Order Substitutions and Education for Balanced Crystalloid Solution Use in an Integrated Health Care System and Association With Major Adverse Kidney Events

IMPORTANCE

Trials comparing balanced crystalloids with normal saline have yielded mixed results regarding reductions in kidney complications and mortality for hospitalized patients receiving intravenous fluids.

OBJECTIVE

To evaluate the association of a multifaceted implementation program encouraging the preferential use of lactated Ringer solution with patient outcomes and intravenous fluid-prescribing practices in a large, multilevel health care system.

DESIGN, SETTING, AND PARTICIPANTS

This type 2 hybrid implementation and comparative effectiveness study enrolled all patients 18 years or older who received 1 L or more of intravenous fluids while admitted to an emergency department and/or inpatient unit at 1 of 22 hospitals in Idaho and Utah between November 1, 2018, and February 29, 2020. An interrupted time series analysis was used to assess study outcomes before and after interventions to encourage use of lactated Ringer solution.

EXPOSURES

Implementation program combining order set modification, electronic order entry alerts, and sequential clinician-targeted education to encourage prescribing of lactated Ringer solution instead of normal saline.

MAIN OUTCOMES AND MEASURES

The primary implementation outcome was the patient-level proportion of intravenous fluids that was balanced crystalloids. The primary effectiveness outcome was the incidence of major adverse kidney events (MAKE30)-a composite of new persistent kidney dysfunction, new initiation of dialysis, and death-at 30 days.

RESULTS

Among 148 423 patients (median [IQR] age, 47 [30-67] years; 91 302 women [61%]), the proportion of total fluids received that was lactated Ringer solution increased from 28% to 75% in the first week vs the last week of the study (immediate implementation effect odds ratio [OR], 3.44; 95% CI, 2.79-4.24). The estimated MAKE30 absolute risk reduction was 2.2% (95% CI, 1.3%-3.3%) based on interrupted time series analysis showing a decrease in the week-on-week trend for MAKE30 (OR difference, 0.03; 95% CI, 0.03-0.03, P < .001). The immediate postimplementation OR for MAKE30 was 0.88 (95% CI, 0.76-1.01), with a decrease in persistent kidney dysfunction (OR, 0.80; 95% CI, 0.69-0.93) and mortality (OR, 0.78; 95% CI, 0.65-0.93) but not dialysis (OR, 1.00; 95% CI, 0.76-1.32).

CONCLUSIONS AND RELEVANCE

In this comparative effectiveness study, an implementation program was associated with an increase in the proportion of fluids administered as lactated Ringer solution compared with normal saline and was associated with a reduction in MAKE30 events among patients treated in a large integrated health care system.

16. SCORE-UC: Antibiotic Stewardship in Urgent Care

Background

Urgent care (UC) is a rapidly growing site of healthcare delivery. The CDC developed Core Elements for Outpatient Antibiotic Stewardship to guide development of outpatient stewardship but little experience exists in applying Core Elements to UC settings. Our objective was to evaluate the effectiveness of a UC stewardship program in a health system.

Figure

Methods

We designed a UC stewardship program for Intermountain Healthcare’s 39 UC sites based on CDC Core Elements. The pre-intervention period was Aug 2017-June 2019. The intervention period was 12 months from Jul 2019 -June 2020. The program consisted of education for patients/providers about appropriate diagnosis and prescribing for respiratory conditions; media campaigns; EHR tools; and a prescribing dashboard for clinicians. The primary outcome was the percentage of respiratory visits where an antibiotic was prescribed. Secondary outcomes included the percentage of encounters receiving antibiotics for conditions where no antibiotics are indicated (e.g. bronchitis) and the percentage of encounters receiving first-line recommended therapy for conditions in which antibiotics may be warrented (otitis media, sinusitis, and pharyngitis). We used a binomial mixed effects hierarchical model to calculate the odds of antibiotic prescribing associated with the intervention period accounting for pre-intervention trends. Models account for clustering within providers and clinics. We present the results of an interim analysis after 7 months of the intervention.

Results

The overall number of UC encounters during the study period was 1,559,403 and 41.5% were for respiratory conditions. The percentage of patients with respiratory conditions that received an antibiotic prescription declined from 49.9% pre-intervention to 35.3% during the intervention (OR 0.73, 95% CI: 0.71, 0.76), reaching a low of 30% during February 2020 (Figure). Prescribing for conditions where antibiotics are not indicated decreased (OR 0.31, 95% CI 0.26–0.36) and first line recommended therapy increased (OR 1.28, 95% CI 1.20–1.26) during the intervention.

