Table 1.

Summary of Surveillance Strategies for Sepsis

	Advantages	Disadvantages	Reported Epidemiologic Trends
Administrative Claims Data	Convenient, easy to use, inexpensive Large, national data sets available High positive predictive value relative to medical record reviews	Susceptible to ascertainment bias from decreasing thresholds to diagnose and code for sepsis over time Limited ability to compare across institutions and regions due to variability in diagnosis and coding practices Limited ability to distinguish between community- and hospital-onset sepsis	Increasing sepsis incidence (8–13% per year in US) [14, 15, 19] Decreasing in-hospital mortality (1.4–2% per year) [14, 17]S
Death Records	Convenient, easy to use, inexpensive Captures deaths occurring outside of the hospital Gives insight into causal role of sepsis in mortality	Cannot be used to study incidence or other outcomes (unless paired with other data sources) Coding often inaccurate and variable Susceptible to ascertainment bias	Variable reports of trends in sepsis deaths (31% increase in US from 1999–2014, vs 30% global decrease from 1990–2017); number of deaths lower versus hospital discharge codes [1, 38]
Prospective Clinical Registries	More consistent inclusion criteria Allows identification of time zero and processes of care	Resource-intensive Susceptible to ascertainment bias due to decreasing threshold to diagnosis sepsis and organ dysfunction Limited ability to compare across institutions due to differing sepsis screening criteria	Decreasing in-hospital mortality (e.g., 35.0% to 18.4% from 2000–2012 in Australian/New Zealand ICUs) [44]
Retrospective Case Reviews	More accurate and rigorous than administrative data alone Allows identification of time zero and processes of care	Resource-intensive, infeasible to apply to large populations Potentially subjective
Sepsis Randomized Controlled Trials	More consistent inclusion criteria Other detailed clinical data often available to adjust for severity of illness No additional cost beyond expense of RCT	Relatively small numbers of patients Can only be used to study sepsis outcomes, not incidence Patients may not be reflective of general sepsis population Still susceptible to ascertainment bias as increased sepsis awareness leads to enrollment of less severely ill patients	Decreasing 28-day mortality, (e.g. 0.42% annual decrease from 2002–2016, but trend non-significant when controlled for severity of illness) [51]
Objective/Clinical criteria from EHR CDC “Adult Sepsis Event”	Objective and less susceptible to ascertainment bias (does not depend on diagnosis and coding practices) May be automated and applied to entire hospitals’ populations Distinguishes between community- and hospital-onset sepsis More objective hospital comparisons	Dependent on availability of electronic health records Requires information technology expertise and resources; only feasible in high-income countries High thresholds for organ dysfunction criteria may miss patients with lower severity of illness Susceptible to bias due to changes in practice patterns (e.g., lactate testing)	Sepsis incidence unchanged from 2009–2014 (without lactate criterion) or mild increase (with lactate criterion) [2] Mortality unchanged (without lactate criterion) or mild decrease (with lactate criterion) [2]