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Fanaroff AC, Patel MS, Chokshi N, Coratti S, Farraday D, Norton L, Rareshide C, Zhu J, Klaiman T, Szymczak JE, Russell LB, Small DS, Volpp KGM. Effect of Gamification, Financial Incentives, or Both to Increase Physical Activity Among Patients at High Risk of Cardiovascular Events: The BE ACTIVE Randomized Controlled Trial. Circulation 2024; 149:1639-1649. [PMID: 38583084 DOI: 10.1161/circulationaha.124.069531] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/28/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Physical activity is associated with a lower risk of major adverse cardiovascular events, but few individuals achieve guideline-recommended levels of physical activity. Strategies informed by behavioral economics increase physical activity, but their longer-term effectiveness is uncertain. We sought to determine the effect of behaviorally designed gamification, loss-framed financial incentives, or their combination on physical activity compared with attention control over 12-month intervention and 6-month postintervention follow-up periods. METHODS Between May 2019 and January 2024, participants with clinical atherosclerotic cardiovascular disease or a 10-year risk of myocardial infarction, stroke, or cardiovascular death of ≥7.5% by the Pooled Cohort equation were enrolled in a pragmatic randomized clinical trial. Participants received a wearable device to track daily steps, established a baseline, selected a step goal increase, and were randomly assigned to control (n=151), behaviorally designed gamification (n=304), loss-framed financial incentives (n=302), or gamification+financial incentives (n=305). The primary outcome of the trial was the change in mean daily steps from baseline through the 12-month intervention period. RESULTS A total of 1062 patients (mean±SD age, 67±8; 61% female; 31% non-White) were enrolled. Compared with control subjects, participants had significantly greater increases in mean daily steps from baseline during the 12-month intervention in the gamification arm (adjusted difference, 538.0 [95% CI, 186.2-889.9]; P=0.0027), financial incentives arm (adjusted difference, 491.8 [95% CI, 139.6-844.1]; P=0.0062), and gamification+financial incentives arm (adjusted difference, 868.0 [95% CI, 516.3-1219.7]; P<0.0001). During the 6-month follow-up, physical activity remained significantly greater in the gamification+financial incentives arm than in the control arm (adjusted difference, 576.2 [95% CI, 198.5-954]; P=0.0028), but it was not significantly greater in the gamification (adjusted difference, 459.8 [95% CI, 82.0-837.6]; P=0.0171) or financial incentives (adjusted difference, 327.9 [95% CI, -50.2 to 706]; P=0.09) arms after adjustment for multiple comparisons. CONCLUSIONS Behaviorally designed gamification, loss-framed financial incentives, and the combination of both increased physical activity compared with control over a 12-month intervention period, with the largest effect in gamification+financial incentives. These interventions could be a useful component of strategies to reduce cardiovascular risk in high-risk patients. REGISTRATION URL: https://clinicaltrials.gov; Unique Identifier: NCT03911141.
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Affiliation(s)
- Alexander C Fanaroff
- Department of Medicine, Perelman School of Medicine, (A.C.F., N.C., J.Z., T.K., K.G.M.V.), University of Pennsylvania, Philadelphia
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.C.F.), University of Pennsylvania, Philadelphia
- Penn Center for Health Incentives and Behavioral Economics (AC.F., S.C., D.F., L.N., C.R., J.Z., T.K., L.B.R., K.G.M.V.), University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics (A.C.F., N.C., L.B.R., D.S.S., K.G.M.V.), University of Pennsylvania, Philadelphia
- Penn Center for Digital Cardiology (A.C.F., N.C.), University of Pennsylvania, Philadelphia
| | | | - Neel Chokshi
- Department of Medicine, Perelman School of Medicine, (A.C.F., N.C., J.Z., T.K., K.G.M.V.), University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics (A.C.F., N.C., L.B.R., D.S.S., K.G.M.V.), University of Pennsylvania, Philadelphia
- Penn Center for Digital Cardiology (A.C.F., N.C.), University of Pennsylvania, Philadelphia
| | - Samantha Coratti
- Penn Center for Health Incentives and Behavioral Economics (AC.F., S.C., D.F., L.N., C.R., J.Z., T.K., L.B.R., K.G.M.V.), University of Pennsylvania, Philadelphia
| | - David Farraday
- Penn Center for Health Incentives and Behavioral Economics (AC.F., S.C., D.F., L.N., C.R., J.Z., T.K., L.B.R., K.G.M.V.), University of Pennsylvania, Philadelphia
| | - Laurie Norton
- Penn Center for Health Incentives and Behavioral Economics (AC.F., S.C., D.F., L.N., C.R., J.Z., T.K., L.B.R., K.G.M.V.), University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy (L.N., J.Z., L.B.R., K.G.M.V.), University of Pennsylvania, Philadelphia
| | - Charles Rareshide
- Penn Center for Health Incentives and Behavioral Economics (AC.F., S.C., D.F., L.N., C.R., J.Z., T.K., L.B.R., K.G.M.V.), University of Pennsylvania, Philadelphia
| | - Jingsan Zhu
- Department of Medicine, Perelman School of Medicine, (A.C.F., N.C., J.Z., T.K., K.G.M.V.), University of Pennsylvania, Philadelphia
- Penn Center for Health Incentives and Behavioral Economics (AC.F., S.C., D.F., L.N., C.R., J.Z., T.K., L.B.R., K.G.M.V.), University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy (L.N., J.Z., L.B.R., K.G.M.V.), University of Pennsylvania, Philadelphia
| | - Tamar Klaiman
- Department of Medicine, Perelman School of Medicine, (A.C.F., N.C., J.Z., T.K., K.G.M.V.), University of Pennsylvania, Philadelphia
- Penn Center for Health Incentives and Behavioral Economics (AC.F., S.C., D.F., L.N., C.R., J.Z., T.K., L.B.R., K.G.M.V.), University of Pennsylvania, Philadelphia
| | - Julia E Szymczak
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City (J.E.S.)
| | - Louise B Russell
- Penn Center for Health Incentives and Behavioral Economics (AC.F., S.C., D.F., L.N., C.R., J.Z., T.K., L.B.R., K.G.M.V.), University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics (A.C.F., N.C., L.B.R., D.S.S., K.G.M.V.), University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy (L.N., J.Z., L.B.R., K.G.M.V.), University of Pennsylvania, Philadelphia
| | - Dylan S Small
- Leonard Davis Institute of Health Economics (A.C.F., N.C., L.B.R., D.S.S., K.G.M.V.), University of Pennsylvania, Philadelphia
- The Wharton School (D.S.S., K.G.M.V.), University of Pennsylvania, Philadelphia
| | - Kevin G M Volpp
- Department of Medicine, Perelman School of Medicine, (A.C.F., N.C., J.Z., T.K., K.G.M.V.), University of Pennsylvania, Philadelphia
- Penn Center for Health Incentives and Behavioral Economics (AC.F., S.C., D.F., L.N., C.R., J.Z., T.K., L.B.R., K.G.M.V.), University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics (A.C.F., N.C., L.B.R., D.S.S., K.G.M.V.), University of Pennsylvania, Philadelphia
- Department of Medical Ethics and Health Policy (L.N., J.Z., L.B.R., K.G.M.V.), University of Pennsylvania, Philadelphia
- The Wharton School (D.S.S., K.G.M.V.), University of Pennsylvania, Philadelphia
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Murray JL, Leung DT, Hanson OR, Ahmed SM, Pavia AT, Khan AI, Szymczak JE, Vaughn VM, Patel PK, Biswas D, Watt MH. Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature. PLOS Glob Public Health 2024; 4:e0002507. [PMID: 38573955 PMCID: PMC10994369 DOI: 10.1371/journal.pgph.0002507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 02/21/2024] [Indexed: 04/06/2024]
Abstract
Antimicrobial resistance is a global public health crisis. Effective antimicrobial stewardship requires an understanding of the factors and context that contribute to inappropriate use of antimicrobials. The goal of this qualitative systematic review was to synthesize themes across levels of the social ecological framework that drive inappropriate use of antimicrobials in South Asia. In September 2023, we conducted a systematic search using the electronic databases PubMed and Embase. Search terms, identified a priori, were related to research methods, topic, and geographic location. We identified 165 articles from the initial search and 8 upon reference review (n = 173); after removing duplicates and preprints (n = 12) and excluding those that did not meet eligibility criteria (n = 115), 46 articles were included in the review. We assessed methodological quality using the qualitative Critical Appraisal Skills Program checklist. The studies represented 6 countries in South Asia, and included data from patients, health care providers, community members, and policy makers. For each manuscript, we wrote a summary memo to extract the factors that impede antimicrobial stewardship. We coded memos using NVivo software; codes were organized by levels of the social ecological framework. Barriers were identified at multiple levels including the patient (self-treatment with antimicrobials; perceived value of antimicrobials), the provider (antimicrobials as a universal therapy; gaps in knowledge and skills; financial or reputational incentives), the clinical setting (lack of resources; poor regulation of the facility), the community (access to formal health care; informal drug vendors; social norms), and policy (absence of a regulatory framework; poor implementation of existing policies). This study is the first to succinctly identify a range of norms, behaviors, and policy contexts driving inappropriate use of antimicrobials in South Asia, emphasizing the importance of working across multiple sectors to design and implement approaches specific to the region.
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Affiliation(s)
- Jennifer L. Murray
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, United States of America
- School of Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Daniel T. Leung
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Olivia R. Hanson
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Sharia M. Ahmed
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Andrew T. Pavia
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Ashraful I. Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Julia E. Szymczak
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Valerie M. Vaughn
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
| | - Payal K. Patel
- Department of Internal Medicine, Intermountain Health, Murray, Utah, United States of America
| | - Debashish Biswas
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Melissa H. Watt
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, United States of America
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Szymczak JE, Petty LA, Gandhi TN, Neetz RA, Hersh A, Presson AP, Lindenauer PK, Bernstein SJ, Muller BM, White AT, Horowitz JK, Flanders SA, Smith JD, Vaughn VM. Protocol for a parallel cluster randomized trial of a participatory tailored approach to reduce overuse of antibiotics at hospital discharge: the ROAD home trial. Implement Sci 2024; 19:23. [PMID: 38439076 PMCID: PMC10910678 DOI: 10.1186/s13012-024-01348-w] [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: 01/03/2024] [Accepted: 02/02/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Antibiotic overuse at hospital discharge is common, costly, and harmful. While discharge-specific antibiotic stewardship interventions are effective, they are resource-intensive and often infeasible for hospitals with resource constraints. This weakness impacts generalizability of stewardship interventions and has health equity implications as not all patients have access to the benefits of stewardship based on where they receive care. There may be different pathways to improve discharge antibiotic prescribing that vary widely in feasibility. Supporting hospitals in selecting interventions tailored to their context may be an effective approach to feasibly reduce antibiotic overuse at discharge across diverse hospitals. The objective of this study is to evaluate the effectiveness of the Reducing Overuse of Antibiotics at Discharge Home multicomponent implementation strategy ("ROAD Home") on antibiotic overuse at discharge for community-acquired pneumonia and urinary tract infection. METHODS This 4-year two-arm parallel cluster-randomized trial will include three phases: baseline (23 months), intervention (12 months), and postintervention (12 months). Forty hospitals recruited from the Michigan Hospital Medicine Safety Consortium will undergo covariate-constrained randomization with half randomized to the ROAD Home implementation strategy and half to a "stewardship as usual" control. ROAD Home is informed by the integrated-Promoting Action on Research Implementation in Health Services Framework and includes (1) a baseline needs assessment to create a tailored suite of potential stewardship interventions, (2) supported decision-making in selecting interventions to implement, and (3) external facilitation following an implementation blueprint. The primary outcome is baseline-adjusted days of antibiotic overuse at discharge. Secondary outcomes include 30-day patient outcomes and antibiotic-associated adverse events. A mixed-methods concurrent process evaluation will identify contextual factors influencing the implementation of tailored interventions, and assess implementation outcomes including acceptability, feasibility, fidelity, and sustainment. DISCUSSION Reducing antibiotic overuse at discharge across hospitals with varied resources requires tailoring of interventions. This trial will assess whether a multicomponent implementation strategy that supports hospitals in selecting evidence-based stewardship interventions tailored to local context leads to reduced overuse of antibiotics at discharge. Knowledge gained during this study could inform future efforts to implement stewardship in diverse hospitals and promote equity in access to the benefits of quality improvement initiatives. TRIAL REGISTRATION Clinicaltrials.gov NCT06106204 on 10/30/23.
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Affiliation(s)
- Julia E Szymczak
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
| | - Lindsay A Petty
- Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Tejal N Gandhi
- Department of Internal Medicine, Division of Infectious Diseases, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Robert A Neetz
- MyMichigan Medical Center Midland, MyMichigan Health, Midland, MI, USA
| | - Adam Hersh
- Department of Pediatrics, Division of Pediatric Infectious Diseases, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Angela P Presson
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Peter K Lindenauer
- Baystate Medical Center Department of Healthcare Delivery and Population Science, Center for Quality of Care Research, Springfield, MA, USA
| | - Steven J Bernstein
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, Division of General Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Brandi M Muller
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Andrea T White
- Department of Internal Medicine, Division of General Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Jennifer K Horowitz
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Scott A Flanders
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Justin D Smith
- Department of Population Health Sciences, Division of Health System Innovation & Research, University of Utah School of Medicine, Salt Lake City, USA
| | - Valerie M Vaughn
- Department of Internal Medicine, Division of General Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
- Department of Internal Medicine, Division of General Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA.
- Department of Internal Medicine, Division of Hospital Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
- Department of Population Health Sciences, Division of Health System Innovation & Research, University of Utah School of Medicine, Salt Lake City, USA.
