A simplified critical illness severity scoring system (CISSS): Development and internal validation

PURPOSE

To create a simplified critical illness severity scoring system with high prediction accuracy for 30-day mortality using only commonly available variables.

MATERIALS AND METHODS

This is a retrospective cohort study of ICU admissions 2010-2015 in 306 ICUs in 117 Veterans Affairs (VA) hospitals. We randomly divided our cohort into a training dataset (75%) and a validation dataset (25%). We created a critical illness severity scoring system (CISSS) using age, comorbidities, heart rate, mean arterial blood pressure, temperature, respiratory rate, hematocrit, white blood cell count, creatinine, sodium, glucose, albumin, bilirubin, bicarbonate, use of invasive mechanical ventilation, and whether the admission was surgical or not. We validated the performance of CISSS to predict 30-day mortality internally.

RESULTS

After excluding 31,743 re-admissions, we divided our sample (n = 534,001) into a training (n = 400,613) and a validation dataset (n = 133,388). In the training dataset, the area under the curve (AUC) of CISSS was 0.847(95%CI = 0.845-0.850). In the validation dataset, the AUC was 0.848 (95%CI = 0.844-0.852), the standardized mortality ratio (SMR) was 1.00 (95%CI = 0.98-1.02), and Brier's score for 30-day mortality was 0.058 (95%CI = 0.057-0.059). CISSS calibration was acceptable.

CONCLUSIONS

CISSS has very good performance and requires only commonly used variables that can be easily extracted by electronic health records.

Role of structures in the masticator space in selecting patients with resectable T4b oral cancer: findings from a survival analysis

Oral squamous cell cancers involving the masticatory space are staged as unresectable cancers and their treatment is difficult. Curative treatment with extensive surgery followed by adjuvant therapy is one of the treatment options. In this retrospective study, the survival of 123 patients (93 with T4a cancers, 30 with T4b cancers), treated during the period August 2009 to August 2015, was evaluated. The majority had bucco-alveolar cancers (62.6%), were male (61.8%), and were tobacco users (76.4%). The select group of T4b oral cancer patients were treated with surgery, which included infratemporal fossa clearance in all 30 patients, followed by adjuvant therapy. The masseter was the most commonly involved masticatory muscle, and 24 patients had fewer than three involved structures. Free margins were obtained in 90.2% of cases; 41.5% of cases were node-positive. One hundred and four patients (84.6%) completed adjuvant treatment. The median follow-up was 42 months. For node-negative patients with T4a and T4b cancers, the 5-year overall survival was 59% and 50.2%, respectively (P= 0.62), and 5-year disease-free survival was 64.6% and 53.5%, respectively (P= 0.01). In conclusion, the select group of patients with T4b oral cancers and less than three masticatory space structures involved had comparable outcomes to those with T4a cancers after treatment with surgery and adjuvant radiotherapy.

A data resource from concurrent intracranial stimulation and functional MRI of the human brain

Mapping the causal effects of one brain region on another is a challenging problem in neuroscience that we approached through invasive direct manipulation of brain function together with concurrent whole-brain measurement of the effects produced. Here we establish a unique resource and present data from 26 human patients who underwent electrical stimulation during functional magnetic resonance imaging (es-fMRI). The patients had medically refractory epilepsy requiring surgically implanted intracranial electrodes in cortical and subcortical locations. One or multiple contacts on these electrodes were stimulated while simultaneously recording BOLD-fMRI activity in a block design. Multiple runs exist for patients with different stimulation sites. We describe the resource, data collection process, preprocessing using the fMRIPrep analysis pipeline and management of artifacts, and provide end-user analyses to visualize distal brain activation produced by site-specific electrical stimulation. The data are organized according to the brain imaging data structure (BIDS) specification, and are available for analysis or future dataset contributions on openneuro.org including both raw and preprocessed data.

