Inpatient and Discharge Fluoroquinolone Prescribing in Veterans Affairs Hospitals Between 2014 and 2017

Background

Between 2007 and 2015, inpatient fluoroquinolone use declined in US Veterans Affairs (VA) hospitals. Whether fluoroquinolone use at discharge also declined, in particular since antibiotic stewardship programs became mandated at VA hospitals in 2014, is unknown.

Methods

In this retrospective cohort study of hospitalizations with infection between January 1, 2014, and December 31, 2017, at 125 VA hospitals, we assessed inpatient and discharge fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin) use as (a) proportion of hospitalizations with a fluoroquinolone prescribed and (b) fluoroquinolone-days per 1000 hospitalizations. After adjusting for illness severity, comorbidities, and age, we used multilevel logit and negative binomial models to assess for hospital-level variation and longitudinal prescribing trends.

Results

Of 560219 hospitalizations meeting inclusion criteria as hospitalizations with infection, 37.4% (209602/560219) had a fluoroquinolone prescribed either during hospitalization (32.5%, 182337/560219) or at discharge (19.6%, 110003/560219). Hospitals varied appreciably in inpatient, discharge, and total fluoroquinolone use, with 71% of hospitals in the highest prescribing quartile located in the Southern United States. Nearly all measures of fluoroquinolone use decreased between 2014 and 2017, with the largest decreases found in inpatient fluoroquinolone and ciprofloxacin use. In contrast, there was minimal decline in fluoroquinolone use at discharge, which accounted for a growing percentage of hospitalization-related fluoroquinolone-days (52.0% in 2014; 61.3% by 2017).

Conclusions

Between 2014 and 2017, fluoroquinolone use decreased in VA hospitals, largely driven by decreased inpatient fluoroquinolone (especially ciprofloxacin) use. Fluoroquinolone prescribing at discharge, as well as levofloxacin prescribing overall, is a growing target for stewardship.

Methicillin-resistant Staphylococcus aureus Colonization and Pre- and Post-hospital Discharge Infection Risk

Background

The Department of Veterans Affairs implemented an active surveillance program for methicillin-resistant Staphylococcus aureus (MRSA) in 2007 in which acute care inpatients are tested for MRSA carriage on admission, unit-to-unit transfer, and discharge. Using these data, we followed patients longitudinally to estimate the difference in infection rates for those who were not colonized, those who were colonized on admission (importers), and those who acquired MRSA during their stay. We examined MRSA infections that occurred prior to discharge and at 30, 90, 180, and 365 days after discharge.

Methods

We constructed a dataset of 985626 first admissions from January 2008 through December 2015 who had surveillance tests performed for MRSA carriage. We performed multivariable Cox proportional hazards and logistic regression models to examine the relationship between MRSA colonization status and infection.

Results

The MRSA infection rate across the predischarge and 180-day postdischarge time period was 5.5% in importers and 7.0% in acquirers without a direct admission to the intensive care unit (ICU) and 11.4% in importers and 11.7% in acquirers who were admitted directly to the ICU. The predischarge hazard ratio for MRSA infection was 29.6 (95% confidence interval [CI], 26.5-32.9) for importers and 28.8 (95% CI, 23.5-35.3) for acquirers compared to those not colonized. Fully 63.9% of all MRSA pre- and postdischarge infections among importers and 61.2% among acquirers occurred within 180 days after discharge.

Conclusions

MRSA colonization significantly increases the risk of subsequent MRSA infection. In addition, a substantial proportion of MRSA infections occur after discharge from the hospital.

Effect of Frequency of Changing Point-of-Use Reminder Signs on Health Care Worker Hand Hygiene Adherence: A Cluster Randomized Clinical Trial

IMPORTANCE

Although hand hygiene (HH) is considered the most effective strategy for preventing hospital-acquired infections, HH adherence rates remain poor.

