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O’Brien WJ, Schweizer ML, Strymish J, Beck BF, Au V, Chan JA, Brown M, Itani KMF, Dukes KC, Walhof JF, Gupta K. Propensity Score-Weighted Analysis of Postoperative Infection in Patients With and Without Preoperative Urine Culture. JAMA Netw Open 2024; 7:e240900. [PMID: 38436958 PMCID: PMC10912952 DOI: 10.1001/jamanetworkopen.2024.0900] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/11/2024] [Indexed: 03/05/2024] Open
Abstract
Importance Although recent guidelines recommend against performance of preoperative urine culture before nongenitourinary surgery, many clinicians still order preoperative urine cultures and prescribe antibiotics for treatment of asymptomatic bacteriuria in an effort to reduce infection risk. Objective To assess the association between preoperative urine culture testing and postoperative urinary tract infection (UTI) or surgical site infection (SSI), independent of baseline patient characteristics or type of surgery. Design, Setting, and Participants This cohort study analyzed surgical procedures performed from January 1, 2017, to December 31, 2019, at any of 112 US Department of Veterans Affairs (VA) medical centers. The cohort comprised VA enrollees who underwent major elective noncardiac, nonurological operations. Machine learning and inverse probability of treatment weighting (IPTW) were used to balance the characteristics between those who did and did not undergo a urine culture. Data analyses were performed between January 2023 and January 2024. Exposures Performance of urine culture within 30 days prior to surgery. Main Outcomes and Measures The 2 main outcomes were UTI and SSI occurring within 30 days after surgery. Weighted logistic regression was used to estimate odds ratios (ORs) for postoperative infection based on treatment status. Results A total of 250 389 VA enrollees who underwent 288 858 surgical procedures were included, with 88.9% (256 753) of surgical procedures received by males and 48.9% (141 340) received by patients 65 years or older. Baseline characteristics were well balanced among treatment groups after applying IPTW weights. Preoperative urine culture was performed for 10.5% of surgical procedures (30 384 of 288 858). The IPTW analysis found that preoperative urine culture was not associated with SSI (adjusted OR [AOR], 0.99; 95% CI, 0.90-1.10) or postoperative UTI (AOR, 1.18; 95% CI, 0.98-1.40). In analyses limited to orthopedic surgery and neurosurgery as a proxy for prosthetic implants, the adjusted risks for UTI and SSI were also not associated with preoperative urine culture performance. Conclusions and Relevance This cohort study found no association between performance of a preoperative urine culture and lower risk of postoperative UTI or SSI. The results support the deimplementation of urine cultures and associated antibiotic treatment prior to surgery, even when using prosthetic implants.
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Affiliation(s)
- William J. O’Brien
- Veterans Affairs (VA) Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
| | - Marin L. Schweizer
- William S. Middleton VA Hospital, Madison, Wisconsin
- Department of Medicine, University of Wisconsin-Madison, Madison
| | | | - Brice F. Beck
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
| | - Vanessa Au
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
| | - Jeffrey A. Chan
- Veterans Affairs (VA) Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
| | - Madisen Brown
- Veterans Affairs (VA) Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
| | - Kamal M. F. Itani
- VA Boston Health Care System Department of Surgery, Boston University and Harvard Medical School, Boston, Massachusetts
| | - Kimberly C. Dukes
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
- Carver College of Medicine, The University of Iowa, Iowa City
| | - Julia Friberg Walhof
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
| | - Kalpana Gupta
- Veterans Affairs (VA) Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, Massachusetts
- VA Boston Department of Medicine, Boston, Massachusetts
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Ohl ME, Richardson Miell K, Beck BF, Mecham B, Bailey G, Mengeling M, Vaughan-Sarrazin M. Mortality Among US Veterans Admitted to Community vs Veterans Health Administration Hospitals for COVID-19. JAMA Netw Open 2023; 6:e2315902. [PMID: 37252740 DOI: 10.1001/jamanetworkopen.2023.15902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
Importance Veterans Health Administration (VHA) enrollees receive care for COVID-19 in both VHA and non-VHA (ie, community) hospitals, but little is known about the frequency or outcomes of care for veterans with COVID-19 in VHA vs community hospitals. Objective To compare outcomes among veterans admitted for COVID-19 in VHA vs community hospitals. Design, Setting, and Participants This retrospective cohort study used VHA and Medicare data from March 1, 2020, to December 31, 2021, on hospitalizations for COVID-19 in 121 VHA and 4369 community hospitals in the US among a national cohort of veterans (aged ≥65 years) enrolled in both the VHA and Medicare with VHA care in the year prior to hospitalization for COVID-19 based on the primary diagnosis code. Exposure Admission to VHA vs community hospitals. Main Outcomes and Measures The main outcomes were 30-day mortality and 30-day readmission. Inverse probability of treatment weighting was used to balance observable patient characteristics (eg, demographic characteristics, comorbidity, mechanical ventilation on admission, area-level social vulnerability, distance to VHA vs community hospitals, and date of admission) between VHA and community hospitals. Results The cohort included 64 856 veterans (mean [SD] age, 77.6 [8.0] years; 63 562 men [98.0%]) dually enrolled in the VHA and Medicare who were hospitalized for COVID-19. Most (47 821 [73.7%]) were admitted to community hospitals (36 362 [56.1%] admitted to community hospitals via Medicare, 11 459 [17.7%] admitted to community hospitals reimbursed via VHA's Care in the Community program, and 17 035 [26.3%] admitted to VHA hospitals). Admission to community hospitals was associated with higher unadjusted and risk-adjusted 30-day mortality compared with admission to VHA hospitals (crude mortality, 12 951 of 47 821 [27.1%] vs 3021 of 17 035 [17.7%]; P < .001; risk-adjusted odds ratio, 1.37 [95% CI, 1.21-1.55]; P < .001). Readmission within 30 days was less common after admission to community compared with VHA hospitals (4898 of 38 576 [12.7%] vs 2006 of 14 357 [14.0%]; risk-adjusted hazard ratio, 0.89 [95% CI, 0.86-0.92]; P < .001). Conclusions and Relevance This study found that most hospitalizations for COVID-19 among VHA enrollees aged 65 years or older were in community hospitals and that veterans experienced higher mortality in community hospitals than in VHA hospitals. The VHA must understand the sources of the mortality difference to plan care for VHA enrollees during future COVID-19 surges and the next pandemic.