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Szymczak JE, Hayes AA, Labellarte P, Zighelboim J, Toor A, Becker AB, Gerber JS, Kuppermann N, Florin TA. Parent and Clinician Views on Not Using Antibiotics for Mild Community-Acquired Pneumonia. Pediatrics 2024; 153:e2023063782. [PMID: 38234215 DOI: 10.1542/peds.2023-063782] [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] [Accepted: 10/31/2023] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVES Preschool-aged children with mild community-acquired pneumonia (CAP) routinely receive antibiotics even though most infections are viral. We sought to identify barriers to the implementation of a "no antibiotic" strategy for mild CAP in young children. METHODS Qualitative study using semistructured interviews conducted in a large pediatric hospital in the United States from January 2021 to July 2021. Parents of young children diagnosed with mild CAP in the previous 3 years and clinicians practicing in outpatient settings (pediatric emergency department, community emergency department, general pediatrics offices) were included. RESULTS Interviews were conducted with 38 respondents (18 parents, 20 clinicians). No parent heard of the no antibiotic strategy, and parents varied in their support for the approach. Degree of support related to their desire to avoid unnecessary medications, trust in clinicians, the emotional difficulty of caring for a sick child, desire for relief of suffering, willingness to accept the risk of unnecessary antibiotics, and judgment about the child's illness severity. Eleven (55%) clinicians were familiar with guidelines specifying a no antibiotic strategy. They identified challenges in not using antibiotics, including diagnostic uncertainty, consequences of undertreatment, parental expectations, follow-up concerns, and acceptance of the risks of unnecessary antibiotic treatment of many children if it means avoiding adverse outcomes for some children. CONCLUSIONS Although both parents and clinicians expressed broad support for the judicious use of antibiotics, pneumonia presents stewardship challenges. Interventions will need to consider the emotional, social, and logistical aspects of managing pneumonia, in addition to developing techniques to improve diagnosis.
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Affiliation(s)
- Julia E Szymczak
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ashley A Hayes
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patricia Labellarte
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julian Zighelboim
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Amandeep Toor
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adam B Becker
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine, Sacramento, California
| | - Todd A Florin
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Vaughn VM, Krein SL, Hersh A, Buckel WR, White AT, Horowitz J, Patel PK, Gandhi TN, Petty LA, Spivak ES, Bernstein SJ, Malani AM, Johnson LB, Neetz RA, Flanders SA, Galyean P, Kimball E, Bloomquist K, Zickmund T, Zickmund SL, Szymczak JE. Excellence in Antibiotic Stewardship: A mixed methods study comparing High, Medium, and Low Performing Hospitals. Clin Infect Dis 2023:ciad743. [PMID: 38059532 DOI: 10.1093/cid/ciad743] [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: 07/28/2023] [Revised: 11/13/2023] [Accepted: 12/01/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Despite antibiotic stewardship programs existing in most acute care hospitals, there continues to be variation in appropriate antibiotic use. While existing research examines individual prescriber behavior, contextual reasons for variation are poorly understood. METHODS We conducted an explanatory, sequential mixed methods study of a purposeful sample of 7 hospitals with varying discharge antibiotic overuse. For each hospital, we conducted surveys, document analysis, and semi-structured interviews with antibiotic stewardship and clinical stakeholders. Data were analyzed separately and mixed during the interpretation phase, where each hospital was examined as a case, with findings organized across cases using a strengths, weaknesses, opportunities, and threats framework to identify factors accounting for differences in antibiotic overuse across hospitals. RESULTS Surveys included 85 respondents. Interviews included 90 respondents (31 hospitalists, 33 clinical pharmacists, 14 stewardship leaders, 12 hospital leaders). On surveys, clinical pharmacists at hospitals with lower antibiotic overuse were more likely to report feeling: respected by hospitalist colleagues (p=0.001), considered valuable team members (p=0.001), comfortable recommending antibiotic changes (p=0.02). Based on mixed-methods analysis, hospitals with low antibiotic overuse had four distinguishing characteristics: a) robust knowledge of and access to antibiotic stewardship guidance, b) high quality clinical pharmacist-physician relationships, c) tools and infrastructure to support stewardship, and d) highly engaged Infectious Diseases physicians who advocated stewardship principles. CONCLUSION This mixed-method study demonstrates the importance of organizational context for high performance in stewardship and suggests improving antimicrobial stewardship requires attention to knowledge, interactions, and relationships between clinical teams and infrastructure that supports stewardship and team interactions.
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Affiliation(s)
- Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Health System Innovation & Research, Department of Population Health Science, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Sarah L Krein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of General Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Adam Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Whitney R Buckel
- Intermountain Healthcare Pharmacy Services, Taylorsville, UT, USA
| | - Andrea T White
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jennifer Horowitz
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Payal K Patel
- Division of Infectious Diseases, Department of Medicine, Intermountain Health, Salt Lake City, Utah, USA
| | - Tejal N Gandhi
- Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lindsay A Petty
- Division of Infectious Diseases, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Emily S Spivak
- Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Steven J Bernstein
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Division of General Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Anurag M Malani
- Division of Infectious Diseases, Department of Internal Medicine, Trinity Health Michigan, Ann Arbor, Michigan, USA
| | - Leonard B Johnson
- Division of Infectious Diseases, Department of Internal Medicine, Ascension St. John Hospital, Detroit, Michigan, USA
| | - Robert A Neetz
- Department of Pharmacy, MyMichigan Health, Midland, Michigan, USA
| | - Scott A Flanders
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Patrick Galyean
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Elisabeth Kimball
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Kennedi Bloomquist
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Tobias Zickmund
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Susan L Zickmund
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Informatics, Decision-Enhancement & Analytic Sciences Center, VA Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Julia E Szymczak
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Murray JL, Leung DT, Hanson OR, Ahmed SM, Pavia AT, Khan AI, Szymczak JE, Vaughn VM, Patel PK, Biswas D, Watt MH. Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature. medRxiv 2023:2023.09.28.23296313. [PMID: 37808732 PMCID: PMC10557824 DOI: 10.1101/2023.09.28.23296313] [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: 10/10/2023]
Abstract
Antimicrobial resistance is a global public health crisis. Effective antimicrobial stewardship requires an understanding of the factors and context that contribute to inappropriate use of antimicrobials. The goal of this qualitative systematic review was to synthesize themes across levels of the social ecological framework that drive inappropriate use of antimicrobials in South Asia. In September 2023, we conducted a systematic search using the electronic databases PubMed and Embase. Search terms, identified a priori, were related to research methods, topic, and geographic location. We identified 165 articles from the initial search and 8 upon reference review (n=173); after removing duplicates and preprints (n=12) and excluding those that did not meet eligibility criteria (n=115), 46 articles were included in the review. We assessed methodological quality using the qualitative Critical Appraisal Skills Program checklist. The studies represented 6 countries in South Asia, and included data from patients, health care providers, community members, and policy makers. For each manuscript, we wrote a summary memo to extract the factors that impede antimicrobial stewardship. We coded memos using NVivo software; codes were organized by levels of the social ecological framework. Barriers were identified at multiple levels including the patient (self-treatment with antimicrobials; perceived value of antimicrobials), the provider (antimicrobials as a universal therapy; gaps in knowledge and skills; financial or reputational incentives), the clinical setting (lack of resources; poor regulation of the facility), the community (access to formal health care; informal drug vendors; social norms), and policy (absence of a regulatory framework; poor implementation of existing policies). The findings highlight the importance of working across multiple sectors to design and implement approaches to antimicrobial stewardship in South Asia.
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Affiliation(s)
- Jennifer L. Murray
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT USA
- School of Medicine, University of Utah, Salt Lake City, UT USA
| | - Daniel T. Leung
- Department of Internal Medicine, University of Utah, Salt Lake City, UT USA
| | - Olivia R. Hanson
- Department of Internal Medicine, University of Utah, Salt Lake City, UT USA
| | - Sharia M. Ahmed
- Department of Internal Medicine, University of Utah, Salt Lake City, UT USA
| | - Andrew T. Pavia
- Department of Internal Medicine, University of Utah, Salt Lake City, UT USA
| | - Ashraful I. Khan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Julia E. Szymczak
- Department of Internal Medicine, University of Utah, Salt Lake City, UT USA
| | - Valerie M. Vaughn
- Department of Internal Medicine, University of Utah, Salt Lake City, UT USA
| | - Payal K. Patel
- Department of Internal Medicine, Intermountain Health, Murray, UT
| | - Debashish Biswas
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Melissa H. Watt
- Department of Population Health Sciences, University of Utah, Salt Lake City, UT USA
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Serletti L, Dutcher L, Degnan KO, Szymczak JE, Cluzet V, David MZ, Cressman L, Glassman LW, Hamilton KW. Analysis of seasonal variation of antibiotic prescribing for respiratory tract diagnoses in primary care practices. Antimicrob Steward Healthc Epidemiol 2023; 3:e147. [PMID: 37771744 PMCID: PMC10523546 DOI: 10.1017/ash.2023.418] [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] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 09/30/2023]
Abstract
Objective To determine antibiotic prescribing appropriateness for respiratory tract diagnoses (RTD) by season. Design Retrospective cohort study. Setting Primary care practices in a university health system. Patients Patients who were seen at an office visit with diagnostic code for RTD. Methods Office visits for the entire cohort were categorized based on ICD-10 codes by the likelihood that an antibiotic was indicated (tier 1: always indicated; tier 2: sometimes indicated; tier 3: rarely indicated). Medical records were reviewed for 1,200 randomly selected office visits to determine appropriateness. Based on this reference standard, metrics and prescriber characteristics associated with inappropriate antibiotic prescribing were determined. Characteristics of antibiotic prescribing were compared between winter and summer months. Results A significantly greater proportion of RTD visits had an antibiotic prescribed in winter [20,558/51,090 (40.2%)] compared to summer months [11,728/38,537 (30.4%)][standardized difference (SD) = 0.21]. A significantly greater proportion of winter compared to summer visits was associated with tier 2 RTDs (29.4% vs 23.4%, SD = 0.14), but less tier 3 RTDs (68.4% vs 74.4%, SD = 0.13). A greater proportion of visits in winter compared to summer months had an antibiotic prescribed for tier 2 RTDs (80.2% vs 74.2%, SD = 0.14) and tier 3 RTDs (22.9% vs 16.2%, SD = 0.17). The proportion of inappropriate antibiotic prescribing was higher in winter compared to summer months (72.4% vs 62.0%, P < .01). Conclusions Increases in antibiotic prescribing for RTD visits from summer to winter were likely driven by shifts in diagnoses as well as increases in prescribing for certain diagnoses. At least some of this increased prescribing was inappropriate.
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Affiliation(s)
- Lacey Serletti
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Lauren Dutcher
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kathleen O. Degnan
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Julia E. Szymczak
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Valerie Cluzet
- Division of Infectious Diseases, Nuvance Health, Poughkeepsie, NY, USA
| | - Michael Z. David
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Leigh Cressman
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Keith W. Hamilton
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Vaughn VM, Gupta A, Petty LA, Malani AN, Osterholzer D, Patel PK, Younas M, Bernstein SJ, Burdick S, Ratz D, Szymczak JE, McLaughlin E, Czilok T, Basu T, Horowitz JK, Flanders SA, Gandhi TN. A Statewide Quality Initiative to Reduce Unnecessary Antibiotic Treatment of Asymptomatic Bacteriuria. JAMA Intern Med 2023; 183:933-941. [PMID: 37428491 PMCID: PMC10334295 DOI: 10.1001/jamainternmed.2023.2749] [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: 11/18/2022] [Accepted: 03/23/2023] [Indexed: 07/11/2023]
Abstract
Importance Hospitalized patients with asymptomatic bacteriuria (ASB) often receive unnecessary antibiotic treatment, which increases antibiotic resistance and adverse events. Objective To determine whether diagnostic stewardship (avoiding unnecessary urine cultures) or antibiotic stewardship (reducing unnecessary antibiotic treatment after an unnecessary culture) is associated with better outcomes in reducing antibiotic use for ASB. Design, Setting, and Participants This 3-year, prospective quality improvement study included hospitalized general care medicine patients with a positive urine culture among 46 hospitals participating in a collaborative quality initiative, the Michigan Hospital Medicine Safety Consortium. Data were collected from July 1, 2017, through March 31, 2020, and analyzed from February to October 2022. Exposure Participation in the Michigan Hospital Medicine Safety Consortium with antibiotic and diagnostic stewardship strategies at hospital discretion. Main Outcomes and Measures Overall improvement in ASB-related antibiotic use was estimated as change in percentage of patients treated with antibiotics who had ASB. Effect of diagnostic stewardship was estimated as change in percentage of patients with a positive urine culture who had ASB. Effect of antibiotic stewardship was estimated as change in percentage of patients with ASB who received antibiotics and antibiotic duration. Results Of the 14 572 patients with a positive urine culture included in the study (median [IQR] age, 75.8 [64.2-85.1] years; 70.5% female); 28.4% (n = 4134) had ASB, of whom 76.8% (n = 3175) received antibiotics. Over the study period, the percentage of patients treated with antibiotics who had ASB (overall ASB-related antibiotic use) declined from 29.1% (95% CI, 26.2%-32.2%) to 17.1% (95% CI, 14.3%-20.2%) (adjusted odds ratio [aOR], 0.94 per quarter; 95% CI, 0.92-0.96). The percentage of patients with a positive urine culture who had ASB (diagnostic stewardship metric) declined from 34.1% (95% CI, 31.0%-37.3%) to 22.5% (95% CI, 19.7%-25.6%) (aOR, 0.95 per quarter; 95% CI, 0.93-0.97). The percentage of patients with ASB who received antibiotics (antibiotic stewardship metric) remained stable, from 82.0% (95% CI, 77.7%-85.6%) to 76.3% (95% CI, 68.5%-82.6%) (aOR, 0.97 per quarter; 95% CI, 0.94-1.01), as did adjusted mean antibiotic duration, from 6.38 (95% CI, 6.00-6.78) days to 5.93 (95% CI, 5.54-6.35) days (adjusted incidence rate ratio, 0.99 per quarter; 95% CI, 0.99-1.00). Conclusions and Relevance This quality improvement study showed that over 3 years, ASB-related antibiotic use decreased and was associated with a decline in unnecessary urine cultures. Hospitals should prioritize reducing unnecessary urine cultures (ie, diagnostic stewardship) to reduce antibiotic treatment related to ASB.