Probing the Effects of Strong Electromagnetic Fields with Charge-Dependent Directed Flow in Pb-Pb Collisions at the LHC

The first measurement at the LHC of charge-dependent directed flow (v_{1}) relative to the spectator plane is presented for Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV. Results are reported for charged hadrons and D^{0} mesons for the transverse momentum intervals p_{T}>0.2  GeV/c and 3<p_{T}<6  GeV/c in the 5%-40% and 10%-40% centrality classes, respectively. The difference between the positively and negatively charged hadron v_{1} has a positive slope as a function of pseudorapidity η, dΔv_{1}/dη=[1.68±0.49(stat)±0.41(syst)]×10^{-4}. The same measurement for D^{0} and D[over ¯]^{0} mesons yields a positive value dΔv_{1}/dη=[4.9±1.7(stat)±0.6(syst)]×10^{-1}, which is about 3 orders of magnitude larger than the one of the charged hadrons. These measurements can provide new insights into the effects of the strong electromagnetic field and the initial tilt of matter created in noncentral heavy ion collisions on the dynamics of light (u, d, and s) and heavy (c) quarks. The large difference between the observed Δv_{1} of charged hadrons and D^{0} mesons may reflect different sensitivity of the charm and light quarks to the early time dynamics of a heavy ion collision. These observations challenge some recent theoretical calculations, which predicted a negative and an order of magnitude smaller value of dΔv_{1}/dη for both light flavor and charmed hadrons.

Evidence of Spin-Orbital Angular Momentum Interactions in Relativistic Heavy-Ion Collisions

The first evidence of spin alignment of vector mesons (K^{*0} and ϕ) in heavy-ion collisions at the Large Hadron Collider (LHC) is reported. The spin density matrix element ρ_{00} is measured at midrapidity (|y|<0.5) in Pb-Pb collisions at a center-of-mass energy (sqrt[s_{NN}]) of 2.76 TeV with the ALICE detector. ρ_{00} values are found to be less than 1/3 (1/3 implies no spin alignment) at low transverse momentum (p_{T}<2  GeV/c) for K^{*0} and ϕ at a level of 3σ and 2σ, respectively. No significant spin alignment is observed for the K_{S}^{0} meson (spin=0) in Pb-Pb collisions and for the vector mesons in pp collisions. The measured spin alignment is unexpectedly large but qualitatively consistent with the expectation from models which attribute it to a polarization of quarks in the presence of angular momentum in heavy-ion collisions and a subsequent hadronization by the process of recombination.

FRI0628-HPR EVALUATING A COMPLEX PACKAGE OF CARE IN THE EAST-MIDLANDS KNEE PAIN FEASIBILITY COHORT RANDOMISED CONTROLLED TRIAL

Background:

The role of nurses in managing painful knee OA has been advocated but whether nurses can deliver such interventions as a package of care is unknown.The overall aim of this research is to develop and test a nurse-led complex intervention for knee pain comprising non-pharmacological and pharmacological components. In the first study phase, we report on fidelity and acceptability of a non-pharmacological intervention, to resolve possible challenges to delivery.

Objectives:

To evaluate fidelity of delivery and acceptability of non-pharmacological components of a complex intervention.

Methods:

This was a mixed-methods study. Participants with chronic knee pain were recruited from the community to receive the intervention, delivered in 4-sessions over a 5-week period by a trained research nurse. The intervention consisted of holistic assessment, patient education and advice, aerobic and strengthening exercise and weight-loss advice if required. All sessions were video-recorded. Fidelity checklists were completed by the nurse (nurse-rated) and two researchers from the video-recordings (video-rated). Median fidelity scores (%) and interquartile ranges (IQR) were calculated for each component and each session. Semi-structured interviews were conducted with participants. These were audio recorded, transcribed and analysed following the framework approach.

Results:

18 participants (34% women), with a mean (SD) age and BMI of 68.7 (9.0) years and 31.2 (8.4) kg/m2, took part in the study. Of these, 14 completed all visits. In total, 62 intervention sessions were assessed for fidelity. Overall fidelity was rated high by both nurse-rated scores (97.7%) and video-rated scores (84.2%). The level of agreement between nurse-rated and video-recorded methods was 73.3% (CI 71.3, 75.3) and the inter-rater agreement was 65.5% (CI 60.3, 70.5). Fidelity of delivery was lower for advice on footwear modification and walking aids in all sessions and moderate for education in session 1 and for exercise in session 4 (Table 1).

Table 1.

Fidelity scores of the components of the intervention for each session,

Intervention componentsSession 1*Session 2*Session 3*Session 4*Education78.1 (74.1, 93.7)87.5 (50, 100)87.5 (50, 100)100 (93.7, 100)Exercise94.4 (88.9, 100)88.9 (75, 94)86.1 (72, 100)75 (67.6, 82.8)Adjunctive treatments50 (45.83, 100)0 (0, 50)50 (0, 100)-

*median (IQR)

17 participants were interviewed. Most found advice supplied straightforward. They were satisfied with the package, which changed their perception of managing knee pain, understanding it can be improved though self-management. However, too much information was provided in a short time-span and it was difficult to fit exercises into their daily routine.

