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Gostyńska A, Dettlaff K, Jelińska A, Stawny M. Improving the Safety of Clinical Management of COVID-19 Patients Receiving Aminoglycosides and Parenteral Nutrition: Y-site Compatibility Studies. J Pharm Sci 2023; 112:2597-2603. [PMID: 37595749 DOI: 10.1016/j.xphs.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 08/20/2023]
Abstract
PURPOSE Aminoglycosides (AMGs) are broad-spectrum bactericidal antibiotics that can resolve bacterial infections co-existing with COVID-19 or exploit their potential antiviral activities. Patients presenting the most severe forms of COVID-19 due to escalating catabolism and significant lean body mass loss often require the concomitant administration of parenteral nutrition (PN) and antibiotics. The Y-site administration is one of the approaches allowing the co-administration of two intravenous medications in patients with limited vascular access. Our study aimed to investigate the compatibility of AMGs and selected commercial PN admixtures enriched in omega-3 fatty acids. METHODS Gentamycin (GM), amikacin (AM), and tobramycin (TM) solutions for infusion were combined with Nutriflex Omega Special (NOS) and Smofkabiven (SFK). Three different volume ratios were investigated: 1:2, 1:1, and 2:1, simulating Y-site administration. Samples underwent visual examination and determination of the lipid emulsion particle size, zeta potential, and pH immediately after preparation and after four hours of storage at room temperature (22 ± 2 °C) with sunlight exposure. RESULTS GM and AM combined with NOS in all studied ratios met the set-up acceptance criteria. The addition of TM to NOS in a 2:1 volume ratio and all tested AMGs to SFK in all studied combinations significantly influenced the stability of the oil-water system leading to the appearance of globules larger than 5 µm exceeding the pharmacopeial limit of 0.05% immediately after preparation or after four hours of storage. CONCLUSION In conclusion, our study showed that NOS was less prone to destabilization of oil-in-water systems by AMGs than SFK. In justified clinical cases, due to the lack of appearance of precipitate or enlarged lipid droplets, the combined administration of GM and AM with the NOS could be considered, provided tested volume ratios of the drug and MCB in the infusion line are maintained. However, it should be noted that such an infusion may be associated with the risk of changes in the pharmacokinetics of the drug.
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Affiliation(s)
- Aleksandra Gostyńska
- Chair and Department of Pharmaceutical Chemistry, Poznan University of Medical Sciences, 6 Grunwaldzka, 60-780 Poznań, Poland.
| | - Katarzyna Dettlaff
- Chair and Department of Pharmaceutical Chemistry, Poznan University of Medical Sciences, 6 Grunwaldzka, 60-780 Poznań, Poland
| | - Anna Jelińska
- Chair and Department of Pharmaceutical Chemistry, Poznan University of Medical Sciences, 6 Grunwaldzka, 60-780 Poznań, Poland
| | - Maciej Stawny
- Chair and Department of Pharmaceutical Chemistry, Poznan University of Medical Sciences, 6 Grunwaldzka, 60-780 Poznań, Poland
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Begier E, Rosenthal NA, Richardson W, Chung J, Gurtman A. Invasive Staphylococcus aureus Infection among Patients Undergoing Elective, Posterior, Instrumented Spinal Fusion Surgeries: A Retrospective Cohort Study. Surg Infect (Larchmt) 2021; 23:12-21. [PMID: 34494895 DOI: 10.1089/sur.2021.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Post-surgical invasive Staphylococcus aureus infections among spinal fusion patients are serious complications that can worsen clinical outcomes and increase healthcare utilization. Risk of such infections at the population level remains unknown. This study assessed the post-surgical risk of invasive Staphylococcus aureus infections among patients undergoing elective posterior instrumented spinal fusion surgeries in 129 U.S. hospitals. Patients and Methods: This retrospective cohort study analyzed adult patients ≥18 years of age who underwent thoracolumbar/lumbar and cervical fusion surgeries during 2010 - 2014 using the Premier Healthcare Database, the largest hospital discharge database in the United States. Risks of blood stream infection (BSI), deep or organ/space surgical site infections (SSI) caused by Staphylococcus aureus during 90 and 180 days post-index surgery were estimated. Infections were identified based on positive culture