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Affiliation(s)
- Valerie M. Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- Division of Health System Innovation & Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Ashwin Gupta
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Lindsay A. Petty
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Anurag N. Malani
- Division of Infectious Diseases, Department of Internal Medicine, Trinity Health, St Joseph Mercy Ann Arbor, Ann Arbor, Michigan
| | - Danielle Osterholzer
- Division of Infectious Diseases, Hurley Medical Center, Flint, Michigan
- Department of Internal Medicine, College of Human Medicine, Michigan State University, East Lansing
| | - Payal K. Patel
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah
| | - Mariam Younas
- Division of Infectious Diseases, Hurley Medical Center, Flint, Michigan
| | - Steven J. Bernstein
- Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Division of General Internal Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Stephanie Burdick
- Division of Hospital Medicine, Corewell Health, Grand Rapids, Michigan
| | - David Ratz
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Julia E. Szymczak
- Division of Health System Innovation & Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Elizabeth McLaughlin
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Tawny Czilok
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Tanima Basu
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Jennifer K. Horowitz
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Scott A. Flanders
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
| | - Tejal N. Gandhi
- Division of Infectious Diseases, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor
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Hamm RF, Levine LD, Szymczak JE, Parry S, Srinivas SK, Beidas RS. An innovative sequential mixed-methods approach to evaluating clinician acceptability during implementation of a standardized labor induction protocol. BMC Med Res Methodol 2023; 23:195. [PMID: 37644387 PMCID: PMC10463761 DOI: 10.1186/s12874-023-02010-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 08/07/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Implementation outcomes, including acceptability, are of critical importance in both implementation research and practice. The gold standard measure of acceptability, Acceptability of Intervention Measure (AIM), skews positively with a limited range. In an ongoing hybrid effectiveness-implementation trial, we aimed to evaluate clinician acceptability of induction standardization. Here, we describe an innovative mixed-methods approach to maximize the interpretability of the AIM using a case study in maternal health. METHODS In this explanatory sequential mixed methods study, we distributed the validated, 4-question AIM (total 4-20) to labor and delivery clinicians 6 months post-implementation at 2 sites (Site 1: 3/2021; Site 2: 6/2021). Respondents were grouped by total score into tertiles. The top ("High" Acceptability) and bottom ("Low" Acceptability) tertiles were invited to participate in a 30-minute semi-structured qualitative interview from 6/2021 to 10/2021 until thematic saturation was reached in each acceptability group. Participants were purposively sampled by role and site. Interviews were coded using an integrated approach, incorporating a priori attributes (Consolidated Framework for Implementation Research constructs) into a modified content analysis approach. RESULTS 104 clinicians completed the initial survey; 24 were interviewed (12 "High" and 12 "Low" Acceptability). Median total AIM scores were 20/20 IQR[20-20] in the High and 12.5/20 IQR[11-14] in the Low Acceptability groups. In both groups, clinicians were enthusiastic about efforts to standardize labor induction, believing it reduces inter-clinician variability and improves equitable, evidence-based care. In the Low Acceptability group, clinicians stated the need for flexibility and consideration for patient uniqueness. Rarely, clinicians felt labor induction could not or should not be standardized, citing discomfort with medicalization of labor, and concerns with "bulldozing" the patient with interventions. Suggested strategies for overcoming negative sentiment included comprehensive clinician education, as well as involving patients as active participants in the protocol prenatally. CONCLUSIONS This study utilized AIM in an innovative sequential mixed-methods approach to characterize clinician acceptability, which may be generalizable across implementation endeavors. By performing this work during a hybrid trial, implementation strategies to improve acceptability emerged (clinician education focusing on respect for flexibility; involving patients as active participants prenatally) for year 2, which will inform future multi-site work.
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Affiliation(s)
- Rebecca Feldman Hamm
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA, 19104, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Lisa D Levine
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA, 19104, USA
| | - Julia E Szymczak
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Samuel Parry
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA, 19104, USA
| | - Sindhu K Srinivas
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA, 19104, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rinad S Beidas
- Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Fanaroff AC, Patel MS, Chokshi N, Coratti S, Farraday D, Norton L, Rareshide C, Zhu J, Szymczak JE, Russell LB, Small DS, Volpp KGM. A randomized controlled trial of gamification, financial incentives, or both to increase physical activity among patients with elevated risk for cardiovascular disease: rationale and design of the be active study. Am Heart J 2023; 260:82-89. [PMID: 36870551 PMCID: PMC10919938 DOI: 10.1016/j.ahj.2023.02.014] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/24/2023] [Accepted: 02/24/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Higher levels of physical activity are associated with improvements in cardiovascular health, and consensus guidelines recommend that individuals with or at risk for atherosclerotic cardiovascular disease (ASCVD) participate in regular physical activity. However, most adults do not achieve recommended levels of physical activity. Concepts from behavioral economics have been used to design scalable interventions that increase physical activity over short time periods, but the longer-term efficacy of these strategies is uncertain. STUDY DESIGN AND OBJECTIVES BE ACTIVE (NCT03911141) is a pragmatic, virtual, randomized controlled trial designed to evaluate the effectiveness of 3 strategies informed by behavioral economic concepts to increase daily physical activity in patients with established ASCVD or 10-year ASCVD risk > 7.5% who are seen in primary care and cardiology clinics affiliated with the University of Pennsylvania Health System. Patients are contacted by email or text message, and complete enrollment and informed consent on the Penn Way to Health online platform. Patients are then provided with a wearable fitness tracker, establish a baseline daily step count, set a goal to increase daily step count by 33% to 50%, and are randomized 1:2:2:2 to control, gamification, financial incentives, or both gamification and financial incentives. Interventions continue for 12 months, with follow-up for an additional 6 months to evaluate the durability of behavior change. The trial has met its enrollment goal of 1050 participants, with a primary endpoint of change from baseline in daily steps over the 12-month intervention period. Key secondary endpoints include change from baseline in daily steps over the 6-month post-intervention follow-up period and change in moderate to vigorous physical activity over the intervention and follow-up periods. If the interventions prove effective, their effects on life expectancy will be compared with their costs in cost-effectiveness analysis. CONCLUSIONS BE ACTIVE is a virtual, pragmatic randomized clinical trial powered to demonstrate whether gamification, financial incentives, or both are superior to attention control in increasing physical activity. Its results will have important implications for strategies to promote physical activity in patients with or at risk for ASCVD, as well as for the design and implementation of pragmatic virtual clinical trials within health systems.
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Affiliation(s)
- Alexander C Fanaroff
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA; Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Penn Center for Digital Cardiology, University of Pennsylvania, Philadelphia, PA.
| | | | - Neel Chokshi
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Penn Center for Digital Cardiology, University of Pennsylvania, Philadelphia, PA
| | - Samantha Coratti
- Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - David Farraday
- Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Laurie Norton
- Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
| | - Charles Rareshide
- Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA
| | - Jingsan Zhu
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
| | - Julia E Szymczak
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Louise B Russell
- Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA
| | - Dylan S Small
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; The Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Kevin G M Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; The Wharton School, University of Pennsylvania, Philadelphia, PA
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11
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Szymczak JE, Getz KD, Madding R, Shuster S, Aftandilian C, Arnold SD, Collier AB, Gramatges MM, Henry M, Hijiya N, Mian A, Raetz E, Fisher BT, Aplenc R. Child and family perceptions of satisfaction with neutropenia management in pediatric acute myeloid leukemia. Pediatr Blood Cancer 2023:e30420. [PMID: 37194639 DOI: 10.1002/pbc.30420] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/26/2023] [Accepted: 04/27/2023] [Indexed: 05/18/2023]
Abstract
PURPOSE Chemotherapy for pediatric acute myeloid leukemia (AML) is very intensive and many, but not all centers, require extended hospitalization until neutrophil recovery. Child and family preferences, beliefs, and experiences around hospitalization have not been systematically assessed. PATIENTS AND METHODS We recruited children with AML and their parents from nine pediatric cancer centers across the United States for a qualitative interview about their experiences of neutropenia management. Interviews were analyzed using a conventional content analysis approach. RESULTS Of 116 eligible individuals, 86 (74.1%) agreed to participate. Interviews were conducted with 32 children and 54 parents from 57 families. Of these 57 families, 39 were cared for as inpatients and 18 were managed as outpatients. A very high proportion of respondents in both groups reported satisfaction with the discharge management strategy recommended by the treating institution: 86% (57 individuals) of respondents who experienced inpatient management and 85% (17 individuals) of respondents who experienced outpatient management expressed satisfaction. Respondent perceptions associated with satisfaction related to safety (access to emergency interventions, infection risk, close monitoring) and psychosocial concerns (family separation, low morale, social support). Respondents believed it could not be assumed that all children would have the same experience due to varied life circumstances. CONCLUSION Children with AML and their parents express a very high degree of satisfaction with the discharge strategy recommended by their treating institution. Respondents saw a nuanced tradeoff between patient safety and psychosocial concerns that was mediated by a child's life circumstances.
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Affiliation(s)
- Julia E Szymczak
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Kelly D Getz
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Clinical Futures, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rachel Madding
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Clinical Futures, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sydney Shuster
- Clinical Futures, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Catherine Aftandilian
- Division of Pediatric Hematology/Oncology, Stanford University School of Medicine and Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Staci D Arnold
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Anderson B Collier
- Department of Pediatrics, Division of Hematology/Oncology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Maria M Gramatges
- Texas Children's Cancer Center, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Meret Henry
- Division of Hematology/Oncology, Children's Hospital of Michigan, Wayne State University, Detroit, Michigan, USA
| | - Nobuko Hijiya
- Division of Pediatric Hematology, Oncology, and Stem Cell Transplant, Department of Pediatrics, Columbia University Irving Medical Center, New York, New York, USA
| | - Amir Mian
- Department of Pediatric Hematology-Oncology, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Elizabeth Raetz
- Stephen D. Hassenfeld Children's Center for Cancer and Blood Disorders, New York, New York, USA
| | - Brian T Fisher
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
- Clinical Futures, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Richard Aplenc
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Clinical Futures, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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12
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Hamm RF, Wang E, Szymczak JE, Levine LD. Implementation of a calculator to predict cesarean during labor induction: a qualitative evaluation of the patient perspective. Am J Obstet Gynecol MFM 2023; 5:100968. [PMID: 37061041 DOI: 10.1016/j.ajogmf.2023.100968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/30/2023] [Accepted: 04/09/2023] [Indexed: 04/17/2023]
Affiliation(s)
- Rebecca F Hamm
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Eileen Wang
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Julia E Szymczak
- Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Lisa D Levine
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Vaughn VM, Giesler DL, Mashrah D, Brancaccio A, Sandison K, Spivak ES, Szymczak JE, Wu C, Horowitz JK, Bashaw L, Hersh AL. Pharmacist gender and physician acceptance of antibiotic stewardship recommendations: An analysis of the reducing overuse of antibiotics at discharge home intervention. Infect Control Hosp Epidemiol 2023; 44:570-577. [PMID: 35670587 PMCID: PMC10754057 DOI: 10.1017/ice.2022.136] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess association of pharmacist gender with acceptance of antibiotic stewardship recommendations. DESIGN A retrospective evaluation of the Reducing Overuse of Antibiotics at Discharge (ROAD) Home intervention. SETTING The study was conducted from May to October 2019 in a single academic medical center. PARTICIPANTS The study included patients receiving antibiotics on a hospitalist service who were nearing discharge. METHODS During the intervention, clinical pharmacists (none who had specialist postgraduate infectious disease residency training) reviewed patients on antibiotics and led an antibiotic timeout (ie, structured conversation) prior to discharge to improve discharge antibiotic prescribing. We assessed the association of pharmacist gender with acceptance of timeout recommendations by hospitalists using logistic regression controlling for patient characteristics. RESULTS Over 6 months, pharmacists conducted 295 timeouts: 158 timeouts (53.6%) were conducted by 12 women, 137 (46.4%) were conducted by 8 men. Pharmacists recommended an antibiotic change in 82 timeouts (27.8%), of which 51 (62.2%) were accepted. Compared to male pharmacists, female pharmacists were less likely to recommend a discharge antibiotic change: 30 (19.0%) of 158 versus 52 (38.0%) of 137 (P < .001). Female pharmacists were also less likely to have a recommendation accepted: 10 (33.3%) of 30 versus 41 (8.8%) of 52 (P < .001). Thus, timeouts conducted by female versus male pharmacists were less likely to result in an antibiotic change: 10 (6.3%) of 158 versus 41 (29.9%) of 137 (P < .001). After adjustments, pharmacist gender remained significantly associated with whether recommended changes were accepted (adjusted odds ratio [aOR], 0.10; 95%confidence interval [CI], 0.03-0.36 for female versus male pharmacists). CONCLUSIONS Antibiotic stewardship recommendations made by female clinical pharmacists were less likely to be accepted by hospitalists. Gender bias may play a role in the acceptance of clinical pharmacist recommendations, which could affect patient care and outcomes.
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Affiliation(s)
- Valerie M. Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Division of Health System Innovation & Research, Department of Population Health Science, University of Utah School of Medicine, Salt Lake City, Utah
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Daniel L. Giesler
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Daraoun Mashrah
- Department of Pharmaceutical Services, Michigan Medicine, Ann Arbor, Michigan
| | - Adamo Brancaccio
- Department of Pharmaceutical Services, Michigan Medicine, Ann Arbor, Michigan
| | - Katie Sandison
- Department of Pharmaceutical Services, Michigan Medicine, Ann Arbor, Michigan
| | - Emily S. Spivak
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Chaorong Wu
- Division of Epidemiology University of Utah, Salt Lake City, Utah
| | - Jennifer K. Horowitz
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Linda Bashaw
- Clinical Experience and Quality Program, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan
| | - Adam L. Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
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Anesi GL, Dress E, Chowdhury M, Wang W, Small DS, Delgado MK, Bayes B, Szymczak JE, Glassman LW, Barreda FX, Weiner JZ, Escobar GJ, Halpern SD, Liu VX. Among-Hospital Variation in Intensive Care Unit Admission Practices and Associated Outcomes for Patients with Acute Respiratory Failure. Ann Am Thorac Soc 2023; 20:406-413. [PMID: 35895629 PMCID: PMC9993147 DOI: 10.1513/annalsats.202205-429oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 05/18/2022] [Accepted: 07/27/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale: We have previously shown that hospital strain is associated with intensive care unit (ICU) admission and that ICU admission, compared with ward admission, may benefit certain patients with acute respiratory failure (ARF). Objectives: To understand how strain-process-outcomes relationships in patients with ARF may vary among hospitals and what hospital practice differences may account for such variation. Methods: We examined high-acuity patients with ARF who did not require mechanical ventilation or vasopressors in the emergency department (ED) and were admitted to 27 U.S. hospitals from 2013 to 2018. Stratifying by hospital, we compared hospital strain-ICU admission relationships and hospital length of stay (LOS) and mortality among patients initially admitted to the ICU versus the ward using hospital strain as a previously validated instrumental variable. We also surveyed hospital practices and, in exploratory analyses, evaluated their associations with the above processes and outcomes. Results: There was significant among-hospital variation in ICU admission rates, in hospital strain-ICU admission relationships, and in the association of ICU admission with hospital LOS and hospital mortality. Overall, ED patients with ARF (n = 45,339) experienced a 0.82-day shorter median hospital LOS if admitted initially to the ICU compared with the ward, but among the 27 hospitals (n = 224-3,324), this effect varied from 5.85 days shorter (95% confidence interval [CI], -8.84 to -2.86; P < 0.001) to 4.38 days longer (95% CI, 1.86-6.90; P = 0.001). Corresponding ranges for in-hospital mortality with ICU compared with ward admission revealed odds ratios from 0.08 (95% CI, 0.01-0.56; P < 0.007) to 8.89 (95% CI, 1.60-79.85; P = 0.016) among patients with ARF (pooled odds ratio, 0.75). In exploratory analyses, only a small number of measured hospital practices-the presence of a sepsis ED disposition guideline and maximum ED patient capacity-were potentially associated with hospital strain-ICU admission relationships. Conclusions: Hospitals vary considerably in ICU admission rates, the sensitivity of those rates to hospital capacity strain, and the benefits of ICU admission for patients with ARF not requiring life support therapies in the ED. Future work is needed to more fully identify hospital-level factors contributing to these relationships.
