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Boyer TL, Solanki P, McGregor JC, Wilson GM, Gibson G, Jurasic MM, Evans CT, Suda KJ. Risk factors for oral infection and dry socket post-tooth extraction in medically complex patients in the absence of antibiotic prophylaxis: A case-control study. Spec Care Dentist 2024. [PMID: 38321539 DOI: 10.1111/scd.12965] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 02/08/2024]
Abstract
INTRODUCTION Dry socket and infection are complications of tooth extractions. The objective was to determine risk factors for post-extraction complications in patients without antibiotic prophylaxis stratified by early- and late-complications and complication type (oral infection and dry socket). METHODS Retrospective, case (with complications)-control (without complications) study of patients (n = 708) who had ≥1 extraction performed at any Veterans Health Administration facility between 2015-2019 and were not prescribed an antibiotic 30 days pre-extraction. RESULTS Early complication cases (n = 109) were more likely to be female [odds ratio (OR) = 2.06; 95% confidence interval (CI):1.05-4.01], younger (OR = 0.29; 95% CI:0.09-0.94 patients ≥ 80 years old, reference:18-44 years), Native American/Alaska Native (OR = 21.11; 95% CI:2.33-191.41) and have fewer teeth extracted (OR = 0.53 3+ teeth extracted; 95% CI:0.31-0.88, reference:1 tooth extracted). Late complication cases (n = 67) were more likely to have a bipolar diagnosis (OR = 2.98; 95% CI:1.04-8.57), history of implant placement (OR = 8.27; 95% CI:1.63-41.82), and history of past smoking (OR = 2.23; 95% CI:1.28-3.88). CONCLUSION Predictors for post-extraction complications among patients who did not receive antibiotic prophylaxis were similar to prior work in cohorts who received prophylaxis. Unique factors identified in a medically complex population included being younger, Native American/Alaska Native, having mental health conditions, history of a dental implant, and fewer teeth extracted.
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Affiliation(s)
- Taylor L Boyer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, U.S. Department of Veterans Affairs, Pittsburgh, Pennsylvania, USA
| | - Pooja Solanki
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Medical Center, U.S. Department of Veterans Affairs, Hines, Illinois, USA
| | | | - Geneva M Wilson
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Medical Center, U.S. Department of Veterans Affairs, Hines, Illinois, USA
- Department of Preventive Medicine, Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gretchen Gibson
- Veterans Health Administration Office of Dentistry, Washington, District of Columbia, USA
- Kansas City University College of Dental Medicine, Joplin, Missouri, USA
| | - M Marianne Jurasic
- Veterans Health Administration Office of Dentistry, Washington, District of Columbia, USA
- Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Medical Center, U.S. Department of Veterans Affairs, Hines, Illinois, USA
- Department of Preventive Medicine, Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, U.S. Department of Veterans Affairs, Pittsburgh, Pennsylvania, USA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Ray MJ, Lacanilao KL, Lazaro MR, Strnad LC, Furuno JP, Royster K, McGregor JC. Use of electronic health record data to identify hospital-associated Clostridioides difficile infections: a validation study. medRxiv 2024:2024.01.10.24301118. [PMID: 38260609 PMCID: PMC10802632 DOI: 10.1101/2024.01.10.24301118] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background Clinical research focused on the burden and impact of Clostridioides difficile infection (CDI) often relies upon accurate identification of cases using existing health record data. Use of diagnosis codes alone can lead to misclassification of cases. Our goal was to develop and validate a multi-component algorithm to identify hospital-associated CDI (HA-CDI) cases using electronic health record (EHR) data. Methods We performed a validation study using a random sample of adult inpatients at a large academic hospital setting in Portland, Oregon from January 2018 to March 2020. We excluded patients with CDI on admission and those with short lengths of stay (< 4 days). We tested a multi-component algorithm to identify HA-CDI; case patients were required to have received an inpatient course of metronidazole, oral vancomycin, or fidaxomicin and have at least one of the following: a positive C. difficile laboratory test or the International Classification of Diseases, Tenth Revision (ICD-10) code for non-recurrent CDI. For a random sample of 80 algorithm-identified HA-CDI cases and 80 non-cases, we performed manual EHR review to identify gold standard of HA-CDI diagnosis. We then calculated overall percent accuracy, sensitivity, specificity, and positive and negative predictive value for the algorithm overall and for the individual components. Results Our case definition algorithm identified HA-CDI cases with 94% accuracy (95% Confidence Interval (CI): 88% to 97%). We achieved 100% sensitivity (94% to 100%), 89% specificity (81% to 95%), 88% positive predictive value (78% to 94%), and 100% negative predictive value (95% to 100%). Requiring a positive C. difficile test as our gold standard further improved diagnostic performance (97% accuracy [93% to 99%], 93% PPV [85% to 98%]). Conclusions Our algorithm accurately detected true HA-CDI cases from EHR data in our patient population. A multi-component algorithm performs better than any isolated component. Requiring a positive laboratory test for C. difficile strengthens diagnostic performance even further. Accurate detection could have important implications for CDI tracking and research.
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Affiliation(s)
- Michael J. Ray
- Oregon State University College of Pharmacy, Department of Pharmacy Practice, Portland, Oregon
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon
| | - Kathleen L. Lacanilao
- Oregon State University College of Pharmacy, Department of Pharmacy Practice, Portland, Oregon
| | - Maela Robyne Lazaro
- Oregon State University College of Pharmacy, Department of Pharmacy Practice, Portland, Oregon
| | - Luke C. Strnad
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon
- Oregon Health & Science University School of Medicine, Division of Infectious Diseases, Portland, Oregon
| | - Jon P. Furuno
- Oregon State University College of Pharmacy, Department of Pharmacy Practice, Portland, Oregon
| | - Kelly Royster
- Oregon State University College of Pharmacy, Department of Pharmacy Practice, Portland, Oregon
| | - Jessina C. McGregor
- Oregon State University College of Pharmacy, Department of Pharmacy Practice, Portland, Oregon
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon
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Ramanathan S, Yan CH, Hubbard C, Calip GS, Sharp LK, Evans CT, Rowan S, McGregor JC, Gross AE, Hershow RC, Suda KJ. Changes in antibiotic prescribing by dentists in the United States, 2012-2019. Infect Control Hosp Epidemiol 2023; 44:1725-1730. [PMID: 37605940 PMCID: PMC10665869 DOI: 10.1017/ice.2023.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/01/2023] [Accepted: 06/09/2023] [Indexed: 08/23/2023]
Abstract
OBJECTIVES Dentists prescribe 10% of all outpatient antibiotics in the United States and are the top specialty prescriber. Data on current antibiotic prescribing trends are scarce. Therefore, we evaluated trends in antibiotic prescribing rates by dentists, and we further assessed whether these trends differed by agent, specialty, and by patient characteristics. DESIGN Retrospective study of dental antibiotic prescribing included data from the IQVIA Longitudinal Prescription Data set from January 1, 2012 to December 31, 2019. METHODS The change in the dentist prescribing rate and mean days' supply were evaluated using linear regression models. RESULTS Dentists wrote >216 million antibiotic prescriptions between 2012 and 2019. The annual dental antibiotic prescribing rate remained steady over time (P = .5915). However, the dental prescribing rate (antibiotic prescriptions per 1,000 dentists) increased in the Northeast (by 1,313 antibiotics per 1,000 dentists per year), among oral and maxillofacial surgeons (n = 13,054), prosthodontists (n = 2,381), endodontists (n = 2,255), periodontists (n = 1,961), and for amoxicillin (n = 2,562; P < .04 for all). The mean days' supply significantly decreased over the study period by 0.023 days per 1,000 dentists per year (P < .001). CONCLUSIONS From 2012 to 2019, dental prescribing rates for antibiotics remained unchanged, despite decreases in antibiotic prescribing nationally and changes in guidelines during the study period. However, mean days' supply decreased over time. Dental specialties, such as oral and maxillofacial surgeons, had the highest prescribing rate with increases over time. Antibiotic stewardship efforts to improve unnecessary prescribing by dentists and targeting dental specialists may decrease overall antibiotic prescribing rates by dentists.
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Affiliation(s)
- Swetha Ramanathan
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Connie H. Yan
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Colin Hubbard
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Gregory S. Calip
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Lisa K. Sharp
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Charlesnika T. Evans
- Center of Innovation for Complex Chronic Healthcare, Hines Veterans’ Affairs Hospital, Hines, Illinois
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Susan Rowan
- College of Dentistry, University of Illinois at Chicago, Chicago, Illinois
| | | | - Alan E. Gross
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Ronald C. Hershow
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Katie J. Suda
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans’ Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Park HS, McCracken CM, Lininger N, Varley CD, Sikka MK, Evans C, Villamagna AH, Makadia JT, McGregor JC. Incidence and risk factors for clinically confirmed secondary bacterial infections in patients hospitalized for coronavirus disease 2019 (COVID-19). Infect Control Hosp Epidemiol 2023; 44:1650-1656. [PMID: 37184033 PMCID: PMC10587378 DOI: 10.1017/ice.2023.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 01/06/2023] [Accepted: 01/25/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVE The true incidence and risk factors for secondary bacterial infections in coronavirus disease 2019 (COVID-19) remains poorly understood. Knowledge of risk factors for secondary infections in hospitalized patients with COVID-19 is necessary to optimally guide selective use of empiric antimicrobial therapy. DESIGN Single-center retrospective cohort study of symptomatic inpatients admitted for COVID-19 from April 15, 2020, through June 30, 2021. SETTING Academic quaternary-care referral center in Portland, Oregon. PATIENTS The study included patients who were 18 years or older with a positive severe acute respiratory coronavirus virus 2 (SARS-CoV-2) PCR test up to 10 days prior to admission. METHODS Secondary infections were identified based on clinical, radiographic, and microbiologic data. Logistic regression was used to identify risk factors for secondary infection. We also assessed mortality, length of stay, and empiric antibiotics among those with and without secondary infections. RESULTS We identified 118 patients for inclusion; 31 (26.3%) had either culture-proven or possible secondary infections among hospitalized patients with COVID-19. Mortality was higher among patients with secondary infections (35.5%) compared to those without secondary infection (4.6%). Empiric antibiotic use on admission was high in both the secondary and no secondary infection groups at 71.0% and 48.3%, respectively. CONCLUSIONS The incidence of secondary bacterial infection was moderate among hospitalized patients with COVID-19. However, a higher proportion of patients received empiric antibiotics regardless of an identifiable secondary infection. Transfer from an outside hospital, baseline immunosuppressant use, and corticosteroid treatment were independent risk factors for secondary infection. Additional studies are needed to validate risk factors and best guide antimicrobial stewardship efforts.
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Affiliation(s)
- Hiromichi S. Park
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Caitlin M. McCracken
- Department of Pharmacy Practice, College of Pharmacy, Oregon State University, Corvallis, Oregon
| | - Noah Lininger
- Program in Epidemiology, Oregon Health & Science University–Portland State University School of Public Health, Portland, Oregon
| | - Cara D. Varley
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon
- Program in Epidemiology, Oregon Health & Science University–Portland State University School of Public Health, Portland, Oregon
| | - Monica K. Sikka
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Christopher Evans
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Angela Holly Villamagna
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jina T. Makadia
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jessina C. McGregor
- Department of Pharmacy Practice, College of Pharmacy, Oregon State University, Corvallis, Oregon
- Program in Epidemiology, Oregon Health & Science University–Portland State University School of Public Health, Portland, Oregon
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Yan CH, Hubbard CC, Lee TA, Sharp LK, Evans CT, Calip GS, Rowan SA, McGregor JC, Gellad WF, Suda KJ. Impact of Hydrocodone Rescheduling on Dental Prescribing of Opioids. JDR Clin Trans Res 2023; 8:402-412. [PMID: 35708454 DOI: 10.1177/23800844221102830] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION In the United States, dentists frequently prescribe hydrocodone. In October 2014, the US Drug Enforcement Administration rescheduled hydrocodone from controlled substance schedule III to II, introducing more restricted prescribing and dispensing regulations, which may have changed dental prescribing of opioids. OBJECTIVE The study aim was to evaluate the impact of the hydrocodone rescheduling on dental prescribing of opioids in the United States. METHODS This was a cross-sectional study of opioids prescribed by dentists between October 2012 and October 2016, using the IQVIA Longitudinal Prescription Dataset. Monthly dentist-based opioid prescribing rate (opioid prescription [Rx]/1,000 dentists) and monthly average opioid dosages per prescription (mean morphine milligram equivalent per day [MME/d]) were measured in the 24 mo before and after hydrocodone rescheduling in October 2014 (index or interruption). An interrupted time-series analysis was conducted using segmented ordinary least square regression models, with Newey-West standard errors to handle autocorrelation. RESULTS Dentists prescribed 50,412,942 opioid prescriptions across the 49 mo. Hydrocodone was the most commonly prescribed opioid pre- and postindex (74.9% and 63.8%, respectively), followed by codeine (13.8% and 21.6%), oxycodone (8.1% and 9.5%), and tramadol (2.9% and 4.8%). At index, hydrocodone prescribing immediately decreased by -834.8 Rx/1,000 dentists (95% confidence interval [CI], -1,040.2 to -629.4), with increased prescribing of codeine (421.9; 95% CI, 369.7-474.0), oxycodone (85.3; 95% CI, 45.4-125.2), and tramadol (111.8; 95% CI, 101.4-122.3). The mean MME increased at index for all opioids except for hydrocodone, and dosages subsequently decreased during the postindex period. CONCLUSION Following the rescheduling, dentist prescribing of hydrocodone declined while prescribing of nonhydrocodone opioids increased. Understanding the impact of this regulation informs strategies to ensure appropriate prescribing of opioids for dental pain. KNOWLEDGE TRANSFER STATEMENT The study findings can be used by policy makers to make informed decisions in developing future risk mitigation strategies aimed to regulate opioid prescribing behaviors. Furthermore, dentist-specific resources and guidelines are needed subsequent to these policies in order to meet the dental population needs.
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Affiliation(s)
- C H Yan
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - C C Hubbard
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - T A Lee
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - L K Sharp
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - C T Evans
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL, USA
- Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - G S Calip
- Department of Pharmacy Systems, Outcomes, and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - S A Rowan
- College of Dentistry, University of Illinois at Chicago, Chicago, IL, USA
| | - J C McGregor
- College of Pharmacy, Oregon State University, Portland, OR, USA
| | - W F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - K J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Wilson GM, McGregor JC, Gibson G, Jurasic MM, Evans CT, Suda KJ. Factors associated with dental implant loss/complications in the Veterans Health Administration, 2015-2019. J Public Health Dent 2023; 83:408-412. [PMID: 37667872 DOI: 10.1111/jphd.12584] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/12/2023] [Accepted: 07/24/2023] [Indexed: 09/06/2023]
Abstract
OBJECTIVES Twelve percent of the U.S. population has a dental implant. Although rare, implant loss/complications can impact quality of life. This study evaluated indicators for implant loss/complications. METHODS Veterans with dental implants placed between 2015 and 2019 were included. Implant loss/complications were defined as implant removal or peri-implant defect treatment within 90 days. Binomial logistic regression identified factors associated with implant loss/complications. RESULTS From 2015 to 2019, 48,811 dental implants were placed in 38,246 Veterans. Implant loss/complications was identified for 202 (0.4%) implants. In adjusted analyses, Veterans aged 50-64 years (OR = 1.92 (95% confidence interval (CI): 1.06, 3.46)) and ≥65 (OR = 2.01 (95% CI: 1.14, 3.53)) were more likely to have implant loss/complications. History of oral infection, tooth location, and number of implants placed all significantly increased the odds of loss/complications. CONCLUSION Dental implant loss/complications are rare outcomes. Older age, location of implant, and the number of implants placed during a visit were significant predictors of loss/complication.