results, related International Classification of Diseases, Ninth Revision (ICD-9) procedure codes, and specific claims information. Results: Among 11,236 patients with thoracolumbar/lumbar fusion, 90- and 180-day BSI/SSI infection risks were higher for multilevel than single level fusion (90-day, 1.52% vs. 1.07%, p = 0.05; 180-day, 1.66% vs. 1.07%, p = 0.014). Among 1,641 patients with cervical fusion, 90- and 180-day BSI/SSI infection risks were also higher in multilevel fusions but not statistically significant (90-day, 1.66% vs. 0.52%, p = 0.350; 180-day, 1.80% vs. 0.51%, p = 0.241). The risk for SSI/BSI was more than twice as high among multilevel thoracolumbar/lumbar fusion patients with more than two comorbidities than those with no comorbidity at both 90-day (2.78% vs. 1.00%, p < 0.05) and 180-day (3.01% vs. 1.10%, p < 0.05). Similar trend without statistical significance was seen in multilevel cervical fusion cohort (90-day, 2.91% vs. 1.25%, p > 0.05; 180-day, 3.88% vs. 1.41%, p > 0.05). Conclusions: The risk of BSI/SSI infection for elective posterior instrumented spinal fusions ranged between 0.5% and 2%. Higher risk was observed in multilevel thoracolumbar/lumbar surgery, with infection risk greatest in patients with more than two comorbidities. These real-world findings highlight the need for additional measures, in addition to antibiotic prophylaxis, to reduce invasive Staphylococcus aureus infections in this setting.
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Affiliation(s)
| | - Ning A Rosenthal
- Premier Applied Sciences, Premier Inc., Charlotte, North Carolina, USA
| | | | - Jessica Chung
- Premier Applied Sciences, Premier Inc., Charlotte, North Carolina, USA
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Pradelli L, Klek S, Mayer K, Omar Alsaleh AJ, Rosenthal MD, Heller AR, Muscaritoli M. Omega-3 fatty acid-containing parenteral nutrition in ICU patients: systematic review with meta-analysis and cost-effectiveness analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:634. [PMID: 33143750 PMCID: PMC7607851 DOI: 10.1186/s13054-020-03356-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/23/2020] [Indexed: 12/26/2022]
Abstract
Background Omega-3 (ω-3) fatty acid (FA)-containing parenteral nutrition (PN) is associated with significant improvements in patient outcomes compared with standard PN regimens without ω-3 FA lipid emulsions. Here, we evaluate the impact of ω-3 FA-containing PN versus standard PN on clinical outcomes and costs in adult intensive care unit (ICU) patients using a meta-analysis and subsequent cost-effectiveness analysis from the perspective of a hospital operating in five European countries (France, Germany, Italy, Spain, UK) and the US.
Methods We present a pharmacoeconomic simulation based on a systematic literature review with meta-analysis. Clinical outcomes and costs comparing ω-3 FA-containing PN with standard PN were evaluated in adult ICU patients eligible to receive PN covering at least 70% of their total energy requirements and in the subgroup of critically ill ICU patients (mean ICU stay > 48 h). The meta-analysis with the co-primary outcomes of infection rate and mortality rate was based on randomized controlled trial data retrieved via a systematic literature review; resulting efficacy data were subsequently employed in country-specific cost-effectiveness analyses. Results In adult ICU patients, ω-3 FA-containing PN versus standard PN was associated with significant reductions in the relative risk (RR) of infection (RR 0.62; 95% CI 0.45, 0.86; p = 0.004), hospital length of stay (HLOS) (− 3.05 days; 95% CI − 5.03, − 1.07; p = 0.003) and ICU length of stay (LOS) (− 1.89 days; 95% CI − 3.33, − 0.45; p = 0.01). In critically ill ICU patients, ω-3 FA-containing PN was associated with similar reductions in infection rates (RR 0.65; 95% CI 0.46, 0.94; p = 0.02), HLOS (− 3.98 days; 95% CI − 6.90, − 1.06; p = 0.008) and ICU LOS (− 2.14 days; 95% CI − 3.89, − 0.40; p = 0.02). Overall hospital episode costs were reduced in all six countries using ω-3 FA-containing PN compared to standard PN, ranging from €-3156 ± 1404 in Spain to €-9586 ± 4157 in the US. Conclusion These analyses demonstrate that ω-3 FA-containing PN is associated with statistically and clinically significant improvement in patient outcomes. Its use is also predicted to yield cost savings compared to standard PN, rendering ω-3 FA-containing PN an attractive cost-saving alternative across different health care systems.