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Affiliation(s)
- Michael E Ohl
- Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Kelly Richardson Miell
- Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Brice F Beck
- Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Bradley Mecham
- Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - George Bailey
- Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Michelle Mengeling
- Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Mary Vaughan-Sarrazin
- Veterans Rural Health Resource Center-Iowa City, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Center for Access & Delivery Research and Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
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3
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Kobayashi T, Van Epps P, Maier MM, Beste LA, Beck BF, Alexander B, Ohl ME. Discussion and Initiation of HIV Pre-exposure Prophylaxis Were Rare Following Diagnoses of Sexually Transmitted Infections Among Veterans. J Gen Intern Med 2022; 37:2482-2488. [PMID: 34341917 PMCID: PMC9360206 DOI: 10.1007/s11606-021-07034-7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Healthcare encounters for the diagnosis and treatment of sexually transmitted infections (STIs) are common and represent an opportunity to discuss and initiate HIV pre-exposure prophylaxis (PrEP). Little is known about how frequently PrEP is discussed and initiated in association with encounters for STIs. DESIGN Retrospective cohort and nested case-control study, matched by STI date, in national Veterans Health Administration (VHA) facilities from January 2013 to December 2018. PARTICIPANTS Veterans with a first STI diagnosis (i.e., early syphilis, gonorrhea, or chlamydia) based on ICD codes, excluding those with prior HIV diagnosis, prior PrEP use, or STI diagnosed on screening during a visit to initiate PrEP. MAIN MEASURES Frequency of PrEP initiation within 90 days of healthcare encounter for STIs. In the case-control study, we performed a structured chart review from the initial STI-related clinical encounter and quantified frequency of PrEP discussions among matched patients who did and did not initiate PrEP in the following 90 days. KEY RESULTS We identified 23,312 patients with a first STI, of whom 90 (0.4%) started PrEP within 90 days. PrEP initiation was associated with urban residence (OR = 5.0, 95% CI 1.8-13.5), White compared to Black race (OR = 1.7, 95% CI 1.0-2.7), and syphilis diagnosis (OR = 5.7, 95% CI 3.7-8.6). Chart review revealed that discussion of PrEP was rare among people with STIs who did not subsequently start PrEP (1.1%, 95% CI 0.1-4.0). PrEP initiation was associated with documentation of sexual history (80.0% of initiators vs. 51.0% of non-initiators, p < 0.01) and discussion of PrEP (52.2% vs. 1.1%, p < 0.01) during the initial STI diagnosis encounter. CONCLUSIONS Discussion and initiation of PrEP were rare following healthcare encounters for STIs. Interventions are needed to improve low rates of sexual history-taking and discussion of PrEP during healthcare encounters for STIs.
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Affiliation(s)
- Takaaki Kobayashi
- Department of Internal Medicine, University of Iowa, 200 Hawkins Drive, SW34 GH, Iowa City, IA, USA. .,Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA. .,VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City, IA, USA.