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Affiliation(s)
- George L. Anesi
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine
- Leonard Davis Institute of Health Economics
- Palliative and Advanced Illness Research Center, Perelman School of Medicine
| | - Erich Dress
- Palliative and Advanced Illness Research Center, Perelman School of Medicine
| | - Marzana Chowdhury
- Palliative and Advanced Illness Research Center, Perelman School of Medicine
| | - Wei Wang
- Palliative and Advanced Illness Research Center, Perelman School of Medicine
| | | | - M. Kit Delgado
- Leonard Davis Institute of Health Economics
- Palliative and Advanced Illness Research Center, Perelman School of Medicine
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, and
| | - Brian Bayes
- Palliative and Advanced Illness Research Center, Perelman School of Medicine
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Lindsay W. Glassman
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | | | | | | | - Scott D. Halpern
- Division of Pulmonary, Allergy, and Critical Care, Perelman School of Medicine
- Leonard Davis Institute of Health Economics
- Palliative and Advanced Illness Research Center, Perelman School of Medicine
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California
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15
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Szymczak JE, Linder JA. "Cultural" Variation in Antibiotic Prescribing: Have Regional Differences Had Their Day? Open Forum Infect Dis 2023; 10:ofad025. [PMID: 36776775 PMCID: PMC9905358 DOI: 10.1093/ofid/ofad025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 01/19/2023] [Indexed: 02/11/2023] Open
Affiliation(s)
| | - Jeffrey A Linder
- Correspondence: Jeffrey A. Linder, MD, MPH, FACP, Division of General Internal Medicine, Northwestern University Feinberg School of Medicine, 750 N Lake Shore Drive, 10th Floor, Chicago, IL 60611 ()
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16
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Schnellinger EM, Cantu E, Kimmel SE, Szymczak JE. A Conceptual Model for Sources of Differential Selection in Lung Transplant Allocation. Ann Am Thorac Soc 2023; 20:226-235. [PMID: 36044711 PMCID: PMC9989866 DOI: 10.1513/annalsats.202202-105oc] [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] [Received: 02/08/2022] [Accepted: 08/31/2022] [Indexed: 02/04/2023] Open
Abstract
Rationale: In the United States, donor lungs are allocated to transplant candidates on the basis of lung allocation scores (LAS). However, additional factors beyond the LAS can impact who is transplanted, including listing and donor-organ acceptance practices. These factors can result in differential selection, undermining the objectivity of lung allocation. Yet their impact on the lung transplant pathway has been underexplored. Objectives: We sought to systematically examine sources of differential selection in lung transplantation via qualitative methods. Methods: We conducted semistructured qualitative interviews with lung transplant surgeons and pulmonologists in the United States between June 2019 and June 2020 to understand clinician perspectives on differential selection in lung transplantation and the LAS. Results: A total of 51 respondents (30 surgeons and 21 pulmonologists) identified many sources of differential selection arising throughout the pathway from referral to transplantation. We synthesized these sources into a conceptual model with five themes: 1) transplant center's degree of risk tolerance and accountability; 2) successfulness and fairness of the LAS; 3) donor-organ availability and regional competition; 4) patient health versus program health; and 5) access to care versus responsible stewardship of organs. Conclusions: Our conceptual model demonstrates how differential selection can arise throughout lung transplantation and facilitates the further study of such selection. As new organ allocation models are developed, differential selection should be considered carefully to ensure that these models are more equitable.
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Affiliation(s)
- Erin M. Schnellinger
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward Cantu
- Department of Surgery, Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - Stephen E. Kimmel
- Department of Epidemiology, College of Public Health and Health Professions, and
- College of Medicine, University of Florida, Gainesville, Florida
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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17
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Hamm RF, Wang E, Szymczak JE, Levine LD. Implementation of a calculator to predict cesarean during labor induction: the patient perspective. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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18
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Szymczak JE, Elle Saine M, Chiotos K, Keller SC, Newland J, Lautenbach E, Heil EL. 965. Prevalence and Drivers of Burnout Among Antimicrobial Stewardship Personnel in the United States: A Cross-Sectional Study. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.808] [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] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Although antimicrobial stewardship (AS) personnel are faced with occupational stressors that may contribute to burnout, little is known about the degree to which they experience this work-related syndrome. Our objective was to characterize the prevalence of, and identify factors associated with, burnout among AS personnel practicing in United States (US) hospitals.
Methods
We conducted a cross-sectional survey in October-December 2021. AS personnel (physicians and pharmacists) were approached via email through four US-based professional organizations. Respondents self-administered a questionnaire measuring demographics, AS program structure, resources, and organizational climate. Burnout was measured using the Maslach Burnout Inventory, a 22-item validated instrument with three subscales. Burnout was defined as a dichotomous outcome based on the presence of high scores on the emotional exhaustion subscale along with either a high depersonalization score or low professional accomplishment score. Descriptive statistics and logistic regression analyses were performed.
Results
A total of 259 AS personnel completed the questionnaire. The majority of respondents were pharmacists (n=201; 78.2%), female (n=166; 64.3%) and worked in a teaching hospital (n=212, 84.1%). The median age was 36 (IQR, 32-41). Thirty-six percent (n=94 of 259) of respondents met the definition for burnout. There were no significant differences in burnout by respondent demographics or professional role. Significant drivers of burnout (P< 0.05) identified in univariable regression modeling included feeling as if AS is not an institutional priority, that hospital leadership is unsupportive of AS, prescriber resistance to AS recommendations is common, having unsupportive infectious diseases or pharmacy colleagues, the AS team does not work well together, and AS work is not intellectually stimulating.
Conclusion
Over one third of AS personnel in our sample met predefined standardized criteria for burnout. Contextual aspects of the work environment, including leadership, unsupportive peer climate and conflict were associated with burnout. There is a need to address factors that contribute to burnout in AS personnel to ensure an engaged workforce and to minimize turnover.
Disclosures
Jason Newland, MD, AHRQ: Grant/Research Support|Merck: Grant/Research Support|NIH: Grant/Research Support|PEW Charitable Trust: Grant/Research Support|Pfizer: Grant/Research Support.
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Affiliation(s)
- Julia E Szymczak
- University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - M Elle Saine
- University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Kathleen Chiotos
- Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - Sara C Keller
- Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Jason Newland
- Washington University School of Medicine , Saint Louis, Missouri
| | | | - Emily L Heil
- University of Maryland School of Pharmacy , Baltimore, Maryland
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19
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Serletti LM, Dutcher L, Degnan K, Cressman L, David MZ, Szymczak JE, Glassman LW, Cluzet V, Hamilton KW. 932. Analysis of Seasonal Variation of Antibiotic Prescribing for Respiratory Tract Diagnoses in Primary Care Practices. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.777] [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] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Seasonal fluctuations in antibiotic prescribing for respiratory tract diagnoses (RTDs) have been identified, but characteristics and appropriateness of these variations have not been well described. The objectives of this study were to describe seasonal variations for RTDs and to determine whether seasonal variation in prescribing is associated with inappropriate use.
Methods
From July 1, 2016 through June 30, 2017, antibiotic prescribing was analyzed for 31 primary care practices comparing winter (October-March) and summer (April-September) months. ICD-10 codes for RTDs were described as tier 1, 2, or 3 based on whether antibiotics are almost always, sometimes, or almost never indicated, respectively. Twenty visits from each of 60 providers were randomly selected and manually reviewed to determine a gold standard of antibiotic appropriateness in order to characterize the appropriateness of these seasonal variations. Associations between season and diagnosis tier, season and appropriateness, and individual provider seasonal changes in antibiotic prescribing and provider characteristics were determined.
Results
There was a lower proportion of visits with tier 3 diagnoses in winter months (68% v. 74%, p< 0.01), but a greater proportion of tier 2 diagnoses (29% v. 23%, p< 0.01). There were greater proportions of visits in which an antibiotic was prescribed for both tier 2 (80% vs 74%, p< 0.01) and tier 3 diagnoses (23% v. 16%, p< 0.01) in winter months. Using medical record review, inappropriate antibiotics were prescribed more frequently for RTDs in winter compared to summer months (73% v. 64%, p< 0.01). Greater individual provider difference in proportion of RTD visits in which an antibiotic was prescribed from summer to winter was associated with family medicine v. internal medicine specialty (8.2% v. 5.1%, p< 0.01), nonteaching v. teaching practice (8.1% v. 2.9%, p< 0.01), and nonurban v. urban setting (9.1% v. 3.9%, p< 0.01).
Conclusion
Although there was a greater proportion of tier 2 compared to tier 3 RTDs in winter months, winter months were associated with more inappropriate prescribing than in summer months. More investigation is needed to understand the drivers for seasonal variations in RTDs and inappropriate prescribing.
Disclosures
Kathleen Degnan, MD, Gilead: Grant/Research Support Michael Z. David, MD PhD, Contrafect: Grant/Research Support|GSK: Advisor/Consultant|Johnson and Johnson: Advisor/Consultant.
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Affiliation(s)
- Lacey M Serletti
- Department of Medicine, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Lauren Dutcher
- University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Kathleen Degnan
- University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Leigh Cressman
- University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Michael Z David
- University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Julia E Szymczak
- University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Lindsay W Glassman
- University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | | | - Keith W Hamilton
- University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
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20
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Glassman LW, Szymczak JE. The influence of social class and institutional relationships on the experiences of vaccine-hesitant mothers: a qualitative study. BMC Public Health 2022; 22:2309. [PMID: 36494647 PMCID: PMC9733306 DOI: 10.1186/s12889-022-14420-1] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 10/21/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Vaccine hesitancy is a growing problem in the United States. However, our understanding of the mechanisms by which socioeconomic status (SES) shapes the experience of vaccine hesitancy and decision-making is incomplete. AIM The aim of this study was to understand how social class influences the experiences and perspectives of vaccine-hesitant mothers. METHODS We conducted semistructured interviews with middle- and working-class vaccine-hesitant mothers. Participants were identified through neighborhood parenthood groups in the Philadelphia area, as well as in-person and online groups whose members express concerns about vaccines. Interviews were audio recorded and inductively analyzed. RESULTS Interviews were conducted with 37 vaccine-hesitant mothers, who described their vaccine decision-making through the lens of interactions with three institutional stakeholders: 1) pediatric clinicians; 2) school administrators; and 3) emergency room staff. In discussing these interactions, middle- and working-class mothers invoked distinct levels of authority in relation to these institutions. Specifically, working-class mothers expressed concerns that medical or school professionals could act as reporters for state intervention, including Child Protective Services, while middle-class mothers did not. These interactions highlighted the ways middle- and working-class mothers in our study felt differently empowered and constrained in their vaccine choices, and ultimately influenced their perceptions of available actions. CONCLUSIONS Our findings indicate that experiences of vaccine hesitancy may be influenced by mothers' social class via their relationships to institutional authorities. These findings have implications for how clinicians communicate with parents from different social backgrounds to best build trust and facilitate vaccine uptake.
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Affiliation(s)
| | - Julia E. Szymczak
- grid.25879.310000 0004 1936 8972Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104 USA
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21
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Ding L, Szymczak JE, Evans E, Canepa E, Martin AE, Contractor F, Aplenc R, Joseph G, Winestone LE. Factors that contribute to disparities in time to acute leukemia diagnosis in young people: an in depth qualitative interview study. BMC Cancer 2022; 22:531. [PMID: 35550034 PMCID: PMC9095817 DOI: 10.1186/s12885-022-09547-8] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 04/11/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Racial and ethnic disparities in outcomes for Black and Hispanic children with acute leukemia have been well documented, however little is known about the determinants of diagnostic delays in pediatric leukemia in the United States. The primary objective of this study is to identify factors contributing to delays preceding a pediatric leukemia diagnosis. METHODS This qualitative study utilized in-depth semi-structured interviews. Parents and/or patients within two years of receiving a new acute leukemia diagnosis were asked to reflect upon their family's experiences preceding the patient's diagnosis. Subjects were purposively sampled for maximum variation in race, ethnicity, income, and language. Interviews were analyzed using inductive theory-building and the constant comparative method to understand the process of diagnosis. Chart review was conducted to complement qualitative data. RESULTS Thirty-two interviews were conducted with a diverse population of English and Spanish speaking participants from two tertiary care pediatric cancer centers. Parents reported feeling frustrated when their intuition conflicted with providers' management decisions. Many felt laboratory testing was not performed soon enough. Additional contributors to delays included misattribution of vague symptoms to more common diagnoses, difficulties in obtaining appointments, and financial disincentives to seek urgent or emergent care. Reports of difficulty obtaining timely appointments and financial concerns were disproportionately raised among low-income Black and Hispanic participants. Comparatively, parents with prior healthcare experiences felt better able to navigate the system and advocate for additional testing at symptom onset. CONCLUSIONS While there are disease-related factors contributing to delays in diagnosis, it is important to recognize there are multiple non-disease-related factors that also contribute to delays. Evidence-based approaches to reduce outcome disparities in pediatric cancer likely need to start in the primary care setting where timeliness of diagnosis can be addressed.