Study registration PROSPERO CRD42019129311.
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Affiliation(s)
- Lorenzo Pradelli
- AdRes-Health Economics and Outcome Research, Via Vittorio Alfieri 17, 10121, Turin, Italy.
| | - Stanislaw Klek
- Department of General and Oncology Surgery With Intestinal Failure Unit, Stanley Dudrick's Memorial Hospital, Tyniecka 15, 32-050, Skawina, Poland
| | - Konstantin Mayer
- Medical Clinic 4, Pneumology and Sleep Medicine, ViDia Hospitals Karlsruhe, Südendstr. 32, 76137, Karlsruhe, Germany
| | | | - Martin D Rosenthal
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, 32610-0019, USA
| | - Axel R Heller
- Department of Anesthesiology and Intensive Care Medicine, University of Augsburg, Universitätsstraße 2, 86159, Augsburg, Germany
| | - Maurizio Muscaritoli
- Department of Clinical Medicine, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185, Rome, RM, Italy
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Pradelli L, Klek S, Mayer K, Omar Alsaleh AJ, Rosenthal MD, Heller AR, Muscaritoli M. Cost-Effectiveness of Parenteral Nutrition Containing ω-3 Fatty Acids in Hospitalized Adult Patients From 5 European Countries and the US. JPEN J Parenter Enteral Nutr 2020; 45:999-1008. [PMID: 32713007 PMCID: PMC8451886 DOI: 10.1002/jpen.1972] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/20/2020] [Indexed: 01/17/2023]
Abstract
Background ω‐3 Fatty acid (FA)–containing parenteral nutrition (PN) is associated with improvements in patient outcomes and with reductions in hospital length of stay (HLOS) vs standard PN regimens (containing non–ω‐3 FA lipid emulsions). We present a cost‐effectiveness analysis of ω‐3 FA–containing PN vs standard PN in 5 European countries (France, Germany, Italy, Spain, UK) and the US. Methods This pharmacoeconomic model was based on estimates of ω‐3 efficacy reported in a recent meta‐analysis and data from country‐specific sources. It utilized a probabilistic discrete event simulation model to compare ω‐3 FA–containing PN with standard PN in a population of critically ill and general ward patients. The influence of model parameters was evaluated using probabilistic and deterministic sensitivity analyses. Results Overall costs were reduced with ω‐3 FA–containing PN in all 6 countries compared with standard PN, ranging from €1741 (±€1284) in Italy to €5576 (±€4193) in the US. Expenses for infections and HLOS were lower in all countries for ω‐3 FA–containing PN vs standard PN, with the largest cost differences for both in the US (infection: €825 ± €4001; HLOS: €4879 ± €1208) and the smallest savings in the UK for infections and in Spain for HLOS (€63 ± €426 and €1636 ± €372, respectively). Conclusion This cost‐effectiveness analysis in 6 countries demonstrates that the superior clinical efficacy of ω‐3 FA–containing PN translates into significant decreases in mean treatment cost, rendering it an attractive cost‐saving alternative to standard PN across different healthcare systems.