| | - Puja Van Epps
- VA North East Ohio Healthcare System, Cleveland, OH, USA.,Division of Infectious Diseases, Department of Internal Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Marissa M Maier
- VA Portland Health Care System, Portland, OR, USA.,Division of Infectious Diseases, Department of Internal Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Lauren A Beste
- General Medicine Service, VA Puget Sound Health Care System, Seattle, WA, USA.,Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Brice F Beck
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA.,VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City, IA, USA
| | - Bruce Alexander
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA.,VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City, IA, USA
| | - Michael E Ohl
- Department of Internal Medicine, University of Iowa, 200 Hawkins Drive, SW34 GH, Iowa City, IA, USA.,Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA, USA.,VA Office of Rural Health, Veterans Rural Health Resource Center-Iowa City, Iowa City, IA, USA
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Livorsi DJ, Nair R, Lund BC, Alexander B, Beck BF, Goto M, Ohl M, Vaughan-Sarrazin MS, Goetz MB, Perencevich EN. Antibiotic Stewardship Implementation and Antibiotic Use at Hospitals With and Without On-site Infectious Disease Specialists. Clin Infect Dis 2021; 72:1810-1817. [PMID: 32267496 DOI: 10.1093/cid/ciaa388] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 04/06/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Many US hospitals lack infectious disease (ID) specialists, which may hinder antibiotic stewardship efforts. We sought to compare patient-level antibiotic exposure at Veterans Health Administration (VHA) hospitals with and without an on-site ID specialist, defined as an ID physician and/or ID pharmacist. METHODS This retrospective VHA cohort included all acute-care patient admissions during 2016. A mandatory survey was used to identify hospitals' antibiotic stewardship processes and their access to an on-site ID specialist. Antibiotic use was quantified as days of therapy per days present and categorized based on National Healthcare Safety Network definitions. A negative binomial regression model with risk adjustment was used to determine the association between presence of an on-site ID specialist and antibiotic use at the level of patient admissions. RESULTS Eighteen of 122 (14.8%) hospitals lacked an on-site ID specialist; there were 525 451 (95.8%) admissions at ID hospitals and 23 007 (4.2%) at non-ID sites. In the adjusted analysis, presence of an ID specialist was associated with lower total inpatient antibacterial use (odds ratio, 0.92; 95% confidence interval, .85-.99). Presence of an ID specialist was also associated with lower use of broad-spectrum antibacterials (0.61; .54-.70) and higher narrow-spectrum β-lactam use (1.43; 1.22-1.67). Total antibacterial exposure (inpatient plus postdischarge) was lower among patients at ID versus non-ID sites (0.92; .86-.99). CONCLUSIONS Patients at hospitals with an ID specialist received antibiotics in a way more consistent with stewardship principles. The presence of an ID specialist may be important to effective antibiotic stewardship.
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Affiliation(s)
- Daniel J Livorsi
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Rajeshwari Nair
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Brian C Lund
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Bruce Alexander
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Brice F Beck
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Michihiko Goto
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Michael Ohl
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Mary S Vaughan-Sarrazin
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Matthew B Goetz
- VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at the University of California in Los Angeles, Los Angeles, California, USA
| | - Eli N Perencevich
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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5
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Ohl ME, Miller DR, Lund BC, Kobayashi T, Richardson Miell K, Beck BF, Alexander B, Crothers K, Vaughan Sarrazin MS. Association of Remdesivir Treatment With Survival and Length of Hospital Stay Among US Veterans Hospitalized With COVID-19. JAMA Netw Open 2021; 4:e2114741. [PMID: 34264329 PMCID: PMC8283561 DOI: 10.1001/jamanetworkopen.2021.14741] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Randomized clinical trials have yielded conflicting results about the effects of remdesivir therapy on survival and length of hospital stay among people with COVID-19. OBJECTIVE To examine associations between remdesivir treatment and survival and length of hospital stay among people hospitalized with COVID-19 in routine care settings. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from the Veterans Health Administration (VHA) to identify adult patients in 123 VHA hospitals who had a first hospitalization with laboratory-confirmed COVID-19 from May 1 to October 8, 2020. Propensity score matching of patients initiating remdesivir treatment to control patients who had not initiated remdesivir treatment by the same hospital day was used to create the analytic cohort. EXPOSURES Remdesivir treatment. MAIN OUTCOMES AND MEASURES Time to death within 30 days of remdesivir treatment initiation (or corresponding hospital day for matched control individuals) and time to hospital discharge with time to death as a competing event. Associations between remdesivir treatment and these outcomes were assessed using Cox proportional hazards regression in the matched cohort. RESULTS The initial cohort included 5898 patients admitted to 123 hospitals, 2374 (40.3%) of whom received remdesivir treatment (2238 men [94.3%]; mean [SD] age, 67.8 [12.8] years) and 3524 (59.7%) of whom never received remdesivir treatment (3302 men [93.7%]; mean [SD] age, 67.0 [14.4] years). After propensity score matching, the analysis included 1172 remdesivir recipients and 1172 controls, for a final matched cohort of 2344 individuals. Remdesivir recipients and matched controls were similar with regard to age (mean [SD], 66.6 [14.2] years vs 67.5 [14.1] years), sex (1101 men [93.9%] vs 1101 men [93.9%]), dexamethasone use (559 [47.7%] vs 559 [47.7%]), admission to the intensive care unit (242 [20.7%] vs 234 [19.1%]), and mechanical ventilation use (69 [5.9%] vs 45 [3.8%]). Standardized differences were less than 10% for all measures. Remdesivir treatment was not associated with 30-day mortality (143 remdesivir recipients [12.2%] vs 124 controls [10.6%]; log rank P = .26; adjusted hazard ratio [HR], 1.06; 95% CI, 0.83-1.36). Results were similar for people receiving vs not receiving dexamethasone at remdesivir initiation (dexamethasone recipients: adjusted HR, 0.93; 95% CI, 0.64-1.35; nonrecipients: adjusted HR, 1.19; 95% CI, 0.84-1.69). Remdesivir recipients had a longer median time to hospital discharge compared with matched controls (6 days [interquartile range, 4-12 days] vs 3 days [interquartile range, 1-7 days]; P < .001). CONCLUSIONS AND RELEVANCE In this cohort study of US veterans hospitalized with COVID-19, remdesivir treatment was not associated with improved survival but was associated with longer hospital stays. Routine use of remdesivir may be associated with increased use of hospital beds while not being associated with improvements in survival.