Conclusion

After 7 months of a planned 12 month intervention, the UC stewardship program was associated with improved antibiotic prescribing.

Disclosures

Rajendu Srivastava, MD, AHRQ, NIH, CDC (Grant/Research Support, I hold grants from AHRQ, NIH and CDC for a variety of clinical research and implementation studies)IPASS Patient Safety Institute (Other Financial or Material Support, I am a physician founder of this company to spread handoff best practices and reduce adverse events. My employer holds my equity in this company.)

Analyzing Associations Between Chronic Disease Prevalence and Neighborhood Quality Through Google Street View Images

Deep learning and, specifically, convoltional neural networks (CNN) represent a class of powerful models that facilitate the understanding of many problems in computer vision. When combined with a reasonable amount of data, CNNs can outperform traditional models for many tasks, including image classification. In this work, we utilize these powerful tools with imagery data collected through Google Street View images to perform virtual audits of neighborhood characteristics. We further investigate different architectures for chronic disease prevalence regression through networks that are applied to sets of images rather than single images. We show quantitative results and demonstrate that our proposed architectures outperform the traditional regression approaches.

Neighbourhood looking glass: 360º automated characterisation of the built environment for neighbourhood effects research

Background

Neighbourhood quality has been connected with an array of health issues, but neighbourhood research has been limited by the lack of methods to characterise large geographical areas. This study uses innovative computer vision methods and a new big data source of street view images to automatically characterise neighbourhood built environments.

Methods

A total of 430 000 images were obtained using Google’s Street View Image API for Salt Lake City, Chicago and Charleston. Convolutional neural networks were used to create indicators of street greenness, crosswalks and building type. We implemented log Poisson regression models to estimate associations between built environment features and individual prevalence of obesity and diabetes in Salt Lake City, controlling for individual-level and zip code-level predisposing characteristics.

Results

Computer vision models had an accuracy of 86%–93% compared with manual annotations. Charleston had the highest percentage of green streets (79%), while Chicago had the highest percentage of crosswalks (23%) and commercial buildings/apartments (59%). Built environment characteristics were categorised into tertiles, with the highest tertile serving as the referent group. Individuals living in zip codes with the most green streets, crosswalks and commercial buildings/apartments had relative obesity prevalences that were 25%–28% lower and relative diabetes prevalences that were 12%–18% lower than individuals living in zip codes with the least abundance of these neighbourhood features.

Conclusion

Neighbourhood conditions may influence chronic disease outcomes. Google Street View images represent an underused data resource for the construction of built environment features.

Using Electronic Health Record Data to Identify Prostate Cancer Patients That May Qualify for Active Surveillance

Introduction:

The introduction of the protein-specific antigen (PSA) test in care means that prostate cancer (PCa) is being detected earlier and more frequently. The result of increased screening using PSA, digital rectal examination and awareness of prostate was an increase in the number of men with low risk cancers. Active surveillance has become a viable alternative to immediate treatment with surgery, radiation and other forms of localized treatment. Evidence suggests that there is no significant difference in mortality rates between AS and surgery. In addition, patients may potentially delay other complications associated with surgery, radiation or deprivation therapy.

Methods:

This quality improvement study using a delivery system science framework describes the electronic identification of AS candidates given an evidence-based identification criteria based upon national guidelines and clinical judgement. The study population (n=649) was drawn from health records of all patients who received a prostate biopsy (n=1731) at Intermountain Healthcare from 1/1/2013 to 12/31/2014. Automated and manual abstraction was performed. Receiver operating characteristic (ROC) analysis was used to compare AS-eligible patients to the actual treatment received to identify potential care improvement opportunities.

Among those with complete data, 24.7% of this population (n=160) met “AS-eligible” criteria. 39.1% of the population had not received surgery, radiation or androgen deprivation therapy and were considered as being treated using an AS approach. 9% of AS-eligible patients did not receive AS; 27% of patients who did not meet AS-eligible criteria received AS. Estimated guideline adherence measured using area under the curve was 0.70 (95% CI: 0.66–0.73). Modest variation in criteria parameters for identifying AS-eligible patients did not significantly change estimated adherence levels.

Conclusion:

Implementation of evidence-based criteria for detection of AS candidates is feasible using electronic health record data and provides a reasonable basis for delivery system evaluation of practice patterns and for quality improvement.