Conclusion:

Delivery of a non-pharmacological intevention by a nurse is feasible within a research setting. Most components of the intervention were delivered as intended, except for advice about the use of adjunctive treatment.

Acknowledgments:

This research was funded by the NIHR Nottingham BRC and Pain Centre Versus Arthritis

Disclosure of Interests:

Polykarpos Angelos Nomikos: None declared, Amy Fuller: None declared, Michelle Hall: None declared, Bonnie Millar: None declared, Reuben Ogollah: None declared, Michael Doherty: None declared, Roshan Nair Speakers bureau: Financial support from pharmaceutical companies (Biogen and Novartis) to present lectures at events related to psychological support for people with multiple sclerosis (Speaker’s bureau)., David Walsh Grant/research support from: 2016: Investigator-led grant from Pfizer Ltd (ICRP) on Pain Phenotypes in RA; non-personal financial disclosure (payment to University)., Consultant of: DAW has undertaken paid consultancy to Pfizer Ltd, Eli Lilly and Company and GSK Consumer Healthcare., Paid instructor for: 2019: Consultancy to Love Productions; consultancy on programme design, contribution to programme content on self-management of chronic pain (payments to University)

2019: Consultancy to AbbVie Ltd; 13.06.19; presentation on RA pain at EULAR, Madrid, and webinar (payments to University).

2019: Consultancy to Eli Lilly and Company Ltd. 06.06.19 Centre for Collaborative Neuroscience, Windlesham, Surrey, UK (payment to University).

2019: Consultancy to Pfizer (payment to University).

2018: Consultancy to Pfizer. 07.12.18. USA. 1 day. Tanezumab (payment to University).

2018: Consultancy to Pfizer. 23.11.18. Manchester UK. 1 day. Tanezumab (payment to University).

2018: Consultancy to Pfizer. 1.11.18. Skype. 4h. Tanezumab (payment to University).

2018: Consultancy to GlaxoSmithKline Plc. 1 day. Pain in RA and anti-GM-CSF (payment to University).

2018: Consultancy to Pfizer Ltd; Presentation at OARSI; non-personal financial disclosure (payment to University)

2018: Consultancy to Pfizer Ltd; Patient preference study; non-personal financial disclosure (payment to University)

2017: Consultancy to Pfizer Ltd; personal financial disclosure

2017: Consultancy to Pfizer Ltd through Nottingham University; non-personal financial disclosure (payment to University).

2015: Consultancy to GSK Consumer Healthcare; personal financial disclosure., Speakers bureau: 2019: Irish Society of Rheumatology: speaker fees (personal pecuniary), Ana Valdes Grant/research support from: Awarded a grant from Pfizer, Abhishek Abhishek: None declared

Caries Risk Prediction Models in a Medical Health Care Setting

Despite development of new technologies for caries control, tooth decay in primary teeth remains a major global health problem. Caries risk assessment (CRA) models for toddlers and preschoolers are rare. Among them, almost all models use dental factors (e.g., past caries experience) to predict future caries risk, with limited clinical/community applicability owing to relatively uncommon dental visits compared to frequent medical visits during the first year of life. The objective of this study was to construct and evaluate risk prediction models using information easily accessible to medical practitioners to forecast caries at 2 and 3 y of age. Data were obtained from the Growing Up in Singapore Towards Healthy Outcomes (GUSTO) mother-offspring cohort. Caries was diagnosed using modified International Caries Detection and Assessment System criteria. Risk prediction models were constructed using multivariable logistic regression coupled with receiver operating characteristic analyses. Imputation was performed using multiple imputation by chained equations to assess effect of missing data. Caries rates at ages 2 y (n = 535) and 3 y (n = 721) were 17.8% and 42.9%, respectively. Risk prediction models predicting overall caries risk at 2 and 3 y demonstrated area under the curve (AUC) (95% confidence interval) of 0.81 (0.75-0.87) and 0.79 (0.74-0.84), respectively, while those predicting moderate to extensive lesions showed 0.91 (0.85-0.97) and 0.79 (0.73-0.85), respectively. Postimputation results showed reduced AUC of 0.75 (0.74-0.81) and 0.71 (0.67-0.75) at years 2 and 3, respectively, for overall caries risk, while AUC was 0.84 (0.76-0.92) and 0.75 (0.70-0.80), respectively, for moderate to extensive caries. Addition of anterior caries significantly increased AUC in all year 3 models with or without imputation (all P < 0.05). Significant predictors/protectors were identified, including ethnicity, prenatal tobacco smoke exposure, history of allergies before 12 mo, history of chronic maternal illness, maternal brushing frequency, childbearing age, and so on. Integrating oral-general health care using medical CRA models may be promising in screening caries-susceptible infants/toddlers, especially when medical professionals are trained to "lift the lip" to identify anterior caries lesions.