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Affiliation(s)
- Geneva M Wilson
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois, USA
- Department of Preventive Medicine, Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Gretchen Gibson
- Veterans Health Administration Office of Dentistry, Washington, District of Columbia, USA
| | - M Marianne Jurasic
- Veterans Health Administration Office of Dentistry, Washington, District of Columbia, USA
- Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts, USA
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois, USA
- Department of Preventive Medicine, Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Heath Care System, Pittsburgh, Pennsylvania, USA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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McCracken CM, Tucker KJ, Tallman GB, Holmer HK, Noble BN, McGregor JC. General Perceptions and Knowledge of Antibiotic Resistance and Antibiotic Use Behavior: A Cross-Sectional Survey of US Adults. Antibiotics (Basel) 2023; 12:antibiotics12040672. [PMID: 37107034 PMCID: PMC10135168 DOI: 10.3390/antibiotics12040672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/02/2023] [Accepted: 03/06/2023] [Indexed: 04/03/2023] Open
Abstract
This study aimed to assess understanding of antibiotic resistance and evaluate antibiotic use themes among the general public. In March 2018, respondents that were ≥21 years old and residing in the United States were recruited from ResearchMatch.org and surveyed to collect data on respondent expectations, knowledge, and opinions regarding prescribing antibiotics and antibiotic resistance. Content analysis was used to code open-ended definitions of antibiotic resistance into central themes. Chi-square tests were used to assess differences between the definitions of antibiotic resistance and antibiotic use. Among the 657 respondents, nearly all (99%) had taken an antibiotic previously. When asked to define antibiotic resistance, the definitions provided were inductively coded into six central themes: 35% bacteria adaptation, 22% misuse/overuse, 22% resistant bacteria, 10% antibiotic ineffectiveness, 7% body immunity, and 3% provided an incorrect definition with no consistent theme. Themes that were identified in respondent definitions of resistance significantly differed between those who reported having shared an antibiotic versus those who had not (p = 0.03). Public health campaigns remain a central component in the fight to combat antibiotic resistance. Future campaigns should address the public’s understanding of antibiotic resistance and modifiable behaviors that may contribute to resistance.
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Affiliation(s)
- Caitlin M. McCracken
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, OR 97331, USA
| | - Kendall J. Tucker
- Department of Pharmacy Practice, Nesbitt School of Pharmacy, Wilkes University, Wilkes-Barre, PA 18766, USA
- Correspondence:
| | | | - Haley K. Holmer
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR 97201, USA
| | - Brie N. Noble
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, OR 97331, USA
| | - Jessina C. McGregor
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, OR 97331, USA
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR 97201, USA
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Hughes AM, Lin E, Hussain RA, Gibson G, Jurasic MM, Sharp LK, Hubbard CC, Poggensee LE, Evans CT, McGregor JC, Gellad WF, Suda KJ. The feasibility of academic detailing for acute oral pain management in outpatient dentistry: A pilot study. J Am Pharm Assoc (2003) 2023; 63:158-163.e6. [PMID: 36031546 PMCID: PMC10807693 DOI: 10.1016/j.japh.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Opioids are overprescribed in the outpatient dental setting. Therefore, opportunities exist for opioid stewardship. OBJECTIVES The purpose of this pilot study was to test the feasibility of an academic detailing (AD) intervention to promote appropriate prescribing of opioids in outpatient dentistry. METHODS We implemented an AD intervention targeting management of acute oral pain in a Midwestern Veterans Affairs outpatient dental facility. The intervention targeted dentists who actively prescribed opioids at the time of the study. The pilot study tested feasibility, adoption, and acceptance of the AD campaign. Visit-based prescribing rates were obtained from the Veterans Health Administration's Corporate Data Warehouse for baseline and postintervention using difference-in-differences analyses to detect potential changes in health service outcomes. RESULTS Results indicate moderate levels of feasibility through participation rates (n = 5, 55.5%) and high levels of organizational readiness for change (average of 88.6% agree to strongly agree). Furthermore, fidelity of the AD intervention was high. Adoption measures show moderate indication of motivation to change, and trends suggest that participating dentists decreased their visit-based opioid prescribing rates (P > 0.05). CONCLUSION The intervention demonstrated feasibility with some indications of adoption of intervention techniques and decrease in opioid prescribing. We further recommend working closely with frontline providers to gather feedback and buy-in before scaling and implementing the AD campaign.
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Sims KD, Batty GD, Smit E, Hystad PW, McGregor JC, Odden MC. Discrimination, Mediating Psychosocial or Economic Factors, and Antihypertensive Treatment: A 4-Way Decomposition Analysis in the Health and Retirement Study. Am J Epidemiol 2022; 191:1710-1721. [PMID: 35689640 DOI: 10.1093/aje/kwac102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 04/20/2022] [Accepted: 06/07/2022] [Indexed: 01/29/2023] Open
Abstract
Untested psychosocial or economic factors mediate associations between perceived discrimination and suboptimal antihypertensive therapy. This study included 2 waves of data from Health and Retirement Study participants with self-reported hypertension (n = 8,557, 75% non-Hispanic White, 15% non-Hispanic Black, and 10% Hispanic/Latino) over 4 years (baselines of 2008 and 2010, United States). Our primary exposures were frequency of experiencing discrimination, in everyday life or across 7 lifetime circumstances. Candidate mediators were self-reported depressive symptoms, subjective social standing, and household wealth. We evaluated with causal mediation methods the interactive and mediating associations between each discrimination measure and reported antihypertensive use at the subsequent wave. In unmediated analyses, everyday (odds ratio (OR) = 0.86, 95% confidence interval (CI): 0.78, 0.95) and lifetime (OR = 0.91, 95% CI: 0.85, 0.98) discrimination were associated with a lower likelihood of antihypertensive use. Discrimination was associated with lower wealth, greater depressive symptoms, and decreased subjective social standing. Estimates for associations due to neither interaction nor mediation resembled unmediated associations for most discrimination-mediator combinations. Lifetime discrimination was indirectly associated with reduced antihypertensive use via depressive symptomatology (OR = 0.99, 95% CI: 0.98, 1.00). In conclusion, the impact of lifetime discrimination on the underuse of antihypertensive therapy appears partially mediated by depressive symptoms.
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Evans CT, Fitzpatrick MA, Poggensee L, Gonzalez B, Gibson G, Jurasic MM, Echevarria K, McGregor JC, Gellad WF, Suda KJ. High prescribing of antibiotics is associated with high prescribing of opioids in medical and dental providers. Pharmacotherapy 2022; 42:716-723. [PMID: 35869691 PMCID: PMC9794436 DOI: 10.1002/phar.2720] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/13/2022] [Indexed: 12/30/2022]
Abstract
STUDY OBJECTIVE High prescribers of antibiotics and opioids are an important target for stewardship interventions. The goal of this study was to assess the association between high antibiotic and high opioid prescribing by provider type. DESIGN A national cross-sectional study. SETTING 2015-2017 Department of Veterans Affairs (VA) electronic health record data. POPULATION Prescribers were identified as dentists (2017: n = 1346) and medical providers (physicians n = 23,072; advanced practice providers [APP] n = 7705; and other providers [pharmacists/chiropractors] n = 3674) (2017: n = 34,451). MEASUREMENTS High prescribing was defined as being in the top 25% of visit-based rates of antibiotic or opioid prescribing (number of prescriptions/number of dental or medical visits). Multivariable random effects logistic regression with clustering by facility was used to assess the adjusted association between high antibiotic and opioid prescribing. RESULTS Medical providers prescribed 4,348,670 antibiotic and 10,256,706 opioid prescriptions; dentists prescribed 277,170 antibiotic and 124,103 opioid prescriptions. Among all high prescribers of antibiotics, 40% were also high prescribers of opioids as compared to 18% of those who were not high antibiotic prescribers (p < 0.0001). High prescribing of antibiotics was associated with high prescribing of opioids in medical providers (adjusted odds ratio [aOR] = 2.87, 95% confidence interval [CI] = 2.72-3.04) and dentists (aOR = 8.40, 95% CI 6.00-11.76). Older provider age, specific US geographic regions, and lower VA facility complexity and rurality were also associated with high opioid prescribing by medical providers. In dentists, younger provider age, male gender, specific regions of the United States, and lower number of dentists in a facility were associated with high opioid prescribing. At the facility level, high dental prescribers of antibiotics or opioids were not at the same facilities as high medical prescribers, respectively (p < 0.0001). CONCLUSIONS High antibiotic prescribing was associated with high opioid prescribing. Thus, stewardship interventions targeting both medication classes may have higher impact to efficiently reduce prescribing of medications with high public health impact. Provider-targeted interventions are needed to improve antibiotic and opioid prescribing in both dentists and medical providers.
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Affiliation(s)
- Charlesnika T. Evans
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois
- Department of Preventive Medicine, Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Margaret A. Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois
- Department of Medicine, Division of Infectious Diseases, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Linda Poggensee
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois
| | - Beverly Gonzalez
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois
- Department of Psychiatry & Behavioral Sciences, Northwestern University, Chicago, Illinois
| | - Gretchen Gibson
- Veterans Health Administration Office of Dentistry, Washington, District of Columbia
| | - M. Marianne Jurasic
- Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts
- VA Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
| | - Kelly Echevarria
- Antimicrobial Stewardship Task Force, Pharmacy Benefits Management Program, Department of Veterans Affairs, Washington, District of Columbia
| | | | - Walid F. Gellad
- Department of Veterans Affairs, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Katie J. Suda
- Department of Veterans Affairs, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Suda KJ, Evans CT, Gibson G, Jurasic MM, Poggensee L, Gonzalez B, Hubbard CC, Vivo A, Cunningham FE, McGregor JC, Gellad WF. Opioid Prescribing by Dentists in the Veterans Health Administration. Am J Prev Med 2022; 63:371-383. [PMID: 35341616 PMCID: PMC9780026 DOI: 10.1016/j.amepre.2022.01.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/17/2021] [Accepted: 01/05/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Nonopioid analgesics are more effective for most oral pain, but data suggest that dental prescribing of opioids is excessive. This study evaluates the extent to which opioids exceed recommendations and the characteristics associated with opioid overprescribing by Veterans Health Administration dentists. METHODS This was a national cross-sectional study of Veterans' dental visits from 2015 to 2018. Overprescribing was defined per national guidelines as >120 morphine milligram equivalents (primary outcome). The association of dental visit and patient demographic and medical characteristics was modeled with overprescribing (defined as >120 morphine milligram equivalents) using Poisson regression with clustering by facility and patient. A secondary analysis assessed opioid prescriptions >3 days' supply. The dates of analysis were January 2020‒May 2021. RESULTS Of the 196,595 visits, 28.7% exceeded 120 morphine milligram equivalents. Friday visits and people with chronic oral pain or substance misuse were associated with a higher prevalence of overprescribing. Women, older Veterans, and Black and Latinx Veterans were less likely to be overprescribed than men, younger Veterans, and White Veterans, respectively. Routine dental visits had a higher prevalence of opioid overprescribing than invasive visits. Opioid overprescribing decreased over time. White Veterans were more likely to receive oxycodone and hydrocodone, whereas people of Black race and Latinx ethnicity were more likely to receive codeine and tramadol. In the secondary analysis, 68.5% of opioid prescriptions exceeded a 3-day supply. CONCLUSIONS Nearly 1 in 3 opioids prescribed by Veterans Health Administration dentists exceed guidelines. Prescribing higher potency and quantities of opioids, especially on Fridays and to certain demographic groups, should be addressed as part of dental opioid stewardship programs.
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Affiliation(s)
- Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, U.S. Department of Veterans Affairs, Pittsburgh, Pennsylvania; Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
| | - Charlesnika T Evans
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Gretchen Gibson
- Veterans Health Administration Office of Dentistry, U.S. Department of Veterans Affairs, Washington, District of Columbia
| | - M Marianne Jurasic
- Veterans Health Administration Office of Dentistry, U.S. Department of Veterans Affairs, Washington, District of Columbia; Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts; Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Hospital, U.S. Department of Veterans Affairs, Bedford, Massachusetts
| | - Linda Poggensee
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, U.S. Department of Veterans Affairs, Hines, Illinois
| | - Beverly Gonzalez
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, U.S. Department of Veterans Affairs, Hines, Illinois
| | - Colin C Hubbard
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Amanda Vivo
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, U.S. Department of Veterans Affairs, Hines, Illinois
| | - Fran E Cunningham
- Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, Hines, Illinois
| | | | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, U.S. Department of Veterans Affairs, Pittsburgh, Pennsylvania; Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Yan CH, Lee TA, Sharp LK, Hubbard CC, Evans CT, Calip GS, Rowan SA, McGregor JC, Gellad WF, Suda KJ. Trends in Opioid Prescribing by General Dentists and Dental Specialists in the U.S., 2012-2019. Am J Prev Med 2022; 63:3-12. [PMID: 35232618 PMCID: PMC9233039 DOI: 10.1016/j.amepre.2022.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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] [Received: 08/14/2021] [Revised: 12/22/2021] [Accepted: 01/07/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Evidence suggests that U.S. dentists prescribe opioids excessively. There are limited national data on recent trends in opioid prescriptions by U.S. dentists. In this study, we examined trends in opioid prescribing by general dentists and dental specialists in the U.S. from 2012 to 2019. METHODS Dispensed prescriptions for oral opioid analgesics written by dentists were identified from IQVIA Longitudinal Prescription Data from January 2012 through December 2019. Autoregressive integrated moving average and joinpoint regression models described monthly population-based prescribing rates (prescriptions/100,000 individuals), dentist-based prescribing rates (prescriptions/1,000 dentists), and opioid dosages (mean daily morphine milligram equivalents/day). All analyses were performed in 2020. RESULTS Over the 8 years, dentists prescribed >87.2 million opioid prescriptions. Population- and dentist-based prescribing rates declined monthly by -1.97 prescriptions/100,000 individuals (95% CI= -9.98, -0.97) and -39.12 prescriptions/1,000 dentists (95% CI= -58.63, -17.65), respectively. Opioid dosages declined monthly by -0.08 morphine milligram equivalents/day (95% CI= -0.13, -0.04). Joinpoint regression identified 4 timepoints (February 2016, May 2017, December 2018, and March 2019) at which monthly prescribing rate trends were often decreasing in greater magnitude than those in the previous time segment. CONCLUSIONS Following national trends, dentists became more conservative in prescribing opioids. A greater magnitude of decline occurred post 2016 following the implementation of strategies aimed to further regulate opioid prescribing. Understanding the factors that influence prescribing trends can aid in development of tailored resources to encourage and support a conservative approach by dentists, to prescribing opioids.
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Affiliation(s)
- Connie H Yan
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois.