OBJECTIVE

To examine whether the frequency of changing reminder signs affects HH adherence among health care workers.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized clinical trial in 9 US Department of Veterans Affairs acute care hospitals randomly assigned 58 inpatient units to 1 of 3 schedules for changing signs designed to promote HH adherence among health care workers: (1) no change; (2) weekly; and (3) monthly. Hand hygiene rates among health care workers were documented at entry and exit to patient rooms during the baseline period from October 1, 2014, to March 31, 2015, of normal signage and throughout the intervention period of June 8, 2015, to December 28, 2015. Data analyses were conducted in April 2018.

INTERVENTIONS

Hospital units were randomly assigned into 3 groups: (1) no sign changes throughout the intervention period, (2) signs changed weekly, and (3) signs changed monthly.

MAIN OUTCOMES AND MEASURES

Hand hygiene adherence as measured by covert observation. Interrupted time series analysis was used to examine changes in HH adherence from baseline through the intervention period by group.

RESULTS

Among 58 inpatient units, 19 units were assigned to the no change group, 19 units were assigned to the weekly change group, and 20 units were assigned to the monthly change group. During the baseline period, 9755 HH opportunities were observed at room entry and 10 095 HH opportunities were observed at room exit. During the intervention period, a total of 15 855 HH opportunities were observed at room entry, and 16 360 HH opportunities were observed at room exit. Overall HH adherence did not change from baseline compared with the intervention period at either room entry (4770 HH events [48.9%] vs 3057 HH events [50.1%]; P = .14) or exit (6439 HH events [63.8%] vs 4087 HH events [65.2%]; P = .06). In units that changed signs weekly, HH adherence declined from baseline at room entry (-1.9% [95% CI, -2.7% to -0.8%] per week; P < .001) and exit (-0.8% [95% CI, -1.5% to 0.1%] per week; P = .02). No significant changes in HH adherence were observed in other groups.

CONCLUSIONS AND RELEVANCE

The frequency of changing reminder signs had no effect on HH rates overall. Units assigned to change signs most frequently demonstrated worsening adherence. Considering the abundance of signs in the acute care environment, the frequency of changing signs did not appear to provide a strong enough cue by itself to promote behavioral change.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02223455.

Transfusion of Blood Products in the Neurocritical Care Unit: An Exploration of Rationing and Futility

Rationing is the allocation of scarce resources, which in healthcare necessarily requires withholding potentially beneficial treatments from some individuals. While it often entails a negative connotation, rationing is unavoidable because need is limitless and resources are not. How rationing occurs is important, because it not only affects individual lives, but also reflects society's most important values. At the core of any rationing, decision is how much a limited resource may benefit a patient, which can be particularly difficult to determine in the practice of neurocritical care, as prognosis is often uncertain. We present a case for the consideration of futility and blood product rationing in neurocritical care.

Use of Oral Vancomycin for Clostridioides difficile Infection and the Risk of Vancomycin-Resistant Enterococci

Background

Vancomycin is now a preferred treatment for all cases of Clostridioides difficile infection (CDI), regardless of disease severity. Concerns remain that a large-scale shift to oral vancomycin may increase selection pressure for vancomycin-resistant Enterococci (VRE). We evaluated the risk of VRE following oral vancomycin or metronidazole treatment among patients with CDI.

Methods

We conducted a retrospective cohort study of patients with CDI in the US Department of Veterans Affairs health system between 1 January 2006 and 31 December 2016. Patients were included if they were treated with metronidazole or oral vancomycin and had no history of VRE in the previous year. Missing data were handled by multiple imputation of 50 datasets. Patients treated with oral vancomycin were compared to those treated with metronidazole after balancing on patient characteristics using propensity score matching in each imputed dataset. Patients were followed for VRE isolated from a clinical culture within 3 months.

Results

Patients treated with oral vancomycin were no more likely to develop VRE within 3 months than metronidazole-treated patients (adjusted relative risk, 0.96; 95% confidence interval [CI], .77 to 1.20), equating to an absolute risk difference of −0.11% (95% CI, −.68% to .47%). Similar results were observed at 6 months.

Conclusions

Our results suggest that oral vancomycin and metronidazole are equally likely to impact patients’ risk of VRE. In the setting of stable CDI incidence, replacement of metronidazole with oral vancomycin is unlikely to be a significant driver of increased risk of VRE at the patient level.