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Affiliation(s)
- Michael E. Ohl
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs (VA) Health Care System, Iowa City
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
| | - Donald R. Miller
- Center for Healthcare Organization & Implementation Research, VA Bedford Health Care System, Bedford, Massachusetts
- Center for Population Health, Department of Biomedical & Nutritional Sciences, University of Massachusetts, Lowell
| | - Brian C. Lund
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs (VA) Health Care System, Iowa City
| | - Takaaki Kobayashi
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs (VA) Health Care System, Iowa City
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
| | - Kelly Richardson Miell
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs (VA) Health Care System, Iowa City
| | - Brice F. Beck
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs (VA) Health Care System, Iowa City
| | - Bruce Alexander
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs (VA) Health Care System, Iowa City
| | - Kristina Crothers
- VA Puget Sound Health Care System, Seattle, Washington
- Department of Internal Medicine, University of Washington, Seattle
| | - Mary S. Vaughan Sarrazin
- Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs (VA) Health Care System, Iowa City
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City
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Suzuki H, Perencevich EN, Alexander B, Beck BF, Goto M, Lund BC, Nair R, Livorsi DJ. Inpatient Fluoroquinolone Stewardship Improves the Quantity and Quality of Fluoroquinolone Prescribing at Hospital Discharge: A Retrospective Analysis Among 122 Veterans Health Administration Hospitals. Clin Infect Dis 2021; 71:1232-1239. [PMID: 31562815 DOI: 10.1093/cid/ciz967] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 09/26/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Despite increasing awareness of harms, fluoroquinolones are still frequently prescribed to inpatients and at hospital discharge. Our goal was to describe fluoroquinolone prescribing at hospital discharge across the Veterans Health Administration (VHA) and to contrast the volume and appropriateness of fluoroquinolone prescribing across 3 antimicrobial stewardship strategy types. METHODS We analyzed a retrospective cohort of patients hospitalized at 122 VHA acute-care hospitals during 2014-2016. Data from a mandatory VHA survey were used to identify 9 hospitals that self-reported 1 of 3 strategies for optimizing fluoroquinolone prescribing: prospective audit and feedback (PAF), restrictive policies (RP), and no strategy. Manual chart reviews to assess fluoroquinolone appropriateness at hospital discharge (ie, postdischarge) were performed across the 9 hospitals (3 hospitals and 125 cases per strategy type). RESULTS There were 1.7 million patient admissions. Overall, there were 1 727 478 fluoroquinolone days of therapy (DOTs), with 674 918 (39.1%) DOTs prescribed for inpatients and 1 052 560 (60.9%) DOTs prescribed postdischarge. Among the 9 reviewed hospitals, postdischarge fluoroquinolone exposure was lower at hospitals using RP, compared to no strategy (3.8% vs 9.3%, respectively; P = .012). Postdischarge fluoroquinolones were deemed inappropriate in 154 of 375 (41.1%) patients. Fluoroquinolones were more likely to be inappropriate at hospitals without a strategy (52.8%) versus those using either RP or PAF (35.2%; P = .001). CONCLUSIONS In this retrospective cohort, the majority of fluoroquinolone DOTs occurred after hospital discharge. A large proportion of postdischarge fluoroquinolone prescriptions were inappropriate, especially in hospitals without a strategy to manage fluoroquinolone prescribing. Our findings suggest that stewardship efforts to minimize and improve fluoroquinolone prescribing should also focus on antimicrobial prescribing at hospital discharge.
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Affiliation(s)
- Hiroyuki Suzuki
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Eli N Perencevich
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Bruce Alexander
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Brice F Beck
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Michihiko Goto
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Brian C Lund
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Rajeshwari Nair
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Daniel J Livorsi
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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7
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Schweizer ML, Richardson K, Vaughan Sarrazin MS, Goto M, Livorsi DJ, Nair R, Alexander B, Beck BF, Jones MP, Puig-Asensio M, Suh D, Ohl M, Perencevich EN. Comparative Effectiveness of Switching to Daptomycin Versus Remaining on Vancomycin Among Patients With Methicillin-resistant Staphylococcus aureus (MRSA) Bloodstream Infections. Clin Infect Dis 2021; 72:S68-S73. [PMID: 33512521 DOI: 10.1093/cid/ciaa1572] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/13/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Patients with methicillin-resistant Staphylococcus aureus bloodstream infections (MRSA BSI) usually receive initial treatment with vancomycin but may be switched to daptomycin for definitive therapy, especially if treatment failure is suspected. Our objective was to evaluate the effectiveness of switching from vancomycin to daptomycin compared with remaining on vancomycin among patients with MRSA BSI. METHODS Patients admitted to 124 Veterans Affairs Hospitals who experienced MRSA BSI and were treated with vancomycin during 2007-2014 were included. The association between switching to daptomycin and 30-day mortality was assessed using Cox regression models. Separate models were created for switching to daptomycin any time during the first hospitalization and for switching within 3 days of receiving vancomycin. RESULTS In total, 7411 patients received vancomycin for MRSA BSI. Also, 606 (8.2%) patients switched from vancomycin to daptomycin during the first hospitalization, and 108 (1.5%) switched from vancomycin to daptomycin within 3 days of starting vancomycin. In the multivariable analysis, switching to daptomycin within 3 days was significantly associated with lower 30-day mortality (hazards ratio [HR] = 0.48; 95% confidence interval [CI]: .25, .92). However, switching to daptomycin at any time during the first hospitalization was not significantly associated with 30-day mortality (HR: 0.87; 95% CI: .69, 1.09). CONCLUSIONS Switching to daptomycin within 3 days of initial receipt of vancomycin is associated with lower 30-day mortality among patients with MRSA BSI. This benefit was not seen when the switch occurred later. Future studies should prospectively assess the benefit of early switching from vancomycin to other anti-MRSA antibiotics.