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Affiliation(s)
| | - Stanislaw Klek
- Department of General and Oncology Surgery with Intestinal Failure Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - Konstantin Mayer
- ViDia Hospitals, Department of Pulmonary and Sleep Medicine, Karlsruhe, Germany
| | | | - Martin D Rosenthal
- Department of Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Axel R Heller
- Department of Anesthesiology and Intensive Care Medicine, University of Augsburg, Augsburg, Germany
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Abstract
OBJECTIVES Recent evidence suggests that half-dose thrombolysis for pulmonary embolism may provide similar efficacy with reduced bleeding risk compared with full-dose therapy, but comparative studies are lacking. We aimed to evaluate the effectiveness and safety of half-dose versus full-dose alteplase for treatment of pulmonary embolism. DESIGN A retrospective cohort study comparing outcomes in patients receiving half-dose (50 mg) versus full-dose (100 mg) alteplase for pulmonary embolism. We used propensity score matching and sensitivity analyses to address confounding and hospital-level clustering. SETTING Data from 420 hospitals obtained from the Premier Healthcare Database between January 2010 and December 2014. SUBJECTS Adult critically ill patients with acute pulmonary embolism treated with IV alteplase therapy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS This study included 3,768 patients: 699 (18.6%) in the half-dose and 3,069 (81.4%) in the full-dose group. At baseline, patients receiving half-dose alteplase required vasopressor therapy (23.3% vs 39.4%; p < 0.01) and invasive ventilation (14.3% vs 28.5%; p < 0.01) less often, compared with full dose. After propensity matching (n = 548 per group), half-dose alteplase was associated with increased treatment escalation (53.8% vs 41.4%; p < 0.01), driven mostly by secondary thrombolysis (25.9% vs 7.3%; p < 0.01) and catheter thrombus fragmentation (14.2% vs 3.8%; p < 0.01). Hospital mortality was similar (13% vs 15%; p = 0.3). There was no difference in cerebral hemorrhage (0.5% vs 0.4%; p = 0.67), gastrointestinal bleeding (1.6% vs 1.6%; p = 0.99), acute blood loss anemia (6.9% vs 4.6%; p = 0.11), use of blood products (p > 0.05 for all), or documented fibrinolytic adverse events (2.6% vs 2.8%; p = 0.82). CONCLUSIONS Compared with full-dose alteplase, half-dose was associated with similar mortality and rates of major bleeding. Treatment escalation occurred more often in half-dose-treated patients. These results question whether half-dose alteplase provides similar efficacy with improved safety, and highlights the need for further study before use of half-dose alteplase therapy can be routinely recommended in patients with pulmonary embolism.
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Cost and Hospital Resource Utilization of Staphylococcus aureus Infection Post Elective Posterior Instrumented Spinal Fusion Surgeries in U.S. Hospitals: A Retrospective Cohort Study. Spine (Phila Pa 1976) 2019; 44:637-646. [PMID: 30325882 PMCID: PMC6485304 DOI: 10.1097/brs.0000000000002898] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The aim of this study was to assess hospital resource utilization and costs associated with Staphylococcus aureus infection within 180 days post elective posterior instrumented spinal fusion surgeries (index surgery) between 2010 and 2015. SUMMARY OF BACKGROUND DATA Surgical site infections (SSIs) and blood stream infections (BSIs) post spinal fusion surgeries are associated with worse clinical outcomes and increased costs. Economic data specific to the most common pathogen of infections post spinal fusion surgeries, S. aureus, are limited. METHODS We analyzed hospital discharge and microbiology data from 129 U.S. hospitals in Premier Healthcare Database. Selection criteria included age ≥ 18 years; had a primary/secondary ICD-9-CM procedure code for index surgery; and had microbiology data during study period. Outcomes included total hospitalization cost, length of stay, and risk of all-cause readmission. Infection status was classified as culture-confirmed invasive (i.e., BSIs, deep or organ/space SSIs), any, and no S. aureus infection. Multivariable regression analyses were used to compare outcome variables between infection groups controlling for known confounders. RESULTS Two hundred ninety-four patients had any S. aureus infection (151 had invasive infection) and 12,918 had no infection. Compared with no infection group, invasive and any infection groups had higher total hospitalization cost (adjusted mean in 2015 U.S. dollars: $88,353 and $64,356 vs. $47,366, P < 0.001), longer length of stay (adjusted mean: 20.98 and 13.15 vs. 6.77 days, P < 0.001), and higher risk of all-cause readmission [adjusted risk ratio: 2.15 (95% confidence interval: 2.06-2.25) for invasive and 1.70 (95% confidence interval: 1.61-1.80) for any infection groups]. CONCLUSION S. aureus infections post elective posterior instrumented spinal fusion surgeries are associated with significantly higher hospitalization cost, length of stay, and 180-day risk of readmission than those with no such infection, which presents substantial burden to hospitals and patients. Reducing such infections may cut costs and hospital resource utilization. LEVEL OF EVIDENCE 3.
