{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T18:33:14Z","timestamp":1793212394241,"version":"4.5.0"},"reference-count":40,"publisher":"Oxford University Press (OUP)","issue":"4","license":[{"start":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T00:00:00Z","timestamp":1782777600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"funder":[{"DOI":"10.13039\/100000133","name":"Agency for Healthcare Research and Quality","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000133","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,10,28]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Diagnostic uncertainty in sepsis contributes to both undertreatment (delayed antibiotics) and overtreatment (unnecessary early antibiotics in nonsepsis patients). We hypothesized hospitals with strong sepsis undertreatment and overtreatment performance have better outcomes.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a retrospective cohort study of hospitalized adults at 20 hospitals (Advocate Health, Michigan Medicine) between 2022 and 2024. Patients met \u22652 systemic inflammatory response syndrome criteria within 6 hours of presentation. Hospital performance was characterized using risk-standardized rates (RSRs) for undertreatment and overtreatment. \u201cDiagnostic excellence\u201d (DxEx) was prespecified as top-tertile performance in 1 measure without bottom-tertile performance in the other. The primary outcome was hospital mortality or hospice discharge. Secondary outcomes were hospital-free days alive at 28 days (HFD), length of stay (LOS), and total antibiotic days.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 152 779 patients, 49 109 (32.1%) received antibiotics within 3 hours and 16 361 (10.7%) ultimately met sepsis criteria. Undertreatment RSRs ranged from 29.3% to 46.8%. Overtreatment RSRs ranged from 21.5% to 37.2%. There was negative correlation between performance ranks (\u03c4 = \u22120.51; P = .01). Four hospitals met DxEx criteria. Receiving treatment at DxEx hospitals was associated with lower hospital mortality or hospice discharge (adjusted OR = 0.61; 95% CI = .41\u2013.90; P = .01), greater HFD (adjusted difference = 0.59; 95% CI = .04\u20131.14; P = .04), reduced LOS (adjusted difference = \u22121.20; 95% CI = \u22122.23 to \u2212.17; P = .02), and fewer antibiotic days (adjusted difference = \u22120.62; 95% CI = \u22121.28\u2013.05; P = .07), versus non-DxEx hospitals.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Hospital performance that jointly minimizes sepsis undertreatment and overtreatment was associated with improved patient outcomes, adjusting for patient and hospital factors. Findings highlight the importance of reducing diagnostic error in efforts to improve sepsis outcomes.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/cid\/ciag382","type":"journal-article","created":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T22:53:48Z","timestamp":1782860028000},"page":"526-534","source":"Crossref","is-referenced-by-count":0,"title":["Sepsis Diagnostic Excellence and Its Association With Mortality in Adults With Potential Infection"],"prefix":"10.1093","volume":"83","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2624-4209","authenticated-orcid":false,"given":"Marc","family":"Kowalkowski","sequence":"first","affiliation":[{"name":"Section of Hospital Medicine, Wake Forest School of Medicine , Winston-Salem, North Carolina ,","place":["USA"]},{"name":"Center for Health System Sciences, Advocate Health , Charlotte, North Carolina ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"Birken","sequence":"additional","affiliation":[{"name":"Department of Implementation Science, Wake Forest School of Medicine , Winston-Salem, North Carolina ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Corey","family":"Obermiller","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Informatics and Analytics, Wake Forest School of Medicine , Winston-Salem, North Carolina ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chadwick