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Affiliation(s)
- Marin L Schweizer
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa USA.,Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa USA
| | - Kelly Richardson
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa USA
| | - Mary S Vaughan Sarrazin
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa USA.,Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa USA
| | - Michihiko Goto
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa USA.,Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa USA
| | - Daniel J Livorsi
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa USA.,Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa USA
| | - Rajeshwari Nair
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa USA.,Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa USA
| | - Bruce Alexander
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa USA
| | - Brice F Beck
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa USA
| | - Michael P Jones
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa USA.,Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa USA
| | - Mireia Puig-Asensio
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa USA
| | - Daniel Suh
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa USA
| | - Madeline Ohl
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa USA
| | - Eli N Perencevich
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, Iowa USA.,Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa USA
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Fortis S, O'Shea AMJ, Beck BF, Comellas A, Vaughan Sarrazin M, Kaboli PJ. Association Between Rural Residence and In-Hospital and 30-Day Mortality Among Veterans Hospitalized with COPD Exacerbations. Int J Chron Obstruct Pulmon Dis 2021; 16:191-202. [PMID: 33564232 PMCID: PMC7866931 DOI: 10.2147/copd.s281162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 09/11/2020] [Accepted: 12/11/2020] [Indexed: 12/30/2022] Open
Abstract
Background We explored the relationship between rural residency and in-hospital mortality in patients hospitalized with COPD exacerbations. Methods We retrospectively analyzed COPD hospitalizations from 2011 to 2017 at 124 acute care Veterans Health Administration (VHA) hospitals in the US. Patient residence was classified using Rural Urban Commuting Area codes as urban, rural, or isolated rural. We stratified patient hospitalizations into quartiles by travel time from patient residence to the nearest VHA primary care provider clinic and hospital. Multivariate analyses utilized generalized estimating equations with a logit link accounting for repeated hospitalizations among patients and adjusting for patient- and hospital-level characteristics. Results Of 64,914 COPD hospitalizations analyzed, 43,549 (67.1%) were for urban, 18,673 (28.8%) for rural, and 2,692 (4.1%) for isolated rural veterans. In-hospital mortality was 4.9% in urban, 5.5% in rural, and 5.2% in isolated rural veterans (P=0.008). Thirty-day mortality was 8.3% in urban, 9.9% in rural, and 9.2% in isolated rural veterans (P<0.001). Travel time to a primary care provider and VHA hospital was not associated with in-hospital mortality among isolated rural and rural veterans. In the multivariable analysis, compared to urban veterans, isolated rural patients did not have increased mortality. Rural residence was not associated with in-hospital (OR=0.87; 95% CI=0.67-1.12, P=0.28) but was associated with increased 30-day mortality (OR=1.13; 95% CI=1.04-1.22, P=0.002). Transfer from another acute care hospital (OR=14.97; 95% CI=9.80-17.16, P<0.001) or an unknown/other facility (OR=33.05; 95% CI=22.66-48.21, P<0.001) were the strongest predictors of increased in-hospital mortality compared to patients coming from the outpatient sector. Transfer from another acute care facility was also a risk factor for 30-day mortality. Conclusion Potential gaps in post-discharge care of rural veterans may be responsible for the rural-urban disparities. Further research should investigate the exact mechanism that inter-hospital transfers affect mortality.
