Care pathways of sepsis survivors: sequelae, mortality and use of healthcare services in France, 2015-2018.

BACKGROUND: Individuals who survive sepsis are at high risk of chronic sequelae, resulting in significant health-economic costs. Several studies have focused on aspects of healthcare pathways of sepsis survivors but comprehensive, longitudinal overview of their pathways of care are scarce. The aim of this retrospective, longitudinal cohort study is to identify sepsis survivor profiles based on their healthcare pathways and describe their healthcare consumption and costs over the 3 years following their index hospitalization. METHODS: The data were extracted from the French National Hospital Discharge Database. The study population included all patients above 15 years old, with bacterial sepsis, who survived an incident hospitalization in an acute care facility in 2015. To identify survivor profiles, state sequence and clustering analyses were conducted over the year following the index hospitalization. For each profile, patient characteristics and their index hospital stay and sequelae were described, as well as use of care and its associated monetary costs, both pre- and post-sepsis. RESULTS: New medical (79.2%), psychological (26.9%) and cognitive (18.5%) impairments were identified post-sepsis, and 65.3% of survivors were rehospitalized in acute care. Cumulative mortality reached 36.6% by 3 years post-sepsis. The total medical cost increased by 856 million € in the year post-sepsis. Five patient clusters were identified: home (65.6% of patients), early death (12.9%), late death (6.8%), short-term rehabilitation (11.3%) and long-term rehabilitation (3.3%). Survivors with early and late death clusters had high rates of cancer and primary bacteremia and experienced more hospital-at-home care post-sepsis. Survivors in short- or long-term rehabilitation clusters were older, with higher percentage of septic shock than those coming back home, and had high rates of multiple site infections and higher rates of new psychological and cognitive impairment. CONCLUSIONS: Over three years post-sepsis, different profiles of sepsis survivors were identified with different mortality rates, sequels and healthcare services usage and cost. This study confirmed the importance of sepsis burden and suggests that strategies of post-discharge care, in accordance with patient profile, should be further tested in order to reduce sepsis burden.

One-year hospital readmission for recurrent sepsis: associated risk factors and impact on 1-year mortality-a French nationwide study.

BACKGROUND: Sepsis is a complex health condition, leading to long-term morbidity and mortality. Understanding the risk factors for recurrent sepsis, as well as its impact on mid- and long-term mortality among other risk factors, is essential to improve patient survival. METHODS: A risk factor analysis, based on French nationwide medico-administrative data, was conducted on a cohort of patients above 15 years old, hospitalized with an incident sepsis in metropolitan France between 1st January 2018 and 31st December 2018 and who survived their index hospitalization. Two main analyses, focusing on outcomes occurring 1-year post-discharge, were conducted: a first one to assess risk factors for recurrent sepsis and a second to assess risk factors for mortality. RESULTS: Of the 178017 patients surviving an incident sepsis episode in 2018 and included in this study, 22.3% died during the 1-year period from discharge and 73.8% had at least one hospital readmission in acute care, among which 18.1% were associated with recurrent sepsis. Patients aged between 56 and 75, patients with cancer and renal disease, with a long index hospital stay or with mediastinal or cardiac infection had the highest odds of recurrent sepsis. One-year mortality was higher for patients with hospital readmission for recurrent sepsis (aOR 2.93; 99% CI 2.78-3.09). Among all comorbidities, patients with cancer (aOR 4.35; 99% CI 4.19-4.52) and dementia (aOR 2.02; 99% CI 1.90-2.15) had the highest odds of 1-year mortality. CONCLUSION: Hospital readmission for recurrent sepsis is one of the most important risk factors for 1-year mortality of septic patients, along with age and comorbidities. Our study suggests that recurrent sepsis, as well as modifiable or non-modifiable other risk factors identified, should be considered in order to improve patient care pathway and survival.

Trends in bacterial sepsis incidence and mortality in France between 2015 and 2019 based on National Health Data System (Système National des données de Santé (SNDS)): a retrospective observational study.