In this multicenter, retrospective cohort study of patients with Clostridioides difficile infection, the use of oral vancomycin did not increase the risk of vancomycin-resistant Enterococci infection at 3 or 6 months compared to metronidazole.

Ethical Considerations in End-of-life Care in the Face of Clinical Futility

Management of patients with terminal brain disorders can be medically, socially, and ethically complex. Although a growing number of feasible treatment options may exist, there are times when further treatment can no longer meaningfully improve either quality or length of life. Clinicians and patients should discuss goals of care while patients are capable of making their own decisions. However, because such discussions can be challenging, they are often postponed. These discussions are then conducted with patients' health care proxies after patients lose the capacity to make their own decisions. Disagreements may arise when a patient's surrogate desires continued aggressive interventions that are either biologically futile (incapable of producing the intended physiologic result) or potentially inappropriate (potentially capable of producing the patient's intended effect but in conflict with the medical team's ethical principles). This article explores best practices in addressing these types of conflicts in the critical care unit, but these concepts also broadly apply to other sites of care.

[Establishment of a living biobank : Improved guidance of precision cancer care with in vitro and in vivo cancer models]

BACKGROUND

Precision oncology is a clinical approach aimed towards tailoring treatment strategies for patients based on the genetic profile of each patient's cancer. The integration of a living biobank, consisting of patient-derived tumor organoids and PDXs, with next generation sequencing approaches and high-throughput drug screening help to guide clinical decision-making and clinical trial development.

METHODS

Tumor organoids derived from fresh tumor samples were used for in vitro and in vivo high-throughput drug testing.

RESULTS

Over a period of two years we established 56 in vitro tumor organoids and 19 in vivo xenografts from 18 different solid tumor types. Tumor morphology and molecular profiles show good concordance between the in vitro and in vivo models compared to their native tumor. High-throughput drug screening (up to 160 drugs) has been tested on eight tumor organoid lines. Seven of them underwent an additional combination drug screen. We nominated several targeted small molecules and novel combinations that have been validated in corresponding xenograft models.

CONCLUSION

This precision medicine approach outlines the integration of genomic data with drug screening from personalized preclinical cancer models to guide precision cancer care. It also fuels next generation research and has been implemented for clinical trial development.

Brain death, the determination of brain death, and member guidance for brain death accommodation requests: AAN position statement

The American Academy of Neurology holds the following positions regarding brain death and its determination, and provides the following guidance to its members who encounter resistance to brain death, its determination, or requests for accommodation including continued use of organ support technology despite neurologic determination of death.

Disorders of Consciousness: Ethical Issues of Diagnosis, Treatment, and Prognostication

Consciousness defines our humanity more than any other biologic phenomena that a clinician might be called upon to examine, diagnose, or treat. When family comes to the bedside of a patient, they hope to find them talking, thinking, and feeling. The complexity of consciousness allows an expansive gradation of dysfunction such that we must consider numerous potential insults, possible interventions, and often an unknown likelihood of recovery. As value-laden questions are more often in the hands of surrogate decision makers, the neurologist is given the herculean task of not only diagnosing and treating alterations of consciousness but also predicting the likely course of the disease to empower surrogates to make a choice most consistent with the preferences of the patient. The degree of uncertainty in the diagnosis and prognosis demands that the clinician consider the ethics of the diagnosis, treatment, and prognostication of disorders of consciousness. Expectations of acute and chronic care, the extent of the formal neurological investigation, the potential of therapeutic trials, the self-fulfilling prophecy that can occur with prognostication, and the challenges of shared decision making are all subjects that we explore.

The Impact of Healthcare-Associated Methicillin-Resistant Staphylococcus aureus Infections on Postdischarge Health Care Costs and Utilization across Multiple Health Care Systems

OBJECTIVE

To measure how much of the postdischarge cost and utilization attributable to methicillin-resistant Staphylococcus aureus (MRSA) health care-associated infections (HAIs) occur within the US Department of Veterans Affairs (VA) system and how much occurs outside.

DATA SOURCES/STUDY SETTING

Health care encounters from 3 different settings and payment models: (1) within the VA; (2) outside the VA but paid for by the VA (purchased care); and (3) outside the VA and paid for by Medicare.