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Affiliation(s)
- Lucky Ding
- grid.266102.10000 0001 2297 6811University of California San Francisco (UCSF) School of Medicine, San Francisco, CA USA
| | - Julia E. Szymczak
- grid.25879.310000 0004 1936 8972Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA USA
| | - Erica Evans
- grid.266102.10000 0001 2297 6811University of California San Francisco (UCSF) School of Medicine, San Francisco, CA USA
| | - Emma Canepa
- grid.266102.10000 0001 2297 6811University of California San Francisco (UCSF) School of Medicine, San Francisco, CA USA
| | - Ashley E. Martin
- grid.239552.a0000 0001 0680 8770Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, PA USA ,grid.239552.a0000 0001 0680 8770PolicyLab, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Farah Contractor
- grid.239552.a0000 0001 0680 8770Center for Childhood Cancer Research, Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Richard Aplenc
- grid.239552.a0000 0001 0680 8770Center for Childhood Cancer Research, Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA USA ,grid.239552.a0000 0001 0680 8770Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Galen Joseph
- grid.266102.10000 0001 2297 6811Department of Humanities and Social Sciences, UCSF, San Francisco, CA USA ,grid.511215.30000 0004 0455 2953UCSF Helen Diller Family Comprehensive Cancer Center, CA San Francisco, USA
| | - Lena E. Winestone
- grid.511215.30000 0004 0455 2953UCSF Helen Diller Family Comprehensive Cancer Center, CA San Francisco, USA ,Division of Allergy, Immunology & BMT, UCSF Benioff Children’s Hospitals, Mail Stop 0434, 550 16th St, 4th Floor, San Francisco, CA USA
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22
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Abstract
Antimicrobial and diagnostic stewardship initiatives have become increasingly important in paediatric settings. The value of qualitative approaches to conduct stewardship work in paediatric patients is being increasingly recognized. This article seeks to provide an introduction to basic elements of qualitative study designs and provide an overview of how these methods have successfully been applied to both antimicrobial and diagnostic stewardship work in paediatric patients. A multidisciplinary team of experts in paediatric infectious diseases, paediatric critical care and qualitative methods has written a perspective piece introducing readers to qualitative stewardship work in children, intended as an overview to highlight the importance of such methods and as a starting point for further work. We describe key differences between qualitative and quantitative methods, and the potential benefits of qualitative approaches. We present examples of qualitative research in five discrete topic areas of high relevance for paediatric stewardship work: provider attitudes; provider prescribing behaviours; stewardship in low-resource settings; parents’ perspectives on stewardship; and stewardship work focusing on select high-risk patients. Finally, we explore the opportunities for multidisciplinary academic collaboration, incorporation of innovative scientific disciplines and young investigator growth through the use of qualitative research in paediatric stewardship. Qualitative approaches can bring rich insights and critically needed new information to antimicrobial and diagnostic stewardship efforts in children. Such methods are an important tool in the armamentarium against worsening antimicrobial resistance, and a major opportunity for investigators interested in moving the needle forward for stewardship in paediatric patients.
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Affiliation(s)
- Charlotte Z. Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA
- Corresponding author. E-mail:
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, 750 E Pratt St., Baltimore, MD 21202, USA
| | - John Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Heather A. Wolfe
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Alex S. Plattner
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Sara Malone
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Kathleen Chiotos
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Julia E. Szymczak
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
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23
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Walter JK, Hill DL, Schall TE, Szymczak JE, Parikh S, DiDomenico C, Carroll KW, Nye RT, Feudtner C. An Interprofessional Team-Based Intervention to Address Barriers to Initiating Palliative Care in Pediatric Oncology: A Multiple-Method Evaluation of Feasibility, Acceptability, and Impact. J Pain Symptom Manage 2021; 62:1135-1144. [PMID: 34153461 PMCID: PMC8648922 DOI: 10.1016/j.jpainsymman.2021.06.008] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT Many children with advanced cancer are not referred to palliative care despite both professional recommendations to do so and bereaved parental preference for earlier support from sub-specialty palliative care. OBJECTIVES To assess the feasibility, acceptability, and impact of an adaptive intervention to address individual and team-level barriers to specialty palliative care referrals. METHODS A multiple-method approach assessed feasibility and acceptability among clinicians from pediatric oncology teams at a single institution. Quantitative measures of comfort with palliative care consultations, team cohesion, and team collaboration were conducted before and after the intervention. Number of palliative care consults were examined before, during, and after sessions. Intervention satisfaction surveys and qualitative interviews were conducted after the intervention. RESULTS Twenty-six team members (90% of consented) attended at least one intervention session with 20 (69%) participants completing 75% or more sessions. The intervention was modified in response to participant feedback. After the intervention, participants reported greater team cohesion, comfort discussing palliative care consultation, team collaboration, process satisfaction, and decision satisfaction. Participants agreed that the training was useful, effective, helpful, and worthwhile, that they would use the skills, and that they would recommend the training to other providers. The numbers of palliative care consults increased before intervention sessions were conducted, but did not significantly change during or after the sessions. In the interviews, participants reported overall favorably regarding the intervention with some participants reporting changes in practice. CONCLUSION An adaptive intervention to reduce barriers to initiating palliative care for pediatric oncology teams is feasible and acceptable.
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Affiliation(s)
- Jennifer K Walter
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Justin Ingerman Center for Palliative Care (J.K.W., S.P., C.F.), Philadelphia, Pennsylvania, USA
| | - Douglas L Hill
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA.
| | - Theodore E Schall
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania (J.E.S.), Philadelphia, Pennsylvania, USA
| | - Shefali Parikh
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Justin Ingerman Center for Palliative Care (J.K.W., S.P., C.F.), Philadelphia, Pennsylvania, USA
| | - Connie DiDomenico
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Division of Pediatric Oncology (C.D.), Philadelphia, Pennsylvania, USA
| | - Karen W Carroll
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA
| | - Russell T Nye
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Children's Hospital of Philadelphia (J.K.W., D.L.H., T.E.S., S.P., C.D., K.W.C., C.F.,), Philadelphia, Pennsylvania, USA; Justin Ingerman Center for Palliative Care (J.K.W., S.P., C.F.), Philadelphia, Pennsylvania, USA
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24
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Li LX, Szymczak JE, Keller SC. Antibiotic stewardship in direct-to-consumer telemedicine: translating interventions into the virtual realm. J Antimicrob Chemother 2021; 77:13-15. [PMID: 34618026 DOI: 10.1093/jac/dkab371] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Direct-to-consumer (DTC) telemedicine is an increasingly popular modality for delivery of medical care via a virtual platform. As most DTC telemedicine visits focus on infection-related complaints, there is growing concern about the magnitude of antibiotic use associated with this setting. However, there is limited scholarship regarding adapting and implementing antibiotic stewardship principles in this setting as most efforts have been focused on hospitals with more recent work in long-term care facilities and primary care settings. We discuss utilizing the core elements for outpatient antibiotic stewardship as a framework for DTC antibiotic stewardship efforts moving forward.
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Affiliation(s)
- Lucy X Li
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sara C Keller
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Saine ME, Szymczak JE, Moore TM, Bamford LP, Barg FK, Forde KA, Schnittker J, Holmes JH, Mitra N, Lo Re V. The impact of disease-related knowledge on perceptions of stigma among patients with Hepatitis C Virus (HCV) infection. PLoS One 2021; 16:e0258143. [PMID: 34610030 PMCID: PMC8491913 DOI: 10.1371/journal.pone.0258143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/19/2021] [Indexed: 12/12/2022] Open
Abstract
Most patients with hepatitis C virus (HCV) infection perceive some degree of disease-related stigma. Misunderstandings about diseases may contribute to disease-related stigma. The objective of this study was to evaluate patient-level knowledge about HCV infection transmission and natural history and its association with HCV-related stigma among HCV-infected patients. We conducted a cross-sectional survey study among 265 patients with HCV in Philadelphia using the HCV Stigma Scale and the National Health and Nutrition Examination Survey (NHANES) Hepatitis C Follow-up Survey (2001-2008). The association between HCV knowledge and HCV-related stigma was evaluated via linear regression. Overall knowledge about HCV transmission and natural history was high, with >80% of participants answering ≥9 of 11 items correctly (median number of correct responses, 9 [82%]), HCV-related knowledge was similar between HIV/HCV-coinfected and HCV-monoinfected participants (p = 0.30). A higher level of HCV-related knowledge was associated with greater perceived HCV-related stigma (β, 2.34 ([95% CI, 0.51-4.17]; p = 0.013). Results were similar after adjusting for age, race, ethnicity, HIV status, education level, stage of HCV management, time since diagnosis, and history of injection drug use. In this study, increased HCV-related knowledge was associated with greater perceptions of HCV stigma. Clinicians may consider allotting time to address common misconceptions about HCV when educating patients about HCV infection, which may counterbalance the stigmatizing impact of greater HCV-related knowledge.
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Affiliation(s)
- M. Elle Saine
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Tyler M. Moore
- Department of Psychiatry, Brain Behavior Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Laura P. Bamford
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, United States of America
| | - Frances K. Barg
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Kimberly A. Forde
- Section of Hepatology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States of America
| | - Jason Schnittker
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America
- Department of Sociology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - John H. Holmes
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Vincent Lo Re
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
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Getz KD, Szymczak JE, Li Y, Madding R, Huang YSV, Aftandilian C, Arnold SD, Bona KO, Caywood E, Collier AB, Gramatges MM, Henry M, Lotterman C, Maloney K, Mian A, Mody R, Morgan E, Raetz EA, Rubnitz J, Verma A, Winick N, Wilkes JJ, Yu JC, Fisher BT, Aplenc R. Medical Outcomes, Quality of Life, and Family Perceptions for Outpatient vs Inpatient Neutropenia Management After Chemotherapy for Pediatric Acute Myeloid Leukemia. JAMA Netw Open 2021; 4:e2128385. [PMID: 34709389 PMCID: PMC8554641 DOI: 10.1001/jamanetworkopen.2021.28385] [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] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Pediatric acute myeloid leukemia (AML) requires multiple courses of intensive chemotherapy that result in neutropenia, with significant risk for infectious complications. Supportive care guidelines recommend hospitalization until neutrophil recovery. However, there are little data to support inpatient over outpatient management. OBJECTIVE To evaluate outpatient vs inpatient neutropenia management for pediatric AML. DESIGN, SETTING, AND PARTICIPANTS This cohort study used qualitative and quantitative methods to compare medical outcomes, patient health-related quality of life (HRQOL), and patient and family perceptions between outpatient and inpatient neutropenia management. The study included patients from 17 US pediatric hospitals with frontline chemotherapy start dates ranging from January 2011 to July 2019, although the specific date ranges differed for the individual analyses by design and relative timing. Data were analyzed from August 2019 to February 2020. EXPOSURES Discharge to outpatient vs inpatient neutropenia management. MAIN OUTCOMES AND MEASURES The primary outcomes of interest were course-specific bacteremia incidence, times to next course, and patient HRQOL. Course-specific mortality was a secondary medical outcome. RESULTS Primary quantitative analyses included 554 patients (272 [49.1%] girls and 282 [50.9%] boys; mean [SD] age, 8.2 [6.1] years). Bacteremia incidence was not significantly different during outpatient vs inpatient management (67 courses [23.8%] vs 265 courses [29.0%]; adjusted rate ratio, 0.73; 95% CI, 0.56 to 1.06; P = .08). Outpatient management was not associated with delays to the next course compared with inpatient management (mean [SD] 30.7 [12.2] days vs 32.8 [9.7] days; adjusted mean difference, -2.2; 95% CI, -4.1 to -0.2, P = .03). Mortality during intensification II was higher for patients who received outpatient management compared with those who received inpatient management (3 patients [5.4%] vs 1 patient [0.5%]; P = .03), but comparable with inpatient management at other courses (eg, 0 patients vs 5 patients [1.3%] during induction I; P = .59). Among 97 patients evaluated for HRQOL, outcomes did not differ between outpatient and inpatient management (mean [SD] Pediatric Quality of Life Inventory total score, 70.1 [18.9] vs 68.7 [19.4]; adjusted mean difference, -2.8; 95% CI, -11.2 to 5.6). A total of 86 respondents (20 [23.3%] in outpatient management, 66 [76.7%] in inpatient management) completed qualitative interviews. Independent of management strategy received, 74 respondents (86.0%) expressed satisfaction with their experience. Concerns for hospital-associated infections among caregivers (6 of 7 caregiver respondents [85.7%] who were dissatisfied with inpatient management) and family separation (2 of 2 patient respondents [100%] who were dissatisfied with inpatient management) drove dissatisfaction with inpatient management. Stress of caring for a neutropenic child at home (3 of 3 respondents [100%] who were dissatisfied with outpatient management) drove dissatisfaction with outpatient management. CONCLUSIONS AND RELEVANCE This cohort study found that outpatient neutropenia management was not associated with higher bacteremia incidence, treatment delays, or worse HRQOL compared with inpatient neutropenia management among pediatric patients with AML. While outpatient management may be safe for many patients, course-specific mortality differences suggest that outpatient management in intensification II should be approached with caution. Patient and family experiences varied, suggesting that outpatient management may be preferred by some but may not be feasible for all families. Further studies to refine and standardize safe outpatient management practices are warranted.