Scattering Studies with Low-Energy Kaon-Proton Femtoscopy in Proton-Proton Collisions at the LHC

The study of the strength and behavior of the antikaon-nucleon (K[over ¯]N) interaction constitutes one of the key focuses of the strangeness sector in low-energy quantum chromodynamics (QCD). In this Letter a unique high-precision measurement of the strong interaction between kaons and protons, close and above the kinematic threshold, is presented. The femtoscopic measurements of the correlation function at low pair-frame relative momentum of (K^{+}p⊕K^{-}p[over ¯]) and (K^{-}p⊕K^{+}p[over ¯]) pairs measured in pp collisions at sqrt[s]=5, 7, and 13 TeV are reported. A structure observed around a relative momentum of 58  MeV/c in the measured correlation function of (K^{-}p⊕K^{+}p[over ¯]) with a significance of 4.4σ constitutes the first experimental evidence for the opening of the (K[over ¯]^{0}n⊕K^{0}n[over ¯]) isospin breaking channel due to the mass difference between charged and neutral kaons. The measured correlation functions have been compared to Jülich and Kyoto models in addition to the Coulomb potential. The high-precision data at low relative momenta presented in this work prove femtoscopy to be a powerful complementary tool to scattering experiments and provide new constraints above the K[over ¯]N threshold for low-energy QCD chiral models.

Patient care experience with utilization of isolation precautions: systematic literature review and meta-analysis

BACKGROUND

Use of isolation precautions (IP) may represent a trade-off between reduced transmission of infectious pathogens and reduced patient satisfaction with their care.

OBJECTIVE

To perform a systematic literature review and meta-analysis to identify if and how IPs impact patients' care experiences.

DATA SOURCES

Medline, ClinicalTrials.gov, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsychInfo, HSRProj and Cochrane Library databases.

STUDY ELIGIBILITY CRITERIA

Interventional and observational studies published January 1990 to May 2019 were eligible for inclusion.

PARTICIPANTS

Patients admitted to an acute-care facility.

INTERVENTIONS

IPs versus no IPs.

METHODS

Six reviewers screened titles, abstracts and full text. Experience of care reported by patients using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was assessed as the outcome for the meta-analysis. Pooled odds ratios were calculated using the random-effects model. Heterogeneity was assessed using the I² value.

RESULTS

After screening 7073 titles and abstracts, 15 independent studies were included in the review. Pooling of unadjusted estimates from the HCAHPS survey demonstrated that IP patients were less likely to give top scores on questions pertaining to respect, communication, receiving assistance and cleanliness compared to the no-IP patients. Patients under IP with longer length of stay appeared to have more negative experiences with the care received during their stay compared to no IP.

CONCLUSIONS

Patients under IP were more likely to be dissatisfied with several aspects of patient care compared to patients not under IP. It is crucial to educate patients and healthcare workers in order to balance successful implementation of IP and patient care experiences, particularly in healthcare settings where it may be beneficial.

Incidence and Outcomes Associated With Clostridium difficile Infections: A Systematic Review and Meta-analysis

IMPORTANCE

An understanding of the incidence and outcomes of Clostridium difficile infection (CDI) in the United States can inform investments in prevention and treatment interventions.

OBJECTIVE

To quantify the incidence of CDI and its associated hospital length of stay (LOS) in the United States using a systematic literature review and meta-analysis.

DATA SOURCES

MEDLINE via Ovid, Cochrane Library Databases via Wiley, Cumulative Index of Nursing and Allied Health Complete via EBSCO Information Services, Scopus, and Web of Science were searched for studies published in the United States between 2000 and 2019 that evaluated CDI and its associated LOS.