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Affiliation(s)
- Spyridon Fortis
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Amy M J O'Shea
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Brice F Beck
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
| | - Alejandro Comellas
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mary Vaughan Sarrazin
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Peter J Kaboli
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA.,Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
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9
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Goto M, Jones MP, Schweizer ML, Livorsi DJ, Perencevich EN, Richardson K, Beck BF, Alexander B, Ohl ME. Association of Infectious Diseases Consultation With Long-term Postdischarge Outcomes Among Patients With Staphylococcus aureus Bacteremia. JAMA Netw Open 2020; 3:e1921048. [PMID: 32049296 DOI: 10.1001/jamanetworkopen.2019.21048] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Staphylococcus aureus bacteremia (SAB) is common and associated with poor long-term outcomes. Previous studies have demonstrated an association between infectious diseases (ID) consultation and improved short-term (ie, within 90 days) outcomes for patients with SAB, but associations with long-term outcomes are unknown. OBJECTIVE To investigate the association of ID consultation with long-term (ie, 5 years) postdischarge outcomes among patients with SAB. DESIGN, SETTING, AND PARTICIPANTS This cohort study included all patients (N = 31 002) with a first episode of SAB who were discharged alive from 116 acute care units of the nationwide Veterans Health Administration where ID consultation was offered. Data were collected from January 2003 to December 2014, with follow-up through September 30, 2018. Data analysis was conducted from February to December 2019. EXPOSURES Infectious diseases consultation during the index hospital stay. MAIN OUTCOMES AND MEASURES The primary outcome was time to development of a composite event of all-cause mortality or recurrence of SAB within 5 years of discharge. As secondary outcomes, SAB recurrence and all-cause mortality with and without recurrence were analyzed while accounting for semicompeting risks. RESULTS The cohort included 31 002 patients (30 265 [97.6%] men; median [interquartile range] age at SAB onset, 64.0 [57.0-75.0] years). Among 31 002 patients, there were 18 794 (60.6%) deaths, 4772 (15.4%) SAB recurrences, and 20 414 (65.8%) composite events during 5 years of follow-up; 12 773 deaths (68.0%) and 2268 recurrences (47.5%) occurred more than 90 days after discharge. Approximately half of patients (15 360 [49.5%]) received ID consultation during the index hospital stay; ID consultation was associated with prolonged improvement in the composite outcome (adjusted hazard ratio at 5 years, 0.71; 95% CI, 0.68-0.74; P < .001). Infectious diseases consultation was also associated with improved outcomes when all-cause mortality without recurrence and SAB recurrence were analyzed separately (all-cause mortality without recurrence: adjusted hazard ratio at 5 years, 0.77; 95% CI, 0.74-0.81; P < .001; SAB recurrence: adjusted hazard ratio at 5 years, 0.68; 95% CI, 0.64-0.72; P < .001). CONCLUSIONS AND RELEVANCE Having an ID consultation during the index hospital stay among patients with SAB was associated with improved postdischarge outcomes for at least 5 years, suggesting that contributions of ID specialists to management during acute infection may have a substantial influence on long-term outcomes. Further investigations of the association of ID consultation with outcomes after S aureus should include long-term follow-up.
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Affiliation(s)
- Michihiko Goto
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Michael P Jones
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City
| | - Marin L Schweizer
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Daniel J Livorsi
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Eli N Perencevich
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Kelly Richardson
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Brice F Beck
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Bruce Alexander
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Michael E Ohl
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
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10
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Fortis S, O'Shea AMJ, Beck BF, Nair R, Goto M, Kaboli PJ, Perencevich EN, Reisinger HS, Sarrazin MV. An automated computerized critical illness severity scoring system derived from APACHE III: modified APACHE. J Crit Care 2018; 48:237-242. [PMID: 30243204 DOI: 10.1016/j.jcrc.2018.09.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/04/2018] [Accepted: 09/04/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the performance of an automated computerized ICU severity scoring derived from the APACHE III. MATERIALS AND METHODS Within a retrospective cohort of patients admitted to Veterans Health Administration ICUs between 2009 and 2015, we created an automated illness severity score(modified APACHE or mAPACHE), that we extracted from the electronic health records, using the same scoring as the APACHE III excluding the Glasgow Coma Scale, urine output, arterial blood gas components of APACHE III. We assessed the mAPACHE discrimination by using the area under the curve(AUC), and calibration by using the Hosmer-Lemeshow test and calculating the difference between observed and expected mortality across equal-sized risk deciles for death. RESULTS The ICU and 30-day mortality was 5.07% of 7.82%, respectively (n = 490,955 patients). The AUC of mAPACHE for ICU and 30-day mortality was 0.771 and 0.786, respectively. The Hosmer-Lemeshow test was significant for both ICU and 30-day mortality (p < .001). The absolute difference between observed and expected mortality did not exceed ±1.53% across equal-sized deciles of risk for death. The AUC for ICU mortality was >0.7 in all admission diagnosis categories except in endocrine, respiratory, and sepsis. The AUC for 30-day mortality was >0.7 in every category. CONCLUSION mAPACHE has adequate performance to predict mortality.
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Affiliation(s)
- Spyridon Fortis
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of Pulmonary, Critical Care and Occupation Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA.
| | - Amy M J O'Shea
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Brice F Beck
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
| | - Rajeshwari Nair
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Michihiko Goto
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Peter J Kaboli
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Eli N Perencevich
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Heather S Reisinger
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Mary V Sarrazin
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
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Fortis S, Sarrazin MV, Beck BF, Panos RJ, Reisinger HS. ICU Telemedicine Reduces Interhospital ICU Transfers in the Veterans Health Administration. Chest 2018; 154:69-76. [DOI: 10.1016/j.chest.2018.04.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 02/05/2018] [Accepted: 04/02/2018] [Indexed: 11/26/2022] Open
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Goto M, McDanel JS, Jones MM, Livorsi DJ, Ohl ME, Beck BF, Richardson KK, Alexander B, Perencevich EN. Antimicrobial Nonsusceptibility of Gram-Negative Bloodstream Isolates, Veterans Health Administration System, United States, 2003-2013 1. Emerg Infect Dis 2018; 23:1815-1825. [PMID: 29047423 PMCID: PMC5652419 DOI: 10.3201/eid2311.161214] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Bacteremia caused by gram-negative bacteria is associated with serious illness and death, and emergence of antimicrobial drug resistance in these bacteria is a major concern. Using national microbiology and patient data for 2003–2013 from the US Veterans Health Administration, we characterized nonsusceptibility trends of community-acquired, community-onset; healthcare-associated, community-onset; and hospital-onset bacteremia for selected gram-negative bacteria (Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, and Acinetobacter spp.). For 47,746 episodes of bacteremia, the incidence rate was 6.37 episodes/10,000 person-years for community-onset bacteremia and 4.53 episodes/10,000 patient-days for hospital-onset bacteremia. For Klebsiella spp., P. aeruginosa, and Acinetobacter spp., we observed a decreasing proportion of nonsusceptibility across nearly all antimicrobial drug classes for patients with healthcare exposure; trends for community-acquired, community-onset isolates were stable or increasing. The role of infection control and antimicrobial stewardship efforts in inpatient settings in the decrease in drug resistance rates for hospital-onset isolates needs to be determined.