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Affiliation(s)
- Kelly D. Getz
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Yimei Li
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel Madding
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Yuan-Shung V. Huang
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Catherine Aftandilian
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Stanford University, Palo Alto, California
| | - Staci D. Arnold
- Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Kira O. Bona
- Pediatric Hematology/Oncology, Children’s Hospital Boston, Boston, Massachusetts
| | - Emi Caywood
- A.I. Dupont Hospital for Children, Nemours, Wilmington, Delaware
| | | | | | | | | | - Kelly Maloney
- Children’s Hospital Colorado and the Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Amir Mian
- Arkansas Children’s Hospital, Little Rock
| | | | - Elaine Morgan
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Elizabeth A. Raetz
- Stephen D. Hassenfeld Children’s Center for Cancer and Blood Disorders, New York, New York
| | - Jeffrey Rubnitz
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Anupam Verma
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Utah, Salt Lake City
| | - Naomi Winick
- Department of Pediatric Hematology Oncology, University of Texas Southwestern Medical Center, Dallas
| | - Jennifer J. Wilkes
- Department of Pediatrics, University of Washington, Division of Hematology/Oncology, Seattle Children’s Hospital, Seattle
| | - Jennifer C. Yu
- Division of Pediatric Hematology Oncology, Rady Children’s Hospital San Diego, San Diego, California
| | - Brian T. Fisher
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Richard Aplenc
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Schmidt H, Spieker AJ, Luo T, Szymczak JE, Grande D. Variability in Primary Care Physician Attitudes Toward Medicaid Work Requirement Exemption Requests Made by Patients With Depression. JAMA Health Forum 2021; 2:e212932. [PMID: 35977164 PMCID: PMC8727036 DOI: 10.1001/jamahealthforum.2021.2932] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/08/2021] [Indexed: 11/14/2022] Open
Abstract
Question To what degree do physicians vary in their willingness to assist patients seeking exemptions from Medicaid work requirements? Findings In this mailed survey experiment with 715 responses, we found that 25% of physicians would assist a patient not qualifying under the state’s criteria for exemptions from Medicaid work requirements, and 54% would not, even when a patient qualifies. We found state, administrative effort, political affiliation, and perceived appropriateness to be significantly associated with willingness to assist. Meaning It is medically, ethically, and legally imperative that measures aimed at protecting vulnerable patients are not undermined by the burdensomeness of exemption procedures, or by physicians’ political or personal views. Importance Medicaid work requirements seek to promote health and personal responsibility but can also jeopardize health care access. Physicians have a central function in assisting patients with exemption requests, but it is unclear how their role affects patient welfare, professionalism, and the ethical and legal justification of programs. Objective To understand the degree of variability in physician response to assist patients with depression in receiving a Medicaid work requirement exemption. Design, Setting, and Participants We conducted a mailed survey experiment among practicing primary care physicians in the first 4 approved states (Arkansas, Kentucky, Indiana, New Hampshire) in July and October of 2019. We report response, cooperation, refusal, and contact rates in line with American Association for Public Opinion Research (AAPOR) standards. Exposures In each state, we used an experimental factorial design to randomize recipients to 1 of 4 patient clinical scenarios. Main Outcomes and Measures The primary outcome was the indicator of willingness to assist a patient reporting depression with an exemption. Results We received 715 responses (overall AAPOR response rate: 21%; cooperation rate: 84%; refusal rate: 4%; contact rate: 25%). Respondents’ mean (SD) age was 54 (12) years; mean (SD) time since graduation, 26 (12) years; 435 (61%) identified as male; 177 as Democrat (25%); 156 as Republican (22%); 197 as Independent/other (28%); and 185 as declined/unknown (26%); the mean (SD) share of Medicaid patients was 29% (21%). We found that 97 of 387 physicians (25%) would offer assistance even when state policy would not support an exemption, and 170 of 315 (54%) would not offer assistance when regulations would require this. Moreover, 49 of 245 respondents (20%) who deemed an exemption appropriate indicated that they would not assist. State, administrative effort, political affiliation, and perceived appropriateness were statistically associated with the odds of assisting with an exemption. Conclusions and Relevance In this survey study of primary care physicians, we found substantial variation regarding willingness to assist patients qualifying for a work requirement exemption where none should exist. Insofar as work requirements are implemented again, it is critical to proactively identify measures to ensure that patients qualifying for exemptions are not put at risk due to either the burdensomeness of exemption procedures, or physicians’ political or personal views.
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Affiliation(s)
- Harald Schmidt
- Department of Medical Ethics and Health Policy, Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Andrew J. Spieker
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tianying Luo
- Department of Computer and Information Sciences, Fordham University, Bronx, New York
| | - Julia E. Szymczak
- Perelman School of Medicine, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia
| | - David Grande
- Perelman School of Medicine, Division of General Internal Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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28
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Szymczak JE. Structural Factors, Power, and the Physician Sex Pay Gap. JAMA Pediatr 2021; 175:868. [PMID: 33999099 DOI: 10.1001/jamapediatrics.2021.0870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Dutcher L, Degnan K, Adu-Gyamfi AB, Lautenbach E, Cressman L, David MZ, Cluzet V, Szymczak JE, Pegues DA, Bilker W, Tolomeo P, Hamilton KW. Improving Outpatient Antibiotic Prescribing for Respiratory Tract Infections in Primary Care; a Stepped-Wedge Cluster Randomized Trial. Clin Infect Dis 2021; 74:947-956. [PMID: 34212177 DOI: 10.1093/cid/ciab602] [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: 02/17/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic prescribing is common in primary care (PC), particularly for respiratory tract diagnoses (RTDs). However, the optimal approach for improving prescribing remains unknown. METHODS We conducted a stepped-wedge study in PC practices within a health system to assess the impact of a provider-targeted intervention on antibiotic prescribing for RTDs. RTDs were grouped into tiers based on appropriateness of antibiotic prescribing: tier 1 (almost always indicated), tier 2 (may be indicated), and tier 3 (rarely indicated). Providers received education on appropriate RTD prescribing followed by monthly peer comparison feedback on antibiotic prescribing for (1) all tiers and (2) tier 3 RTDs. Chi-squared testing was used to compare the proportion of visits with antibiotic prescriptions before and during the intervention. Mixed-effects multivariable logistic regression analysis was performed to assess the association between the intervention and antibiotic prescribing. RESULTS Across 30 PC practices and 185,755 total visits, overall antibiotic prescribing was reduced with the intervention, from 35.2% to 23.0% of visits (p<0.001). In multivariable analysis, the intervention was associated with a reduced odds of antibiotic prescription for tiers 2 (OR 0.57; 95% CI 0.52 - 0.62) and 3 (OR 0.57; 95% CI 0.53 - 0.61), but not for tier 1 (OR 0.98; 95% CI 0.83 - 1.16). CONCLUSION A provider-focused intervention reduced overall antibiotic prescribing for RTDs without affecting prescribing for infections that likely require antibiotics. Future research should examine the sustainability of such interventions, potential unintended adverse effects on patient health or satisfaction, and provider perceptions and acceptability.
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Affiliation(s)
- Lauren Dutcher
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kathleen Degnan
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Leigh Cressman
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael Z David
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Valerie Cluzet
- Division of Infectious Diseases, Health Quest, Poughkeepsie, NY, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - David A Pegues
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Warren Bilker
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Pam Tolomeo
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Keith W Hamilton
- Division of Infectious Diseases, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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Farr BD, Otto CM, Szymczak JE. Expert Perspectives on the Performance of Explosive Detection Canines: Performance Degrading Factors. Animals (Basel) 2021; 11:1978. [PMID: 34359105 PMCID: PMC8300196 DOI: 10.3390/ani11071978] [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] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/11/2021] [Accepted: 06/28/2021] [Indexed: 01/03/2023] Open
Abstract
The explosive detection canine (EDC) team is currently the best available mobile sensor capability in the fight against explosive threats. While the EDC can perform at a high level, the EDC team faces numerous factors during the search process that may degrade performance. Understanding these factors is key to effective selection, training, assessment, deployment, and operationalizable research. A systematic description of these factors is absent from the literature. This qualitative study leveraged the perspectives of expert EDC handlers, trainers, and leaders (n = 17) to determine the factors that degrade EDC performance. The participants revealed factors specific to utilization, the EDC team, and the physical, climate, operational, and explosive odor environments. Key results were the reality of performance degradation, the impact of the handler, and the importance of preparation. This study's results can help improve EDC selection, training, assessment, and deployment and further research into sustaining EDC performance.
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Affiliation(s)
- Brian D. Farr
- Army Medical Department Student Detachment, 187th Medical Battalion, 32nd Medical Brigade, Joint Base San Antonio-Fort Sam Houston, San Antonio, TX 78006, USA
- Penn Vet Working Dog Center, Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19019, USA;
| | - Cynthia M. Otto
- Penn Vet Working Dog Center, Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19019, USA;
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19019, USA;
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Wang R, Degnan KO, Luther VP, Szymczak JE, Goren EN, Logan A, Shnekendorf R, Hamilton KW. Development of a Multifaceted Antimicrobial Stewardship Curriculum for Undergraduate Medical Education: The Antibiotic Stewardship, Safety, Utilization, Resistance, and Evaluation (ASSURE) Elective. Open Forum Infect Dis 2021; 8:ofab231. [PMID: 34164562 PMCID: PMC8215691 DOI: 10.1093/ofid/ofab231] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/03/2021] [Indexed: 12/04/2022] Open
Abstract
To address the growing need for dedicated stewardship training in undergraduate
medical education, we developed an antimicrobial stewardship curriculum for
medical students with the objectives of increasing expertise in antimicrobial
prescribing, introducing antimicrobial stewardship fundamentals, and enhancing
comfort with engagement in interprofessional antimicrobial stewardship
activities.
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Affiliation(s)
- Rebecca Wang
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathleen O Degnan
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vera P Luther
- Division of Infectious Diseases, Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric N Goren
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ashleigh Logan
- Infectious Diseases Society of America, Arlington, Virginia, USA
| | | | - Keith W Hamilton
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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32
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Szymczak JE. Mandates are not magic bullets: Leveraging context, meaning and relationships to increase meaningful use of prescription monitoring programs. Pharmacoepidemiol Drug Saf 2021; 30:979-981. [PMID: 33797156 DOI: 10.1002/pds.5238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 03/26/2021] [Indexed: 11/07/2022]
Affiliation(s)
- Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Szymczak JE, Keller SC, Linder JA. "I Never Get Better Without an Antibiotic": Antibiotic Appeals and How to Respond. Mayo Clin Proc 2021; 96:543-546. [PMID: 33673907 DOI: 10.1016/j.mayocp.2020.09.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/18/2020] [Accepted: 09/28/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.
| | - Sara C Keller
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeffrey A Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
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Lavigne SH, Louis S, Rankin SC, Zaoutis TE, Szymczak JE. How companion animal veterinarians in the United States perceive financial constraints on antibiotic decision-making. Vet Rec 2021; 188:e62. [PMID: 34143461 DOI: 10.1002/vetr.62] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/03/2020] [Accepted: 12/24/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND The misuse of antibiotics is a persistent problem in both human and veterinary medicine. While complex social and behavioural factors drive inappropriate use in human medicine, less is known about factors that impact antibiotic use in companion animal medicine. OBJECTIVE To identify the perceptions that veterinarians practicing companion animal medicine hold about the influence of financial considerations on antibiotic use. METHODS Semi-structured qualitative interviews were conducted with veterinarians practicing companion animal medicine in a major metropolitan area in the Eastern United States. Respondents were sampled purposefully, and data were analysed using a thematic analysis approach. RESULTS Interviews were conducted with 36 veterinarians from 19 practices. Veterinarians believed that their clients' willingness to pay for diagnostic testing or treatment interfered with their ability to make appropriate decisions about antibiotic use. Concerns over antibiotic expiration and subsequent financial losses limited which antibiotics veterinarians stocked. Some veterinarians feared that restricting antibiotic use to appropriate uses could harm their business and lead to economic euthanasia of their patients. CONCLUSIONS Veterinarians perceive that financial factors can impede their ability to appropriately prescribe antibiotics. Interventions that address the financial aspects of prescribing have the potential to improve antibiotic decision-making in veterinary medicine.
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Affiliation(s)
- Sondra H Lavigne
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Souci Louis
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shelley C Rankin
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Theoklis E Zaoutis
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Paediatrics, Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Saine ME, Szymczak JE, Forde KA, Moore TM, Bamford LP, Barg FK, Schnittker J, Holmes JH, Mitra N, Re VL. 1072. The Impact of Hepatitis C-Related Knowledge on Perceptions of Stigma Among Infected Individuals. Open Forum Infect Dis 2020. [PMCID: PMC7776710 DOI: 10.1093/ofid/ofaa439.1258] [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 Stigma is an important and understudied barrier to hepatitis C virus (HCV) infection treatment and elimination. Education to dispel disease-based myths and misinformation has been identified as a key intervention point to reduce disease-related stigma; however, the association between knowledge about HCV infection and perceptions of stigma among HCV-infected patients remains unknown. Methods To address this gap and evaluate the association between patient-level HCV knowledge and HCV-related stigma, we conducted a cross-sectional study among 270 HCV-infected patients (147 [56%] HIV-coinfected) from 5 clinics across Philadelphia. HCV-related stigma was measured using the validated 33-item HCV Stigma Scale (range, 33-132). HCV-related knowledge was measured via the National Health and Nutrition Examination Survey (NHANES) Hepatitis C Follow-up Survey (2003-2008), an eleven item True/False survey (range, 0 to 11) comprising statements about HCV-related health effects and transmission. The association between HCV knowledge and HCV-related stigma was evaluated via linear regression by HIV status. Self-reported demographic, behavioral, and clinical covariates were evaluated in adjusted analyses. Results The median overall HCV knowledge score was high at 9 out of 11 points (IQR, 9-10). Median knowledge scores did not significantly differ between HIV/HCV-coinfected and HCV-monoinfected participants (10 versus 9; p=0.29). However, higher HCV knowledge scores were associated with higher HCV-related stigma score among HCV-monoinfected participants (p=0.03) but not among HCV/HIV-coinfected participants (p=0.12). Differences by HIV status were also observed when adjusting for demographic, behavioral, and clinical covariates. Conclusion Regardless of HIV status, the majority of both HIV/HCV-coinfected and HCV-monoinfected participants in this study answered questions about HCV knowledge correctly. Surprisingly, greater HCV knowledge was associated with increased HCV-related stigma among HCV-monoinfected participants, but this association was not observed among coinfected participants. Additional studies are needed to understand why this association was observed only among monoinfected persons. Disclosures M. Elle Saine, PhD, MA, Leonard Davis Institute of Health Economics Research (Grant/Research Support)
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Affiliation(s)
- M Elle Saine
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Kimberly A Forde
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tyler M Moore
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Frances K Barg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - John H Holmes
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nandita Mitra
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vincent Lo Re
- Department of Biostatistics, Epidemiology, and Informatics, Philadelphia, Pennsylvania
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Saine ME, Szymczak JE, Moore TM, Bamford LP, Barg FK, Schnittker J, Holmes JH, Mitra N, Re VL. Determinants of stigma among patients with hepatitis C virus infection. J Viral Hepat 2020; 27:1179-1189. [PMID: 32500618 PMCID: PMC9390068 DOI: 10.1111/jvh.13343] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 02/19/2020] [Accepted: 05/21/2020] [Indexed: 12/12/2022]
Abstract
Stigma around hepatitis C virus (HCV) infection is an important and understudied barrier to HCV treatment and elimination. The determinants of HCV-related stigma, including the impacts of stage of HCV treatment (ie spontaneously cleared; diagnosed, untreated; previously treated, not cured; currently being treated; and treated, cured) and coinfection with human immunodeficiency virus (HIV), remain unknown. To address these gaps, we conducted a cross-sectional study among patients with a history of HCV infection (n = 270) at outpatient clinics in Philadelphia from July 2018 to May 2019. We evaluated stigma using the validated HCV Stigma Scale, adapted from the Berger HIV Stigma Scale. Associations among HCV-related stigma and hypothesized demographic, behavioural, and clinical risk factors were evaluated by multivariable linear regression. Most participants (95.5%) experienced HCV-related stigma. Mean stigma scores did not differ significantly between HCV-monoinfected and HIV/HCV-coinfected participants (P = .574). However, we observed significant interactions between HIV status and multiple determinants; therefore, we stratified analyses by HIV status. Among HIV/HCV-coinfected participants, previous HCV treatment without cure, female gender, Hispanic/Latinx ethnicity and some college education were significantly associated with higher HCV-stigma scores. An annual income of $10 000-$40 000 was associated with significantly lower stigma scores. No significant associations were observed among HCV-monoinfected participants. We found that most participants experienced stigma associated with HCV diagnosis. While stigma scores were similar between HCV-monoinfected and HIV/HCV-coinfected participants, the determinants associated with HCV stigma differed by HIV status. Understanding how experiences of stigma differ between HCV-monoinfected and HIV/HCV-coinfected patients may aid in the development of targeted interventions to address the HCV epidemic.