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Lisa K Sharp
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Colin C Hubbard
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois; Department of Preventive Medicine, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Gregory S Calip
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Susan A Rowan
- College of Dentistry, University of Illinois at Chicago, Chicago, Illinois
| | | | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Hartung DM, Johnston KA, McGregor JC, Bourdette DN. Characteristics of Prescription Drug Use Among Individuals With Multiple Sclerosis in the US Medicare Population. Int J MS Care 2022; 24:90-97. [PMID: 35462869 PMCID: PMC9017658 DOI: 10.7224/1537-2073.2021-062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
BACKGROUND Few studies have characterized the full spectrum of prescription drug use for individuals with multiple sclerosis (MS). The objective of this study was to describe patterns and expenditures for disease-modifying therapies (DMTs) and other prescription drugs among Medicare beneficiaries with MS. METHODS Using Medicare claims data in 2014, we identified a cohort of Medicare beneficiaries with 12 months of continuous eligibility and 3 or more MS-related inpatient, outpatient, or prescription claims. We quantified the number, type, and costs of prescribed DMTs and other medications for MS-related symptoms. Medication costs were calculated according to whether beneficiaries received additional subsidies, which eliminate most out-of-pocket costs. RESULTS Of 43,283 Medicare beneficiaries identified with MS, 70% were DMT users. Most used self-administered DMTs (67%), and 3% used natalizumab; 93% received a supportive care medication. Among the 82% of individuals without subsidies, the annual median total and out-of-pocket DMT costs were $56,794 (interquartile range [IQR], $44,837-$62,038) and $4566 (IQR, $849-$5270), respectively. The most commonly used supportive care drugs were antidepressants (62%), opioid analgesics (50%), antispasticity drugs (47%), and anticonvulsants (46%). Annual median total and out-of-pocket costs for these drugs were $15,134 (IQR, $6571-$19,620) and $255 (IQR, $56-$877), respectively. CONCLUSIONS Most Medicare beneficiaries with MS using DMTs face considerable out-of-pocket costs. Beneficiaries also used a significant number of medications potentially used for MS-related symptoms, although total and out-of-pocket costs were modest.
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Affiliation(s)
- Daniel M. Hartung
- From the College of Pharmacy, Oregon State University, Portland, OR, USA (DMH, KAJ, JCM)
| | - Kirbee A. Johnston
- From the College of Pharmacy, Oregon State University, Portland, OR, USA (DMH, KAJ, JCM)
| | - Jessina C. McGregor
- From the College of Pharmacy, Oregon State University, Portland, OR, USA (DMH, KAJ, JCM)
| | - Dennis N. Bourdette
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA (DNB)
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Hartung DM, Johnston KA, McGregor JC, Bourdette DN. Association Between Pharmacy Benefit Restrictions and Disease-Modifying Therapy Use in the Medicare Part D Program. Neurol Clin Pract 2022; 12:36-42. [PMID: 36157618 PMCID: PMC9491506 DOI: 10.1212/cpj.0000000000001118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 06/23/2021] [Indexed: 02/03/2023]
Abstract
Background and Objectives To determine the association between Medicare Part D plan disease-modifying therapy (DMT) restrictiveness and adherence and outcomes among people with multiple sclerosis (MS). Methods We used Medicare claims data from 2010 to 2014 to identify individuals with a full year enrollment (Parts A, B, and D), an MS diagnosis, and 1 or more self-administered DMT prescription. Plans were considered restrictive if all available DMTs required a prior authorization or step therapy restriction; otherwise they were considered permissive. We compared DMT adherence, defined as a medication possession ratio ≥80%, MS-related emergency department or inpatient admissions, and outpatient visits by Part D plan restrictiveness. We used multivariate regression models to control for patient demographics and comorbidities. Results There were 37,713 Medicare beneficiaries with MS who were enrolled in either restrictive (n = 29,901) or permissive (n = 7812) Part D plans during the study period. Patients enrolled in restrictive plans were older (60 vs 58 years; p < 0.001), more likely to live in the south (38% vs 23%; p < 0.001), eligible through disability (67% vs 60%; p < 0.001), and more likely to have several chronic comorbid conditions. Patients enrolled in restrictive plans were less likely to be adherent to their DMT (54% vs 57%; p < 0.001; adjusted odds ratio [aOR] 0.92, 95% confidence interval [CI] 0.88-0.98) and had a higher rate of MS-related outpatient visits (1.7 vs 1.4 per year; p < 0.001; aRR 1.27, 95% CI 1.23-1.31). Discussion Medicare beneficiaries with MS enrolled in restrictive Part D plans were less adherent to their DMT and had higher rates of MS-related outpatient visits.
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Evans CT, Fitzpatrick MA, Poggensee L, Gonzalez B, Gibson G, Jurasic MM, Echevarria K, McGregor JC, Cunningham F, Gellad WF, Suda KJ. Outpatient Prescribing of Antibiotics and Opioids by Veterans Health Administration Providers, 2015-2017. Am J Prev Med 2021; 61:e235-e244. [PMID: 34376291 PMCID: PMC8541933 DOI: 10.1016/j.amepre.2021.05.009] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Antibiotics and opioids are targeted by public health and stewardship communities for reductions in prescribing across the country. This study evaluates trends and factors associated with outpatient prescribing by dental and medical providers in a large integrated health system. METHODS This was a cross-sectional study of national dental and medical outpatient visits from Department of Veterans Affairs facilities in 2015-2017; analyzed in 2019-2020. Antibiotic and opioid prescribing rates were assessed by provider and facility characteristics. Multivariable Poisson regression adjusted for repeated measures by the provider was used to assess the independent association between facility and provider characteristics and rate of prescribing. RESULTS Over the study period, 4,625,840 antibiotic and 10,380,809 opioid prescriptions were identified for 115,625,890 visits. Physicians prescribed most antibiotics (67%). Dentists prescribed 6% of the antibiotics but had the highest per-visit antibiotic prescribing rate compared to medical providers (6.75 vs 3.90 prescriptions per 100 visits, p<0.0001), which was largely driven by dental specialists. By contrast, dentists had lower opioid prescribing than medical providers (3.02 vs 9.20 prescriptions per 100 visits, p<0.0001). Overall, antibiotic and opioid prescribing decreased over time, with opioids having the greatest decreases (-28.0%). In multivariable analyses, U.S. geographic region, rurality, and complexity were associated with prescribing for both drug classes. Opioid and antibiotic prescribing were positively correlated. CONCLUSIONS Although antibiotic and opioid prescribing has decreased, there are still important target areas for improvement. Interventions need to be tailored to community characteristics such as rurality and provider type.
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Affiliation(s)
- Charlesnika T Evans
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Center for Health Services & Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Margaret A Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois; Division of Infectious Diseases, Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois
| | - Linda Poggensee
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois
| | - Beverly Gonzalez
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois; Department of Psychiatry & Behavioral Sciences, Northwestern University, Chicago, Illinois
| | - Gretchen Gibson
- Veterans Health Administration Office of Dentistry, Washington, District of Columbia
| | - M Marianne Jurasic
- Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts; VA Center for Healthcare Organization & Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
| | - Kelly Echevarria
- Antimicrobial Stewardship Task Force, Pharmacy Benefits Management Program, U.S. Department of Veterans Affairs, Washington, District of Columbia
| | | | - Fran Cunningham
- Pharmacy Benefits Management Services, U.S. Department of Veterans Affairs, Hines, Illinois
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, U.S. Department of Veterans Affairs, Pittsburgh, Pennsylvania; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, U.S. Department of Veterans Affairs, Pittsburgh, Pennsylvania; Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Fontana LM, Villamagna AH, Sikka MK, McGregor JC. Understanding viral shedding of severe acute respiratory coronavirus virus 2 (SARS-CoV-2): Review of current literature. Infect Control Hosp Epidemiol 2021; 42:659-668. [PMID: 33077007 PMCID: PMC7691645 DOI: 10.1017/ice.2020.1273] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 09/30/2020] [Accepted: 10/09/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Transmission of SARS-CoV-2 has significant implications for hospital infection prevention and control, discharge management, and public health. We reviewed available literature to reach an evidenced-based consensus on the expected duration of viral shedding. DESIGN We queried 4 scholarly repositories and search engines for studies reporting SARS-CoV-2 viral shedding dynamics by PCR and/or culture available through September 8, 2020. We calculated the pooled median duration of viral RNA shedding from respiratory and fecal sources. RESULTS The review included 77 studies on SARS-CoV-2. All studies reported PCR-based testing and 12 also included viral culture data. Among 28 studies, the overall pooled median duration of RNA shedding from respiratory sources was 18.4 days (95% CI, 15.5-21.3; I2 = 98.87%; P < .01). When stratified by disease severity, the pooled median duration of viral RNA shedding from respiratory sources was 19.8 days (95% CI, 16.2-23.5; I2 = 96.42%; P < .01) among severely ill patients and 17.2 days (95% CI, 14.0-20.5; I2 = 95.64%; P < .01) in mild-to-moderate illness. Viral RNA was detected up to 92 days after symptom onset. Viable virus was isolated by culture from -6 to 20 days relative to symptom onset. CONCLUSIONS SARS-COV-2 RNA shedding can be prolonged, yet high heterogeneity exists. Detection of viral RNA may not correlate with infectivity since available viral culture data suggests shorter durations of shedding of viable virus. Additional data are needed to determine the duration of shedding of viable virus and the implications for risk of transmission.
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Affiliation(s)
- Lauren M. Fontana
- Department of Medicine, University of Minnesota Infectious Diseases and International Medicine, Minneapolis, MN, USA
| | - Angela Holly Villamagna
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Monica K. Sikka
- Division of Infectious Diseases, Department of Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon
| | - Jessina C. McGregor
- Department of Pharmacy Practice, College of Pharmacy, Oregon State University, Portland, Oregon
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Hubbard CC, Evans CT, Calip GS, Rowan SA, Gellad WF, Campbell A, Gross AE, Hershow RC, McGregor JC, Sharp LK, Suda KJ. Characteristics Associated With Opioid and Antibiotic Prescribing by Dentists. Am J Prev Med 2021; 60:648-657. [PMID: 33745816 PMCID: PMC8549405 DOI: 10.1016/j.amepre.2020.11.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/31/2020] [Accepted: 11/19/2020] [Indexed: 01/15/2023]
Abstract
INTRODUCTION The objective of this study is to identify county-level characteristics that may be high-impact targets for opioid and antibiotic interventions to improve dental prescribing. METHODS Prescriptions during 2012-2017 were extracted from the IQVIA Longitudinal Prescription database. Primary outcomes were yearly county-level antibiotic and opioid prescribing rates. Multivariable negative binomial regression identified associations between prescribing rates and county-level characteristics. All analyses occurred in 2020. RESULTS Over time, dental opioid prescribing rates decreased by 20% (from 4.02 to 3.22 per 100 people), whereas antibiotic rates increased by 5% (from 6.85 to 7.19 per 100 people). Higher number of dentists per capita, higher proportion of female residents, and higher proportion of residents aged <65 years were associated with increased opioid rates. Relative to location in the West, location in the Northeast (59%, 95% CI=52, 65) and Midwest (64%, 95% CI=60, 70) was associated with lower opioid prescribing rates. Higher clinician density, median household income, proportion female, and proportion White were all independently associated with higher antibiotic rates. Location in the Northeast (149%, 95% CI=137, 162) and Midwest (118%, 95% CI=111, 125) was associated with higher antibiotic rates. Opioid and antibiotic prescribing rates were positively associated. CONCLUSIONS Dental prescribing of opioids is decreasing, whereas dental antibiotic prescribing is increasing. High prescribing of antibiotics is associated with high prescribing of opioids. Strategies focused on optimizing dental antibiotics and opioids are needed given their impact on population health.
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Affiliation(s)
- Colin C Hubbard
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois
| | - Charlesnika T Evans
- Department of Preventive Medicine, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois; Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital, Hines, Illinois
| | - Gregory S Calip
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois
| | - Susan A Rowan
- Department of Restorative Dentistry, College of Dentistry, University of Illinois Chicago, Chicago, Illinois
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania; Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Alan E Gross
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois
| | - Ronald C Hershow
- Department of Epidemiology, School of Public Health, University of Illinois Chicago, Chicago, Illinois
| | - Jessina C McGregor
- Department of Pharmacy Practice, College of Pharmacy, Oregon State University, Corvallis, Oregon
| | - Lisa K Sharp
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois Chicago, Chicago, Illinois
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania; Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
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Tsai T, Vo K, Ostrogorsky TL, McGregor JC, McCracken CM, Singh H. A Peer-Teaching Model to Reinforce Pharmacy Students' Clinical Knowledge of Commonly Prescribed Medications. Am J Pharm Educ 2021; 85:8451. [PMID: 34283733 PMCID: PMC8174616 DOI: 10.5688/ajpe8451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 02/05/2021] [Indexed: 06/13/2023]
Abstract
Objective. To implement and assess the effectiveness of a peer teaching series to increase third year Doctor of Pharmacy (PharmD) students' knowledge of and confidence regarding commonly prescribed medications.Methods. All third-year pharmacy students (n=98) at a college of pharmacy were encouraged to participate in the RxReady peer teaching series prior to beginning their advanced pharmacy practice experiences. Each student in the class was assigned a drug to learn in-depth. Twenty-four of the students were randomly selected to provide peer teaching regarding a single medication. These students were required to meet with a faculty member to prepare for their presentation. Assessment methods included completion of pre- and post-intervention quizzes and anonymous surveys regarding the peer-teaching modality. Students also provided qualitative feedback on the series as part of a course survey.Results. Among the 96 students who completed the pre- and post-intervention quizzes, there was a mean increase of 15% (SD=11%) on the post-intervention quiz score compared to the pre-intervention quiz score. Ninety-two (96%) students achieved a higher score on the post-intervention quiz. There was no difference in mean percent change in scores between the pre-and post-intervention quiz for students who presented in class compared with students who did not present (17% [SD=10%] vs 15% [SD=11%], respectively). Student-reported confidence significantly improved across all drug knowledge categories. In each category, the median confidence score increased from 2 (somewhat confident) to 3 (moderately confident). The students' qualitative feedback was generally positive, and they provided suggestions to improve the content and design of the RxReady peer teaching series.Conclusion. A peer teaching approach to reviewing drug information can assist in targeting gaps in PharmD students' drug knowledge and help to build their confidence in their readiness to begin APPEs.
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Affiliation(s)
- Tiffany Tsai
- University of Saint Joseph, School of Pharmacy and Physician Assistant Studies, Hartford, Connecticut
| | - Kim Vo
- Marshall B. Ketchum University, College of Pharmacy, Fullerton, California
| | | | | | | | - Harleen Singh
- Oregon State University, College of Pharmacy, Corvallis, Oregon
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Ayoub J, McGregor JC, Castner RM, Singh H. Opportunities for successful de-escalation of proton pump inhibitors at a federally qualified health center. BMC Pharmacol Toxicol 2021; 22:20. [PMID: 33863393 PMCID: PMC8052786 DOI: 10.1186/s40360-021-00486-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 09/24/2020] [Accepted: 03/29/2021] [Indexed: 11/18/2022] Open
Abstract
Background A Proton Pump Inhibitor (PPI) de-escalation initiative was piloted at a Family Medicine Federally Qualified Health Center (FQHC) after a needs assessment showed that PPIs were prescribed inappropriately. The objective was to evaluate implementation of a PPI de-escalation program for an urban, underinsured patient population at a (FQHC). Methods Patients receiving PPI with an upcoming appointment with their primary care provider (PCP) were evaluated by a pharmacist for the appropriateness of therapy. The pharmacist administered a questionnaire to patients to assess PPI usage patterns and then evaluated for appropriate PPI therapy which included diagnoses, risk factors for gastrointestinal bleed, symptom control, and duration of PPI therapy. For consenting patients, de-escalation was implemented per pharmacist protocol. Results A total of 36 patients were evaluated for appropriate PPI use, among those, 21 (58%) were eligible for de-escalation, and 19 agreed to de-escalation. Fifteen patients (15/19) had successful PPI de-escalation after 4 weeks without discomfort or symptoms which disrupted daily activities. Conclusions This pharmacist led initiative in collaboration with PCPs resulted in successful de-escalation of PPIs in an underserved primary care setting. Supplementary Information The online version contains supplementary material available at 10.1186/s40360-021-00486-x.