STUDY SELECTION

Incidence data were collected only from multicenter studies that had at least 5 sites. The LOS studies were included only if they assessed postinfection LOS or used methods accounting for time to infection using a multistate model or compared propensity score-matched patients with CDI with control patients without CDI. Long-term-care facility studies were excluded. Of the 119 full-text articles, 86 studies (72.3%) met the selection criteria.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers performed the data abstraction and quality assessment. Incidence data were pooled only when the denominators used the same units (eg, patient-days). These data were pooled by summing the number of hospital-onset CDI incident cases and the denominators across studies. Random-effects models were used to obtain pooled mean differences. Heterogeneity was assessed using the I2 value. Data analysis was performed in February 2019.

MAIN OUTCOMES AND MEASURES

Incidence of CDI and CDI-associated hospital LOS in the United States.

RESULTS

When the 13 studies that evaluated incidence data in patient-days due to hospital-onset CDI were pooled, the CDI incidence rate was 8.3 cases per 10 000 patient-days. Among propensity score-matched studies (16 of 20 studies), the CDI-associated mean difference in LOS (in days) between patients with and without CDI varied from 3.0 days (95% CI, 1.44-4.63 days) to 21.6 days (95% CI, 19.29-23.90 days).

CONCLUSIONS AND RELEVANCE

Pooled estimates from currently available literature suggest that CDI is associated with a large burden on the health care system. However, these estimates should be interpreted with caution because higher-quality studies should be completed to guide future evaluations of CDI prevention and treatment interventions.

Incidence Trends of Lip, Oral Cavity, and Pharyngeal Cancers: Global Burden of Disease 1990–2017

The worldwide incidence trends of the lip, oral cavity, and pharyngeal cancers (LOCPs) need to be updated. This study aims to examine the temporal incidence trends of LOCPs from 1990 to 2017, using the latest Global Burden of Disease (GBD) study data to explore sex, age, and regional differences. GBD incidence data for LOCPs were driven by population cancer registries and were estimated from mortality data. Age-standardized incidence rates (ASIRs) were directly extracted from the 2017 GBD database to calculate the estimated annual percentage change (EAPC) over the study period. Incidence trends are mapped and compared separately by sex (females vs. males), age groups (15–49, 50–69, and 70+ y), regions (21 geographical and 5 sociodemographic regions), and countries. Among 678,900 incident cases of LOCPs notified in 2017, more than half were lip and oral cavity cancers. From 1990 to 2017, the estimated global incidence for nasopharyngeal cancers decreased dramatically (EAPC = −1.52; 95% confidence interval [CI], –1.70 to −1.34), while the incidence for lip and oral cavity cancers (EAPC = 0.26; 95% CI, 0.16–0.37) and other pharyngeal cancers (EAPC = 0.62; 95% CI, 0.54–0.71) increased. Higher ASIRs were observed among males than females across all age groups. However, females had larger EAPC variation when compared to males. Population groups aged 15 to 49 y presented the lowest ASIRs, with larger values of EAPC than those aged 50 to 69 and 70+ y. While high-income countries had higher ASIRs with little EAPC variation, ASIRs varied across low/middle-income regions with larger EAPC variations. South Asia and East Asia had the highest ASIRs and EAPC for lip and oral cavity cancers, respectively. In conclusion, the global incidence of LOCPs has increased among females, those aged 15 to 49 y, and people from low/middle-income countries over the study period, excepting nasopharyngeal cancers, which had a decreasing worldwide trend.

Risk of Recurrent Staphylococcus aureus Prosthetic Joint Infection in Rheumatoid Arthritis Patients-A Nationwide Cohort Study

Background

Treatment of rheumatoid arthritis (RA) often involves immune-suppressive therapies. Concern for recurrent prosthetic joint infection (PJI) in RA patients might be high and could reduce use of joint implantation in these patients. We aimed to evaluate the risk of recurrence of PJI in RA patients compared with osteoarthritis (OA) patients by utilizing a large health care system.