OBJECTIVE: This study aims to provide a case definition of sepsis of presumed bacterial aetiology based on 10th revision of the International Classification of Diseases (ICD-10) codes, to assess trends in sepsis incidence and mortality between 2015 and 2019 in France, and to describe the characteristics of affected patients and hospital stays. DESIGN: Nationwide, population-based, retrospective observational study. SETTING: Metropolitan France between 2015 and 2019. PARTICIPANTS: Between 2015 and 2019, 1 224 433 patients with sepsis of presumed bacterial aetiology were selected from the French National Hospital Discharge Database (Programme de Médicalisation des Systèmes d'Information) and were identified from corresponding ICD-10 codes for explicit sepsis or implicit sepsis. MAIN OUTCOMES MEASURES: Annual overall and age-specific and gender-specific incidence and 95% CI, as well as trends in sepsis incidence and mortality, were estimated. Comorbidities, length of hospital stay and outcomes were described. RESULTS: The sex-standardised and age-standardised incidence per 100 000 (95% CI) increased from 357 (356.0 to 359.0) in 2015 to 403 (401.9 to 405.0) in 2019 and remained higher for males compared with females. Children under 1 year and patients over 75 years consistently had the highest incidence. The most common comorbidities were cancer and chronic heart failure. The median hospital length of stay was 12 days. Most patients came from home, but only half returned home after their hospital stay and approximately 15% were discharged to long-term care. In-hospital mortality was about 25% and declined along the study period. CONCLUSIONS: Medico-administrative databases can be used to provide nationwide estimates of the in-hospital burden of bacterial sepsis. The results confirm the high burden of sepsis in France. These data should be complemented by estimating the additional burden associated with fungal and viral infections during the COVID-19 pandemic.

The "Real Welfare" Scheme: Changes in UK Finishing Pig Welfare since the Introduction of Formal Welfare Outcome Assessment.

Farm animal welfare is an increasingly important issue, leading to the need for an efficient methodology to deliver accurate benchmarking. The "Real Welfare" project developed a methodology based on regular recording of a limited number of animal-based measures, so-called welfare outcomes, which allows faster and easier on-farm assessment of finishing pig welfare. The objective of this paper is to estimate, with sufficient robustness and confidence, the prevalence of different mandatory and optional welfare outcomes in the mainstream herd of the finishing farms in the UK based on the "Real Welfare" scheme data and to assess the changes in prevalence over time, inspection visits and seasons. The mean overall prevalence of the four mandatory welfare outcomes (pigs requiring hospitalization, lame pigs, pigs with severe body marks, and pigs with severe tail lesions) was very low (≤0.2%) and a significant decreasing trend was observed for the first three of these mandatory welfare outcomes since the inception of the scheme. This result might reflect either a reduction in factors giving rise to welfare problems in the mainstream herd or increasing awareness about management of compromised pigs. Additional data are required to clarify these possibilities, but both represent improved pig welfare.

Designing a Syndromic Bovine Mortality Surveillance System: Lessons Learned From the 1-Year Test of the French OMAR Alert Tool.

Between May 2018 and 2019, a syndromic bovine mortality surveillance system (OMAR) was tested in 10 volunteer French départements (French intermediate-level administrative unit) to assess its performance in real conditions, as well as the human and financial resources needed to ensure normal functioning. The system is based on the automated weekly analysis of the number of cattle deaths reported by renderers in the Fallen Stock Data Interchange Database established in January 2011. In our system, every Thursday, the number of deaths is grouped by ISO week and small surveillance areas and then analyzed using traditional time-series analysis steps (cleaning, prediction, signal detection). For each of the five detection algorithms implemented (i.e., the exponentially weighted moving average chart, cumulative sum chart, Shewhart chart, Holt-Winters, and historical limits algorithms), seven detection limits are applied, giving a signal score from 1 (low excess mortality) to 7 (high excess mortality). The severity of excess mortality (alarm) is then classified into four categories, from very low to very high, by combining the signal scores, the relative excess mortality, and the persistence of the signal(s) over the previous 4 weeks. Detailed and interactive weekly reports and a short online questionnaire help pilot départements and the OMAR central coordination cell assess the performance of the system. During the 1-year test, the system showed highly variable sensitivity among départements. This variability was partly due not only to the demographic distribution of cattle (very few signals in low-density areas) but also to the renderer's delay in reporting to the Fallen Stock Data Interchange Database (on average, only 40% of the number of real deaths had been transmitted within week, with huge variations among départements). As a result, in the pilot départements, very few alarms required on-farm investigation and excess mortality often involved a small number of farms already known to have health or welfare problems. Despite its perfectibility, the system nevertheless proved useful in the daily work of animal health professionals for collective and individual surveillance. The test is still ongoing for a second year in nine départements to evaluate the effectiveness of the improvements agreed upon at the final meeting.