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Affiliation(s)
- Joelle Ayoub
- Western University of Health Sciences College of Pharmacy, 309 E. Second St., Pomona, 91766, CA, USA.
| | - Jessina C McGregor
- Oregon State University College of Pharmacy Portland Campus at Oregon Health & Science University, 2730 SW Moody Ave., CL5CP, Portland, 97239, OR, USA
| | - Rebecca M Castner
- Roosevelt University College of Pharmacy, 1400 N Roosevelt Blvd, Schaumburg, 60173, IL, USA
| | - Harleen Singh
- Oregon State University College of Pharmacy Portland Campus at Oregon Health & Science University, 2730 SW Moody Ave., CL5CP, Portland, 97239, OR, USA
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Affiliation(s)
- Jessina C McGregor
- Department of Pharmacy Practice, College of Pharmacy, Oregon State University, Portland
| | - Margaret A Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr VA Hospital, Hines, Illinois
- Division of Infectious Diseases, Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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McGregor JC, McCracken CM, Hohmann SF, Pakyz AL. 232. Impact of Weekend Initiation of Vancomycin or Piperacillin/Tazobactam on Days of Therapy Received upon Hospital Admission. Open Forum Infect Dis 2020. [PMCID: PMC7777941 DOI: 10.1093/ofid/ofaa439.276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Antibiotic therapy for inpatients with suspected infections is typically empirically initiated and therapy narrowed or altered when additional diagnostic evidence becomes available. For patients whose therapy is initiated on a weekend, differences in hospital staffing may impact the timing of therapy changes. We aimed to compare the duration of therapy of vancomycin and piperacillin-tazobactam between those who had therapy initiated on a weekday versus a weekend day.
Methods
We performed a cross-sectional study among U.S. hospitals that contributed pharmacy data for inpatients to the Vizient clinical database in 2016. We identified vancomycin and piperacillin-tazobactam courses initiated within the first 48 hours of admission; courses were categorized as weekend initiation (Friday, Saturday, Sunday) versus weekday initiation. The median days of therapy were compared between weekend and weekday initiation using the Wilcoxon rank-sum test.
Results
Among the 145 hospitals representing approximately 3.7 million patient encounters there were 401,101 encounters with vancomycin and 221,751 with piperacillin/tazobactam initiated within the first 48 hours of admission. Of these courses, 33% of vancomycin and 40% of piperacillin/tazobactam were initiated on a weekend day. The median (IQR) days of therapy for vancomycin initiated on a weekend was 2 days (1–4 days) compared to 2 days (1–3 days) when initiated on a weekday (p< .01). The median (IQR) days of therapy for piperacillin/tazobactam was 3 days (2–5 days) for courses initiated on either a weekend or weekday (p< .01).
Conclusion
We observed a statistically significant difference in the days of therapy received by patient encounters with vancomycin or piperacillin/tazobactam initiated on weekdays versus weekends. However, because of the large sample size in this study, we had power to identify small differences as statistically significant. Still, for vancomycin the 75th percentile received at least one additional day of therapy when initiated on a weekend versus a weekday. Further exploration is needed to identify if weekend initiation is associated with extended durations of therapy in specific sub-populations of patients.
Disclosures
All Authors: No reported disclosures
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Affiliation(s)
| | | | | | - Amy L Pakyz
- Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
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Colangeli HN, Noble BN, Crnich CJ, McGregor JC, Bearden DT, Chan D, Furuno JP, Furuno JP. 200. Frequency and Characteristics of Patients Switched from Intravenous to Oral Antibiotic Therapy on Discharge to Nursing Homes. Open Forum Infect Dis 2020. [PMCID: PMC7777905 DOI: 10.1093/ofid/ofaa439.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Determining eligibility for intravenous (IV) to oral (PO) antibiotic conversion is challenging in patients transitioning to nursing homes (NHs) due to atypical infection presentation, increased diagnostic uncertainty, and multimorbidity. Understanding current practice and patient characteristics influencing prescriber behavior is necessary to provide effective antibiotic stewardship in this vulnerable population. We compared the frequency and characteristics of patients discharged with IV antibiotics to those switched from IV to PO therapy. Methods This was a retrospective cohort study of Oregon Health & Science University Hospital patients treated with IV antibiotics and discharged to a NH from 1/1/2016-12/31/2018. We focused on IV to PO antibiotic switch within 48 hours of discharge. Using a repository of electronic health record data, we collected patient demographic, diagnosis, length of stay, and treatment duration data. Results Among 2,410 patients discharged to a NH on antibiotics, 1,483 (61.5%) received an IV antibiotic within 48 hours of discharge. IV to PO switch occurred in 46.7% of patients prior to discharge, and these patients had fewer baseline comorbidities (Table 1). Of those continuing IV antibiotics, 96.1% were prescribed a different PO medication at discharge indicating potential to take PO medications. Cephalosporins (45%) and penicillins (22%) were the most commonly prescribed IV antibiotics, with IV to PO conversion rates of 26% and 46%, respectively. The median (interquartile range) outpatient duration of therapy was 21 (12–33) days for IV antibiotics and 7 (4–10) days for PO antibiotics. Osteomyelitis diagnosis was more frequent among IV therapy patients; pneumonia and urinary tract infections were more frequent in IV to PO switch patients. IV to PO switch patients were less likely to experience a hospital stay > 7 days or receive an infectious disease consult (p < 0.001). Table 1. Comparison of Patient and Treatment Characteristics among IV and Oral Antibiotic Prescriptions on Discharge ![]()
Conclusion The proportion of patients discharged to a NH on IV antibiotics remains high, even among patients able to tolerate PO medication. Continuing IV therapy was associated with longer treatment durations, hospital stays, and broad spectrum regimens, while patients with IV to PO switch had a higher comorbidity burden at baseline. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | | | - Christopher J Crnich
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - David T Bearden
- Oregon State University/Oregon Health & Sciences University, Portland, OR
| | | | - Jon P Furuno
- Oregon State University College of Pharmacy, Portland, Oregon
| | - Jon P Furuno
- Oregon State University College of Pharmacy, Portland, Oregon
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Werth BJ, Werth BJ, Dilworth TJ, Escobar ZK, Gross AE, Suda K, McGregor JC, Morris AM, LaPlante K, Kuper K. 621. Reporting Behaviors and Perceptions Towards the National Healthcare Safety Network Antimicrobial Use (AU) and Antimicrobial Resistance (AR) Options. Open Forum Infect Dis 2020. [PMCID: PMC7777057 DOI: 10.1093/ofid/ofaa439.815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Antibiotic use (AU) and antibiotic resistance (AR; AUR) reporting to National Healthcare Safety Network (NHSN) is suboptimal by US hospitals. The Society of Infectious Diseases Pharmacists (SIDP) and the Society for Healthcare Epidemiology of America (SHEA) conducted a survey of their membership to 1) Identify characteristics of US health systems that report AUR data 2) Determine how NHSN AUR data are used by health systems and 3) Identify barriers to AUR reporting. Methods An anonymous survey was posted on SurveyMonkey from 1/21- 2/21/2020 and links were emailed to SIDP and SHEA Research Network members. Data were analyzed in Excel and RStudio. Respondent and hospital data were reported as frequencies and percentages. Fisher’s Exact test was used to compare survey responses from NHSN AUR reporters to non-reporters. Results A total of 238 individuals from 43 states responded to our survey. Respondents were primarily pharmacists (84%), from urban (45%), non-profit medical centers (80%) with >250 beds (65%). 62% of respondents reported to the AU option while 19% reported to the AR option. Respondents not using software for local AU or AR tracking were less likely than those using any software for local tracking to report to AU (19% vs 64%) and AR (2% vs 30%) options (P< 0.0001). Among AU and AR reporters 41% and 54% used clinical decision support software to aggregate compile data for upload while 54% and 38% used their electronic health record, and 5% and 8% used another method. Over half of AU (56%) and AR (51%) reporters upload data manually. Regular use of the NHSN data analysis tools was reported by 36% and 9% of those reporting AU and AR data respectively. The most common barriers to reporting were related to technical issues (software, IT support, data formatting) and time/salary support. Among non-reporters, increased expectations to report and better software solutions were most commonly identified as the best ways to increase reporting. Conclusion Efforts to improve AUR reporting should focus on software solutions and increasing the utility of AUR analytical tools. Increasing expectations to report may also help to improve reporting rates. The lower rate of AR vs AU reporting suggests that interventions should also target the AR option. Disclosures Brian J. Werth, PharmD, Shionogi Inc. (Grant/Research Support) Kerry LaPlante, PharmD, Merck (Advisor or Review Panel member, Research Grant or Support)Ocean Spray Cranberries, Inc. (Research Grant or Support)Pfizer Pharmaceuticals (Research Grant or Support)Shionogi, Inc. (Research Grant or Support)
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Affiliation(s)
- Brian J Werth
- University of Washington, Seattle (Washington), Washington
| | - Brian J Werth
- University of Washington, Seattle (Washington), Washington
| | - Thomas J Dilworth
- AdvocateAuroraHealth, Aurora St. Luke’s Medical Center, milwaukee, Wisconsin
| | | | | | - Katie Suda
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | - Kerry LaPlante
- Rhode Island Infectious Diseases Research Program, Kingston, RI
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Tucker KJ, Ham Y, Holmer HK, McCracken CM, Sukerman E, Lewis J, McGregor JC. 162. Assessment of Beta-lactam Allergies as Rationale for Receipt of Vancomycin for Surgical Prophylaxis. Open Forum Infect Dis 2020. [PMCID: PMC7777446 DOI: 10.1093/ofid/ofaa439.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Beta-lactam (BL) antibiotics are first-line agents for most patients receiving antimicrobial prophylaxis in surgical procedures. Despite evidence showing low cross-reactivity between classes of BLs, patients with allergies commonly receive vancomycin as an alternative to avoid allergic reaction. The objective of this study was to identify potentially inappropriate use of vancomycin surgical prophylaxis among patients with reported BL allergies. Methods Adult patients (≥18 years) receiving vancomycin for surgical prophylaxis with a reported penicillin and/or cephalosporin allergy at our institution between August 2017 to July 2018 were retrospectively evaluated for potential eligibility for penicillin allergy testing and/or receipt of standard prophylaxis. Surgery type and allergy history were extracted from the electronic medical record. Per our institution’s penicillin-testing protocol, patients with IgE-mediated reactions < 10 years ago were eligible for penicillin skin testing (PST), mild reactions or IgE-mediated reaction > 10 years ago were eligible for direct oral amoxicillin challenge, and severe non-IgE mediated allergies were ineligible for penicillin allergy evaluation or BL prophylaxis. Results Among 830 patients who received vancomycin for surgical prophylaxis, 196 reported BL allergy and were included in the analysis (155 with penicillin allergy alone; 21 with cephalosporin allergy; 20 with both cephalosporin and penicillin allergy). Approximately 40% of surgeries were orthopedic. Six patients were ineligible for BL prophylaxis. Per institutional protocol, 73 of 155 patients (48%) may have qualified for PST; 81 of 155 (52%) patients may have received a direct oral amoxicillin challenge. Only 3 of 22 patients with history of methicillin-resistant Staphylococcus aureus appropriately received additional prophylaxis with vancomycin and a BL. Conclusion Patients with BL allergies often qualify for receipt of a first-line BL antibiotic. An opportunity exists for improved BL allergy assessment as an antimicrobial stewardship intervention. Future studies should evaluate outcomes associated with BL allergy evaluation and delabeling in patients receiving surgical prophylaxis. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | - YoungYoon Ham
- Oregon Health & Science University, Portland, Oregon
| | - Haley K Holmer
- Portland Veterans Administration Medical Center, Portland, Oregon
| | | | | | - James Lewis
- Oregon Health and Science University, Portland, Oregon
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Ray MJ, McCracken CM, Tucker KJ, Yu D, Underwood M, Wu E, Kastelic K, Nolt D, McGregor JC. 225. Evaluating Appropriateness of Antibiotic Prescribing in Pediatric Inpatients. Open Forum Infect Dis 2020. [PMCID: PMC7778239 DOI: 10.1093/ofid/ofaa439.269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Antibiotic appropriateness is the gold standard for informing antimicrobial stewardship efforts to optimize prescribing. The objectives of this study were to evaluate appropriateness of antibiotics for resistant gram-positive infections in pediatric inpatients and identify factors associated with inappropriate prescribing. Methods We included pediatric inpatients between July 2017 and July 2018 where an antibiotic typically used for resistant Gram-positive infections (per NHSN) was administered. We developed an algorithm based on laboratory data and diagnosis codes to categorize each antibiotic day of therapy as appropriate, inappropriate, or indeterminate. If indeterminate, we reviewed charts to assess appropriateness. We calculated total, appropriate, and inappropriate days of therapy (DOT) overall and per patient-day. We evaluated clinical characteristics and indications as potential predictors of inappropriate DOT using Chi-squared or Kruskal-Wallis tests. Results Among 591 included encounters, we assessed 708 total antibiotic courses. The algorithm allowed for classification of 422 encounters (71%) and the remaining 171 encounters (29%) were classified using manual record review. The most frequent antibiotics were vancomycin (68%) and clindamycin (29%). Patients received a median of 3 days of gram-positive agent therapy per visit, or 5 per every 10 patient-days. Most common indications for gram-positive therapy were surgical prophylaxis (28% of encounters) and empiric therapy (10%) (Figure 1). Of the 1,754 total days of therapy assessed, 94.8% were ruled appropriate. Thirty-one (4.4%) courses were classified as at least partially inappropriate among 27 unique encounters (4.6%). There was a median of 2 inappropriate days among those with any inappropriate therapy. The reason for inappropriate rulings for empiric or prophylaxis indications was most often “longer than necessary duration,” which was the case for 16 of 21 (76%) occurrences. Figure 1. Appropriate and Inappropriate Days of Therapy (DOT) by Indication and Antibiotic ![]()
Conclusion Inappropriate antibiotic use for Gram-positive infections was low in our patient population for the agents studied. We identified limiting the duration for patients receiving prophylactic or empiric therapy as a potential stewardship intervention target. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | | | | | - Diana Yu
- Oregon Health and Science University/Doernbecher Children’s Hospital, Portland, OR
| | | | - Erin Wu
- Oregon State University College of Pharmacy, Portland, Oregon
| | | | - Dawn Nolt
- Oregon Health and Science University/Doernbecher Children’s Hospital, Portland, OR