Methods

We conducted a retrospective cohort study of all patients admitted for a Staphylococcus aureus PJI who underwent debridement, antibiotics, and implant retention (DAIR) or 2-stage exchange (2SE) between 2003 and 2010 at 86 Veterans Affairs Medical Centers. Both RA patients and the comparison group of osteoarthritis (OA) patients were identified using International Classification of Diseases, Ninth Revision, codes. All index PJI and recurrent positive cultures for S. aureus during 2 years of follow-up were validated by manual chart review. A Cox proportional hazards regression model was used to compare the time to recurrent PJI for RA vs OA.

Results

In our final cohort of 374 veterans who had either DAIR or 2SE surgery for their index S. aureus PJI, 11.2% had RA (n = 42). The majority of the cohort was male (97.3%), and 223 (59.6%) had a methicillin-susceptible S. aureus PJI. RA patients had a similar risk of failure compared with OA patients, after adjusting for covariates (hazard ratio, 0.81; 95% confidence interval, 0.48–1.37).

Conclusions

Prior diagnosis of RA does not increase the risk of recurrent S. aureus PJI. Further studies are needed to evaluate the effect of different RA therapies on outcomes of episodes of PJI.

Measurement of ϒ(1S) Elliptic Flow at Forward Rapidity in Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

The first measurement of the ϒ(1S) elliptic flow coefficient (v_{2}) is performed at forward rapidity (2.5<y<4) in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV with the ALICE detector at the LHC. The results are obtained with the scalar product method and are reported as a function of transverse momentum (p_{T}) up to 15  GeV/c in the 5%-60% centrality interval. The measured ϒ(1S)v_{2} is consistent with 0 and with the small positive values predicted by transport models within uncertainties. The v_{2} coefficient in 2<p_{T}<15  GeV/c is lower than that of inclusive J/ψ mesons in the same p_{T} interval by 2.6 standard deviations. These results, combined with earlier suppression measurements, are in agreement with a scenario in which the ϒ(1S) production in Pb-Pb collisions at LHC energies is dominated by dissociation limited to the early stage of the collision, whereas in the J/ψ case there is substantial experimental evidence of an additional regeneration component.

Private Dental Care Benefits Non-Indigenous Children More Than Indigenous Children

INTRODUCTION

Various arrangements for funding health care facilities can have different levels of performance of care provision on different groups of people. Such differential performance of oral care is not previously known concerning Indigenous communities.

OBJECTIVE

This study aimed to assess the effect of visiting a public or private dental care facility on the performance of oral care experienced by Indigenous versus non-Indigenous children in Australia.

METHODS

Data from the National Child Oral Health Survey were used with a representative sample of children from all the states and territories of Australia. The performance of oral care was measured with the Child Oral Care Performance Assessment Scale (COPAS), which contains 37 items from 9 domains (Effective, Appropriate, Efficient, Responsive, Accessible, Safe, Continuous, Capable, and Sustainable) with a score ranging from 0 to 148. Mixed effects models that accounted for stratum and sampling weights were used for the stratified analyses (Indigenous vs. non-Indigenous) that assessed the effect of public versus private care on the COPAS. Relative excess risk due to interaction was calculated to assess effect modification.

RESULTS

Among the Indigenous children, private care was similar to public care (regression coefficient [RC] = -1.27, 95% CI = -9.5 to 6.97), whereas private care was higher than public care among non-Indigenous children (RC = 4.60, 95% CI = 3.67 to 6.18). This trend was similar among the 9 domains of the COPAS as well, except for Effectiveness, which was similar for private and public facilities among non-Indigenous children (RC = -0.03, 95% CI = -0.29 to 0.23). Based on the continuous COPAS score, effect modification was 4.46 (95% CI = 0.11 to 8.82) on the additive scale and 1.06 (1.01, 1.13) on the multiplicative scale. The relative excess risk due to interaction reported an excess chance of 1.17 (95% CI = 0.01 to 0.33), which was consistent with the stratified analyses and effect modification measured with the continuous score.

CONCLUSION

Thus, this study found a higher performance of oral care in private care locations among non-Indigenous children versus Indigenous children.

KNOWLEDGE TRANSFER STATEMENT

The findings caution policy makers and other stakeholders that moving oral care from public to private care facilities can increase the inequity faced by Indigenous children in Australia.

162. Identifying Determinants of Therapeutic Switch to Linezolid among Patients with Methicillin-Resistant Staphylococcus aureus Bloodstream Infections

Background

In order to target future randomized controlled trials (RCT) of treatment of methicillin-resistant S aureus bloodstream infections (MRSA BSI), it will be important to understand the drivers of antibiotic selection. We aimed to determine factors associated with switching from vancomycin to inpatient linezolid administration during the management of MRSA BSI.