STUDY DESIGN

Historical cohort study using data from admissions to VA hospitals between 2007 and 2012.

METHODS

We assessed the impact of a positive MRSA test result on costs and utilization during the 365 days following discharge using inverse probability of treatment weights to balance covariates.

PRINCIPAL FINDINGS

Among a cohort of 152,687 hospitalized Veterans, a positive MRSA test result was associated with an overall increase of 6.6 (95 percent CI: 5.7-7.5) inpatient days and $9,237 (95 percent CI: $8,211-$10,262) during the postdischarge period. VA inpatient admissions, Medicare reimbursements, and purchased care payments accounted for 60.6 percent, 22.5 percent, and 16.9 percent of these inpatient costs.

CONCLUSIONS

While most of the excess postdischarge health care costs associated with MRSA HAIs occurred in the VA, non-VA costs make up an important subset of the overall burden.

The Potential for Interventions in a Long-term Acute Care Hospital to Reduce Transmission of Carbapenem-Resistant Enterobacteriaceae in Affiliated Healthcare Facilities

Background

Carbapenem-resistant Enterobacteriaceae (CRE) are high-priority bacterial pathogens targeted for efforts to decrease transmissions and infections in healthcare facilities. Some regions have experienced CRE outbreaks that were likely amplified by frequent transmission in long-term acute care hospitals (LTACHs). Planning and funding of intervention efforts focused on LTACHs is one proposed strategy to contain outbreaks; however, the potential regional benefits of such efforts are unclear.

Methods

We designed an agent-based simulation model of patients in a regional network of 10 healthcare facilities including 1 LTACH, 3 short-stay acute care hospitals (ACHs), and 6 nursing homes (NHs). The model was calibrated to achieve realistic patient flow and CRE transmission and detection rates. We then simulated the initiation of an entirely LTACH-focused intervention in a previously CRE-free region, including active surveillance for CRE carriers and enhanced isolation of identified carriers.

Results

When initiating the intervention at the first clinical CRE detection in the LTACH, cumulative CRE transmissions over 5 years across all 10 facilities were reduced by 79%-93% compared to no-intervention simulations. This result was robust to changing assumptions for transmission within non-LTACH facilities and flow of patients from the LTACH. Delaying the intervention until the 20th CRE detection resulted in substantial delays in achieving optimal regional prevalence, while still reducing transmissions by 60%-79% over 5 years.

Conclusions

Focusing intervention efforts on LTACHs is potentially a highly efficient strategy for reducing CRE transmissions across an entire region, particularly when implemented as early as possible in an emerging outbreak.

Dynamic transmission models for economic analysis applied to health care-associated infections: A review of the literature

BACKGROUND

Cost-effectiveness analyses are an important methodology in assessing whether a health care technology is suitable for widespread adoption. Common models used by economists, such as decision trees and Markov models, are appropriate for noninfectious diseases where treatment and exposure are independent. Diseases whose treatment and exposure are dependent require dynamic models to incorporate the nonlinear transmission effect. Two different types of models are often used for dynamic cost-effectiveness analyses: compartmental models and individual models. In this methodology-focused literature review, we describe each model type and summarize the literature associated with each using the example of health care-associated infections (HAIs).

METHODS

We conducted a review of the literature to identify dynamic cost-effectiveness analyses that examined interventions to prevent or treat HAIs. To be included in the review, studies needed to have each of 3 necessary components: involve economics, such as cost-effectiveness analysis and evidence of economic theory, use a dynamic transmission model, and examine HAIs.

RESULTS

Of the 9 articles published between 2005 and 2016 that met criteria to be included in our study, 3 used compartmental models and 6 used individual models.

CONCLUSIONS

Very few published studies exist that use dynamic transmission models to conduct economic analyses related to HAIs and even fewer studies have used these models to perform cost-effectiveness analyses.

Molecular alterations in prostate cancer and association with MRI features

BACKGROUND

Multiparametric magnetic resonance imaging (mpMRI) has been increasingly used for prostate cancer (PCa). Recent studies identified distinct molecular subclasses of PCa with recurrent genomic alterations. However, the associations between molecular alterations in PCa and characteristics on mpMRI are unknown. Therefore, the objective of this study was to investigate recurrent molecular alterations in PCa and their associations with mpMRI features.