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Ramanathan S, Yan CH, Hubbard C, Calip G, Sharp LK, Rowan SA, McGregor JC, Gross AE, Campbell A, Evans CT, Hershow R, Suda KJ. 218. Changes in Dental Antibiotic Prescribing in the United States, 2012–2017. Open Forum Infect Dis 2020. [PMCID: PMC7777855 DOI: 10.1093/ofid/ofaa439.262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Data suggest dental antibiotic prescribing is increasing with relatively less documented about prescribing trends in adults and children. Therefore, the aim was to evaluate trends in antibiotic prescribing by US dentists from 2012–2017. Methods This was a cross-sectional study of US dental prescribing using IQVIA Longitudinal Prescription Data from 2012 to 2017. Prescribing rates (prescriptions [Rx] per 100,000 dentists), mean days’ supply, and mean quantity dispensed were calculated monthly across eight oral antibiotic groups: amoxicillin, clindamycin, cephalexin, azithromycin, penicillin, doxycycline, fluoroquinolone, and other antibiotics. Descriptive frequencies and multiple linear regressions were performed to obtain trends overall and stratified by adults (≥ 18) and children (< 18). Results 220, 325 dentists prescribed 135 million Rx (94.0% in adults). 61.0% were amoxicillin, 14.4% clindamycin, 11.7% penicillin, 4.4% azithromycin, 4.3% cephalexin, 2.0% other antibiotics, 1.4% doxycycline, and 0.7% fluoroquinolones. Prescribing increased by 33 Rx/100,000 dentists (p< 0.0001) each month for all antibiotics. Amoxicillin (p< 0.0001) and clindamycin (p=0.02) prescribing rate increased by 73 and 5 Rx/100,000 dentists, respectively. Prescribing decreased by 8, 12, and 2 Rx/100,000 dentists for cephalexin (p< 0.0001), doxycycline (p< 0.0001), and fluoroquinolones (p=0.008), respectively. Mean days’ supply increased for amoxicillin, penicillin, and clindamycin (p< 0.0001), and decreased for cephalexin (p< 0.0001).Mean quantity dispensed decreased (p< 0.0001) for all groups except azithromycin and doxycycline. Among adults, cephalexin prescribing rates (7 Rx/100,000 dentist; p< 0.0001) and other antibiotics days’ supply (p< 0.0001) decreased. Among children, azithromycin prescribing rates (1 Rx/100,000 dentists, p=0.02), and fluoroquinolone and other antibiotics days’ supply (p< 0.0001) decreased. Conclusion These findings support dental antibiotic prescribing is increasing, specifically for amoxicillin and clindamycin. Further, trends differed between adults and children. Understanding what is driving these trends is important to target dental antibiotic stewardship efforts. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | - Connie H Yan
- University of Illinois at Chicago, Naperville, Illinois
| | | | | | - Lisa K Sharp
- University of Illinois Chicago, Chicago, Illinois
| | | | | | | | | | | | | | - Katie J Suda
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines VA Hospital and University of Illinois at Chicago College of Pharmacy, Hines, IL
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McGregor JC, McCracken CM, Hohmann SF, Pakyz AL. 142. Frequency of Short-course Empiric Antibiotic Use as an Antimicrobial Stewardship Metric. Open Forum Infect Dis 2020. [PMCID: PMC7777923 DOI: 10.1093/ofid/ofaa439.452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Antimicrobial stewardship metrics that provide actionable guidance are needed to support efforts to improve hospital use of antibiotics. Antibiotics such as vancomycin and piperacillin/tazobactam are common empiric agents used frequently when the infectious process remains unknown. Thus short, incomplete courses of therapy are used more frequently for such agents. We aimed to evaluate the variability in short courses of vancomycin and piperacillin/tazobactam use across U.S. hospitals. ![]()
Methods We performed a cross-sectional study among U.S. hospitals that contributed inpatient pharmacy data to the Vizient clinical database in 2016. We identified vancomycin and piperacillin-tazobactam courses initiated within the 48 hours of admission, measured as days of therapy received. We calculated the percent of patients that received 1, 2, 3, 4 or >4 days of therapy at each facility to describe short course empiric therapy use. To describe the variability across facilities, we then assessed the median, interquartile range (IQR), and total range of that percentage. Results We identified 145 hospitals representing approximately 3.7 million patient encounters for inclusion in this study. Within 48 hours of admission, 13.9% of encounters received vancomycin, 7.7% piperacillin/tazobactam, and 4.6% received both. The figure demonstrates the variability in the frequency of short course antibiotic use across hospitals; boxes indicate the IQR with the transecting line representing the median and whiskers representing the full range. The proportion of patients that received one day of therapy varied most across hospitals, with vancomycin ranging from 0–100%. In contrast, the frequency of patients that received greater than four days of therapy varied considerably less across hospitals; 0–33% for vancomycin. Conclusion The variability in use of short course empiric therapies suggests that use for non-infectious processes or infections not appropriately treated by these agents varies greatly across facilities. Measuring short course use for common empiric agents may serve as an important antimicrobial stewardship metric. Such a metric could inform antimicrobial stewardship efforts to reduce unnecessary initiation of empiric antimicrobial therapy. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | | | | | - Amy L Pakyz
- Virginia Commonwealth University School of Pharmacy, Richmond, Virginia
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Lantz TL, Noble BN, Crnich CJ, McGregor JC, Chan D, Furuno JP, Furuno JP, Bearden DT. 201. Healthcare utilization outcomes of patients prescribed fluoroquinolones on discharge from the hospital to nursing homes. Open Forum Infect Dis 2020. [PMCID: PMC7778078 DOI: 10.1093/ofid/ofaa439.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Fluoroquinolones (FQs) are frequently prescribed in nursing homes (NHs) despite concerns regarding broad spectrum antibiotic selective pressure, increased risk of Clostridioides difficile infection, and other adverse events. NH antibiotics are also frequently initiated in hospitals prior to NH admission. We quantified the frequency and outcomes of patients prescribed FQs on discharge from the hospital to NHs. Methods This was a retrospective cohort study of adult (age ≥ 18 years) inpatients prescribed a FQ on discharge from Oregon Health & Science University Hospital (OHSU) to a NH between 1/1/2016 and 12/31/2018. Study data were collected from a repository of electronic health record data. The outcome of interest was a composite of 30-day hospital readmission or emergency department (ED) visit to OHSU. Associations were quantified using odds ratios (ORs) and 95% confidence intervals (CIs). Results Among 9,546 patients discharged to a NH, 2,410 (25%) were prescribed at least one antibiotic and 423 (17.6%) were prescribed a FQ. Of these patients, 36.9% were age ≤ 65, 53% were male, 11.6% received a specialty infectious diseases consultation, 34.8% had a surgical diagnosis, and 49.7% had a hospital length of stay > 7 days. The most prevalent comorbidities were cancer (30.5%), chronic obstructive pulmonary disease (29.6%), and renal disease (26%). The most prevalent FQs prescribed were ciprofloxacin (56.7%), levofloxacin (40.2%), and moxifloxacin (3.1%). Duration of NH therapy > 7 days occurred in 37.6% of patients. The most common infectious diagnoses were bloodstream infection and endocarditis (39%), pneumonia (17%), and urinary tract infection (14.2%). Of patients prescribed a FQ, 276 (65.3%) had an ED visit or hospital admission to index facility within 30 days of discharge. Patients who were ≤ 65 years old (OR 2.3, 95% CI 1.4–3.5), male (OR 1.6, 95% CI 1.1–2.5), had comorbid renal disease (OR 1.8, 95% CI 1.1–2.9), or osteomyelitis as infectious diagnosis (OR 2.4, 95% CI 1.0–5.7) were more likely to have a 30-day ED visit or hospital admission. Conclusion Patients prescribed FQs on discharge to NHs frequently returned to the hospital for an ED visit or inpatient admission within 30 days of discharge. Disclosures All Authors: No reported disclosures
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Affiliation(s)
- Tyler L Lantz
- Oregon State University College of Pharmacy, Portland, Oregon
| | | | - Christopher J Crnich
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | | | - Jon P Furuno
- Oregon State University College of Pharmacy, Portland, Oregon
| | - Jon P Furuno
- Oregon State University College of Pharmacy, Portland, Oregon
| | - David T Bearden
- Oregon State University/Oregon Health & Sciences University, Portland, OR
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Molina KE, Noble BN, Crnich CJ, McGregor JC, Bearden DT, Chan D, Furuno JP, Furuno JP. 63. Frequency and Outcomes of Patients Prescribed Antibiotics for Extended Durations on Discharge from the Hospital to Nursing Homes. Open Forum Infect Dis 2020. [PMCID: PMC7777420 DOI: 10.1093/ofid/ofaa439.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Nursing home (NH) residents are at increased risk of being prescribed antibiotic for extended durations and experiencing antibiotic-associated adverse events. However, many of these antibiotics are prescribed in the hospital prior to NH admission. We quantified the frequency, characteristics and outcomes of patients receiving antibiotic treatment in the hospital and discharged to NHs with an antibiotic prescription for greater than 7 days. Methods This was a retrospective cohort study of adult (age >18 years) patients with a prescription for an antibiotic on discharge from Oregon Health & Science University Hospital (OHSU) to a NH between January 1, 2016 and December 31, 2018. Study data were collected from an electronic repository of patients’ electronic health record data. Outcomes of interest included having an emergency department (ED) visit, inpatient hospital admission, or inpatient admission for Clostridioides difficile infection (CDI) at the index facility within 30 days of discharge. Results Among 2969 antibiotic prescriptions on discharge, 1267 (42.7%) were prescribed for greater than 7 days to a total of 1059 patients. A diagnosis of a bacterial infection was present for 902 (85.2%) patients. The most frequent diagnoses were bloodstream/endocarditis (21.8%), osteomyelitis (11.6%), and skin and soft tissue infections (10.6%). The most frequently prescribed antibiotics were cephalosporins (24.2%), penicillins (14.1%), glycopeptides (12.9%), and fluoroquinolones (12.6%). Of the 1059 identified patients, 126 (11.9%) had an ED visit, 216 (20.4%) inpatient admission, and 16 (1.5%) had an admission for CDI within 30 days of discharge. Conclusion More than 40% of antibiotic prescriptions on discharge to a NH were for greater than 7 days. This frequency and associated poor outcomes suggest extended antibiotic duration are a high-value target to improve antibiotic prescribing on discharge to NHs. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | | | - Christopher J Crnich
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - David T Bearden
- Oregon State University/Oregon Health & Sciences University, Portland, OR
| | | | - Jon P Furuno
- Oregon State University College of Pharmacy, Portland, Oregon
| | - Jon P Furuno
- Oregon State University College of Pharmacy, Portland, Oregon
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Hartung DM, Johnston KA, McGregor JC, Bourdette DN. The effect of out-of-pocket costs on initiation of disease-modifying therapies among medicare beneficiaries with multiple sclerosis. Mult Scler Relat Disord 2020; 46:102554. [DOI: 10.1016/j.msard.2020.102554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/23/2020] [Accepted: 09/30/2020] [Indexed: 02/08/2023]
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Zhou J, Calip GS, Rowan S, McGregor JC, Perez RI, Evans CT, Gellad WF, Suda KJ. Potentially Inappropriate Medication Combination with Opioids among Older Dental Patients: A Retrospective Review of Insurance Claims Data. Pharmacotherapy 2020; 40:992-1001. [PMID: 32767780 PMCID: PMC8483014 DOI: 10.1002/phar.2452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/30/2020] [Accepted: 06/30/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Opioid prescribing by dentists for older patients receiving medications with potential contraindications and the subsequent impact on acute care outcomes is not well described. OBJECTIVES Our objective of this paper was to evaluate the use of potentially inappropriate medication combinations (PIMCs) involving opioids prescribed by dentists according to the Beers Criteria and risks of 30-day emergency department (ED) visits and all-cause hospitalization among commercially insured dental patients ages 65 years and older. METHODS We conducted a retrospective cohort study of 40,800 older dental patient visits in which opioids were prescribed between 2011 and 2015 using the IBM MarketScan databases. Data collection from dental, medical, and pharmacy claims included information on the concurrent use of PIMCs and outcomes of all-cause acute care utilization over the 30-day period after dental encounters. RESULTS For the overall cohort, the median age was 69 years, and 45% were women. The prevalence of PIMCs per Beers Criteria was 10.4%. A total of 947 all-cause acute care events were observed in the 30 days post-dental visit. Patients with PIMCs involving opioids prescribed by dentists according to the Beers Criteria had higher rates of acute care use (3.3% vs 2.2%, p<0.001), which were associated with an increased risk of all-cause acute care utilization (adjusted risk ratio [RR] 1.23, 95% confidence interval [CI] 1.02-1.48). A dose-response relationship was seen with increasing oral morphine equivalents prescribed and increased acute care utilization (p<0.001). CONCLUSION A significant proportion of older patients receiving opioids at dental visits use psychotropic medications that in combination should be avoided according to the American Geriatric Society Beers Criteria.
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Affiliation(s)
- Jifang Zhou
- University of Illinois at Chicago, College of Pharmacy, Chicago, IL
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Gregory S. Calip
- University of Illinois at Chicago, College of Pharmacy, Chicago, IL
- Flatiron Health, New York, NY
| | - Susan Rowan
- University of Illinois at Chicago, College of Dentistry, Chicago, IL
| | | | - Rosanne I. Perez
- University of Illinois at Chicago, College of Medicine, Chicago, IL
| | - Charlesnika T. Evans
- Northwestern University Feinberg School of Medicine, Chicago, IL
- Center of Innovation for Complex Chronic Healthcare, Hines VA Hospital, Hines, IL
| | - Walid F. Gellad
- University of Pittsburgh, Department of Medicine, Pittsburgh, PA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Katie J. Suda
- University of Pittsburgh, Department of Medicine, Pittsburgh, PA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
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Abstract
OBJECTIVES To identify the frequency with which antibiotics are prescribed in the absence of a documented indication in the ambulatory care setting, to quantify the potential effect on assessments of appropriateness of antibiotics, and to understand patient, provider, and visit level characteristics associated with antibiotic prescribing without a documented indication. DESIGN Cross sectional study. SETTING 2015 National Ambulatory Medical Care Survey. PARTICIPANTS 28 332 sample visits representing 990.9 million ambulatory care visits nationwide. MAIN OUTCOME MEASURES Overall antibiotic prescribing and whether each antibiotic prescription was accompanied by appropriate, inappropriate, or no documented indication as identified through ICD-9-CM (international classification of diseases, 9th revision, clinical modification) codes. Survey weighted multivariable logistic regression was used to evaluate potential risk factors for receipt of an antibiotic prescription without a documented indication. RESULTS Antibiotics were prescribed during 13.2% (95% confidence interval 11.6% to 13.7%) of the estimated 990.8 million ambulatory care visits in 2015. According to the criteria, 57% (52% to 62%) of the 130.5 million prescriptions were for appropriate indications, 25% (21% to 29%) were inappropriate, and 18% (15% to 22%) had no documented indication. This corresponds to an estimated 24 million prescriptions without a documented indication. Being an adult male, spending more time with the provider, and seeing a non-primary care specialist were significantly positively associated with antibiotic prescribing without an indication. Sulfonamides and urinary anti-infective agents were the antibiotic classes most likely to be prescribed without documentation. CONCLUSIONS This nationally representative study of ambulatory visits identified a large number of prescriptions for antibiotics without a documented indication. Antibiotic prescribing in the absence of a documented indication may severely bias national estimates of appropriate antibiotic use in this setting. This study identified a wide range of factors associated with antibiotic prescribing without a documented indication, which may be useful in directing initiatives aimed at supporting better documentation.