Methods

This retrospective cohort included all patients admitted to Veteran Affairs hospitals from 2007 to 2014 and had received vancomycin for MRSA BSI. Patients were considered to have switched to linezolid from vancomycin if they received at least 2 consecutive days of inpatient treatment and were not on concurrent vancomycin treatment. Cox proportional hazards models were used to identify factors that were associated with switch within 14 days and 30 days. Median with interquartile range (IQR), hazard ratio (HR) and 95% confidence intervals were reported.

Results

Among 7289 patients diagnosed with MRSA BSI during their index admission, 474 (6.5%) switched to linezolid during the admission. The median inpatient duration of vancomycin treatment among all patients was 13 days (IQR: 5–34) and among patients who switched was 16 days (IQR: 6–52). The median inpatient duration of linezolid treatment was 5 days (IQR: 1–13 days). Patients who switched to linezolid were more likely to have a MRSA isolate with MIC >=2 µg/mL (6.8% vs. 4.9%), diagnosis of respiratory tract infection (36.7% vs. 32.9%), or be obese (16.5% vs. 13.6%) than those who continued on vancomycin (P < 0.10). In risk-adjustment models, presence of a respiratory tract infection diagnosis was associated with greater likelihood of being switched to linezolid within 14- and 30-days (HR=1.29, 95% CI 1.01–1.64; HR=1.32, 95% CI 1.06–1.65).

Conclusion

Less than 10% of patients initially treated with vancomycin for MRSA BSI were switched to linezolid in this real-world study. A diagnosis of respiratory tract infection was a major determinant of switching to linezolid. It is important to identify potential subsets of MRSA BSI patients so that future comparative effectiveness RCTs can be targeted to indications with clinical equipoise in real-world practice settings.

Disclosures

All authors: No reported disclosures.

2892. The Relationship Between Inpatient and Post-discharge Antimicrobial Use at the Hospital-level Across an Integrated Healthcare Network

Background

Hospital-based antimicrobial stewardship interventions and metrics have typically focused only on inpatient antimicrobial exposure. However, single-center studies have found a large portion of antimicrobial exposure occurs immediately after hospital discharge. We sought to describe antimicrobial-prescribing upon hospital discharge across the Veterans Health Administration (VHA) and to compare inpatient and post-discharge antimicrobial use at the hospital-level.

Methods

This retrospective study used national VHA administrative data to identify all acute-care admissions from January 1, 2014 to December 31, 2016. Post-discharge antimicrobials were defined as oral outpatient antimicrobials prescribed at the time of hospital discharge. We measured inpatient-days of therapy (DOT) and post-discharge DOTs. At the hospital-level, inpatient DOTs per 100 admissions were compared with post-discharge DOTs per 100 admissions using Spearman’s rank-order correlation.

Results

Among 1.7 million acute-care admissions across 122 VHA hospitals, 46.1% were administered inpatient antimicrobials and 19.9% were prescribed an oral antimicrobial at discharge. Fluoroquinolones were the most common antimicrobial prescribed at discharge among 335,396 antimicrobial prescriptions (38.3%). At the hospital-level, median inpatient antimicrobial use was 331.3 DOTs per 100 admissions (interquartile range (IQR) 284.9–367.9) and median post-discharge use was 209.5 DOTs per 100 admissions (IQR 181.5–239.6). Thirty-nine percent of the total duration of antimicrobial exposure occurred after hospital discharge. The metrics of inpatient DOTs per 100 admissions and post-discharge DOTs per 100 admissions were weakly correlated at the hospital-level (rho = 0.44, P < 0.0001).

Conclusion

Antimicrobial-prescribing at hospital discharge was common and contributed substantially to the total antimicrobial exposure associated with an acute-care hospital stay. A hospital’s inpatient antimicrobial use was only weakly correlated with its post-discharge antimicrobial use. Antimicrobial stewardship interventions should specifically target antimicrobial-prescribing at discharge.

Disclosures

All Authors: No reported Disclosures.

2894. Metrics of Antimicrobial Use Within Inpatient Settings: Impacts of Statistical Methods and Case-Mix Adjustments

Background

The necessary data elements and optimal statistical methods for benchmarking hospital-level antimicrobial use are still being debated. We aimed to describe the relative influence of case-mix adjustment and different statistical methods when ranking hospitals on antimicrobial use (AU) within inpatient settings.