Connecting Different Data Sources to Assess the Interconnections between Biosecurity, Health, Welfare, and Performance in Commercial Pig Farms in Great Britain.

This study aimed to provide an overview of the interconnections between biosecurity, health, welfare, and performance in commercial pig farms in Great Britain. We collected on-farm data about the level of biosecurity and animal performance in 40 fattening pig farms and 28 breeding pig farms between 2015 and 2016. We identified interconnections between these data, slaughterhouse health indicators, and welfare indicator records in fattening pig farms. After achieving the connections between databases, a secondary data analysis was performed to assess the interconnections between biosecurity, health, welfare, and performance using correlation analysis, principal component analysis, and hierarchical clustering. Although we could connect the different data sources the final sample size was limited, suggesting room for improvement in database connection to conduct secondary data analyses. The farm biosecurity scores ranged from 40 to 90 out of 100, with internal biosecurity scores being lower than external biosecurity scores. Our analysis suggested several interconnections between health, welfare, and performance. The initial correlation analysis showed that the prevalence of lameness and severe tail lesions was associated with the prevalence of enzootic pneumonia-like lesions and pyaemia, and the prevalence of severe body marks was associated with several disease indicators, including peritonitis and milk spots (r > 0.3; P < 0.05). Higher average daily weight gain (ADG) was associated with lower prevalence of pleurisy (r > 0.3; P < 0.05), but no connection was identified between mortality and health indicators. A subsequent cluster analysis enabled identification of patterns which considered concurrently indicators of health, welfare, and performance. Farms from cluster 1 had lower biosecurity scores, lower ADG, and higher prevalence of several disease and welfare indicators. Farms from cluster 2 had higher biosecurity scores than cluster 1, but a higher prevalence of pigs requiring hospitalization and lameness which confirmed the correlation between biosecurity and the prevalence of pigs requiring hospitalization (r > 0.3; P < 0.05). Farms from cluster 3 had higher biosecurity, higher ADG, and lower prevalence for some disease and welfare indicators. The study suggests a smaller impact of biosecurity on issues such as mortality, prevalence of lameness, and pig requiring hospitalization. The correlations and the identified clusters suggested the importance of animal welfare for the pig industry.

Familiarity with and uptake of alternative methods to control sheep gastro-intestinal parasites on farms in England.

A questionnaire was distributed electronically amongst sheep farmers in England; it aimed to provide a quantification of current anthelmintic practices, farmer awareness of the issue of anthelmintic resistance (AR) and the uptake, awareness and opinions surrounding conventional and alternative methods of nematode control. The majority of farmers relied on several anthelmintics and used faecal egg counts to identify worm problems. Although farmers were aware of the issue of AR amongst helminth parasites in the UK, there was a disconnection between such awareness and on farm problems and practice of nematode control. Grazing management was used by 52% of responders, while breeding for resistance and bioactive forages by 22 and 18% respectively. Farms with more than 500 ewes, and farmers who felt nematodes were a problem, had a higher probability of using selective breeding. Farmers who considered their wormer effective, had a qualification in agriculture and whose staff did not include any family members, were more likely to use bioactive forages; the opposite was the case if farmers dosed their lambs frequently. Amongst the alternatives, highest preference was for selective breeding and vaccination, if the latter was to become commercially available, with more respondents having a preference for breeding than actually using it. Several barriers to the uptake of an alternative were identified, the most influential factor being the cost to set it up and the length of time for which it would remain effective. The disconnection between awareness of AR and practice of nematode control on farm reinforces the need for emphasising the links between the causes of AR and the consequences of strategies to address its challenge.