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Affiliation(s)
- Michael J Ray
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR 97239, USA
- Oregon State University College of Pharmacy, Portland, OR 97201, USA
| | | | - David T Bearden
- Oregon State University College of Pharmacy, Portland, OR 97201, USA
| | - Miriam R Elman
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR 97239, USA
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Kanchagar C, Noble BN, Crnich C, McGregor JC, Bearden DT, Furuno JP. 2051. Frequency of Inappropriate Antibiotic Prescribing in Nursing Homes. Open Forum Infect Dis 2019. [PMCID: PMC6809861 DOI: 10.1093/ofid/ofz360.1731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Antibiotics are among the most prescribed medications in nursing homes (NHs). The increasing incidence of multidrug-resistant and C. Difficile infections due to antibiotic overuse has driven the requirement for NHs to establish antibiotic stewardship programs (ASPs). However, estimates of the frequency of inappropriate antibiotic prescribing in NHs have varied considerably between studies. We evaluated the frequency of inappropriate antibiotic prescribing in a multi-state sample of NHs. Methods We utilized a retrospective, (20%) random sample of residents of 17 for-profit NHs in Oregon, California, and Nevada who received antibiotics between January 1, 2017 and May 31, 2018. Study NHs ranged in size from 50 to 188 beds and offered services including subacute care, long-term care, ventilator care, and Alzheimer’s/memory care. Data were collected from residents’ electronic medical records. Antibiotic appropriateness was defined using Loeb Minimum Criteria for initiation of antibiotics for residents with indications for lower respiratory tract infection (LRTI), urinary tract infection (UTI) and skin and soft-tissue infection (SSTI). Residents with other types of infections were excluded from the study. Results Among 232 antibiotic prescriptions reviewed, 61% (141/232) were initiated in the NH. Of these, 65% were for female residents and 81% were for residents above the age of 65. Nearly 70% (98/141) of antibiotic prescriptions were for an indication of an LRTI, UTI, or SSTI of which 51% (57% of LRTIs, 52% of UTIs, and 35% of SSTIs) did not meet the Loeb Minimum Criteria and were determined to be inappropriate. Among antibiotics that did not meet the Loeb Minimum Criteria, more than half were cephalosporins (40%) or fluoroquinolones (14%) and the median (interquartile range) duration of therapy was 7 (5–10) days. Conclusion These data from a multi-state sample of NHs suggest the continued need for improvement in antibiotic prescribing practices and the importance of ASPs in NHs. ![]()
Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Chitra Kanchagar
- Oregon State University/Oregon Health and Science University, Beaverton, Oregon
| | | | | | - Jessina C McGregor
- Oregon State University/Oregon Health and Science University, Beaverton, Oregon
| | - David T Bearden
- Oregon State University/Oregon Health & Sciences University, Portland, Oregon
| | - Jon P Furuno
- Oregon State University College of Pharmacy, Portland, Oregon
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Holmer HK, McCracken CM, Tallman GB, Gore SJ, Shan T, Yu D, Bearden DT, McGregor JC. 1034. Automating Assessments of Vancomycin Appropriateness. Open Forum Infect Dis 2019. [PMCID: PMC6811234 DOI: 10.1093/ofid/ofz360.898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Assessing appropriateness of hospital antibiotic use is typically a labor-intensive task for antimicrobial stewardship teams and relies heavily on clinician judgement rather than a systematic process. Vancomycin is a frequently used agent that is a common stewardship target. We developed an algorithm to automatically classify the appropriateness of vancomycin days of therapy (DOTs) based upon electronic health record data.
Methods
We constructed a retrospective cohort of Oregon Health and Science University (OHSU) Hospital and Doernbecher Children’s Hospital patients admitted August 1, 2017 to July 31, 2018 receiving vancomycin. Data were collected on demographic, encounter, pharmacy, microbiology, and surgery data. An electronic algorithm was applied to classify vancomycin DOTs as appropriate, inappropriate, or indeterminate. Inappropriate use was defined as any case in which there was an opportunity for de-escalation as identified using microbiology data, ICD-10 codes, and procedure codes.
Results
We included 4,231 encounters; 493 (12%) were pediatric patients. Our algorithm automatically classified 59%, 3%, and 38% of encounters as having either appropriate, inappropriate, or indeterminate DOTs, respectively. Forty-four percent of all encounters received no more than a 24-hour course of vancomycin and were considered appropriate empiric therapy; half of these were attributed to surgical prophylaxis. Nine percent of all encounters had vancomycin administered within 3 days of a blood, sputum or tissue culture in which either a methicillin-resistant Staphylococcus species or an ampicillin-resistant, vancomycin-susceptible Enterococcus species was isolated and were classified as appropriate. Six percent of all encounters had cultures in which only Gram-negatives, fungi, or yeast were isolated and were therefore considered appropriate in the empiric period (≤48 hours) but inappropriate thereafter.
Conclusion
Automated assessments of antibiotic appropriateness could facilitate more informed antimicrobial stewardship initiatives and serve as a valuable stewardship metric. Characterization of indeterminate vancomycin use may inform increased automated classification. Further effort is needed to validate these assessments.
Disclosures
All authors: No reported disclosures.
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Affiliation(s)
| | | | | | - Sara J Gore
- Oregon Health and Science University, Portland, Oregon
| | - Timothy Shan
- Oregon State University College of Pharmacy, Portland, Oregon
| | - Diana Yu
- Oregon Health and Science University/Doernbecher Children’s Hospital, Portland, Oregon
| | - David T Bearden
- Oregon State University/Oregon Health and Sciences University, Portland, Oregon
| | - Jessina C McGregor
- Oregon State University/Oregon Health and Science University, Portland, Oregon
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Ray MJ, Tallman GB, McCracken CM, Elman MR, McGregor JC. 2058. Patient Satisfaction Not Impacted by Antibiotic Prescribing for Viral Upper Respiratory Infections. Open Forum Infect Dis 2019. [PMCID: PMC6809170 DOI: 10.1093/ofid/ofz360.1738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Treating viral upper respiratory infections (URI) with antibiotics is a major contributor to the rise of antimicrobial resistance. Major drivers of unnecessary prescribing are a patient’s expectation to receive an antibiotic for acute illness and the physician’s desire to provide satisfactory care. Our objective was to determine whether receiving an antibiotic prescription for a URI is associated with increased patient satisfaction. Methods We identified emergency department (ED) and ambulatory visit (AC) visits with an acute URI diagnosis code between September 2015 and May 2016 that had an associated patient satisfaction survey. The survey queried patients’ overall satisfaction (“Overall rating of care received during your visit”) using a Likert-type scale ranging from 1 (Very Poor) to 5 (Very Good). We assessed survey responses among patients receiving and not receiving antibiotics using the Wilcoxon rank-sum test. Results from ED and AC visits were compared separately. Results We collected survey responses from 282 ED patients and 1306 AC patients with acute URI. Compared with non-recipients, ED respondents receiving an antibiotic were more likely to be female (67% vs. 55%) and on Medicare (28% vs. 21%); AC respondents receiving a prescription were more likely to be female (68% vs. 61%) and have private insurance (63% vs. 53%). Overall satisfaction was very high (Median = 5, IQR 4–5 for both groups). Median responses did not differ by antibiotic prescription status in either group (rank-sum P = 0.4 and 0.8 for ED and AC respectively). When dichotomizing the overall satisfaction score, more patients receiving an antibiotic reported satisfaction of good to very good than those not receiving an antibiotic (84% vs. 76%; Pearson’s Χ2P = 0.1) among ED patients, but not AC patients (95% vs. 94%; P = 0.5). Conclusion Patient satisfaction with their visit was not strongly associated with antibiotic receipt among ED and AC patients with URI in our study. This finding suggests that providers may limit the spread of antibiotic resistance by ceasing to unnecessarily prescribe antibiotics without jeopardizing patient satisfaction. Given low response rates to visit satisfaction surveys, further work is needed to verify the validity of this study and evaluate its generalizability. Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | | | | | | | - Jessina C McGregor
- Oregon State University/Oregon Health & Science University, Portland, Oregon
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Shan T, Gore SJ, McCracken CM, Tallman GB, Holmer HK, Bearden DT, McGregor JC. 1027. Vancomycin Use in Community-Acquired Pneumonia: Assessing Inappropriate Therapy. Open Forum Infect Dis 2019. [PMCID: PMC6811279 DOI: 10.1093/ofid/ofz360.891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Current Infectious Disease Society of America guidelines recommend anti-methicillin-resistant Staphylococcus aureus(MRSA) agents for treatment of community-acquired pneumonia (CAP) only in specific high-risk patients. There are limited data on duration of vancomycin use that is appropriate in hospitalized patients with CAP. The objective of this study was to evaluate the use of vancomycin for CAP among inpatients. Methods We conducted a retrospective cohort study of inpatients at Oregon Health and Science University Hospital from August 1st, 2017 to July 31st, 2018 who received IV vancomycin and had a pneumonia encounter ICD-9 diagnosis code. Patients with hospital or ventilator-associated pneumonia were excluded. Appropriate therapy was defined as empiric therapy with known risk-factors, concordant therapy with no de-escalation option, or concurrent sepsis or febrile neutropenia. Vancomycin appropriateness was assessed based on medical history and microbiology for both empiric and definitive therapy. We characterized patients receiving inappropriate therapy and calculated the proportion of inappropriate days of therapy (DOT). Results We identified 52 patients with CAP who were treated with vancomycin for a median of 2 DOT (Interquartile Range (IQR): 1–3). Approximately 21% (11/52) of patients had risk factors warranting vancomycin empiric therapy and 42% (22/52) had concurrent sepsis. Nine CAP patients received inappropriate courses of vancomycin, median of 1 day (IQR: 1–2.25) of inappropriate therapy. The most common reason for classifying use as inappropriate was a positive culture for organisms other than MRSA. Patients receiving inappropriate therapy were more frequently transferred from another hospital (44% vs. 30%, P = 0.22). Overall, 16% (20/125) of vancomycin DOT were inappropriate. Conclusion In our study,CAP patients accounted for a small number of pneumonia patients who received vancomycin. The median inappropriate DOT was relatively short, possibly indicating that identification and de-escalation was performed quickly. Further work is required to determine the impact of these findings on patients. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Timothy Shan
- Oregon State University/Oregon Health and Science University College of Pharmacy, Portland, Oregon
| | - Sara J Gore
- Oregon Health and Science University, Portland, Oregon
| | | | | | | | - David T Bearden
- Oregon State University/Oregon Health and Sciences University, Portland, Oregon
| | - Jessina C McGregor
- Oregon State University/Oregon Health and Science University, Portland, Oregon
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Furuno JP, Noble BN, Nordby V, Weber B, McGregor JC, Bearden DT, Chan D, Tjia J, Crnich C. 2054. Hospital-initiated Antibiotics in Nursing Homes. Open Forum Infect Dis 2019. [PMCID: PMC6810688 DOI: 10.1093/ofid/ofz360.1734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Nursing homes (NHs) are required by the Centers for Medicare and Medicaid Services to maintain antimicrobial stewardship programs. Hospital-initiated antibiotics may pose a barrier to optimizing antibiotic prescribing in this setting. Our objective was to characterize hospital-initiated antibiotic prescriptions among NH residents. Methods We collected electronic health record data on antibiotic prescribing events within 60 days of residents’ admission to 17 for-profit NHs in Oregon, California, and Nevada between January 1, and December 31, 2017. We characterized antibiotics prescribed, administration route, and proportion initiated in a hospital setting. Results Over the one-year study period, there were 4350 antibiotic prescribing events among 1633 NH residents. Mean (standard deviation) age was 77 (12) years and 58% were female. Approximately 45% (1,973/4,350) of antibiotics prescribed within 60 days of NH admission were hospital-initiated. The most frequently prescribed hospital-initiated antibiotics were cephalosporins (27%; 1st gen: 54%, 2nd gen: 6%, 3rd gen: 34%, 4th gen: 5%, 5th gen: 1%), fluoroquinolones (20%), and penicillins (14%; natural penicilins: 4%, semisynthetic penicillins: 3%, aminopenicillans: 57%, β-lactam/β-lactamase inhibitors: 21%, and antipseudomonal penicillins: 15%). Additionally, 24% of antibiotics were parenteral and the median (interquartile range) duration of therapy was 6 (3–10) days. Over 15% of residents with hospital-initiated antibiotics were readmitted to the hospital within 30 days. Conclusion Approximately 45% of antibiotic prescribing in a multistate sample of NHs were hospital-initiated, of which roughly 40% was broad-spectrum. Interventions specifically targeting antibiotic prescribing during and following the transition from hospitals to NHs are needed. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Jon P Furuno
- College of Pharmacy, Oregon State University, Portland, Oregon
| | | | | | | | - Jessina C McGregor
- Oregon State University/Oregon Health & Science University, Portland, Oregon
| | - David T Bearden
- Oregon State University/Oregon Health & Science University, Portland, Oregon
| | | | - Jennifer Tjia
- University of Massachusetts Medical School, Worcester, Massachusetts
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Furuno JP, Noble BN, Weber B, Nordby V, McGregor JC, Bearden DT, Chan D, Tjia J, Crnich C. 2053. Information Gaps Among Patients Prescribed Antibiotics on Discharge to Nursing Homes. Open Forum Infect Dis 2019. [PMCID: PMC6810014 DOI: 10.1093/ofid/ofz360.1733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Antibiotic use in nursing homes (NHs) is frequently initiated in acute care hospitals. Comprehensive antibiotic administration instructions are critical to inform antimicrobial stewardship efforts in NHs. However; little is known about the quality of discharge communication for residents transitioning from hospitals to NHs with an antibiotic prescription. Methods We reviewed hospital discharge summaries from a 10% random sample of hospital-initiated antibiotic prescriptions among residents of 17 for-profit NHs in Oregon, California, and Nevada admitted between January 1 and December 31, 2017. Data elements of interest were documentation of antibiotic choice, indication, instructions, and pending microbiology tests. Results Among 217 hospital-initiated antibiotic prescriptions, mean (standard deviation) age was 64 (29) years and 57% were female. The most frequently prescribed hospital-initiated antibiotics were cephalosporins (36%), fluoroquinolones (16%), and penicillins (14%). Hospital discharge summaries were missing from 19% (42/217) of the resident medical records. Core antibiotic prescribing information was missing from 38% (67/175) of the medical records with a discharge summary: 11% (20/175) were missing all core elements, 23% (41/175) were missing the antibiotic indication, 27% (48/175) were missing antibiotic dose, 27% (48/175) were missing antibiotic frequency, and 32% (56/175) were missing antibiotic duration. Parental antibiotics were more frequently missing information compared with oral antibiotic prescriptions (45% vs. 37%, P = 0.32). Conclusion Information gaps around antibiotic prescriptions are prevalent in transfer documentation for NH residents admitted from acute care hospitals. Interventions are needed to improve the quality of information transferred from acute care hospitals to NHs. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Jon P Furuno
- Oregon State University College of Pharmacy, Portland, Oregon
| | | | | | | | - Jessina C McGregor
- Oregon State University/Oregon Health & Science University, Portland, Oregon
| | - David T Bearden
- University of Massachusetts Medical School, Worcester, Massachusetts
| | | | - Jennifer Tjia
- University of Massachusetts Medical School, Worcester, Massachusetts
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Suda KJ, Gibson G, Jurasic MM, Poggensee L, Gonzalez B, Fitzpatrick MA, Echevarria K, McGregor JC, Evans CT. 2093. Prescribing of Antibiotics by Provider Type Across the Veterans Health Administration (VHA), 2015–2017. Open Forum Infect Dis 2019. [PMCID: PMC6809201 DOI: 10.1093/ofid/ofz360.1773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Antibiotic stewardship frequently targets high prescribing providers. Our objective was to determine differences by provider type in antibiotic prescribing rates, high prescribing and trends over time. Methods Cross-sectional study in 2015–2017 of non-trainee dental and medical providers actively practicing (defined as ≥20 VHA visits). Medical providers included all physicians and advanced practice providers (APP). Antibiotics prescribed within 7 days of a visit were included. “High prescribing” was defined as providers with visit-based rates ≥75th percentile. Chi square assessed differences in the frequency of high prescribing. Poisson and logistic regression were applied; models were clustered within the facility. Results At 130 VHA facilities, there were 32,000 unique medical providers and 1300 dentists actively practicing/year. From 2015–2017, overall antibiotic prescribing rates decreased by 6.4% (P < 0.0001 for trend); decreasing by 1.8% for dentists (P < 0.001) and 6.6% for all medical providers (P < 0.001). More antibiotics were prescribed/visit among dentists vs. medical providers (6.7 vs. 4.3/100 visits; IRR = 1.7). Among medical providers, APP had higher rates (5.0 vs. 4.1/100 visits; P < 0.001). Among dentists, specialty dentists had higher rates compared with general dentists (7.6 vs. 6.5/100 visits; P < 0.001), increasing by 1.9% for specialty dentists and decreasing by 3.1% for general dentists. At the facility-level, dentists who were high prescribers (≥ 75th percentile) of antibiotics were at different facilities as medical providers who were high prescribers (P < 0.001). However, there was no difference in the odds of being a high antibiotic prescriber for dentists when compared with medical providers. Specialty dentists (OR = 1.7; 95% CI: 1.4–2.1) had higher odds of being high prescribers when compared with general dentists. There was no difference among the type of medical provider. Conclusion As compared with physicians, dentists and APP have higher antibiotic prescribing rates, though prescribing may differ based on the frequency of infection-related visits. Facility-level interventions to curb the high use of antibiotics may not be reaching high prescribing dentists. Stewardship should be targeted to non-physician providers. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Katie J Suda
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines VA Hospital and University of Illinois at Chicago College of Pharmacy, Hines, Illinois
| | - Gretchen Gibson
- Oral Health Quality Group, Veterans Health Care System of the Ozarks, Fayetteville, Arkansas
| | - Marianne M Jurasic
- VA Office of Dentistry, Oral Health Quality Group and Boston University, Boston, Massachusetts
| | | | | | | | - Kelly Echevarria
- Pharmacy Benefits Management, Department of Veterans Affairs, San Antonio, Texas
| | - Jessina C McGregor
- Oregon State University/Oregon Health & Science University, Portland, Oregon
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Carlsen D, Suda KJ, Patel UC, Gibson G, Jurasic MM, Poggensee L, Fitzpatrick MA, Echevarria K, Durkin M, McGregor JC, Evans CT. 967. Concordance of Antibiotic Prescribing with the Proposed American Dental Association Acute Oral Infection Guidelines within Veterans Affairs (VA) Dentistry. Open Forum Infect Dis 2019. [PMCID: PMC6808714 DOI: 10.1093/ofid/ofz359.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
US dentists prescribe 10% of outpatient antibiotics. However, assessing the appropriateness of dental antibiotic prescribing has been challenging due to a lack of guidelines for common infections. In 2019, the American Dental Association proposed clinical practice guidelines (CPG) on the management of common acute oral infections for the first time. Our objective was to describe national baseline antibiotic prescribing for the treatment of irreversible pulpitis, apical periodontitis, and acute apical abscess prior to the release of the proposed CPG.
