The National Healthcare Safety Network's digital quality measures: CDC's automated measures for surveillance of patient safety

OBJECTIVE

This article presents the National Healthcare Safety Network (NHSN)'s approach to automation for public health surveillance using digital quality measures (dQMs) via an open-source tool (NHSNLink) and piloting of this approach using real-world data in a newly established collaborative program (NHSNCoLab). The approach leverages Health Level Seven Fast Healthcare Interoperability Resources (FHIR) application programming interfaces to improve data collection and reporting for public health and patient safety beginning with common, clinically significant, and preventable patient harms, such as medication-related hypoglycemia, healthcare facility-onset Clostridioides difficile infection, and healthcare-associated venous thromboembolism.

CONCLUSIONS

The NHSN's FHIR dQMs hold the promise of minimizing the burden of reporting, improving accuracy, quality, and validity of data collected by NHSN, and increasing speed and efficiency of public health surveillance.

Healthcare-associated infections and conditions in the era of digital measurement

As the third edition of the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals is released with the latest recommendations for the prevention and management of healthcare-associated infections (HAIs), a new approach to reporting HAIs is just beginning to unfold. This next generation of HAI reporting will be fully electronic and based largely on existing data in electronic health record (EHR) systems and other electronic data sources. It will be a significant change in how hospitals report HAIs and how the Centers for Disease Control and Prevention (CDC) and other agencies receive this information. This paper outlines what that future electronic reporting system will look like and how it will impact HAI reporting.

Treated, hospital-onset Clostridiodes difficile infection: An evaluation of predictors and feasibility of benchmarking comparing 2 risk-adjusted models among 265 hospitals

OBJECTIVES

To evaluate the incidence of a candidate definition of healthcare facility-onset, treated Clostridioides difficile (CD) infection (cHT-CDI) and to identify variables and best model fit of a risk-adjusted cHT-CDI metric using extractable electronic heath data.

METHODS

We analyzed 9,134,276 admissions from 265 hospitals during 2015-2020. The cHT-CDI events were defined based on the first positive laboratory final identification of CD after day 3 of hospitalization, accompanied by use of a CD drug. The generalized linear model method via negative binomial regression was used to identify predictors. Standardized infection ratios (SIRs) were calculated based on 2 risk-adjusted models: a simple model using descriptive variables and a complex model using descriptive variables and CD testing practices. The performance of each model was compared against cHT-CDI unadjusted rates.

RESULTS

The median rate of cHT-CDI events per 100 admissions was 0.134 (interquartile range, 0.023-0.243). Hospital variables associated with cHT-CDI included the following: higher community-onset CDI (CO-CDI) prevalence; highest-quartile length of stay; bed size; percentage of male patients; teaching hospitals; increased CD testing intensity; and CD testing prevalence. The complex model demonstrated better model performance and identified the most influential predictors: hospital-onset testing intensity and prevalence, CO-CDI rate, and community-onset testing intensity (negative correlation). Moreover, 78% of the hospitals ranked in the highest quartile based on raw rate shifted to lower percentiles when we applied the SIR from the complex model.

CONCLUSIONS

Hospital descriptors, aggregate patient characteristics, CO-CDI burden, and clinical testing practices significantly influence incidence of cHT-CDI. Benchmarking a cHT-CDI metric is feasible and should include facility and clinical variables.

Coronavirus disease 2019 (COVID-19) vaccination rates and staffing shortages among healthcare personnel in nursing homes before, during, and after implementation of mandates for COVID-19 vaccination among 15 US jurisdictions, National Healthcare Safety Network, June 2021-January 2022

OBJECTIVE

To examine temporal changes in coverage with a complete primary series of coronavirus disease 2019 (COVID-19) vaccination and staffing shortages among healthcare personnel (HCP) working in nursing homes in the United States before, during, and after the implementation of jurisdiction-based COVID-19 vaccination mandates for HCP.

SAMPLE AND SETTING

HCP in nursing homes from 15 US jurisdictions.