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Affiliation(s)
- M. Elle Saine
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia E. Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tyler M. Moore
- Department of Psychiatry, Brain Behavior Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Laura P. Bamford
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Philadelphia FIGHT Community Health Centers, Philadelphia, PA, USA
| | - Frances K. Barg
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jason Schnittker
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA,Department of Sociology, University of Pennsylvania, Philadelphia, PA, USA
| | - John H. Holmes
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Vincent Lo Re
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Redding LE, Muller BM, Szymczak JE. Small and Large Animal Veterinarian Perceptions of Antimicrobial Use Metrics for Hospital-Based Stewardship in the United States. Front Vet Sci 2020; 7:582. [PMID: 33102546 PMCID: PMC7505943 DOI: 10.3389/fvets.2020.00582] [Citation(s) in RCA: 5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 07/20/2020] [Indexed: 12/23/2022] Open
Abstract
Background: Robust measurement and tracking of antimicrobial use (AMU) is a fundamental component of stewardship interventions. Feeding back AMU metrics to individual clinicians is a common approach to changing prescribing behavior. Metrics must be meaningful and comprehensible to clinicians. Little is known about how veterinary clinicians working in the United States (US) hospital setting think about AMU metrics for antimicrobial stewardship. Objective: To identify hospital-based veterinary clinicians' attitudes toward audit and feedback of AMU metrics, their perceptions of different AMU metrics, and their response to receiving an individualized prescribing report. Methods: Semi-structured interviews were conducted with veterinarians working at two hospitals in the Eastern US. Interviews elicited perceptions of antimicrobial stewardship in veterinary medicine. Respondents were shown a personalized AMU Report characterizing their prescribing patterns relative to their peers and were asked to respond. Interviews were recorded, transcribed, and analyzed using the framework method with matrices. Results: Semi-structured interviews were conducted with 34 veterinary clinicians (22 small animal and 12 large animal). Respondents generally felt positive about the reports and were interested in seeing how their prescribing compared to that of their peers. Many respondents expressed doubt that the reports accurately captured the complexities of their prescribing decisions and found metrics associated with animal daily doses (ADDs) confusing. Only 13 (38.2%) respondents felt the reports would change how they used antimicrobials. When asked how the impact of the reports could be optimized, respondents recommended providing a more detailed explanation of how the AMU metrics were derived, education prior to report roll-out, guidance on how to interpret the metrics, and development of meaningful benchmarks for goal-setting. Conclusions: These findings provide important insight that can be used to design veterinary-specific AMU metrics as part of a stewardship intervention that are meaningful to clinicians and more likely to promote judicious prescribing.
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Affiliation(s)
- Laurel E Redding
- Department of Clinical Sciences, University of Pennsylvania School of Veterinary Medicine, Philadelphia, PA, United States
| | - Brandi M Muller
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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Szymczak JE. Are Surgeons Different? The Case for Bespoke Antimicrobial Stewardship. Clin Infect Dis 2020; 69:21-23. [PMID: 30445615 DOI: 10.1093/cid/ciy847] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 09/28/2018] [Indexed: 12/30/2022] Open
Affiliation(s)
- Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania.,Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia
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Kohut MR, Keller SC, Linder JA, Tamma PD, Cosgrove SE, Speck K, Ahn R, Dullabh P, Miller MA, Szymczak JE. The inconvincible patient: how clinicians perceive demand for antibiotics in the outpatient setting. Fam Pract 2020; 37:276-282. [PMID: 31690948 DOI: 10.1093/fampra/cmz066] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Perceived patient demand for antibiotics drives unnecessary antibiotic prescribing in outpatient settings, but little is known about how clinicians experience this demand or how this perceived demand shapes their decision-making. OBJECTIVE To identify how clinicians perceive patient demand for antibiotics and the way these perceptions stimulate unnecessary prescribing. METHODS Qualitative study using semi-structured interviews with clinicians in outpatient settings who prescribe antibiotics. Interviews were analyzed using conventional and directed content analysis. RESULTS Interviews were conducted with 25 clinicians from nine practices across three states. Patient demand was the most common reason respondents provided for why they prescribed non-indicated antibiotics. Three related factors motivated clinically unnecessary antibiotic use in the face of perceived patient demand: (i) clinicians want their patients to regard clinical visits as valuable and believe that an antibiotic prescription demonstrates value; (ii) clinicians want to avoid negative repercussions of denying antibiotics, including reduced income, damage to their reputation, emotional exhaustion, and degraded relationships with patients; (iii) clinicians believed that certain patients are impossible to satisfy without an antibiotic prescription and felt that efforts to refuse antibiotics to such patients wastes time and invites the aforementioned negative repercussions. Clinicians in urgent care settings were especially likely to describe being motivated by these factors. CONCLUSION Interventions to improve antibiotic use in the outpatient setting must address clinicians' concerns about providing value for their patients, fear of negative repercussions from denying antibiotics, and the approach to inconvincible patients.
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Affiliation(s)
- Mike R Kohut
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.,Armstrong Institute for Patient Safety and Quality, Baltimore, MD
| | - Sara C Keller
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.,Armstrong Institute for Patient Safety and Quality, Baltimore, MD
| | - Jeffrey A Linder
- Northwestern University Feinberg School of Medicine, Division of General Internal Medicine and Geriatrics, Chicago, IL
| | - Pranita D Tamma
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sara E Cosgrove
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.,Armstrong Institute for Patient Safety and Quality, Baltimore, MD
| | - Kathleen Speck
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.,Armstrong Institute for Patient Safety and Quality, Baltimore, MD
| | - Roy Ahn
- NORC at the University of Chicago, Chicago, IL
| | | | - Melissa A Miller
- Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality, Rockville, MD
| | - Julia E Szymczak
- Perelman School of Medicine, University of Pennsylvania, Department of Biostatistics, Epidemiology and Informatics, Philadelphia, PA, USA
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Saine ME, Moore TM, Szymczak JE, Bamford LP, Barg FK, Mitra N, Schnittker J, Holmes JH, Lo Re V. Validation of a modified Berger HIV stigma scale for use among patients with hepatitis C virus (HCV) infection. PLoS One 2020; 15:e0228471. [PMID: 32023310 PMCID: PMC7001940 DOI: 10.1371/journal.pone.0228471] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 01/15/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Stigma around hepatitis C virus (HCV) infection is an important and understudied barrier to HCV prevention, treatment, and elimination. To date, no validated instrument exists to measure patients' experiences of HCV stigma. This study aimed to revise the Berger (2001) HIV stigma scale and evaluate its psychometric properties among patients with HCV infection. METHODS The Berger HIV stigma scale was revised to ask about HCV and administered to patients with HCV (n = 270) in Philadelphia, Pennsylvania. Scale reliability was evaluated as internal consistency by calculating Cronbach's alpha. Exploratory factor analysis was performed to evaluate construct validity by comparing item clustering to the Berger HIV stigma scale subscales. Item response theory was employed to further evaluate individual items and to calibrate items for simulated computer adaptive testing sessions in order to identify potential shortened instruments. RESULTS The revised HCV Stigma Scale was found to have good reliability (α = 0.957). After excluding items for low loadings, the exploratory factor analysis indicated good construct validity with 85% of items loading on pre-defined factors. Analyses strongly suggested the predominance of an underlying unidimensional factor solution, which yielded a 33-item scale after items were removed for low loading and differential item functioning. Adaptive simulations indicated that the scale could be substantially shortened without detectable information loss. CONCLUSIONS The 33-item HCV Stigma Scale showed sufficient reliability and construct validity. We also conducted computer adaptive testing simulations and identified shortened six- and three-item scale alternatives that performed comparably to the original 40-item scale.
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Affiliation(s)
- M. Elle Saine
- Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Tyler M. Moore
- Department of Psychiatry, Brain Behavior Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Julia E. Szymczak
- Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Laura P. Bamford
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Philadelphia FIGHT Community Health Centers, Philadelphia, PA, United States of America
| | - Frances K. Barg
- Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States of America
| | - Nandita Mitra
- Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Jason Schnittker
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America
- Department of Sociology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - John H. Holmes
- Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Vincent Lo Re
- Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
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Hill DL, Walter JK, Szymczak JE, DiDomenico C, Parikh S, Feudtner C. Seven Types of Uncertainty When Clinicians Care for Pediatric Patients With Advanced Cancer. J Pain Symptom Manage 2020; 59:86-94. [PMID: 31425822 PMCID: PMC6942218 DOI: 10.1016/j.jpainsymman.2019.08.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/05/2019] [Accepted: 08/08/2019] [Indexed: 11/18/2022]
Abstract
CONTEXT Clinicians deciding whether to refer a patient or family to specialty palliative care report facing high levels of uncertainty. Most research on medical uncertainty has focused on prognostic uncertainty. As part of a pediatric palliative referral intervention for oncology teams we explored how uncertainty might influence palliative care referrals. OBJECTIVES To describe distinct meanings of the term "uncertainty" that emerged during the qualitative evaluation of the development and implementation of an intervention to help oncologists overcome barriers to palliative care referrals. METHODS We conducted a phenomenological qualitative analysis of "uncertainty" as experienced and described by interdisciplinary pediatric oncology team members in discussions, group activities and semistructured interviews regarding the introduction of palliative care. RESULTS We found that clinicians caring for patients with advanced cancer confront seven broad categories of uncertainty: prognostic, informational, individual, communication, relational, collegial, and inter-institutional. Each of these kinds of uncertainty can contribute to delays in referring patients to palliative care. CONCLUSION Various types of uncertainty arise in the care of pediatric patients with advanced cancer. To manage these forms of uncertainty, providers need to develop strategies and techniques to handle professionally challenging situations, communicate bad news, manage difficult interactions with families and colleagues, and collaborate with other organizations.
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Affiliation(s)
- Douglas L Hill
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer K Walter
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Concetta DiDomenico
- Division of Pediatric Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shefali Parikh
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Pediatric Advanced Care Team, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
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Szymczak JE, Lee G, Klieger SB, Woods C, Creech CB, Gilsdorf JR, Dennehy P, Zaoutis T. Multifaceted but Invisible: Perceptions of the Value of a Pediatric Cognitive Specialty. Hosp Pediatr 2019; 8:385-393. [PMID: 29946040 DOI: 10.1542/hpeds.2017-0240] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Systems for standardizing physician payment have been shown to undervalue cognitive clinical encounters. Because health care reform emphasizes value-based approaches, we need an understanding of the way pediatric cognitive specialties are used to contribute to the provision of high-value care. We sought to investigate how clinical and administrative stakeholders perceive the value of pediatric infectious disease (PID) specialists. METHODS We conducted qualitative interviews with a purposive sample of physicians and administrators from 5 hospitals across the United States in which children are cared for. All interviews were transcribed and systematically analyzed for common themes. RESULTS We interviewed 97 stakeholders. Analysis revealed the following 3 domains of value: clinical, organizational, and communicative. Clinically, PID specialists were perceived to be highly valuable in treating patients with unusual infections that respond poorly to therapy, in optimizing the use of antimicrobial agents and in serving as outpatient homes for complex patients. Respondents perceived that PID specialists facilitate communication with patients and their families, the health care team and the media. PID specialists were perceived to generate value by participating in systemwide activities, including antimicrobial stewardship and infection prevention. Despite this, much of the valuable work PID specialists perform is difficult to measure causing some administrative stakeholders to question how many PID specialists are necessary to achieve high-quality care. CONCLUSIONS With our findings, we suggest that pediatric cognitive specialties contribute value in multiple ways to the health care delivery system. Many of these domains are difficult to capture by using current metrics, which may lead administrators to overlook valuable work and to under-allocate resources.