Methods
We performed a cross-sectional analysis of national VA data from January 1, 2017 to December 31, 2017. We identified cases of irreversible pulpitis, apical periodontitis, and acute apical abscess using ICD-10-CM codes. Patient demographics, facility location, medical conditions, dental procedure codes (“CDTs”), and diagnostic (ICD-10-CM) codes were extracted from the VA Corporate Data Warehouse. Antibiotics prescribed by a dentist within 7 days of a visit were included. Multivariable logistic regression identified variables associated with antibiotic prescribing for each infection.
Results
Of the 470,039 VA dental visits with oral infections coded, 25% of irreversible pulpitis, 41% of apical periodontitis, and 61% of acute apical abscess visits received antibiotics. Amoxicillin was prescribed most frequently. Although the median days’ supply was 7 days, prolonged use of antibiotics was frequent (9.2% of irreversible pulpitis, 17.8% of apical periodontitis, 28.7% of acute apical abscess received antibiotics for ≥8 days). Of the irreversible pulpitis visits with antibiotics prescribed, 20.0% received ≥2 antibiotics. Patients with high-risk cardiac conditions, prosthetic joints, and certain dental procedures were associated with receipt of antibiotics (table).
Conclusion
Prior to the release of the ADA guidelines, 75.8% and 59.4% of irreversible pulpitis and apical periodontitis were concordant with proposed recommendations. These data identify opportunities to improve prescribing and serve as a benchmark for future outpatient antimicrobial stewardship efforts. Future work should assess definitive dental treatment and populations without access to oral health care.
Disclosures
All Authors: No reported Disclosures.
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Affiliation(s)
| | - Katie J Suda
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines VA Hospital and University of Illinois at Chicago College of Pharmacy, Hines, Illinois
| | | | - Gretchen Gibson
- Oral Health Quality Group, Veterans Health Care System of the Ozarks, Fayetteville, Arkansas
| | - Marianne M Jurasic
- VA Office of Dentistry, Oral Health Quality Group and Boston University, Boston, Massachusetts
| | | | - Margaret A Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. VA Hospital, Hines, Illinois
| | - Kelly Echevarria
- Pharmacy Benefits Management, Department of Veterans Affairs, San Antonio, Texas
| | - Michael Durkin
- Washington University School of Medicine, St. Louis, Missouri
| | - Jessina C McGregor
- Oregon State University/Oregon Health and Science University, Portland, Oregon
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Gross AE, Suda KJ, Zhou J, Calip G, Rowan SA, Hershow R, Perez R, Evans CT, McGregor JC. 1895. Serious Antibiotic-Related Adverse Effects Following Unnecessary Dental Prophylaxis in the United States. Open Forum Infect Dis 2019. [PMCID: PMC6809462 DOI: 10.1093/ofid/ofz359.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Dentists prescribe 10% of outpatient antibiotics in the United States, with a significant portion of these being for prophylaxis. We previously found that 80% of prescriptions for prophylaxis prescribed prior to dental visits are unnecessary; however, the sequelae of these unnecessary antibiotics have not been characterized. Our objective was to assess the harms of unnecessary antibiotic prophylaxis using Truven, a national health claims database. Methods This was a retrospective cohort study of patients with dental visits from 2011 to 2015 linked to medical and prescription claims. Patients with commercial dental insurance without a hospitalization or extra-oral infection 14 days prior to antibiotic prophylaxis (≤2 days supply dispensed within 7 days before a dental visit) were assessed for inclusion. Patients with unnecessary antibiotic prophylaxis (defined as antibiotic prophylaxis in patients who both did not undergo a procedure that manipulated the gingiva/tooth periapex and did not have an appropriate cardiac diagnosis) were included and assessed for serious antibiotic-related adverse effects (AAE). The primary endpoint was the cumulative incidence of any AAE within 14 days post-prescription (composite of allergy, anaphylaxis, C. difficile infection, or ED visit). The secondary analyses were the cumulative incidence of each individual AAE and the risk difference of the primary endpoint between amoxicillin and clindamycin. Results Of the 168,420 dental visits with antibiotic prophylaxis, 136,177 (80%) were unnecessary and included for analysis. 3.8% of unnecessary prescriptions were associated with an AAE; primary and secondary endpoints are listed in the Table. ED visits (1.2%) and new allergies (2.9%) were most frequent. Clindamycin was associated with more AAE than amoxicillin (risk difference 322.1 per 1000 person-years, 95% CI: 238.5 - 405.8). Conclusion Even though antibiotic prophylaxis is prescribed for a short duration (≤2 days), it is not without risk. Since most AAE are diagnosed in medical settings, dentists may not be aware of these adverse effects. These data provide further impetus to decrease unnecessary prescribing of antibiotic prophylaxis prior to dental procedures. ![]()
Disclosures All Authors: No reported Disclosures.
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Affiliation(s)
- Alan E Gross
- College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Katie J Suda
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Hines VA Hospital and College of Pharmacy, University of Illinois at Chicago, Hines, Illinois
| | - Jifang Zhou
- College of Pharmacy, Univ of Illinois at Chicago, Chicago, Illinois
| | - Gregory Calip
- University of Illinois at Chicago, Chicago, Illinois
| | - Susan A Rowan
- College of Dentistry, University of Illinois at Chicago, Chicago, Illinois
| | - Ronald Hershow
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Rose Perez
- University of Illinois at Chicago, Chicago, Illinois
| | | | - Jessina C McGregor
- Oregon State University/Oregon Health & Science University, Portland, Oregon
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Suda KJ, Calip GS, Zhou J, Rowan S, Gross AE, Hershow RC, Perez RI, McGregor JC, Evans CT. Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015. JAMA Netw Open 2019; 2:e193909. [PMID: 31150071 PMCID: PMC6547109 DOI: 10.1001/jamanetworkopen.2019.3909] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 03/27/2019] [Indexed: 12/12/2022] Open
Abstract
Importance Antibiotics are recommended before certain dental procedures in patients with select comorbidities to prevent serious distant site infections. Objective To assess the appropriateness of antibiotic prophylaxis before dental procedures using Truven, a national integrated health claims database. Design, Setting, and Participants Retrospective cohort study. Dental visits from 2011 to 2015 were linked to medical and prescription claims from 2009 to 2015. The dates of analysis were August 2018 to January 2019. Participants were US patients with commercial dental insurance without a hospitalization or extraoral infection 14 days before antibiotic prophylaxis (defined as a prescription with ≤2 days' supply dispensed within 7 days before a dental visit). Exposures Presence or absence of cardiac diagnoses and dental procedures that manipulated the gingiva or tooth periapex. Main Outcomes and Measures Appropriate antibiotic prophylaxis was defined as a prescription dispensed before a dental visit with a procedure that manipulated the gingiva or tooth periapex in patients with an appropriate cardiac diagnosis. To assess associations between patient or dental visit characteristics and appropriate antibiotic prophylaxis, multivariable logistic regression was used. A priori hypothesis tests were performed with an α level of .05. Results From 2011 to 2015, antibiotic prophylaxis was prescribed for 168 420 dental visits for 91 438 patients (median age, 63 years; interquartile range, 55-72 years; 57.2% female). Overall, these 168 420 dental visits were associated with 287 029 dental procedure codes (range, 1-14 per visit). Most dental visits were classified as diagnostic (70.2%) and/or preventive (58.8%). In 90.7% of dental visits, a procedure was performed that would necessitate antibiotic prophylaxis in high-risk cardiac patients. Prevalent comorbidities include prosthetic joint devices (42.5%) and cardiac conditions at the highest risk of adverse outcome from infective endocarditis (20.9%). Per guidelines, 80.9% of antibiotic prophylaxis prescriptions before dental visits were unnecessary. Clindamycin was more likely to be unnecessary relative to amoxicillin (odds ratio [OR], 1.10; 95% CI, 1.05-1.15). Prosthetic joint devices (OR, 2.31; 95% CI, 2.22-2.41), tooth implant procedures (OR, 1.66; 95% CI, 1.45-1.89), female sex (OR, 1.21; 95% CI, 1.17-1.25), and visits occurring in the western United States (OR, 1.15; 95% CI, 1.06-1.25) were associated with unnecessary antibiotic prophylaxis. Conclusion and Relevance More than 80% of antibiotics prescribed for infection prophylaxis before dental visits were unnecessary. Implementation of antimicrobial stewardship in dental practices is an opportunity to improve antibiotic prescribing for infection prophylaxis.
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Affiliation(s)
- Katie J. Suda
- College of Pharmacy, University of Illinois at Chicago
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois
| | | | - Jifang Zhou
- College of Pharmacy, University of Illinois at Chicago
| | - Susan Rowan
- College of Dentistry, University of Illinois at Chicago
| | - Alan E. Gross
- College of Pharmacy, University of Illinois at Chicago
| | - Ronald C. Hershow
- School of Public Health, University of Illinois at Chicago
- College of Medicine, University of Illinois at Chicago
| | - Rose I. Perez
- College of Medicine, University of Illinois at Chicago
| | - Jessina C. McGregor
- Oregon State University, Corvallis
- College of Pharmacy, Oregon Health and Science University, Portland
| | - Charlesnika T. Evans
- Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr VA Hospital, Hines, Illinois
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Kadoyama KL, Noble BN, Izumi S, Fromme EK, Tjia J, McPherson ML, Candrian CB, McGregor JC, Ku IY, Furuno JP. Frequency and Documentation of Medication Decisions on Discharge from the Hospital to Hospice Care. J Am Geriatr Soc 2019; 67:1258-1262. [DOI: 10.1111/jgs.15860] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/06/2019] [Accepted: 02/06/2019] [Indexed: 01/24/2023]
Affiliation(s)
- Kirsten L. Kadoyama
- Department of Pharmacy Practice; Oregon State University/Oregon Health & Science University College of Pharmacy; Portland Oregon
| | - Brie N. Noble
- Department of Pharmacy Practice; Oregon State University/Oregon Health & Science University College of Pharmacy; Portland Oregon
| | - Shigeko Izumi
- Oregon Health & Science University School of Nursing; Portland Oregon
| | - Erik K. Fromme
- Department of Psychosocial Oncology and Palliative Care; Dana-Farber Cancer Institute; Boston Massachusetts
- Ariadne Labs at Brigham and Women's Hospital and the Harvard T. H. Chan School of Public Health; Boston Massachusetts
| | - Jennifer Tjia
- Department of Quantitative Health Sciences; University of Massachusetts Medical School; Worcester Massachusetts
| | - Mary Lynn McPherson
- Department of Pharmacy Practice and Science; University of Maryland School of Pharmacy; Baltimore Maryland
| | - Carey B. Candrian
- Division of General Internal Medicine, Department of Medicine; University of Colorado School of Medicine; Aurora Colorado
| | - Jessina C. McGregor
- Department of Pharmacy Practice; Oregon State University/Oregon Health & Science University College of Pharmacy; Portland Oregon
| | - In Young Ku
- Department of Pharmacy Practice; Oregon State University/Oregon Health & Science University College of Pharmacy; Portland Oregon
| | - Jon P. Furuno
- Department of Pharmacy Practice; Oregon State University/Oregon Health & Science University College of Pharmacy; Portland Oregon
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Holmer HK, Pakyz A, Tallman GB, Elman MR, Hohmann S, Fu R, Kuper K, McGregor JC. 1873. Next Steps in Predicting Anti-MRSA Antibiotic Prescribing. Open Forum Infect Dis 2018. [PMCID: PMC6253185 DOI: 10.1093/ofid/ofy210.1529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Antibiotic use metrics are utilized by antimicrobial stewardship programs to benchmark performance against peer institutions and inform stewardship efforts. Benchmarking requires risk adjustment for patient- and facility-level factors so that remaining differences are attributable only to prescribing practices. Antibiotics for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) are one of the most frequently used drug classes. Our objective was to identify predictors of anti-MRSA antibiotic use in a nationwide network of hospitals. Methods We used data from inpatient encounters at facilities participating in the Vizient data repository between January 1, 2016 and December 31, 2016. The outcome, anti-MRSA antibiotic use, was calculated as days of therapy per patient-days present for each encounter. We constructed a multivariable negative binomial regression model and assessed the following predictors for inclusion: age, sex, race, ethnicity, diagnosis related groups (DRGs), ICU days, admit month, facility bed size, facility teaching status, and region. A clinical framework was used to categorize DRGs based on risk of anti-MRSA antibiotic use. A backwards stepwise approach was used to identify the final model. We evaluated predictor effect size and significance, and assessed model fit using a deviance-based pseudo-R2. Results One hundred forty-five facilities representing 3,608,711 encounters met inclusion criteria. All predictors considered in our model were significant. Predictors with the greatest magnitude of association included DRG categories and patient age. The DRG categories with the strongest associations were DRGs for infections likely due to Staphylococcus aureus (RR = 1.66, P < 0.0001) or for diagnoses likely to receive long-term MRSA coverage (RR = 1.49, P < 0.0001). The age group with the strongest association was age 2–10 years (RR = 1.64; P < 0.001). The deviance-based pseudo-R2 of the final model was 0.19, indicating good model fit. Conclusion DRGs and patient-level characteristics can be utilized to account for variability in anti-MRSA antibiotic use beyond what is explained through facility-level characteristics. Incorporation of the significant predictors identified in this study may aid in more meaningful interhospital comparisons of anti-MRSA antibiotic use in both adults and pediatrics. Disclosures J. C. McGregor, Merck: Grant Investigator, Research grant.
