Impact of the Japanese clinical practice guidelines for management of sepsis and septic shock (J-SSCG) 2020 on real-world adherence and interhospital variation: a nationwide inpatient database study

Background: The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock (J-SSCG) 2020 aimed to standardize sepsis care in Japan. However, the extent of their impact on clinical practice remains uncertain. Methods: We conducted a nationwide retrospective cohort study using the Japanese Diagnosis Procedure Combination database between April 2018 and December 2021. Of the 118 clinical questions (CQs) in the J-SSCG 2020, we identified 26 recommendations to which adherence could be evaluated using patient-level data. We evaluated adherence trends before and after the guideline’s publication using interrupted time series analysis and quantified hospital-level variation using intraclass correlation coefficients. Results: A total of 213,099 patients with sepsis from 791 hospitals were included. Adherence rates varied widely across CQs (range: 0.5–98.7%). Recommendations “against” interventions generally showed high adherence, whereas those “for” interventions exhibited lower and more variable adherence. After guideline publication, adherence increased by < 3% points for most CQs. Interrupted time series analysis demonstrated no abrupt or substantial changes, and statistically significant trends were modest (< 2% annually). Among the 26 CQs, 14 were consistent with J-SSCG 2016 and 12 were newly introduced in 2020; both groups showed similarly limited changes in adherence. Adjusted intraclass correlation coefficients exceeded 10% for 22 CQs, indicating persistent between-hospital variation, which remained unchanged after the guideline’s release. Conclusions: This nationwide study identified persistent evidence–practice gaps, minimal improvements in adherence after J-SSCG 2020, and substantial interhospital variation that remained unaltered. These findings underscore the challenges of implementing guidelines in practice and highlight the need to better understand contextual barriers to standardized sepsis care in Japan.