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Mandel SR, Langan S, Mathioudakis NN, Sidhaye AR, Bashura H, Bie JY, Mackay P, Tucker C, Demidowich AP, Simonds WF, Jha S, Ebenuwa I, Kantsiper M, Howell EE, Wachter P, Golden SH, Zilbermint M. Retrospective study of inpatient diabetes management service, length of stay and 30-day readmission rate of patients with diabetes at a community hospital. J Community Hosp Intern Med Perspect 2019; 9:64-73. [PMID: 31044034 PMCID: PMC6484466 DOI: 10.1080/20009666.2019.1593782] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 03/07/2019] [Indexed: 01/09/2023] Open
Abstract
Background: Hospitalized patients with diabetes are at risk of complications and longer length of stay (LOS). Inpatient Diabetes Management Services (IDMS) are known to be beneficial; however, their impact on patient care measures in community, non-teaching hospitals, is unknown. Objectives: To evaluate whether co-managing patients with diabetes by the IDMS team reduces LOS and 30-day readmission rate (30DR). Methods: This retrospective quality improvement cohort study analyzed LOS and 30DR among patients with diabetes admitted to a community hospital. The IDMS medical team consisted of an endocrinologist, nurse practitioner, and diabetes educator. The comparison group consisted of hospitalized patients with diabetes under standard care of attending physicians (mostly internal medicine-trained hospitalists). The relationship between study groups and outcome variables was assessed using Generalized Estimating Equation models. Results: 4,654 patients with diabetes (70.8 ± 0.2 years old) were admitted between January 2016 and May 2017. The IDMS team co-managed 18.3% of patients, mostly with higher severity of illness scores (p < 0.0001). Mean LOS in patients co-managed by the IDMS team decreased by 27%. Median LOS decreased over time in the IDMS group (p = 0.046), while no significant decrease was seen in the comparison group. Mean 30DR in patients co-managed by the IDMS decreased by 10.71%. Median 30DR decreased among patients co-managed by the IDMS (p = 0.048). Conclusions: In a community hospital setting, LOS and 30DR significantly decreased in patients co-managed by a specialized diabetes team. These changes may be translated into considerable cost savings.
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Affiliation(s)
| | - Susan Langan
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nestoras Nicolas Mathioudakis
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Aniket R Sidhaye
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Holly Bashura
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jun Y Bie
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Periwinkle Mackay
- Department of Nursing Education, Suburban Hospital, Bethesda, MD, USA
| | - Cynthia Tucker
- Department of Nursing Education, Suburban Hospital, Bethesda, MD, USA
| | - Andrew P Demidowich
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA.,Department of Medicine, Johns Hopkins Community Physicians at Howard County General Hospital, Columbia, MD, USA
| | - William F Simonds
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Smita Jha
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Ifechukwude Ebenuwa
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Melinda Kantsiper
- Johns Hopkins School of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Eric E Howell
- Johns Hopkins School of Medicine, Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Patricia Wachter
- Hospitalist Division, Johns Hopkins Community Physicians, Baltimore, MD, USA
| | - Sherita Hill Golden
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
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Banko D, Rosenthal N, Chung J, Lomax C, Washesky PF. Comparing the risk of bloodstream infections by type of parenteral nutrition preparation method: A large retrospective, observational study. Clin Nutr ESPEN 2019; 30:100-106. [PMID: 30904208 DOI: 10.1016/j.clnesp.2019.01.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/16/2019] [Accepted: 01/24/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS Complications such as blood stream infections (BSI) have been observed with the administration of parenteral nutrition (PN). Prior published studies reported the incidence of BSI for inpatient hospitalizations by comparing patients treated with custom compounded parenteral nutrition to those treated with premixed multichamber bag (MCB) formulations. Previous publications grouped patients treated with MCBs into a single category and no distinction was made between patients receiving only a MCB and those receiving a MCB supplemented with manual additions. This Study aims to assess differences in risk of blood stream infection, cost, and clinical outcomes among patients receiving multichamber bag parenteral nutrition products only (MCB-only), MCB with additions (MCB-addition), and compounded (COM) PN products using seven years of Premier Healthcare Data from 688 hospitals in the United States of America. METHODS Adult inpatients who were discharged between 01/01/2008 and 12/31/2014, had a hospital length of stay ≥3 days and received PN during the index hospitalization were analyzed. PN preparation method was determined by billing charge descriptions. BSI was defined as having primary or secondary ICD-9 diagnosis codes of 038.x (septicemia), 995.91 (sepsis), 995.92 (severe sepsis), and 790.7 (bacteremia). Multivariable regression models were used to assess effect of PN preparation on patient outcomes, adjusting for confounders. RESULTS 84,564 patients were analyzed (MCB-only: 6.3%; MCB-addition: 14.8%; COM: 78.9%). Multivariable analysis indicated that compared to COM group, MCB-addition group had similar risk of BSI (7.0% vs. 6.8%, P > 0.05) and a 2.7% lower average total hospitalization cost ($28,072 vs. $28,861, P < 0.05) but had a higher PN treatment cost ($1135 vs. $1,031, P < 0.05) and a higher percentage of being discharged to rehabilitation or other acute care facilities (39.4% vs. 31.1%, P < 0.05). MCB-only group had lower risk of BSI and hospitalization cost. CONCLUSIONS In the U.S., compounded PN is the most commonly used in clinical practice followed by MCB with additions. MCB-addition group had similar BSI risk with COM. The slightly lower overall cost in MCB-addition group may be offset by higher post-hospitalization care cost to providers and payers under bundled payment methods in the U.S.