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Affiliation(s)
- Haley K Holmer
- Epidemiology, Oregon Health and Science University/Portland State University, School of Public Health, Portland, Oregon
| | - Amy Pakyz
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, Virginia
| | - Gregory B Tallman
- Department of Pharmacy Practice, Oregon State University/Oregon Health and Science University College of Pharmacy, Portland, Oregon
| | - Miriam R Elman
- Biostatistics and Design Program, Oregon Health and Science University-Portland State University School of Public Health, Portland, Oregon
| | - Samuel Hohmann
- Center for Advanced Analytics, Vizient, Chicago, Illinois
- Department of Health Systems Management, Rush University, Chicago, Illinois
| | - Rochelle Fu
- Epidemiology, Oregon Health and Science University/Portland State University, School of Public Health, Portland, Oregon
| | | | - Jessina C McGregor
- Epidemiology, Oregon Health and Science University/Portland State University, School of Public Health, Portland, Oregon
- Department of Pharmacy Practice, Oregon State University/Oregon Health and Science University College of Pharmacy, Portland, Oregon
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Suda K, Adimadhyam S, Calip G, Rowan S, Gross AE, Perez R, Hershow R, McGregor JC, Evans C. 1630. Antibiotics Prescribed for Infection Prophylaxis Prior to Dental Procedures Are Frequently Unnecessary in the United States. Open Forum Infect Dis 2018. [PMCID: PMC6252591 DOI: 10.1093/ofid/ofy209.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Antibiotics are recommended prior to certain dental procedures (“antibiotic prophylaxis”) in patients with select comorbidities to prevent serious distant site infections. Our objective was to assess the appropriateness of antibiotic prophylaxis by dentists using Truven, a national integrated medical, dental, and prescription (Rx) claims database of 350 commercial plans.
Methods
Cross-sectional study of 8.7 million adult dental visits in 2015. Antibiotic prophylaxis was defined as Rx with <3 days supply dispensed within 7 days before a dental visit. Medical diagnoses were evaluated in medical/hospital claims from 2009 to 2015. Patients with hospitalizations and infection diagnoses 14 days prior to the Rx date were excluded. Appropriate antibiotic prophylaxis was defined as a dental visit with a procedure that manipulated the gingiva/tooth periapex in patients with an appropriate cardiac diagnosis. Chi Square and logistic regression were applied.
Results
In 2015, 30,726 antibiotics were prescribed for dental infection prophylaxis for 21,986 patients (mean age=58.6 + 15.0 years; 55.9% female). Amoxicillin (68.5%) and clindamycin (14.7%) were most common. 29,879 dental visits were associated with 69,639 dental codes ([CDTs]; range 1–14 CDTs/visit). Most dental visits were diagnostic (65.9% of visits with >1 diagnostic CDT), preventative (53.0%), and restorative (11.2%). 98.4% of dental visits had an appropriate CDT for antibiotic prophylaxis. Comorbidities include orthopedic implants (45.4%) and cardiac diagnoses at the highest risk of infective endocarditis (22.2%). Per guidelines, 78.0% of dental visits with antibiotic prophylaxis were inappropriate. Amoxicillin was more likely to be inappropriate than other agents (OR=1.65; 95% CI: 1.55–1.76). Orthopedic implants (OR=3.35; 95% CI: 3.14–3.56), tooth implant procedures (OR=3.30; 95% CI: 2.48–4.39), females (OR=1.35; 95% CI: 1.27–1.43) and the western US (OR=1.22; 95% CI: 1.09–1.36) were associated with inappropriate prescribing.
Conclusion
Antibiotic prophylaxis is prescribed for indicated dental procedures, but is not appropriately limited to patients with cardiac diagnoses per guidelines. Implementing antimicrobial stewardship efforts in dental practices may be an opportunity to improve antibiotic prescribing for infection prophylaxis.
Disclosures
J. C. McGregor, Merck: Grant Investigator, Research grant.
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Affiliation(s)
- Kj Suda
- University of Illinois at Chicago, Chicago, Illinois
| | | | - Greg Calip
- University of Illinois at Chicago, Chicago, Illinois
| | - Susan Rowan
- University of Illinois at Chicago, Chicago, Illinois
| | - Alan E Gross
- Pharmacy Practice, University of Illinois at Chicago, College of Pharmacy, Chicago, Illinois
| | - Rose Perez
- University of Illinois at Chicago, Chicago, Illinois
| | - Ronald Hershow
- School of Public Health, University of Illinois, Chicago, Illinois
| | - Jessina C McGregor
- Department of Pharmacy Practice, Oregon State University/Oregon Health and Science University College of Pharmacy, Portland, Oregon
| | - Charlesnika Evans
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans Affairs Hospital, Hines, Illinois
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Morgan B, Tallman GB, Elman MR, Bearden DT, McGregor JC. 1502. Identifying Risk Factors for Recurrent Urinary Tract Infections Among Female Outpatients. Open Forum Infect Dis 2018. [PMCID: PMC6254566 DOI: 10.1093/ofid/ofy210.1331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Up to 44% of women who experience a urinary tract infection (UTI) develop a recurrent infection (rUTI) within one year. Insufficient evidence about risk factors for recurrence limits clinicians’ ability to identify women at risk for rUTI who may benefit from further interventions. Methods We conducted a retrospective cohort study of women age ≥18 years who presented for treatment of a UTI at Oregon Health & Science University ambulatory care clinics between 2011 and 2016. Pregnant women as well as those with a recent urinary catheter, genitourinary (GU) procedure, or hospitalization were excluded. The outcome was defined as the first episode of rUTI within one year of an index UTI. Demographics, biologically relevant comorbidities, and the antibiotic prescribed to treat the index UTI were evaluated as potential risk factors for first rUTI using multivariable logistic regression. A best subsets approach was used to determine the most parsimonious model. Results A total of 3,632 patients met inclusion criteria. The mean age of the cohort was 50 ± 20 years and 12% had a diabetes diagnosis. To treat their index UTI, 36% of women were prescribed fluoroquinolones, 33% sulfamethoxazole and/or trimethoprim, and 25% nitrofurantoin. Over the study period, the cumulative incidence of first rUTI was 16% (95% confidence interval (CI): 15.3%, 17.7%); 35% (95% CI: 31%, 39%) of these patients had >1 rUTI. Our model identified age (Odds ratio (OR): 1.02; 95% CI: 1.01, 1.02), urban residence (OR: 1.78; 95% CI: 1.28, 2.57), and neurologic disease diagnosis (OR: 1.46; 95% CI: 1.13, 1.89) affecting GU function (e.g., multiple sclerosis or spinal cord injury) as significant, independent risk factors of first rUTI after adjusting for the confounding effects of diabetes, obesity, and history of stroke or other cerebrovascular disease. Conclusion Diagnosis of neurologic disease that impacts GU function, age, and urban residence were identified as significant risk factors for first rUTI. The antibiotic selected to treat patients’ index UTI was not a significant risk factor for first rUTI. Future studies are needed to identify risk factors beyond what is currently captured discretely in the electronic health record to address critical gaps in our understanding of risk factors for rUTI. Disclosures J. C. McGregor, Merck: Grant Investigator, Research grant
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Affiliation(s)
- Brittany Morgan
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon
| | - Gregory B Tallman
- Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon
| | - Miriam R Elman
- Biostatistics and Design Program, Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon
| | - David T Bearden
- Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon
- Department of Pharmacy Services, Oregon Health & Science University Hospitals and Clinics, Portland, Oregon
| | - Jessina C McGregor
- Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon
- Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon
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Tallman GB, Furuno JP, Noble BN, Bubalo JS, Forrest GN, Lewis JS, Bienvenida AF, Holmes CA, Weber BR, McGregor JC. Clinical Outcomes of the Oral Suspension vs Delayed-Release Tablet Formulations of Posaconazole for Prophylaxis of Invasive Fungal Infections. Open Forum Infect Dis 2017. [PMCID: PMC5631689 DOI: 10.1093/ofid/ofx163.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Posaconazole is effective prophylaxis for invasive fungal infections (IFIs). We compared incidence of breakthrough IFI (bIFI) and early posaconazole discontinuation between patients receiving delayed-release tablet and oral suspension formulations.
Methods
This was a retrospective cohort study of patients receiving posaconazole at Oregon Health & Science University Hospital between 1/1/2010 and 6/30/2016. Oral suspension was the preferred formulation until 2/2014; afterwards the tablet was preferred. We included all courses of primary prophylaxis for each patient during the study period. Data were extracted from an electronic health record repository and via chart review. Three independent reviewers identified bIFI using European Organization for Research and Treatment of Cancer criteria. We assessed rationale for early discontinuation of posaconazole for patients that were still indicated for antifungal prophylaxis based on National Comprehensive Cancer Network (NCCN) criteria.
Results
547 patients received 859 courses of posaconazole (53% oral suspension and 48% tablet). Prophylaxis was indicated according to NCCN criteria in 91% of courses. The primary indications for prophylaxis were acute myelogenous leukemia (68%), graft-vs-host disease (18%), and myelodysplastic syndrome (3%). There were no significant differences in demographics or indication between patients receiving the different formulations. The overall incidence rate of bIFI was 4.15/10,000 posaconazole-days (16 total bIFI events). Incidence of bIFI was not significantly different between patients receiving the different formulations (P = 0.92). Posaconazole was discontinued early in 147 (17%) courses; frequency of discontinuation was not significantly different between the tablet (20%) and oral suspension (15%) formulations (P = 0.10). The primary reasons for early discontinuation were elevated liver function tests or QT prolongation (25%), inability to take an oral formulation (17%), and drug cost (17%).
Conclusion
Among patients receiving posaconazole prophylaxis, incidence of bIFI was low and not significantly different between those receiving the tablet vs oral suspension formulations.
Disclosures
J. P. Furuno, Merck & Co.: Consultant and Grant Investigator, Consulting fee, Research grant and Speaker honorarium. J. S. Lewis II, Merck & Co.: Consultant, Consulting fee. J. C. McGregor, Merck & Co.: Grant Investigator, Research grant
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Affiliation(s)
- Gregory B Tallman
- Dept. of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon
| | - Jon P Furuno
- Dept. Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon
| | - Brie N Noble
- Dept. of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon
| | - Joseph S Bubalo
- Pharmacy, Oregon Health & Science University, Portland, Oregon
| | - Graeme N Forrest
- Division of Infectious Disease, Veterans Affairs Portland Health Care System, Portland, Oregon
| | - James S Lewis
- Department of Pharmacy, Oregon Health & Science University, Portland, Oregon
| | - Ana F Bienvenida
- Dept. Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon
| | - Courtney A Holmes
- Dept. Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon
| | - Bo R Weber
- Dept. Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon
| | - Jessina C McGregor
- Dept. Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon
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Tallman GB, Elman MR, Irwin AN, Noble BN, Atkins PK, Ham Y, Waldrip K, McGregor JC. Impact of Culturing All Uncomplicated Urinary Tract Infections on the Estimated Prevalence Of Resistance in the Primary Care Setting. Open Forum Infect Dis 2017. [PMCID: PMC5631673 DOI: 10.1093/ofid/ofx163.839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Urine cultures to confirm a urinary tract infection (UTI) are not consistently collected in the primary care setting; thus estimates of the prevalence of resistance in uropathogens may be biased. As part of an ongoing study, microbiologic cultures were collected for all patients presenting with uncomplicated UTI at primary care clinics over a six-month period to assess the potential misclassification in frequency of resistance.
Methods
Data from an electronic health record repository were used to identify clinic encounters for women with a diagnosis code for unspecified UTI or cystitis from six primary care clinics between October 1, 2015 and February 28, 2017 in this cross-sectional study. Prior to August 22, 2016, urine microbiology cultures were collected at the discretion of the provider (usual care period), and from August 22, 2016 to February 28, 2017 urinary microbiology cultures were collected from all patients suspected of having uncomplicated UTI (full culturing period). Urinary microbiology culture and pharmacy data occurring within three days of the encounter were collected. Antibiotic susceptibility data was summarized for isolated Enterobacteriaceae. Frequency of susceptibility to trimethoprim-sulfamethoxazole (TMP-SMX), nitrofurantoin, and fluoroquinolones were compared between usual care vs. the full culturing periods using a chi-square test.
Results
We identified 131 urine microbiology cultures in the usual care period and 104 in the full culturing period with 61.1% and 55.8%, respectively, being positive cultures. Enterobacteriaceae were isolated from 85.0% of positive cultures in the usual care period and 86.2% in the full culturing period. Between the usual and full culturing periods, antibiotic susceptibility in the Enterobacteriaceae did not differ statistically for TMP-SMX (85.1% vs.. 88.0%; P = 0.65), nitrofurantoin (98.5% vs. 94.0%; P = 0.19), and fluoroquinolones (89.6% vs. 90.0%; P = 0.94).
Conclusion
Full culturing did not significantly change estimates of the prevalence of antibiotic resistance among Enterobacteriaceae isolated from urine samples. Current urine culturing practices provide adequate susceptibility information to inform empiric prescribing for women with uncomplicated UTIs.
Disclosures
J. C. McGregor, Merck & Co.: Grant Investigator, Research grant
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Affiliation(s)
- Gregory B Tallman
- Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon
| | - Miriam R Elman
- Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon
| | - Adriane N Irwin
- Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Corvallis, Oregon
| | - Brie N Noble
- Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon
| | - Peter K Atkins
- Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Corvallis, Oregon
| | - YoungYoon Ham
- Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Corvallis, Oregon
| | - Kallie Waldrip
- Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Corvallis, Oregon
| | - Jessina C McGregor
- Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon
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McGregor JC, Pakyz AL. Enhancing the Utility of Antibiotic Susceptibility Reporting as a Tool for Antimicrobial Stewardship. Curr Treat Options Infect Dis 2017. [DOI: 10.1007/s40506-017-0108-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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McGregor JC, Harris AD, Furuno JP, Bradham DD, Perencevich EN. Relative Influence of Antibiotic Therapy Attributes on Physician Choice in Treating Acute Uncomplicated Pyelonephritis. Med Decis Making 2016; 27:387-94. [PMID: 17585004 DOI: 10.1177/0272989x07302556] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Reducing excess duration of antibiotic therapy is a strategy for limiting the spread of antibiotic resistance, but altering physician practice to accomplish this requires knowledge of the factors that influence physician antibiotic choice. The authors aimed to quantify physician willingness to trade between 4 attributes of antibiotic therapies: different therapy durations, failure rates, dosing frequencies, and days of diarrhea as a side effect when treating acute uncomplicated pyelonephritis. Methods. The authors distributed conjoint analysis questionnaires to physicians enrolling patients in a randomized trial comparing 2 antibiotics in pyelonephritis treatment. For each question, respondents were required to select 1 of 2 antibiotics based on the values of the 4 attributes. Proportional hazards regression was used to model predictors of physician choice. Results. Eighty-seven of 88 physicians completed the questionnaire. Duration of therapy, days of diarrhea, and failure rate were significant predictors of choice (P < 0.05), but dosing frequency (once daily v. twice daily) was not. Increasing days of diarrhea greatly reduced the probability of an antibiotic being chosen. If failure and side effects were equivalent, physicians were more likely to prescribe a 5- v. 10-day duration of therapy (odds ratio = 4.18, P < 0.01). Conclusion. Antibiotic choice is most influenced by physicians' desires to limit treatment failure and side effects, although physicians were willing to accept increases in treatment failure to obtain reduced days of diarrhea as a side effect. Because shorter-course therapy is frequently associated with fewer side effects, efforts to encourage physicians to choose shorter treatment durations should include mention of reduced treatment-associated side effects.
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Affiliation(s)
- Jessina C McGregor
- Department of Epidemiology and Preventive Medicine, University of Maryland, Baltimore, USA.
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