV, COVID-19 (adjusted RR 2.26 (95% CI 1.52 to 3.36)) and early bacterial-viral coinfection (adjusted RR 1.66 (95% CI 1.17 to 2.37)) were directly associated with hospital mortality. CONCLUSIONS Critically ill patients with COVID-19 had substantially higher hospital mortality when compared with propensity-matched patients with influenza A.
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Affiliation(s)
- Raymond Bak Hei Chu
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Shi Zhao
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jack Zhenhe Zhang
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - King Chung Kenny Chan
- Department of Anaesthesia and Intensive Care, Tuen Mun Hospital, Hong Kong SAR, China
- Department of Intensive Care, Pok Oi Hospital, Hong Kong SAR, China
| | - Pauline Yeung Ng
- Adult Intensive Care Unit, The University of Hong Kong, Hong Kong SAR, China
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Carol Chan
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
| | - Ka Man Fong
- Department of Intensive Care, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Shek Yin Au
- Department of Medicine, Tseung Kwan O Hospital, Hong Kong SAR, China
| | - Alwin Wai Tak Yeung
- Department of Medicine & Geriatrics, Ruttonjee and Tang Shiu Kin Hospitals, Hong Kong SAR, China
| | | | - Hin Hung Tsang
- Department of Intensive Care, Kwong Wah Hospital, Hong Kong SAR, China
| | - Kin Ip Law
- Department of Intensive Care, United Christian Hospital, Hong Kong SAR, China
| | - Fu Loi Chow
- Department of Intensive Care, Caritas Medical Centre, Hong Kong SAR, China
| | - Koon Ngai Lam
- Department of Intensive Care, North District Hospital, Hong Kong SAR, China
| | - Kai Man Chan
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong SAR, China
| | - Manimala Dharmangadan
- Department of Intensive Care, Princess Margaret Hospital, Hong Kong SAR, China
- Department of Intensive Care, Yan Chai Hospital, Hong Kong SAR, China
| | - Wai Tat Wong
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Gavin Matthew Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Maggie Haitian Wang
- The Chinese University of Hong Kong Shenzhen Research Institute, Shenzhen, China
| | - Lowell Ling
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
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Ling L, Ho CM, Ng PY, Chan KCK, Shum HP, Chan CY, Yeung AWT, Wong WT, Au SY, Leung KHA, Chan JKH, Ching CK, Tam OY, Tsang HH, Liong T, Law KI, Dharmangadan M, So D, Chow FL, Chan WM, Lam KN, Chan KM, Mok OF, To MY, Yau SY, Chan C, Lei E, Joynt GM. Characteristics and outcomes of patients admitted to adult intensive care units in Hong Kong: a population retrospective cohort study from 2008 to 2018. J Intensive Care 2021; 9:2. [PMID: 33407925 PMCID: PMC7788755 DOI: 10.1186/s40560-020-00513-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/07/2020] [Indexed: 11/10/2022] Open
Abstract
Background Globally, mortality rates of patients admitted to the intensive care unit (ICU) have decreased over the last two decades. However, evaluations of the temporal trends in the characteristics and outcomes of ICU patients in Asia are limited. The objective of this study was to describe the characteristics and risk adjusted outcomes of all patients admitted to publicly funded ICUs in Hong Kong over a 11-year period. The secondary objective was to validate the predictive performance of Acute Physiology And Chronic Health Evaluation (APACHE) IV for ICU patients in Hong Kong. Methods This was an 11-year population-based retrospective study of all patients admitted to adult general (mixed medical-surgical) intensive care units in Hong Kong public hospitals. ICU patients were identified from a population electronic health record database. Prospectively collected APACHE IV data and clinical outcomes were analysed. Results From 1 April 2008 to 31 March 2019, there were a total of 133,858 adult ICU admissions in Hong Kong public hospitals. During this time, annual ICU admissions increased from 11,267 to 14,068, whilst hospital mortality decreased from 19.7 to 14.3%. The APACHE IV standard mortality ratio (SMR) decreased from 0.81 to 0.65 during the same period. Linear regression demonstrated that APACHE IV SMR changed by − 0.15 (95% CI − 0.18 to − 0.11) per year (Pearson’s R = − 0.951, p < 0.001). Observed median ICU length of stay was shorter than that predicted by APACHE IV (1.98 vs. 4.77, p < 0.001). C-statistic for APACHE IV to predict hospital mortality was 0.889 (95% CI 0.887 to 0.891) whilst calibration was limited (Hosmer–Lemeshow test p < 0.001). Conclusions Despite relatively modest per capita health expenditure, and a small number of ICU beds per population, Hong Kong consistently provides a high-quality and efficient ICU service. Number of adult ICU admissions has increased, whilst adjusted mortality has decreased over the last decade. Although APACHE IV had good discrimination for hospital mortality, it overestimated hospital mortality of critically ill patients in Hong Kong. Supplementary Information The online version contains supplementary material available at 10.1186/s40560-020-00513-9.
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Affiliation(s)
- Lowell Ling
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, 4/F Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, Hong Kong, China.
| | - Chun Ming Ho
- Department of Anaesthesia and Intensive Care, Tuen Mun Hospital, Hong Kong, China
| | - Pauline Yeung Ng
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.,Department of Adult Intensive Care, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | | | - Hoi Ping Shum
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Cheuk Yan Chan
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Alwin Wai Tak Yeung
- Department of Medicine & Geriatrics, Ruttonjee and Tang Shiu Kin Hospitals, Hong Kong, China
| | - Wai Tat Wong
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, 4/F Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, Hong Kong, China
| | - Shek Yin Au
- Department of Intensive Care, Queen Elizabeth Hospital, Hong Kong, China
| | | | | | - Chi Keung Ching
- Department of Medicine, Tseung Kwan O Hospital, Hong Kong, China
| | - Oi Yan Tam
- Department of Intensive Care, Kwong Wah Hospital, Hong Kong, China
| | - Hin Hung Tsang
- Department of Intensive Care, Kwong Wah Hospital, Hong Kong, China
| | - Ting Liong
- Department of Intensive Care, United Christian Hospital, Hong Kong, China
| | - Kin Ip Law
- Department of Intensive Care, United Christian Hospital, Hong Kong, China
| | - Manimala Dharmangadan
- Department of Intensive Care, Princess Margaret Hospital, Hong Kong, China.,Department of Intensive Care, Yan Chai Hospital, Hong Kong, China
| | - Dominic So
- Department of Intensive Care, Princess Margaret Hospital, Hong Kong, China.,Department of Intensive Care, Yan Chai Hospital, Hong Kong, China
| | - Fu Loi Chow
- Department of Intensive Care, Caritas Medical Centre, Hong Kong, China
| | - Wai Ming Chan
- Department of Adult Intensive Care, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | - Koon Ngai Lam
- Department of Intensive Care, North District Hospital, Hong Kong, China
| | - Kai Man Chan
- Intensive Care Unit, Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong, China
| | - Oi Fung Mok
- Quality and Safety Division, Hospital Authority Head Office, Hong Kong, China
| | - Man Yee To
- Quality and Safety Division, Hospital Authority Head Office, Hong Kong, China
| | - Sze Yuen Yau
- Quality and Safety Division, Hospital Authority Head Office, Hong Kong, China
| | - Carmen Chan
- Quality and Safety Division, Hospital Authority Head Office, Hong Kong, China
| | - Ella Lei
- Quality and Safety Division, Hospital Authority Head Office, Hong Kong, China
| | - Gavin Matthew Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, 4/F Main Clinical Block and Trauma Centre, Prince of Wales Hospital, Shatin, Hong Kong, China
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