DESIGN

We analyzed weekly COVID-19 vaccination data reported to the Centers for Disease Control and Prevention's National Healthcare Safety Network from June 7, 2021, through January 2, 2022. We assessed 3 periods (preintervention, intervention, and postintervention) based on the announcement of vaccination mandates for HCP in 15 jurisdictions. We used interrupted time-series models to estimate the weekly percentage change in vaccination with complete primary series and the odds of reporting a staffing shortage for each period.

RESULTS

Complete primary series vaccination among HCP increased from 66.7% at baseline to 94.3% at the end of the study period and increased at the fastest rate during the intervention period for 12 of 15 jurisdictions. The odds of reporting a staffing shortage were lowest after the intervention.

CONCLUSIONS

These findings demonstrate that COVID-19 vaccination mandates may be an effective strategy for improving HCP vaccination coverage in nursing homes without exacerbating staffing shortages. These data suggest that mandates can be considered to improve COVID-19 coverage among HCP in nursing homes to protect both HCP and vulnerable nursing home residents.

SARS-CoV-2 Infection and Death Rates Among Maintenance Dialysis Patients During Delta and Early Omicron Waves - United States, June 30, 2021-September 27, 2022

Persons receiving maintenance dialysis are at increased risk for SARS-CoV-2 infection and its severe outcomes, including death. However, rates of SARS-CoV-2 infection and COVID-19-related deaths in this population are not well described. Since November 2020, CDC's National Healthcare Safety Network (NHSN) has collected weekly data monitoring incidence of SARS-CoV-2 infections (defined as a positive SARS-CoV-2 test result) and COVID-19-related deaths (defined as the death of a patient who had not fully recovered from a SARS-CoV-2 infection) among maintenance dialysis patients. This analysis used NHSN dialysis facility COVID-19 data reported during June 30, 2021-September 27, 2022, to describe rates of SARS-CoV-2 infection and COVID-19-related death among maintenance dialysis patients. The overall infection rate was 30.47 per 10,000 patient-weeks (39.64 among unvaccinated patients and 27.24 among patients who had completed a primary COVID-19 vaccination series). The overall death rate was 1.74 per 10,000 patient-weeks. Implementing recommended infection control measures in dialysis facilities and ensuring patients and staff members are up to date with recommended COVID-19 vaccination is critical to limiting COVID-19-associated morbidity and mortality.

Association between prevalence of laboratory-identified Clostridioides difficile infection (CDI) and antibiotic treatment for CDI in US acute-care hospitals, 2019

OBJECTIVE

To evaluate hospital-level variation in using first-line antibiotics for Clostridioides difficile infection (CDI) based on the burden of laboratory-identified (LabID) CDI.

METHODS

Using data on hospital-level LabID CDI events and antimicrobial use (AU) for CDI (oral/rectal vancomycin or fidaxomicin) submitted to the National Healthcare Safety Network in 2019, we assessed the association between hospital-level CDI prevalence (per 100 patient admissions) and rate of CDI AU (days of therapy per 1,000 days present) to generate a predicted value of AU based on CDI prevalence and CDI test type using negative binomial regression. The ratio of the observed to predicted AU was then used to identify hospitals with extreme discordance between CDI prevalence and CDI AU, defined as hospitals with a ratio outside of the intervigintile range.

RESULTS

Among 963 acute-care hospitals, rate of CDI prevalence demonstrated a positive dose-response relationship with rate of CDI AU. Compared with hospitals without extreme discordance (n = 902), hospitals with lower-than-expected CDI AU (n = 31) had, on average, fewer beds (median, 106 vs 208), shorter length of stay (median, 3.8 vs 4.2 days), and higher proportion of undergraduate or nonteaching medical school affiliation (48% vs 39%). Hospitals with higher-than-expected CDI AU (n = 30) were similar overall to hospitals without extreme discordance.