D","family":"Miller","sequence":"additional","affiliation":[{"name":"Department of Emergency Medicine, Wake Forest School of Medicine , Winston-Salem, North Carolina ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6333-365X","authenticated-orcid":false,"given":"Jessica A","family":"Palakshappa","sequence":"additional","affiliation":[{"name":"Section of Pulmonary and Critical Care Medicine, Wake Forest School of Medicine , Winston-Salem, North Carolina ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0003-8616-6908","authenticated-orcid":false,"given":"Bradley","family":"Rowland","sequence":"additional","affiliation":[{"name":"Section of Hospital Medicine, Wake Forest School of Medicine , Winston-Salem, North Carolina ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessie","family":"King","sequence":"additional","affiliation":[{"name":"Division of Hospital Medicine, Michigan Medicine , Ann Arbor, Michigan ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Timothy","family":"Rogers","sequence":"additional","affiliation":[{"name":"Center for Health System Sciences, Advocate Health , Charlotte, North Carolina ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9883-2961","authenticated-orcid":false,"given":"Shuo","family":"Tian","sequence":"additional","affiliation":[{"name":"Division of Hospital Medicine, Michigan Medicine , Ann Arbor, Michigan ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7878-8756","authenticated-orcid":false,"given":"Sachita","family":"Shrestha","sequence":"additional","affiliation":[{"name":"Division of Hospital Medicine, Michigan Medicine , Ann Arbor, Michigan ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laura","family":"Clark","sequence":"additional","affiliation":[{"name":"Department of Implementation Science, Wake Forest School of Medicine , Winston-Salem, North Carolina ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6163-9666","authenticated-orcid":false,"given":"Stephanie","family":"Taylor","sequence":"additional","affiliation":[{"name":"Division of Hospital Medicine, Michigan Medicine , Ann Arbor, Michigan ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,6,30]]},"reference":[{"key":"2026102813435317700_ciag382-B1","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1515\/dx-2019-0104","article-title":"Rate of diagnostic errors and serious misdiagnosis-related harms for major vascular events, infections, and cancers: toward a national incidence estimate using the \u201cBig Three\u201d","volume":"8","author":"Newman-Toker","year":"2021","journal-title":"Diagnosis (Berl)"},{"key":"2026102813435317700_ciag382-B2","doi-asserted-by":"crossref","first-page":"1008","DOI":"10.1136\/bmjqs-2019-010822","article-title":"Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta-analysis","volume":"29","author":"Gunderson","year":"2020","journal-title":"BMJ Qual Saf"},{"key":"2026102813435317700_ciag382-B3","doi-asserted-by":"crossref","first-page":"762","DOI":"10.1001\/jama.2016.0288","article-title":"Assessment of clinical criteria for sepsis: for the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)","volume":"315","author":"Seymour","year":"2016","journal-title":"JAMA"},{"key":"2026102813435317700_ciag382-B4","doi-asserted-by":"publisher","DOI":"10.1007\/s11908-021-00747-0","article-title":"Host diagnostic biomarkers of infection in the ICU: where are we and where are we going?","volume":"23","author":"Heffernan","year":"2021","journal-title":"Curr Infect Dis Rep"},{"key":"2026102813435317700_ciag382-B5","doi-asserted-by":"crossref","first-page":"426","DOI":"10.1513\/AnnalsATS.201809-646PS","article-title":"Improving sepsis treatment by embracing diagnostic uncertainty","volume":"16","author":"Prescott","year":"2019","journal-title":"Ann Am Thorac Soc"},{"key":"2026102813435317700_ciag382-B6","doi-asserted-by":"crossref","first-page":"2400","DOI":"10.1016\/j.ajem.2020.09.014","article-title":"Utilization of a multidisciplinary emergency department sepsis huddle to reduce time to