METHODS

Sixty-two PCa nodules >0.5 cm had a preoperative mpMRI. Nodules were evaluated for ERG rearrangement, PTEN deletion, SPINK1 overexpression, SPOP mutation and CHD1 deletion. Each PCa focus was matched to the corresponding location on mpMRI. Lesions were scored by single observer according to the PI-RADSv2 scale.

RESULTS

Of the 62 nodules, 22 (35.5%) were ERG positive, 6 (9.7%) had SPINK1 overexpression, 6 (9.7%) had SPOP mutations, 4 (6.5%) had CHD1 deletions and 1 (1.6%) had PTEN deletion. All of the nodules with CHD1 deletions were not visible on mpMRI (P=0.037). All of the nodules with SPINK1 overexpression were visible on mpMRI, although the association was not statistically significant (P=0.06). There were no significant associations between any molecular alteration with the severity of the PI-RADS scores (all P>0.05).

CONCLUSIONS

This investigation represents the first description of an association between recurrent molecular alterations and the characterization of PCa nodules on mpMRI. This study can be considered hypothesis-generating for future studies to rigorously evaluate the association of specific PCa molecular subclasses with imaging features and potentially define specific subsets of PCa for which the utility of MRI is higher or lower.

Comparative Effectiveness of Vancomycin and Metronidazole for the Prevention of Recurrence and Death in Patients With Clostridium difficile Infection

IMPORTANCE

Metronidazole hydrochloride has historically been considered first-line therapy for patients with mild to moderate Clostridium difficile infection (CDI) but is inferior to vancomycin hydrochloride for clinical cure. The choice of therapy may likewise have substantial consequences on other downstream outcomes, such as recurrence and mortality, although these secondary outcomes have been less studied.

OBJECTIVE

To evaluate the risk of recurrence and all-cause 30-day mortality among patients receiving metronidazole or vancomycin for the treatment of mild to moderate and severe CDI.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, propensity-matched cohort study evaluated patients treated for CDI, defined as a positive laboratory test result for the presence of C difficile toxins or toxin genes in a stool sample, in the US Department of Veterans Affairs health care system from January 1, 2005, through December 31, 2012. Data analysis was performed from February 7, 2015, through November 22, 2016.

EXPOSURES

Treatment with vancomycin or metronidazole.

MAIN OUTCOMES AND MEASURES

The outcomes of interest in this study were CDI recurrence and all-cause 30-day mortality. Recurrence was defined as a second positive laboratory test result within 8 weeks of the initial CDI diagnosis. All-cause 30-day mortality was defined as death from any cause within 30 days of the initial CDI diagnosis.

RESULTS

A total of 47 471 patients (mean [SD] age, 68.8 [13.3] years; 1947 women [4.1%] and 45 524 men [95.9%]) developed CDI, were treated with vancomycin or metronidazole, and met criteria for entry into the study. Of 47 147 eligible first treatment episodes, 2068 (4.4%) were with vancomycin. Those 2068 patients were matched to 8069 patients in the metronidazole group for a total of 10 137 included patients. Subcohorts were constructed that comprised 5452 patients with mild to moderate disease and 3130 patients with severe disease. There were no differences in the risk of recurrence between patients treated with vancomycin vs those treated with metronidazole in any of the disease severity cohorts. Among patients in the any severity cohort, those who were treated with vancomycin were less likely to die (adjusted relative risk, 0.86; 95% CI, 0.74 to 0.98; adjusted risk difference, -0.02; 95% CI, -0.03 to -0.01). No significant difference was found in the risk of mortality between treatment groups among patients with mild to moderate CDI, but vancomycin significantly reduced the risk of all-cause 30-day mortality among patients with severe CDI (adjusted relative risk, 0.79; 95% CI, 0.65 to 0.97; adjusted risk difference, -0.04; 95% CI, -0.07 to -0.01).