CONCLUSIONS

The prevalence rate of LabID CDI had a significant dose-response association with first-line antibiotics for treating CDI. We identified hospitals with extreme discordance between CDI prevalence and CDI AU, highlighting potential opportunities for data validation and improvements in diagnostic and treatment practices for CDI.

Surveillance of COVID-19 Vaccination in Nursing Homes, United States, December 2020-July 2021

Monitoring COVID-19 vaccination coverage among nursing home residents and staff is important to ensure high coverage rates and guide patient-safety policies. With the termination of the federal Pharmacy Partnership for Long-Term Care Program, another source of facility-based vaccination data is needed. We compared numbers of COVID-19 vaccinations administered to nursing home residents and staff reported by pharmacies participating in the temporary federal Pharmacy Partnership for Long-Term Care Program with the numbers of COVID-19 vaccinations reported by nursing homes participating in new COVID-19 vaccination modules of the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN). Pearson correlation coefficients comparing the number vaccinated between the 2 approaches were 0.89, 0.96, and 0.97 for residents and 0.74, 0.90, and 0.90 for staff, in the weeks ending January 3, 10, and 17, 2021, respectively. Based on subsequent NHSN reporting, vaccination coverage with ≥1 vaccine dose reached 73.7% for residents and 47.6% for staff the week ending January 31 and increased incrementally through July 2021. Continued monitoring of COVID-19 vaccination coverage is important as new nursing home residents are admitted, new staff are hired, and additional doses of vaccine are recommended.

Building an Interactive Geospatial Visualization Application for National Health Care-Associated Infection Surveillance: Development Study

Background

The Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) is the most widely used health care–associated infection (HAI) and antimicrobial use and resistance surveillance program in the United States. Over 37,000 health care facilities participate in the program and submit a large volume of surveillance data. These data are used by the facilities themselves, the CDC, and other agencies and organizations for a variety of purposes, including infection prevention, antimicrobial stewardship, and clinical quality measurement. Among the summary metrics made available by the NHSN are standardized infection ratios, which are used to identify HAI prevention needs and measure progress at the national, regional, state, and local levels.

Objective

To extend the use of geospatial methods and tools to NHSN data, and in turn to promote and inspire new uses of the rendered data for analysis and prevention purposes, we developed a web-enabled system that enables integrated visualization of HAI metrics and supporting data.

Methods

We leveraged geocoding and visualization technologies that are readily available and in current use to develop a web-enabled system designed to support visualization and interpretation of data submitted to the NHSN from geographically dispersed sites. The server–client model–based system enables users to access the application via a web browser.

Results

We integrated multiple data sets into a single-page dashboard designed to enable users to navigate across different HAI event types, choose specific health care facility or geographic locations for data displays, and scale across time units within identified periods. We launched the system for internal CDC use in January 2019.

Conclusions

CDC NHSN statisticians, data analysts, and subject matter experts identified opportunities to extend the use of geospatial methods and tools to NHSN data and provided the impetus to develop NHSNViz. The development effort proceeded iteratively, with the developer adding or enhancing functionality and including additional data sets in a series of prototype versions, each of which incorporated user feedback. The initial production version of NHSNViz provides a new geospatial analytic resource built in accordance with CDC user requirements and extensible to additional users and uses in subsequent versions.

909. Reassessing Pathogens Eligible for the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN) “Mucosal Barrier Injury-Laboratory Confirmed Bloodstream Infection” Criteria

Background

NHSN Mucosal Barrier Injury-Laboratory Confirmed Bloodstream Infection (MBI-LCBI) includes pathogens likely to cause bloodstream infections (BSI) in some oncology patients. MBI-LCBIs are excluded from central line-associated BSI (CLABSI) reporting to the Centers for Medicare & Medicaid Services. NHSN users have requested other pathogens be added to MBI-LCBI. To make decision, we compared CLABSI pathogen distributions in three NHSN patient location groups.