antibiotics and improve SEP-1 compliance","volume":"38","author":"Sonis","year":"2020","journal-title":"Am J Emerg Med"},{"key":"2026102813435317700_ciag382-B7","doi-asserted-by":"crossref","first-page":"927","DOI":"10.7326\/M20-5043","article-title":"Treatment patterns and clinical outcomes after the introduction of the Medicare sepsis performance measure (SEP-1)","volume":"174","author":"Barbash","year":"2021","journal-title":"Ann Intern Med"},{"key":"2026102813435317700_ciag382-B8","doi-asserted-by":"publisher","first-page":"1406","DOI":"10.1164\/rccm.201712-2545OC","article-title":"Mortality changes associated with mandated public reporting for sepsis. The results of the New York state initiative","volume":"198","author":"Levy","year":"2018","journal-title":"Am J Respir Crit Care Med"},{"key":"2026102813435317700_ciag382-B9","doi-asserted-by":"crossref","first-page":"520","DOI":"10.1513\/AnnalsATS.201910-757RL","article-title":"Trends in false-positive code sepsis activations in the emergency department","volume":"17","author":"Taylor","year":"2020","journal-title":"Ann Am Thorac Soc"},{"key":"2026102813435317700_ciag382-B10","first-page":"157","article-title":"The impact of an inpatient nurse-triggered sepsis alert on antimicrobial utilization","volume":"47","author":"Kang","year":"2021","journal-title":"Jt Comm J Qual Patient Saf"},{"key":"2026102813435317700_ciag382-B11","doi-asserted-by":"crossref","first-page":"2235","DOI":"10.1056\/NEJMoa1703058","article-title":"Time to treatment and mortality during mandated emergency care for sepsis","volume":"376","author":"Seymour","year":"2017","journal-title":"N Engl J Med"},{"key":"2026102813435317700_ciag382-B12","doi-asserted-by":"crossref","first-page":"1589","DOI":"10.1097\/01.CCM.0000217961.75225.E9","article-title":"Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock","volume":"34","author":"Kumar","year":"2006","journal-title":"Crit Care Med"},{"key":"2026102813435317700_ciag382-B13","doi-asserted-by":"crossref","first-page":"852","DOI":"10.1164\/rccm.202310-1800OC","article-title":"Heterogeneity of benefit from earlier time-to-antibiotics for sepsis","volume":"209","author":"Hechtman","year":"2024","journal-title":"Am J Respir Crit Care Med"},{"key":"2026102813435317700_ciag382-B14","doi-asserted-by":"crossref","first-page":"2570","DOI":"10.1016\/j.ajem.2019.12.045","article-title":"Impact of SEP-1 on broad-spectrum combination antibiotic therapy in the emergency department","volume":"38","author":"Miller","year":"2020","journal-title":"Am J Emerg Med"},{"key":"2026102813435317700_ciag382-B15","doi-asserted-by":"crossref","first-page":"1308","DOI":"10.1001\/jamainternmed.2017.1938","article-title":"Association of adverse events with antibiotic use in hospitalized patients","volume":"177","author":"Tamma","year":"2017","journal-title":"JAMA Intern Med"},{"key":"2026102813435317700_ciag382-B16","doi-asserted-by":"publisher","first-page":"261","DOI":"10.1002\/phar.2201","article-title":"Duration of exposure to antipseudomonal \u03b2-lactam antibiotics in the critically ill and development of new resistance","volume":"39","author":"Teshome","year":"2019","journal-title":"Pharmacotherapy"},{"key":"2026102813435317700_ciag382-B17","doi-asserted-by":"crossref","first-page":"1484","DOI":"10.1111\/acem.12820","article-title":"Overtesting and the downstream consequences of overtreatment: implications of \u201cpreventing overdiagnosis\u201d for emergency medicine","volume":"22","author":"Carpenter","year":"2015","journal-title":"Acad Emerg Med"},{"key":"2026102813435317700_ciag382-B18","doi-asserted-by":"crossref","first-page":"S17","DOI":"10.1093\/cid\/ciaa1581","article-title":"National estimates of healthcare costs associated with multidrug-resistant bacterial infections among hospitalized patients in the United States","volume":"72","author":"Nelson","year":"2021","journal-title":"Clin Infect Dis"},{"key":"2026102813435317700_ciag382-B19","doi-asserted-by":"crossref","first-page":"662","DOI":"10.1377\/hlthaff.2017.1153","article-title":"Antibiotic-resistant