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13
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Goto M, Schweizer ML, Vaughan-Sarrazin MS, Perencevich EN, Livorsi DJ, Diekema DJ, Richardson KK, Beck BF, Alexander B, Ohl ME. Association of Evidence-Based Care Processes With Mortality in Staphylococcus aureus Bacteremia at Veterans Health Administration Hospitals, 2003-2014. JAMA Intern Med 2017; 177:1489-1497. [PMID: 28873140 PMCID: PMC5710211 DOI: 10.1001/jamainternmed.2017.3958] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [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] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Staphylococcus aureus bacteremia is common and frequently associated with poor outcomes. Evidence indicates that specific care processes are associated with improved outcomes for patients with S aureus bacteremia, including appropriate antibiotic prescribing, use of echocardiography to identify endocarditis, and consultation with infectious diseases (ID) specialists. Whether use of these care processes has increased in routine care for S aureus bacteremia or whether use of these processes has led to large-scale improvements in survival is unknown. OBJECTIVE To examine the association of evidence-based care processes in routine care for S aureus bacteremia with mortality. DESIGN, SETTING, AND PARTICIPANTS This retrospective observational cohort study examined all patients admitted to Veterans Health Administration (VHA) acute care hospitals who had a first episode of S aureus bacteremia from January 1, 2003, through December 31, 2014. EXPOSURES Use of appropriate antibiotic therapy, echocardiography, and ID consultation. MAIN OUTCOMES AND MEASURES Thirty-day all-cause mortality. RESULTS Analyses included 36 868 patients in 124 hospitals (mean [SD] age, 66.4 [12.5] years; 36 036 [97.7%] male), including 19 325 (52.4%) with infection due to methicillin-resistant S aureus and 17 543 (47.6%) with infection due to methicillin-susceptible S aureus. Risk-adjusted mortality decreased from 23.5% (95% CI, 23.3%-23.8%) in 2003 to 18.2% (95% CI, 17.9%-18.5%) in 2014. Rates of appropriate antibiotic prescribing increased from 2467 (66.4%) to 1991 (78.9%), echocardiography from 1256 (33.8%) to 1837 (72.8%), and ID consultation from 1390 (37.4%) to 1717 (68.0%). After adjustment for patient characteristics, cohort year, and other care processes, receipt of care processes was associated with lower mortality, with adjusted odds ratios of 0.74 (95% CI, 0.68-0.79) for appropriate antibiotics, 0.73 (95% CI, 0.68-0.78) for echocardiography, and 0.61 (95% CI, 0.56-0.65) for ID consultation. Mortality decreased progressively as the number of care processes that a patient received increased (adjusted odds ratio for all 3 processes compared with none, 0.33; 95% CI, 0.30-0.36). An estimated 57.3% (95% CI, 48.4%-69.9%) of the decrease in mortality between 2003 and 2014 could be attributed to increased use of these evidence-based care processes. CONCLUSIONS AND RELEVANCE Mortality associated with S aureus bacteremia decreased significantly in VHA hospitals, and a substantial portion of the decreasing mortality may have been attributable to increased use of evidence-based care processes. The experience in VHA hospitals demonstrates that increasing application of these care processes may improve survival among patients with S aureus bacteremia in routine health care settings.
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Affiliation(s)
- Michihiko Goto
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Marin L Schweizer
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Mary S Vaughan-Sarrazin
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Eli N Perencevich
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Daniel J Livorsi
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Daniel J Diekema
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Kelly K Richardson
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Brice F Beck
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Bruce Alexander
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Michael E Ohl
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
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Appenheimer AB, Bokhour B, McInnes DK, Richardson KK, Thurman AL, Beck BF, Vaughan-Sarrazin M, Asch SM, Midboe AM, Taylor T, Dvorin K, Gifford AL, Ohl ME. Should Human Immunodeficiency Virus Specialty Clinics Treat Patients With Hypertension or Refer to Primary Care? An Analysis of Treatment Outcomes. Open Forum Infect Dis 2017; 4:ofx005. [PMID: 28480278 DOI: 10.1093/ofid/ofx005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 01/19/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Care for people with human immunodeficiency virus (HIV) increasingly focuses on comorbidities, including hypertension. Evidence indicates that antiretroviral therapy and opportunistic infections are best managed by providers experienced in HIV medicine, but it is unclear how to structure comorbidity care. Approaches include providing comorbidity care in HIV clinics ("consolidated care") or combining HIV care with comorbidity management in primary care clinics ("shared care"). We compared blood pressure (BP) control in HIV clinics practicing consolidated care versus shared care. METHODS We created a national cohort of Veterans with HIV and hypertension receiving care in HIV clinics in Veterans Administration facilities and merged these data with a survey asking HIV providers how they delivered hypertension care (5794 Veterans in 73 clinics). We defined BP control as BP ≤140/90 mmHg on the most recent measure. We compared patients' likelihood of experiencing BP control in clinics offering consolidated versus shared care, adjusting for patient and clinic characteristics. RESULTS Forty-two of 73 clinics (57.5%) practiced consolidated care for hypertension. These clinics were larger and more likely to use multidisciplinary teams. The unadjusted frequency of BP control was 65.6% in consolidated care clinics vs 59.4% in shared care clinics (P < .01). The likelihood of BP control remained higher for patients in consolidated care clinics after adjusting for patient and clinic characteristics (odds ratio, 1.32; 95% confidence interval, 1.04-1.68). CONCLUSIONS Patients were more likely to experience BP control in clinics reporting consolidated care compared with clinics reporting shared care. For shared-care clinics, improving care coordination between HIV and primary care clinics may improve outcomes.