Methods

We analyzed CLABSI data from hospitals conducting surveillance for ≥ 1 month from January 2014–December 2018 in ≥ 1 MBI high-risk location (leukemia, lymphoma, and adult and pediatric hematopoietic stem cell transplant wards). We compared CLABSI pathogen distributions and rates in MBI high-risk locations to medium-risk (solid tumor, adult and pediatric general hematology-oncology wards) and low-risk locations (adult and pediatric medical, surgical, and medical-surgical wards), and used χ2 tests to compare percentages with statistical significance at P ≤ 0.05.

Results

Overall, 122 hospitals reported 23,578 CLABSIs and 12,961,921 central line (CL)-days (1.81 CLABSIs per 1,000 CL-days) (Table). Percentages of CLABSIs due to three MBI-LCBI pathogens (E. coli, E. faecium, Viridans streptococci) were significantly higher in high- versus low-risk locations, while for other MBI-LCBI pathogens (K. pneumoniae/oxytoca, E. faecalis, Candida spp., Enterobacter spp.) percentages were significantly lower in high-risk locations (Figure). For pathogens not currently in MBI-LCBI, coagulase-negative staphylococci caused similar percentages of CLABSIs across locations, S. aureus caused a significantly higher percentage of CLABSIs in low-risk locations, while PA caused a significantly higher percentage of CLABSIs in high-risk locations.

Table CLABSIs attributed to MBI high-risk, medium-risk, and low-risk locations, NHSN, 2014–2018

Conclusion

Differences in percentages of CLABSIs due to selected pathogens between MBI high-risk and low-risk locations are evident in NHSN data. Lower percentages of Klebsiella and Candida spp. in high-risk locations might be partially due to antimicrobial prophylaxis in oncology patients. Although PA caused a significantly higher percentage of CLABSIs in high-risk locations, the absolute difference was modest. Additional analyses are needed.

Disclosures

All Authors: No reported disclosures

785. Association between Prevalence of Laboratory-Identified Clostridioides difficile Infections (CDIs) and CDI Antibiotic Treatment in U.S. Acute Care Hospitals, 2018

Background

Clostridioides difficile infections (CDIs) are an urgent public health threat, accounting for 223,900 infections and 12,800 deaths in hospitalized patients annually. In early 2018, the Infectious Disease Society of America (IDSA) recommended oral vancomycin or fidaxomicin as the first-line antibiotics for CDIs. To track the uptake of IDSA’s recommendations, we evaluated the association between CDI prevalence and use of first-line antibiotics in hospitals reporting to the Centers for Disease Control and Prevention’s (CDC’s) National Healthcare Safety Network (NHSN).

Methods

We matched 2018 hospital-level, NHSN data on laboratory-identified CDIs with NHSN antimicrobial use (AU) data for the same time period. Hospitals that submitted < 6 months of either data type in 2018 were excluded. The association between quarterly hospital-level CDI prevalence rates per 100 patient-admissions and use of CDI antibiotics (oral vancomycin plus fidaxomicin) per 1,000 days-present was evaluated using Pearson’s linear correlation coefficient and using Goodman and Kruskal’s gamma (G) on ordinal quartiles to assess rates of discordant pairs.

Results

Among the 2735 hospital-level quarters based on 714 hospitals included in the study, CDI prevalence (median: 0.46 per 100 patient-admissions) and CDI antibiotic use (median: 8.85 antibiotic-days per 1,000 days-present) demonstrated only a moderately positive correlation (r = 0.48). Among hospitals in the highest quartile for CDI prevalence, 5.1% were in the lowest quartile for antibiotic use. Among hospitals in the highest quartile for antibiotic use, 5.3% were in the lowest quartile for CDI prevalence, and 54.2% were in the highest quartile for CDI prevalence (G = 0.60; 95% CI: 0.57–0.63).