infection treatment costs have doubled since 2002, now exceeding $2 billion annually","volume":"37","author":"Thorpe","year":"2018","journal-title":"Health Aff (Millwood)"},{"key":"2026102813435317700_ciag382-B20","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1001\/jama.2021.23916","article-title":"Achieving diagnostic excellence for sepsis","volume":"327","author":"Angus","year":"2022","journal-title":"JAMA"},{"key":"2026102813435317700_ciag382-B21","doi-asserted-by":"crossref","first-page":"1673","DOI":"10.1056\/NEJMp1400276","article-title":"Regulatory mandates for sepsis care\u2013reasons for caution","volume":"370","author":"Rhee","year":"2014","journal-title":"N Engl J Med"},{"key":"2026102813435317700_ciag382-B22","doi-asserted-by":"crossref","first-page":"323","DOI":"10.1016\/j.cmi.2024.12.019","article-title":"Sepsis: a summary of the SEP-1 quality measure and future considerations","volume":"31","author":"Scherger","year":"2025","journal-title":"Clin Microbiol Infect"},{"key":"2026102813435317700_ciag382-B23","doi-asserted-by":"crossref","first-page":"505","DOI":"10.1093\/cid\/ciad447","article-title":"Improving sepsis outcomes in the era of pay-for-performance and electronic quality measures: a joint IDSA\/ACEP\/PIDS\/SHEA\/SHM\/SIDP position paper","volume":"78","author":"Rhee","year":"2024","journal-title":"Clin Infect Dis"},{"key":"2026102813435317700_ciag382-B24","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1093\/cid\/ciae445","article-title":"Development of an electronic clinical surveillance measure for unnecessary rapid antibiotic administration in suspected sepsis","volume":"80","author":"Taylor","year":"2025","journal-title":"Clin Infect Dis"},{"key":"2026102813435317700_ciag382-B25","doi-asserted-by":"crossref","first-page":"1197","DOI":"10.1093\/cid\/ciaf118","article-title":"Frequency of antibiotic overtreatment and associated harms in patients presenting with suspected sepsis to the emergency department: a retrospective cohort study","volume":"80","author":"Shappell","year":"2025","journal-title":"Clin Infect Dis"},{"key":"2026102813435317700_ciag382-B26","doi-asserted-by":"crossref","first-page":"1644","DOI":"10.1378\/chest.101.6.1644","article-title":"Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP\/SCCM Consensus Conference Committee. American College of Chest Physicians\/Society of Critical Care Medicine","volume":"101","author":"Bone","year":"1992","journal-title":"Chest"},{"key":"2026102813435317700_ciag382-B27","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1017\/ice.2015.264","article-title":"Objective sepsis surveillance using electronic clinical data","volume":"37","author":"Rhee","year":"2016","journal-title":"Infect Control Hosp Epidemiol"},{"key":"2026102813435317700_ciag382-B28","doi-asserted-by":"crossref","first-page":"e1063","DOI":"10.1097\/CCM.0000000000005337","article-title":"Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021","volume":"49","author":"Evans","year":"2021","journal-title":"Crit Care Med"},{"key":"2026102813435317700_ciag382-B29","doi-asserted-by":"publisher","first-page":"558","DOI":"10.7326\/M17-2947","article-title":"Evidence underpinning the Centers for Medicare & Medicaid Services\u2019 severe sepsis and septic shock management bundle (SEP-1): a systematic review","volume":"168","author":"Pepper","year":"2018","journal-title":"Ann Intern Med"},{"key":"2026102813435317700_ciag382-B30","doi-asserted-by":"crossref","first-page":"307","DOI":"10.1097\/CCM.0000000000003521","article-title":"Sepsis surveillance using adult sepsis events simplified eSOFA criteria versus sepsis-3 sequential organ failure assessment criteria","volume":"47","author":"Rhee","year":"2019","journal-title":"Crit Care Med"},{"key":"2026102813435317700_ciag382-B31","doi-asserted-by":"crossref","first-page":"648","DOI":"10.1513\/AnnalsATS.202009-1130OC","article-title":"Measurement of sepsis in a national cohort using three different methods to define