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Affiliation(s)
- A Ben Appenheimer
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Barbara Bokhour
- Boston University School of Public Health, Department of Health Law, Policy, and Management, Massachusetts.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - D Keith McInnes
- Boston University School of Public Health, Department of Health Law, Policy, and Management, Massachusetts.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - Kelly K Richardson
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa
| | - Andrew L Thurman
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa
| | - Brice F Beck
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa
| | - Mary Vaughan-Sarrazin
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Steven M Asch
- Division of General Medical Science, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Amanda M Midboe
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Thom Taylor
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California
| | - Kelly Dvorin
- Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - Allen L Gifford
- Boston University School of Public Health, Department of Health Law, Policy, and Management, Massachusetts.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial VA Healthcare System, Bedford, Massachusetts
| | - Michael E Ohl
- Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City VA Medical Center, Iowa.,Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
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15
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Goto M, O'Shea AMJ, Livorsi DJ, McDanel JS, Jones MM, Richardson KK, Beck BF, Alexander B, Evans ME, Roselle GA, Kralovic SM, Perencevich EN. The Effect of a Nationwide Infection Control Program Expansion on Hospital-Onset Gram-Negative Rod Bacteremia in 130 Veterans Health Administration Medical Centers: An Interrupted Time-Series Analysis. Clin Infect Dis 2016; 63:642-650. [PMID: 27358355 DOI: 10.1093/cid/ciw423] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/07/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The Veterans Health Administration (VHA) introduced the Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention Initiative in March 2007. Although the initiative has been perceived as a vertical intervention focusing on MRSA, it also expanded infection prevention and control programs and resources. We aimed to assess the horizontal effect of the initiative on hospital-onset (HO) gram-negative rod (GNR) bacteremia. METHODS This retrospective cohort included all patients who had HO bacteremia due to Escherichia coli, Klebsiella species, or Pseudomonas aeruginosa at 130 VHA facilities from January 2003 to December 2013. The effects were assessed using segmented linear regression with autoregressive error models, incorporating autocorrelation, immediate effect, and time before and after the initiative. Community-acquired (CA) bacteremia with same species was also analyzed as nonequivalent dependent controls. RESULTS A total of 11 196 patients experienced HO-GNR bacteremia during the study period. There was a significant change of slope in HO-GNR bacteremia incidence rates from before the initiative (+0.3%/month) to after (-0.4%/month) (P < .01), while CA GNR incidence rates did not significantly change (P = .08). Cumulative effect of the intervention on HO-GNR bacteremia incidence rates at the end of the study period was estimated to be -43.2% (95% confidence interval, -51.6% to -32.4%). Similar effects were observed in subgroup analyses of each species and antimicrobial susceptibility profile. CONCLUSIONS Within 130 VHA facilities, there was a sustained decline in HO-GNR bacteremia incidence rates after the implementation of the MRSA Prevention Initiative. As these organisms were not specifically targeted, it is likely that horizontal components of the initiative contributed to this decline.
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Affiliation(s)
- Michihiko Goto
- Iowa City Veterans Affairs (VA) Health Care System.,University of Iowa Carver College of Medicine, Iowa City
| | - Amy M J O'Shea
- Iowa City Veterans Affairs (VA) Health Care System.,University of Iowa Carver College of Medicine, Iowa City
| | - Daniel J Livorsi
- Iowa City Veterans Affairs (VA) Health Care System.,University of Iowa Carver College of Medicine, Iowa City
| | - Jennifer S McDanel
- Iowa City Veterans Affairs (VA) Health Care System.,University of Iowa Carver College of Medicine, Iowa City
| | - Makoto M Jones
- Salt Lake City VA Health Care System.,University of Utah School of Medicine, Salt Lake City
| | | | - Brice F Beck
- Iowa City Veterans Affairs (VA) Health Care System
| | | | - Martin E Evans
- Veterans Health Administration (VHA) MDRO Program Office.,Lexington VA Medical Center.,University of Kentucky College of Medicine, Lexington
| | - Gary A Roselle
- VHA National Infectious Diseases Service.,Cincinnati VA Medical Center.,University of Cincinnati College of Medicine, Ohio
| | - Stephen M Kralovic
- VHA National Infectious Diseases Service.,Cincinnati VA Medical Center.,University of Cincinnati College of Medicine, Ohio
| | - Eli N Perencevich
- Iowa City Veterans Affairs (VA) Health Care System.,University of Iowa Carver College of Medicine, Iowa City
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