Correlation of hospital-level Clostridioides difficile infection (CDI) prevalence rates and oral vancomycin and fidaxomicin use in U.S. acute care hospitals, 2018

Distribution of hospital-level Clostridioides difficile infection (CDI) prevalence rates and oral vancomycin and fidaxomicin use in ordinal quartiles (Q1–Q4) to access rates of discordant pairs

Conclusion

The moderate correlation and discordant rates suggest that vancomycin and fidaxomicin are less frequently used as primary antibiotics in some hospitals; whereas in others, CDI antibiotic use is occurring in the absence of positive laboratory tests for CDI. To further investigate this discordance, there is a need to assess hospitals’ prescribing and testing practices in an ongoing manner. These findings may be useful to serve as baseline for measuring progress of appropriateness of treatment and testing for CDIs.

Disclosures

All Authors: No reported disclosures

Improving Mandatory Vaccination Against Influenza: Minimizing Anxiety of Employees to Maximize Health of Patients

The objective was to describe qualitatively the attitudes among employees toward mandatory vaccination against influenza to ultimately improve such programs and prevent hospital-acquired influenza. Qualitative interviews were conducted with 21 employees at a freestanding children's hospital. Analysis of interview transcripts used grounded theory and the constant comparative method; codes were iteratively revised and refined as themes emerged. Themes emerged elucidating promoters and concerns. Promoters included a desire to protect self, family, and patients; perception of vaccination as part of professional responsibility; and free vaccination as a benefit from the organization. Concerns included negative feelings surrounding the forced nature and substantial anxiety about the physical injection. Participants expressed a strong desire for a private, compassionate, unhurried environment for the injection. Managing personal anxiety and a desire for privacy emerged as strong concerns among health care workers getting vaccinated at work. This information enabled future improvements in the mandatory vaccination campaign.

Electronic approaches to making sense of the text in the adverse event reporting system

INTRODUCTION

Health care organizations working to eliminate preventable harm and to improve patient safety must have robust programs to collect and to analyze data on adverse events in order to use the information to affect improvement. Such adverse event reporting systems are based on frontline personnel reporting issues that arise in the course of their daily work. Limitations in how existing software systems handle these reports mean that use of this potentially rich information is resource intensive and prone to variable results.

AIM

The aim of this study was to develop an electronic approach to processing the text in medical event reports that would be reliable enough to be used to improve patient safety.

METHODS

At Connecticut Children's Medical Center, staff manually enter reports of adverse events into a web-based software tool. We evaluated the ability of 2 electronic methods-rule-based query and semi-supervised machine learning-to identify specific types of events ("use cases") versus a reference standard. Rule-based query was tested on 5 use cases and machine learning on a subset of 2 using 9164 events reported from February 2012-January 2014.

RESULTS

Machine learning found 93% of the weight-based errors and 92% of the errors in patient-identification. Rule-based query had accuracy of 99% or greater, high precision, and high recall for all use cases.

CONCLUSIONS

Electronic approaches to streamlining the use of adverse event reports are feasible to automate and valuable for categorizing this important data for use in improving patient safety.

Republished: Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators

OBJECTIVE

The objective of this study was to qualitatively describe the impact of a Rapid Response Team (RRT) at a 944-bed, university-affiliated hospital.

METHODS

We analysed 49 open-ended interviews with administrators, primary team attending physicians, trainees, RRT attending hospitalists, staff nurses, nurses and respiratory technicians.

RESULTS

Themes elicited were categorised into the domains of (1) morale and teamwork, (2) education, (3) workload, (4) patient care, and (5) hospital administration. Positive implications beyond improved care for acutely ill patients were: increased morale and empowerment among nurses, real-time redistribution of workload for nurses (reducing neglect of non-acutely ill patients during emergencies), and immediate access to expert help. Negative implications were: increased tensions between nurses and physician teams, a burden on hospitalist RRT members, and reduced autonomy for trainees.

CONCLUSIONS

The RRT provides advantages that extend well beyond a reduction in rates of transfers to intensive care units or codes but are balanced by certain disadvantages. The potential impact from these multiple sources should be evaluated to understand the utility of any RRT programme.

Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators

OBJECTIVE

The objective of this study was to qualitatively describe the impact of a Rapid Response Team (RRT) at a 944-bed, university-affiliated hospital.

METHODS

We analysed 49 open-ended interviews with administrators, primary team attending physicians, trainees, RRT attending hospitalists, staff nurses, nurses and respiratory technicians.

RESULTS

Themes elicited were categorised into the domains of (1) morale and teamwork, (2) education, (3) workload, (4) patient care, and (5) hospital administration. Positive implications beyond improved care for acutely ill patients were: increased morale and empowerment among nurses, real-time redistribution of workload for nurses (reducing neglect of non-acutely ill patients during emergencies), and immediate access to expert help. Negative implications were: increased tensions between nurses and physician teams, a burden on hospitalist RRT members, and reduced autonomy for trainees.

CONCLUSIONS

The RRT provides advantages that extend well beyond a reduction in rates of transfers to intensive care units or codes but are balanced by certain disadvantages. The potential impact from these multiple sources should be evaluated to understand the utility of any RRT programme.

How good are the data? Feasible approach to validation of metrics of quality derived from an outpatient electronic health record

Although electronic health records (EHRs) promise to be efficient resources for measuring metrics of quality, they are not designed for such population-based analyses. Thus, extracting meaningful clinical data from them is not straightforward. To avoid poorly executed measurements, standardized methods to measure and to validate metrics of quality are needed. This study provides and evaluates a use case for a generally applicable approach to validating quality metrics measured electronically from EHR-based data. The authors iteratively refined and validated 4 outpatient quality metrics and classified errors in measurement. Multiple iterations of validation and measurement resulted in high levels of sensitivity and agreement versus the "gold standard" of manual review. In contrast, substantial differences remained for measurement based on coded billing data. Measuring quality metrics using an EHR-based electronic process requires validation to ensure accuracy; approaches to validation such as those described in this study should be used by organizations measuring quality from EHR-based information.

Secure web messaging in a pediatric chronic care clinic: a slow takeoff of "kids' airmail"

BACKGROUND

Although e-mail may be an efficient clinician-patient communication tool, standard e-mail is not adequately secure to meet Health Insurance Portability and Accountability Act (HIPAA) guidelines. For this reason, firewall-secured electronic messaging systems have been developed for use in health care. Impact and usability of these secure systems have not been broadly assessed.

OBJECTIVE

To evaluate the impact of a secure electronic messaging system implemented for a pediatric subspecialty clinic.

METHODS

This study was performed in an outpatient, academic pediatric respiratory clinic in spring 2009 in New Haven, Connecticut. Patients were surveyed prior to implementation regarding internet usage. The Kryptiq messaging system was implemented and messages were monitored continuously and tracked. Open-ended qualitative interviews with 28 users and nonusers were conducted, and we described the process of implementation.

RESULTS

All of the 127 patients/families surveyed expressed interest in using the Internet to contact their clinic providers, and they all reported having the ability to access the Internet. In the 8 months after implementation, only 5 messages were initiated by patients in contrast to 2363 phone calls. Themes emerged from the open-ended interviews that indicated promoters, barriers, and potential uses. Prominent barriers included the lack of convenience and personal touch and being technically difficult to use.

CONCLUSIONS

Although these patients/families expressed strong interest in e-mailing, secure Web messaging was less convenient than using the phone, too technically cumbersome, lacked a personal touch, and was used only by a handful of patients.

How can we communicate about vaccines with adolescents and their parents?

OBJECTIVE

To describe parents' and adolescents' perceptions about vaccination.

METHODS

Qualitative interviews of 22 mothers/grandmothers and 25 10- to 14-year-olds.

RESULTS

Themes emerged in 3 focus areas. (a) Understanding: Both adults and adolescents had difficulty understanding concepts of risks, benefits, prevention, and vaccination. (b) Decision making: Adults saw vaccination as an opportunity to help their adolescent develop skills for transition to adulthood. Adolescents worried about being lied to (reinforced by being told "it won't hurt"), physical pain, and cleanliness. ( c) Preventing sexually transmitted infections: Adults were divided between those who felt their child would not need such a vaccine and those who wanted to "be safe" to protect their child in the future.