baseline organ function","volume":"18","author":"Wayne","year":"2021","journal-title":"Ann Am Thorac Soc"},{"key":"2026102813435317700_ciag382-B32","doi-asserted-by":"crossref","first-page":"1724","DOI":"10.1001\/jama.2025.2526","article-title":"Concordance of 30-day mortality and in-hospital mortality or hospice discharge after sepsis","volume":"333","author":"Prescott","year":"2025","journal-title":"JAMA"},{"key":"2026102813435317700_ciag382-B33","doi-asserted-by":"crossref","first-page":"556","DOI":"10.1093\/cid\/ciaa456","article-title":"Impact of the Centers for Medicare and Medicaid services sepsis core measure on antibiotic use","volume":"72","author":"Pakyz","year":"2021","journal-title":"Clin Infect Dis"},{"key":"2026102813435317700_ciag382-B34","doi-asserted-by":"crossref","first-page":"805","DOI":"10.1001\/jamainternmed.2022.2291","article-title":"Temporal trends in antimicrobial prescribing during hospitalization for potential infection and sepsis","volume":"182","author":"Prescott","year":"2022","journal-title":"JAMA Intern Med"},{"key":"2026102813435317700_ciag382-B35","doi-asserted-by":"crossref","first-page":"907","DOI":"10.15585\/mmwr.mm7234a2","article-title":"Sepsis program activities in acute care hospitals\u2014national healthcare safety network, United States, 2022","volume":"72","author":"Dantes","year":"2023","journal-title":"MMWR Morb Mortal Wkly Rep"},{"key":"2026102813435317700_ciag382-B36","doi-asserted-by":"crossref","first-page":"1617","DOI":"10.1001\/jama.2023.16693","article-title":"The Centers for Disease Control and Prevention\u2019s hospital sepsis program core elements","volume":"330","author":"Prescott","year":"2023","journal-title":"JAMA"},{"key":"2026102813435317700_ciag382-B37","doi-asserted-by":"crossref","first-page":"3302","DOI":"10.1007\/s11606-025-09519-1","article-title":"Hospital variation in response to CDC sepsis program core elements assessment tool","volume":"40","author":"Kowalkowski","year":"2025","journal-title":"J Gen Intern Med"},{"key":"2026102813435317700_ciag382-B38","doi-asserted-by":"crossref","first-page":"1730","DOI":"10.1016\/j.ajem.2017.07.001","article-title":"Comparison of QSOFA score and SIRS criteria as screening mechanisms for emergency department sepsis","volume":"35","author":"Haydar","year":"2017","journal-title":"Am J Emerg Med"},{"key":"2026102813435317700_ciag382-B39","doi-asserted-by":"crossref","first-page":"284","DOI":"10.1136\/emermed-2020-210416","article-title":"Comparison of qSOFA and hospital early warning scores for prognosis in suspected sepsis in emergency department patients: a systematic review","volume":"39","author":"Sabir","year":"2022","journal-title":"Emerg Med J"},{"key":"2026102813435317700_ciag382-B40","doi-asserted-by":"crossref","first-page":"800","DOI":"10.1002\/jhm.70052","article-title":"Diagnostic safety and quality optimization in sepsis study protocol","volume":"20","author":"Shrestha","year":"2025","journal-title":"J Hosp Med"}],"container-title":["Clinical Infectious Diseases"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/cid\/advance-article-pdf\/doi\/10.1093\/cid\/ciag382\/68651531\/ciag382.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/cid\/article-pdf\/83\/4\/526\/68651531\/ciag382.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/cid\/article-pdf\/83\/4\/526\/68651531\/ciag382.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,28]],"date-time":"2026-10-28T17:44:01Z","timestamp":1793209441000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/cid\/article\/83\/4\/526\/8722073"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,30]]},"references-count":40,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,6,30]]},"published-print":{"date-parts":[[2026,10,28]]}},"URL":"https:\/\/doi.org\/10.1093\/cid\/ciag382","relation":{},"ISSN":["1058-4838","1537-6591"],"issn-type":[{"value":"1058-4838","type":"print"},{"value":"1537-6591","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,10,15]]},"published":{"date-parts":[[2026,6,30]]}}}