Characterization of diffuse fibrosis in the failing human heart via diffusion tensor imaging and quantitative histological validation

Non-invasive imaging techniques are highly desirable as an alternative to conventional biopsy for the characterization of the remodeling of tissues associated with disease progression, including end-stage heart failure. Cardiac diffusion tensor imaging (DTI) has become an established method for the characterization of myocardial microstructure. However, the relationships between diffuse myocardial fibrosis, which is a key biomarker for staging and treatment planning of the failing heart, and measured DTI parameters have yet to be investigated systematically. In this study, DTI was performed on left ventricular specimens collected from patients with chronic end-stage heart failure as a result of idiopathic dilated cardiomyopathy (n = 14) and from normal donors (n = 5). Scalar DTI parameters, including fractional anisotropy (FA) and mean (MD), primary (D1 ), secondary (D2 ) and tertiary (D3 ) diffusivities, were correlated with collagen content measured by digital microscopy. Compared with hearts from normal subjects, the FA in failing hearts decreased by 22%, whereas the MD, D2 and D3 increased by 12%, 14% and 24%, respectively (P < 0.01). No significant change was detected for D1 between the two groups. Furthermore, significant correlation was observed between the DTI scalar indices and quantitative histological measurements of collagen (i.e. fibrosis). Pearson's correlation coefficients (r) between collagen content and FA, MD, D2 and D3 were -0.51, 0.59, 0.56 and 0.62 (P < 0.05), respectively. The correlation between D1 and collagen content was not significant (r = 0.46, P = 0.05). Computational modeling analysis indicated that the behaviors of the DTI parameters as a function of the degree of fibrosis were well explained by compartmental exchange between myocardial and collagenous tissues. Combined, these findings suggest that scalar DTI parameters can be used as metrics for the non-invasive assessment of diffuse fibrosis in failing hearts.

Physician assistants and their intent to retire

OBJECTIVES

To determine predictors of physician assistants (PAs) to retire or to permanently leave clinical practice. The intent was to create a measure of retention and attrition for purposes of forecasting PA supply.

STUDY DESIGN

All PAs 55 years or older who were nationally certified in 2011 were surveyed.

METHODS

Statistical analysis included descriptive measures utilizing means, standard deviations, range, and proportions for all survey questions. Univariable analysis using χ² test for the categorical variables determined gender differences in participants' intent to retire. A studentized t test analysis for continuous variables was used to compare differences across genders. The estimated time interval until retirement was calculated using reported values from participants and then subtracting their projected retirement age from current age. The same calculation was used for estimating PA career length from date of graduation to retirement. For all analyses, a P value < .05 was considered statistically significant.

RESULTS

A total of 12,005 were eligible and surveyed online; 4767 responded (38%). The mean age was 60 years and the years in clinical practice was 25. When asked to predict a retirement date or age, the mean duration of working beyond age 55 years was 12 years (range 5 to 21). Most respondents reported being confident they were on track to retire with an adequate income. The significant differences that emerged were that men were more confident than women in preparing to retire, having enough money for medical expenses, and being able to live comfortably in retirement. Men more than women stated that, if forced to retire, they were more confident in the preparation to do so.

CONCLUSIONS

PAs 55 years and older report they are likely to delay retirement from practice until age 67 years, on average. Women were less confident than men in retirement preparation. This age prediction expands career projections and refines forecasting models for the profession. Correlations based on expectation-action chain of events should be developed by periodically measuring how often intent and reality coalesce.

Morbidity and mortality in heart transplant candidates supported with mechanical circulatory support: is reappraisal of the current United network for organ sharing thoracic organ allocation policy justified?

BACKGROUND

Survival of patients on left ventricular assist devices (LVADs) has improved. We examined the differences in risk of adverse outcomes between LVAD-supported and medically managed candidates on the heart transplant waiting list.

METHODS AND RESULTS

We analyzed mortality and morbidity in 33,073 heart transplant candidates registered on the United Network for Organ Sharing (UNOS) waiting list between 1999 and 2011. Five groups were selected: patients without LVADs in urgency status 1A, 1B, and 2; patients with pulsatile-flow LVADs; and patients with continuous-flow LVADs. Outcomes in patients requiring biventricular assist devices, total artificial heart, and temporary VADs were also analyzed. Two eras were defined on the basis of the approval date of the first continuous-flow LVAD for bridge to transplantation in the United States (2008). Mortality was lower in the current compared with the first era (2.1%/mo versus 2.9%/mo; P<0.0001). In the first era, mortality of pulsatile-flow LVAD patients was higher than in status 2 (hazard ratio [HR], 2.15; P<0.0001) and similar to that in status 1B patients (HR, 1.04; P=0.61). In the current era, patients with continuous-flow LVADs had mortality similar to that of status 2 (HR, 0.80; P=0.12) and lower mortality compared with status 1A and 1B patients (HR, 0.24 and 0.47; P<0.0001 for both comparisons). However, status upgrade for LVAD-related complications occurred frequently (28%) and increased the mortality risk (HR, 1.75; P=0.001). Mortality was highest in patients with biventricular assist devices (HR, 5.00; P<0.0001) and temporary VADs (HR, 7.72; P<0.0001).