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Affiliation(s)
- David Banko
- B. Braun Medical Inc., Bethlehem, PA, 18018, USA.
| | - Ning Rosenthal
- Premier Research Services, Premier Inc., Charlotte, NC, 28277, USA
| | - Jessica Chung
- Premier Research Services, Premier Inc., Charlotte, NC, 28277, USA
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Pichler L, Poeran J, Zubizarreta N, Cozowicz C, Sun EC, Mazumdar M, Memtsoudis SG. Liposomal Bupivacaine Does Not Reduce Inpatient Opioid Prescription or Related Complications after Knee Arthroplasty: A Database Analysis. Anesthesiology 2018; 129:689-699. [PMID: 29787389 PMCID: PMC6148397 DOI: 10.1097/aln.0000000000002267] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS MANUSCRIPT TELLS US THAT IS NEW: BACKGROUND:: Although some trials suggest benefits of liposomal bupivacaine, data on real-world use and effectiveness is lacking. This study analyzed the impact of liposomal bupivacaine use (regardless of administration route) on inpatient opioid prescription, resource utilization, and opioid-related complications among patients undergoing total knee arthroplasties with a peripheral nerve block. It was hypothesized that liposomal bupivacaine has limited clinical influence on the studied outcomes. METHODS The study included data on 88,830 total knee arthroplasties performed with a peripheral nerve block (Premier Healthcare Database 2013 to 2016). Multilevel multivariable regressions measured associations between use of liposomal bupivacaine and (1) inpatient opioid prescription (extracted from billing) and (2) length of stay, cost of hospitalization, as well as opioid-related complications. To reflect the difference between statistical and clinical significance, a relative change of -15% in outcomes was assumed to be clinically important. RESULTS Overall, liposomal bupivacaine was used in 21.2% (n = 18,817) of patients that underwent a total knee arthroplasty with a peripheral nerve block. Liposomal bupivacaine use was not associated with a clinically meaningful reduction in inpatient opioid prescription (group median, 253 mg of oral morphine equivalents, adjusted effect -9.3% CI -11.1%, -7.5%; P < 0.0001) and length of stay (group median, 3 days, adjusted effect -8.8% CI -10.1%, -7.5%; P < 0.0001) with no effect on cost of hospitalization. Most importantly, liposomal bupivacaine use was not associated with decreased odds for opioid-related complications. CONCLUSIONS Liposomal bupivacaine was not associated with a clinically relevant improvement in inpatient opioid prescription, resource utilization, or opioid-related complications in patients who received modern pain management including a peripheral nerve block.
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Affiliation(s)
- Lukas Pichler
- From the Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York (L.P., C.C., S.G.M.) Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria (L.P., C.C., S.G.M.) Icahn School of Medicine at Mount Sinai, New York, New York (J.P., N.Z., M.M.) Stanford University, Stanford, California (E.C.S.)