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Affiliation(s)
- Julia E Szymczak
- Division of Infectious Diseases, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;
| | - Grace Lee
- Division of Infectious Diseases, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California and Lucile Salter Packard Children's Hospital, Palo Alto, California
| | - Sarah B Klieger
- Division of Infectious Diseases, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Charles Woods
- Division of Infectious Disease, Department of Pediatrics, University of Louisville, Louisville, Kentucky
| | - C Buddy Creech
- Division of Pediatric Infectious Diseases, Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Janet R Gilsdorf
- Division of Pediatric Infectious Diseases, University of Michigan, Ann Arbor, Michigan; and
| | - Penelope Dennehy
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Hasbro Children's Hospital, Providence, Rhode Island
| | - Theoklis Zaoutis
- Division of Infectious Diseases, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Triantafillou V, Kopsidas I, Kyriakousi A, Zaoutis TE, Szymczak JE. Influence of national culture and context on healthcare workers' perceptions of infection prevention in Greek neonatal intensive care units. J Hosp Infect 2019; 104:552-559. [PMID: 31790745 DOI: 10.1016/j.jhin.2019.11.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 09/03/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Healthcare-associated infections (HAIs) in neonatal intensive care units (NICUs) result in increased morbidity, mortality and healthcare costs. HAI rates in Greek NICUs are among the highest in Europe. There is a need to identify the factors that influence the transmission of HAIs and implementation of prevention interventions in this setting. AIM To understand healthcare workers' perceptions about HAI prevention in Greek NICUs. METHODS Qualitative interviews were conducted with NICU staff (physicians and nurses) and infection prevention stakeholders (infectious diseases physicians and infection control nurses) working in three hospitals in Athens. Interviews were conducted in Greek, transcribed and translated into English, and analysed using a modified grounded theory approach. FINDINGS Interviews were conducted with 37 respondents (20 physicians and 17 nurses). Four main barriers to HAI prevention were identified: (1) resource limitations leading to understaffing and cramped space; (2) poor knowledge about HAI prevention; (3) Greek-specific cultural norms, including hierarchy-driven decisions, a reluctance for public workers to do more than they are paid for, a belief that personal experience trumps evidence-based knowledge, and reactive rather than proactive approaches to societal challenges; and (4) lack of a national infection prevention infrastructure. Respondents believed that these barriers could be overcome through organized initiatives, high-quality HAI performance data, interpersonal interactions to build engagement around HAI prevention, and leveraging the hierarchy to promote change from the 'top down'. CONCLUSION Implementing HAI prevention interventions in Greek NICUs will require consideration of contextual features surrounding the delivery of care, with particular attention paid to national culture.
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Affiliation(s)
- V Triantafillou
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Centre for Clinical Epidemiology and Outcomes Research, Non-Profit Civil Partnership, Athens, Greece
| | - I Kopsidas
- Centre for Clinical Epidemiology and Outcomes Research, Non-Profit Civil Partnership, Athens, Greece
| | - A Kyriakousi
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - T E Zaoutis
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Centre for Clinical Epidemiology and Outcomes Research, Non-Profit Civil Partnership, Athens, Greece; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - J E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Kim CJ, Szymczak JE, Herman DJ, Kennedy LA, Talati NJ, Akhter SN, Schnellinger EM, Hamilton KW. 1062. Provider-Based Survey to Determine the Relative Importance of Clinical Factors Used to Make Empiric Antibiotic Decisions. Open Forum Infect Dis 2019. [PMCID: PMC6811120 DOI: 10.1093/ofid/ofz360.926] [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 Despite advances in rapid organism identification, clinicians must make empiric antibiotic decisions prior to knowing the causative organism. Though many risk factors and patient characteristics have been studied and incorporated into predictive clinical decision support tools for empiric antibiotic prescription, little evidence exists on the relative importance of these factors in clinician judgment. The purpose of this study was to establish how providers evaluate patient and clinical risk factors when making empiric antimicrobial decisions. Methods An anonymous survey tool was distributed in February 2019 to medical providers who routinely prescribe antibiotics in 4 acute care hospitals throughout the University of Pennsylvania Health System. Providers were asked to rank the importance of 12 clinical factors using a 5-point scale from not important at all (1) to extremely important (5) in 3 unique clinical scenarios: uncomplicated cystitis, septic shock of unknown etiology, and uncomplicated pneumonia. Results Response rate was 30% (217/732). The importance of each factor varied among different clinical scenarios except for prior antibiotic exposure, local resistance patterns, drug-drug interactions, and treatment guidelines. However, the absolute difference varied by the factor and clinical scenario. Presence of indwelling catheter(s) had the largest absolute variation (median difference of 2 between septic shock and pneumonia, P < 0.001), and it was one of the top 5 most important factors for septic shock, but the least important factor for pneumonia. Conclusion The importance of clinicians place on clinical factors varies in different clinical scenarios. A better understanding of clinical decision-making in empiric antibiotic prescribing has the potential to guide stewardship efforts and clinical decision support. ![]()
Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Casey J Kim
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - David J Herman
- Penn Medicine Princeton Medical Center, Princeton, New Jersey
| | | | | | | | | | - Keith W Hamilton
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Affiliation(s)
- Valerie M Vaughn
- Patient Safety Enhancement Program, University of Michigan and Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan (V.M.V.)
| | - Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (J.E.S.)
| | - Duane W Newton
- Clinical Microbiology Laboratory, Department of Pathology, Michigan Medicine, Ann Arbor, Michigan (D.W.N.)
| | - Mohamad G Fakih
- Care Excellence, Ascension Healthcare, St. Louis, Missouri (M.G.F.)
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Clapp JT, Diraviam SP, Lane-Fall MB, Szymczak JE, Muralidharan M, Chung JJ, Gutsche JT, Curley MAQ, Berns JS, Fleisher LA. Nephrology in the Academic Intensive Care Unit: A Qualitative Study of Interdisciplinary Collaboration. Am J Kidney Dis 2019; 75:61-71. [PMID: 31492489 DOI: 10.1053/j.ajkd.2019.05.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 03/04/2019] [Accepted: 05/22/2019] [Indexed: 12/29/2022]
Abstract
RATIONALE & OBJECTIVE Collaboration between nephrology consultants and intensive care unit (ICU) teams is important in light of the high incidence of acute kidney injury in today's ICUs. Although there is considerable debate about how nephrology consultants and ICU teams should collaborate, communicative dynamics between the 2 parties remain poorly understood. This article describes interactions between nephrology consultants and ICU teams in the academic medical setting. STUDY DESIGN Focused ethnography using semi-structured interviews and participant observation. SETTING & PARTICIPANTS Purposive sampling was used to enroll nephrologists, nephrology fellows, and ICU practitioners across several roles collaborating in 3 ICUs (a medical ICU, a surgical ICU, and a cardiothoracic surgical ICU) of a large urban US academic medical center. Participant observation (150 hours) and semi-structured interviews (35) continued until theoretical saturation. ANALYTICAL APPROACH Interview and fieldnote transcripts were coded in an iterative team-based process. Explanation was developed using an abductive approach. RESULTS Nephrology consultants and surgical ICU teams exhibited discordant preferences about the aggressiveness of renal replacement therapy based on different understandings of physiology, goals of care, and acuity. Collaborative difficulties resulting from this discordance led to nephrology consultants often serving as dialysis proceduralists rather than diagnosticians in surgical ICUs and to consultants sometimes choosing not to express disagreements about clinical care because of the belief that doing so would not lead to changes in the course of care. LIMITATIONS Aspects of this single-site study of an academic medical center may not be generalizable to other clinical settings and samples. Surgical team perspectives would provide further detail about nephrology consultation in surgical ICUs. The effects of findings on patient care were not examined. CONCLUSIONS Differences in approach between internal medicine-trained nephrologists and anesthesia- and surgery-trained intensivists and surgeons led to collaborative difficulties in surgical ICUs. These findings stress the need for medical teamwork research and intervention to address issues stemming from disciplinary siloing rooted in long-term socialization to different disciplinary practices.
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Affiliation(s)
- Justin T Clapp
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Sushmitha P Diraviam
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Meghan B Lane-Fall
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Julia E Szymczak
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Madhavi Muralidharan
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jamison J Chung
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Martha A Q Curley
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Jeffrey S Berns
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lee A Fleisher
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Szymczak JE, Klieger SB, Miller M, Fiks AG, Gerber JS. What Parents Think About the Risks and Benefits of Antibiotics for Their Child's Acute Respiratory Tract Infection. J Pediatric Infect Dis Soc 2018; 7:303-309. [PMID: 28992328 DOI: 10.1093/jpids/pix073] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 08/09/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Parental pressure is often cited as a reason for why pediatricians overuse antibiotics for children with acute respiratory tract infection (ARTI). We sought to capture parent perceptions of antibiotics at the time of their child's presentation with an ARTI. METHODS We conducted semistructured interviews with parents of children who presented with ARTI symptoms to 1 of 4 diverse practices in a large hospital-affiliated network of pediatric primary care practices. Parents were interviewed before their child was seen by the pediatrician and asked about their perceptions of antibiotics. RESULTS Interviews were conducted with 109 parents. None of the parents said they planned to ask the pediatrician for antibiotics but instead expected to gain reassurance and a plan to minimize symptoms. Three perceptions about antibiotics were identified: parents have a sense of wariness when their child is prescribed antibiotics, they have an understanding that antibiotic overuse is a problem but that it is driven by the demands of other parents, and they have a preference for alternative treatment. The majority of the parents were not concerned about antibiotic resistance. In response to closed-ended questions designed to assess their level of concern with adverse effects, parents were most concerned with their child developing an upset stomach, having an allergic reaction, and experiencing diarrhea. The parents were not concerned with antibiotic treatment failure. CONCLUSIONS Parents in our study expressed a sense of caution about antibiotics and an awareness that they should be used judiciously. Our findings indicate that parents are aware of the downsides of antibiotics and might be willing to partner with healthcare providers to improve appropriate use.
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Affiliation(s)
- Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sarah B Klieger
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania
| | - Matthew Miller
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania
| | - Alexander G Fiks
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania.,Department of General Pediatrics, Children's Hospital of Philadelphia, Pennsylvania
| | - Jeffrey S Gerber
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Pennsylvania.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania
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Gerber JS, Ross R, Xiao R, Localio AR, Grundmeier R, Rettig S, Teszner E, Szymczak JE, Canning D, Coffin SE. 2132. Infections After Pediatric Ambulatory Surgery: Incidence and Risk Factors. Open Forum Infect Dis 2018. [PMCID: PMC6252811 DOI: 10.1093/ofid/ofy210.1788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 11/25/2022] Open
Abstract
Background Approximately 3 million pediatric ambulatory surgical procedures are performed each year in the United States; however, little is known about the incidence of and risk factors for surgical site infections (SSI) after pediatric surgical procedures performed in these settings. Therefore, we aimed to describe the epidemiology of SSI in children after ambulatory surgery. Methods We conducted a prospective, observational study in a single healthcare network with three ambulatory surgical facilities (ASF) and one hospital-based facility. We enrolled children <18 years who had an ambulatory surgical procedure between June 2012 and December 2015. Data on follow-up care were collected via a structured telephone interview (30–45 days post-surgery) and review of the electronic health record (EHR) 60 days post-surgery. We identified SSIs 30 days after surgery by applying 2010 National Healthcare Safety Network (NHSN) definitions. We also developed a broader definition of possible infectious events associated with surgery up to 60 days after surgery. Results We enrolled 8,502 surgical encounters; 64% occurred at the hospital-based facility. Three procedure categories (soft tissue excision, hernia, scrotal/testicular) accounted for 56% of encounters at ASFs. We identified 21 NHSN defined SSIs (2.5 SSIs per 1,000 surgical encounters). In adjusted analysis, there was no difference between hospital-based facility and ASF SSI rates (OR 0.7; 95% CI 0.2–2.3). Using the broader definition, we identified 404 surgical encounters with strong or some evidence of possible infection (48 per 1,000 surgical encounters). There was poor agreement of possible infections identified via parent interview vs. EHR. In multivariable analysis using the broader definition, older age and black race were associated with a reduced risk. Conclusion Using a rigorous surveillance definition, the incidence of surgical site infections was low after pediatric ambulatory surgery although our data suggest there may be additional infectious complications that are not captured by the NHSN definition. Given the annual rate of pediatric ambulatory surgery, even a low rate of infection may result in a significant medical burden. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Jeffrey S Gerber
- Department of Pediatrics, Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rachael Ross
- Department of Pediatrics, Division of Infectious Diseases, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rui Xiao
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Robert Grundmeier
- General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan Rettig
- Infection Prevention and Control, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Eva Teszner
- Infection Prevention and Control, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Julia E Szymczak
- Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas Canning
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan E Coffin
- Center for Pediatric Clinical Effectiveness, Pediatric Infectious Diseases Epidemiology and Antimicrobial Stewardship Research Group, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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Szymczak JE. Beyond barriers and facilitators: the central role of practical knowledge and informal networks in implementing infection prevention interventions. BMJ Qual Saf 2018; 27:763-765. [PMID: 30007916 DOI: 10.1136/bmjqs-2018-008512] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Szymczak JE, Schall T, Hill DL, Walter JK, Parikh S, DiDomenico C, Feudtner C. Pediatric Oncology Providers' Perceptions of a Palliative Care Service: The Influence of Emotional Esteem and Emotional Labor. J Pain Symptom Manage 2018; 55:1260-1268. [PMID: 29425881 PMCID: PMC5908218 DOI: 10.1016/j.jpainsymman.2018.01.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [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: 11/02/2017] [Revised: 01/28/2018] [Accepted: 01/30/2018] [Indexed: 11/30/2022]
Abstract
CONTEXT Pediatric palliative care consults for children with cancer often occur late in the course of disease and close to death, when earlier involvement would reduce suffering. The perceptions that pediatric oncology providers hold about the pediatric palliative care service (PPCS) may shape referral patterns. OBJECTIVES To explore how pediatric oncology providers at one institution perceived the hospital's PPCS and the way these perceptions may influence the timing of consultation. METHODS We conducted semistructured qualitative interviews with pediatric oncology providers at a large children's hospital. Interviews were audio-recorded, transcribed, and analyzed by two coders using a modified grounded theory approach. RESULTS We interviewed 16 providers (10 physicians, one nurse practitioner, two social workers, two psychologists, and one child life specialist). Three core perceptions emerged: 1) the PPCS offers a diverse range of valuable contributions to the care of children with advancing cancer; 2) providers held favorable opinions about the PPCS owing to positive interactions with individual palliative care specialists deemed extraordinarily emotionally skilled; and 3) there is considerable emotional labor involved in calling a PPCS consult that serves as a barrier to early initiation. CONCLUSION The pediatric oncology providers in our study held a highly favorable opinion about their institution's PPCS and agreed that early consultation is ideal. However, they also described that formally consulting PPCS is extremely difficult because of what the PPCS symbolizes to families and the emotional labor that the provider must manage in introducing them. Interventions to encourage the early initiation of palliative care in this population may benefit from a focus on the emotional experiences of providers.
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Affiliation(s)
- Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Theodore Schall
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Douglas L Hill
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer K Walter
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shefali Parikh
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Concetta DiDomenico
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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