Methods

Using administrative data from the Veterans Health Administration (VHA) system in October 2016, we calculated total antimicrobial days of therapy (DOT) and days present according to the National Healthcare Safety Network (NHSN) protocol. Patient-level demographics, comorbidities, and recent procedures were used for case-mix adjustments. We compared hospital rankings across 4 different methods: (A) crude antimicrobial DOT per 1,000 days present, aggregated at the hospital-level; (B) observed/expected (O/E) AU ratio with risk adjustment for ward-level variables (analogous to NHSN’s Standardized Antimicrobial Administration Ratio); (C) O/E AU ratio with risk adjustment for ward-/patient-level variables; (D) predicted/expected (P/E) AU ratio with risk adjustment for ward-/patient-level variables, based on a multilevel model accounting for clustering effects at hospital- and ward-levels.

Results

The cohort included 165,949 DOTs and 318,321 days present at 122 acute care hospitals within VHA. Crude DOTs per 1,000 days present ranged from 153.6 to 900.8 (Figure A), and ward-level risk adjustment only modestly changed rankings (Figure B). When adjusted for ward- and patient-level variables (including demographics, 14 comorbidities and 22 procedures), rankings changed substantially (Figure C). Risk-adjustment by a multilevel model changed rankings even further, while shrinking variabilities (Figure D). Ten hospitals in the lowest and 11 hospitals in the highest quartiles by O/E risk adjustment for only ward-level variables were classified to different quartiles on P/E risk adjustment.

Conclusion

We observed that the selection of variables and statistical methods for case-mix adjustment had a substantial impact on hospital rankings for antimicrobial use within inpatient settings. Careful consideration of methodologies is warranted when providing benchmarking metrics for hospitals.

Disclosures

All Authors: No reported Disclosures.

1072. The Role of an On-site Infectious Disease Specialist in Hospital-Based Antimicrobial Stewardship Programs

Background

Antimicrobial stewardship programs (ASPs) are now a requirement for many hospitals, but a large proportion of US hospitals lack an on-site Infectious Disease (ID) specialist. We sought to compare the processes and outcomes of ASPs at Veterans Health Administration (VHA) hospitals with and without an on-site ID specialist.

Methods

This retrospective cohort included all acute-care patients in VHA hospitals admitted during 2016, or 2 years after a VHA mandate for hospital-based ASPs. Data from a mandatory nationwide survey were used to identify hospitals that self-reported the absence of an on-site ID specialist, including an ID physician or ID pharmacist, in 2016. Antimicrobial use was quantified at the hospital-level as days-of-therapy (DOTs) per 1,000 days present and categorized based on National Healthcare Safety Network definitions. A facility-level negative binomial regression model with risk adjustments made for aggregated case-mix and facility-level factors was used to determine the association between the presence of an on-site ID specialist and antimicrobial use.

Results

Eighteen of 122 (14.8%) hospitals lacked an on-site ID specialist. Non-ID hospitals had fewer admissions per month than ID sites (mean 107.3 vs. 425.4, P < 0.01). An ASP policy and an ASP pharmacy champion were present at ≥90% of hospitals with and without an ID specialist. Core ASP strategies were frequently used in both ID and non-ID sites, including prior authorization (90.4% vs. 83.3%, P = 0.41) and prospective audit-and-feedback (76.9% vs. 66.7%, P = 0.38). Broad-spectrum antibacterial use (263.9 vs. 317.6 DOTs per 1,000 days-present, P = 0.01) but not total antimicrobial use (600.8 vs. 634.3 DOTs per 1,000 days-present, P = 0.34) was lower at ID vs. non-ID hospitals. After facility-level risk-adjustment, broad-spectrum antibacterial use (OR = 0.81, 95% CI 0.69–0.94) but not total antimicrobial use (OR = 0.92, 95% CI 0.70–1.21) was lower at ID hospitals.

Conclusion

An on-site ID specialist was not associated with greater use of core ASP strategies, but the presence of an on-site ID specialist was associated with less frequent prescribing of broad-spectrum antibacterial agents. An on-site ID specialist may be an important part of an effective hospital-based ASP.

Disclosures

All authors: No reported disclosures.