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Alfonso JE, Berlana D, Ukleja A, Boullata J. Clinical, Ergonomic, and Economic Outcomes With Multichamber Bags Compared With (Hospital) Pharmacy Compounded Bags and Multibottle Systems: A Systematic Literature Review. JPEN J Parenter Enteral Nutr 2016; 41:1162-1177. [DOI: 10.1177/0148607116657541] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
| | | | - Andrew Ukleja
- Gastroenterology, Cleveland Clinic, Weston, Florida, USA
| | - Joseph Boullata
- Hospital of the University of Pennsylvania, and Drexel University, Philadelphia, Pennsylvania, USA
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Beattie C, Allard J, Raman M. Comparison Between Premixed and Compounded Parenteral Nutrition Solutions in Hospitalized Patients Requiring Parenteral Nutrition. Nutr Clin Pract 2016; 31:229-34. [PMID: 26888855 DOI: 10.1177/0884533615621046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Parenteral nutrition (PN) may be provided through compounded or premixed solutions. OBJECTIVE To determine the proportion of stable custom-compounded PN prescriptions that would fit within a 20% deviance of an existing premixed PN solution. METHODS A retrospective study design was used. Inpatients who received PN in non-critical care units in the preceding year were screened for eligibility. Results are reported descriptively as means (95% confidence intervals) and proportions. RESULTS We reviewed 97 PN prescriptions that met inclusion criteria. Stable hospital PN prescriptions compared with the reference premixed prescription provided 1838 (1777-1898) vs 1843 (1781-1905) kcal/d, P = .43; dextrose, 266 (254-277) vs 225 (216-234) g/d, P < .001; amino acids, 100 (95.9-104) vs 95.2 (91.7-98.7) g/d, P < .001; and lipids, 53.2 (51.3-55.1) vs 76.5 (73.8-79.2) g/d, P < .001. Fifty-eight of 97 (59.8%) matched for 2 of 3 macronutrients. Hospital compared with premixed lipid was lower 53.6 (43-64.2) g/d vs 75.5 (60.5-90.5) g/d, P < .001. Electrolytes differed between hospital and premixed solutions: sodium, 98.6 (95.0-102) vs 66.9 (64.6-69.9) mmol/L, P < .001; potassium, 93.7 (89.0-98.3) vs 57.4 (55.4-59.4) mmol/L, P < .001; and magnesium, 5.4 (4.8-5.4) vs 7.6 (7.4-7.9) mmol/L. CONCLUSIONS Calories and protein were remarkably similar, but dextrose, lipid, and electrolytes differed between hospital PN and the reference premixed prescription. We believe that there may be a role for premixed solutions in quaternary centers in stable non-critically ill patients.
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Hamdy O, Ernst FR, Baumer D, Mustad V, Partridge J, Hegazi R. Differences in resource utilization between patients with diabetes receiving glycemia-targeted specialized nutrition vs standard nutrition formulas in U.S. hospitals. JPEN J Parenter Enteral Nutr 2014; 38:86S-91S. [PMID: 25227669 DOI: 10.1177/0148607114550315] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The purpose of the study was to compare patient outcomes and costs for patients with diabetes mellitus (DM) receiving glycemia-targeted specialized nutrition (GTSN) with similar patients receiving standard nutrition (STDN) formulas during acute care hospitalizations. RESEARCH DESIGN AND METHODS The study was designed as a retrospective analysis over a 10-year period (2000-2009) of clinical and cost data from 125,000 hospital inpatient episodes in the Premier Research Database. Patients received either GTSN or STDN, by tube or orally, as a component of comprehensive care for hyperglycemia in patients with DM. To adjust for potential cohort imbalances, GTSN patients were matched with STDN patients on the basis of propensity scores, adjusting for many characteristics, including age, sex, race, All Patient Refined Diagnosis-Related Group (APR-DRG) illness severity, APR-DRG mortality risk, and comorbidities. RESULTS Tube-fed patients with DM who were provided GTSN had a 0.88-day (95% confidence interval [CI], 0.73-1.02) shorter length of hospital stay (LOS) on average compared with those patients provided STDN. Orally fed patients with DM who were provided GTSN had a 0.17-day (95% CI, 0.14-0.21) shorter LOS than did those patients provided STDN. The shorter LOS associated with GTSN contributed to a cost savings of $2586 for tube-fed patients and $1356 for orally fed patients. CONCLUSIONS The use of GTSN feeding formulas for patients with DM in acute care hospital settings was associated with reduced LOS and inpatient hospital episode cost in comparison to STDN.
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Affiliation(s)
- Osama Hamdy
- Joslin Diabetes Center, Boston, Massachusetts
| | - Frank R Ernst
- Premier healthcare alliance, Charlotte, North Carolina
| | | | - Vikkie Mustad
- Abbott Nutrition, Research & Development, Columbus, Ohio
| | | | - Refaat Hegazi
- Abbott Nutrition, Research & Development, Columbus, Ohio Department of Internal Medicine, The Brody School of Medicine, East Carolina University, North Carolina
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