CONCLUSIONS

Mortality and morbidity on the heart transplant waiting list have decreased. Candidates supported with contemporary continuous-flow LVADs have favorable waiting list outcomes; however, they worsen significantly once a serious LVAD-related complication occurs. Transplant candidates requiring temporary and biventricular support have the highest risk of adverse outcomes. These results may help to guide optimal allocation of donor hearts.

A Randomized and Clinical Effectiveness Trial Comparing Two Pharmacogenetic Algorithms and Standard Care for Individualizing Warfarin Dosing (CoumaGen-II)

Background—

Warfarin is characterized by marked variations in individual dose requirements and a narrow therapeutic window. Pharmacogenetics (PG) could improve dosing efficiency and safety, but clinical trials evidence is meager.

Methods and Results—

A Randomized and Clinical Effectiveness Trial Comparing Two Pharmacogenetic Algorithms and Standard Care for Individualizing Warfarin Dosing (CoumaGen-II) comprised 2 comparisons: (1) a blinded, randomized comparison of a modified 1-step (PG-1) with a 3-step algorithm (PG-2) (N=504), and (2) a clinical effectiveness comparison of PG guidance with use of either algorithm with standard dosing in a parallel control group (N=1866). A rapid method provided same-day CYP2C9 and VKORC1 genotyping. Primary outcomes were percentage of out-of-range international normalized ratios at 1 and 3 months and percentage of time in therapeutic range. Primary analysis was modified intention to treat. In the randomized comparison, PG-2 was noninferior but not superior to PG-1 for percentage of out-of-range international normalized ratios at 1 month and 3 months and for percentage of time in therapeutic range at 3 months. However, the combined PG cohort was superior to the parallel controls (percentage of out-of-range international normalized ratios 31% versus 42% at 1 month; 30% versus 42% at 3 months; percentage of time in therapeutic range 69% versus 58%, 71% versus 59%, respectively, all P <0.001). Differences persisted after adjustment for age, sex, and clinical indication. There were fewer percentage international normalized ratios ≥4 and ≤1.5 and serious adverse events at 3 months (4.5% versus 9.4% of patients, P <0.001) with PG guidance.

Conclusions—

These findings suggest that PG dosing should be considered for broader clinical application, a proposal that is being tested further in 3 major randomized trials. The simpler 1-step PG algorithm provided equivalent results and may be preferable for clinical application.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00927862.

Clinical and hemodynamic effects of renin-angiotensin system blockade in cardiac transplant recipients

Chronic kidney disease continues to be a major limiting factor for long-term survival of heart transplant recipients. Little is known about the early use of renin-angiotensin system (RAS) blocking agents and their impact on renal function and hemodynamics in heart transplant recipients. In this cohort study all eligible recipients of orthotopic heart transplants at the UTAH cardiac transplantation program from 2001 through 2007 were divided into 2 groups-patients who were started on angiotensin-converting enzyme inhibitors or angiotensin receptor blockers within the first 4 weeks of transplantation and continued on these for ≥4 weeks during the first 3 months (RAS blockade group, n = 75) and those who were not (non-RAS blockade group, n = 52). All patients were followed for 1 year after transplantation. There were no significant differences at baseline between the 2 groups. Estimated glomerular filtration rate at 12 months was significantly higher in the RAS blockade group compared to the non-RAS blockade group (mean ± SD, 56.3 ± 22.4 vs 47.3 ± 18.1 ml/min/1.73 m(2), p = 0.036). At 12 months pulmonary artery systolic pressure was significantly lower in the RAS blockade group compared to the non-RAS blockade group (30.2 ± 7.4 vs 32.9 ± 9.3 mm Hg, p = 0.023). Left ventricular ejection fraction and pulmonary capillary wedge pressure were similar between the 2 groups. In conclusion, early RAS blockade after heart transplantation is safe, well tolerated, and associated with better renal function and hemodynamic profile at 1 year after transplantation.