CONCLUSIONS AND RELEVANCE

Recurrence rates were similar among patients treated with vancomycin and metronidazole. However, the risk of 30-day mortality was significantly reduced among patients who received vancomycin. Our findings may further justify the use of vancomycin as initial therapy for severe CDI.

What to Do When There Aren't Enough Beds in the PICU

The concepts of medical futility and rationing are often misunderstood and lead to significant consternation when resources are stretched and pediatric intensive care unit (PICU) beds are unavailable. While the two concepts overlap, each has its own distinct application and moral justification. Most importantly, we should avoid using one to justify the other. Bioethics professionals should assist critical care clinicians in clarifying when each rubric should be applied as well as how to develop policies to standardize the approach.

Economic Analysis of Veterans Affairs Initiative to Prevent Methicillin-Resistant Staphylococcus aureus Infections

INTRODUCTION

In an effort to reduce methicillin-resistant Staphylococcus aureus (MRSA) transmission through universal screening and isolation, the Department of Veterans Affairs (VA) launched the National MRSA Prevention Initiative in October 2007. The objective of this analysis was to quantify the budget impact and cost effectiveness of this initiative.

METHODS

An economic model was developed using published data on MRSA hospital-acquired infection (HAI) rates in the VA from October 2007 to September 2010; estimates of the costs of MRSA HAIs in the VA; and estimates of the intervention costs, including salaries of staff members hired to support the initiative at each VA facility. To estimate the rate of MRSA HAIs that would have occurred if the initiative had not been implemented, two different assumptions were made: no change and a downward temporal trend. Effectiveness was measured in life-years gained.

RESULTS

The initiative resulted in an estimated 1,466-2,176 fewer MRSA HAIs. The initiative itself was estimated to cost $207 million during this 3-year period, while the cost savings from prevented MRSA HAIs ranged from $27 million to $75 million. The incremental cost-effectiveness ratios ranged from $28,048 to $56,944/life-years. The overall impact on the VA's budget was $131-$179 million.

CONCLUSIONS

Wide-scale implementation of a national MRSA surveillance and prevention strategy in VA inpatient settings may have prevented a substantial number of MRSA HAIs. Although the savings associated with prevented infections helped offset some but not all of the cost of the initiative, this model indicated that the initiative would be considered cost effective.

Estimates of Outbreak Risk from New Introductions of Ebola with Immediate and Delayed Transmission Control

Identifying incoming patients can have a larger risk-reduction effect than efforts to reduce transmissions from identified patients.

While the ongoing Ebola outbreak continues in the West Africa countries of Guinea, Sierra Leone, and Liberia, health officials elsewhere prepare for new introductions of Ebola from infected evacuees or travelers. We analyzed transmission data from patients (i.e., evacuees, international travelers, and those with locally acquired illness) in countries other than the 3 with continuing Ebola epidemics and quantitatively assessed the outbreak risk from new introductions by using different assumptions for transmission control (i.e., immediate and delayed). Results showed that, even in countries that can quickly limit expected number of transmissions per case to <1, the probability that a single introduction will lead to a substantial number of transmissions is not negligible, particularly if transmission variability is high. Identifying incoming infected travelers before symptom onset can decrease worst-case outbreak sizes more than reducing transmissions from patients with locally acquired cases, but performing both actions can have a synergistic effect.

Finding 'Evidence of Absence' in Medical Notes: Using NLP for Clinical Inferencing

Extracting evidence of the absence of a target of interest from medical text can be useful in clinical inferencing. The purpose of our study was to develop a natural language processing (NLP) pipelineto identify the presence of indwelling urinary catheters from electronic medical notes to aid in detection of catheter-associated urinary tract infections (CAUTI). Finding clear evidence that a patient does not have an indwelling urinary catheter is useful in making a determination regarding CAUTI. We developed a lexicon of seven core concepts to infer the absence of a urinary catheter. Of the 990,391 concepts extractedby NLP from a large corpus of 744,285 electronic medical notes from 5589 hospitalized patients, 63,516 were labeled as evidence of absence.Human review revealed three primary causes for false negatives. The lexicon and NLP pipeline were refined using this information, resulting in outputs with an acceptable false positive rate of 11%.