CONCLUSIONS

At the same time that even basic concepts about vaccination should be explained to both adults and adolescents, adolescence represents a time for learning about responsible decision making. Discussion regarding the risks and benefits of vaccines can be part of transitioning to adult decision making.

We never thought this would happen: transitioning care of adolescents with perinatally acquired HIV infection from pediatrics to internal medicine

PURPOSE

Transitioning the medical care of children with perinatally acquired HIV from pediatric care to internal medicine practices has become increasingly important as newer therapies prolong survival. The study aims to describe challenges to caring for these adolescents and the potential barriers to transitioning them to internal medicine-based care.

METHODS

Qualitative study in which data were gathered from open-ended interviews conducted from November 2005 to April 2006 with 18 adolescents with HIV, 15 of their parents, and 9 pediatric health care providers from the Yale Pediatric AIDS Care Program, New Haven, Connecticut.

RESULTS

Issues of stigma played a prominent role in both the challenges to care and barriers to transitioning care. Challenges to care were: (1) poor adherence to medication regimens; (2) adolescent sexuality; and (3) disorganized social environments. Potential barriers to transitioning care were: (1) families' negative perceptions of and experiences with stigma of HIV disease - which undermined the desire to meet new providers; (2) perceived and actual lack of autonomy - pediatric providers feared that staff in adult clinics would demand a level of independence that adolescents did not have; and (3) difficulty letting go of relationships - adolescents, guardians, and providers described a familial relationship and expressed anxiety about terminating their relationships.

CONCLUSION

Understanding these challenges and barriers can inform both pediatric and adult HIV care providers and enable them to create successful transition programs, with the goal of improving retention and follow-up to care.

Risk factors for invasive pneumococcal disease among Navajo adults

Invasive pneumococcal disease (IPD) is 3-5 times more common among Navajo adults than in the general US population. The authors conducted a case-control study to identify risk factors for IPD among Navajo adults. Navajos aged > or =18 years with IPD were identified through prospective, population-based active laboratory surveillance (December 1999-February 2002). Controls matched to cases on age, gender, and neighborhood were selected. Risk factors were identified through structured interviews and medical record reviews. The authors conducted a matched analysis based on 118 cases and 353 controls. Risk factors included in the final multivariable analysis were chronic renal failure (odds ratio (OR) = 2.6, 95% confidence interval (CI): 0.9, 7.7), congestive heart failure (OR = 5.6, 95% CI: 2.2, 14.5), self-reported alcohol use or alcoholism (OR = 2.9, 95% CI: 1.5, 5.4), body mass index (weight (kg)/height (m)(2)) <5th (OR = 3.2, 95% CI: 1.0, 10.6) or >95th (OR = 2.8, 95% CI: 1.0, 8.0) percentile, and unemployment (OR = 2.6, 95% CI: 1.2, 5.5). The population attributable fractions were 10% for chronic renal failure, 18% for congestive heart failure, 30% for self-reported alcohol use or alcoholism, 6% for body mass index, and 20% for unemployment. Several modifiable risk factors for IPD in Navajos were identified. The high prevalence of renal failure, alcoholism, and unemployment among Navajo adults compared with the general US population may explain some of their increased risk of IPD.

Influenza Vaccination as Secondary Prevention for Cardiovascular Disease

Evidence from cohort studies and a randomized clinical trial indicates that annual vaccination against seasonal influenza prevents cardiovascular morbidity and all-cause mortality in patients with cardiovascular conditions. The American Heart Association and American College of Cardiology recommend influenza immunization with inactivated vaccine (administered intramuscularly) as part of comprehensive secondary prevention in persons with coronary and other atherosclerotic vascular disease (Class I, Level B). Immunization with live, attenuated vaccine (administered intranasally) is not currently recommended for persons with cardiovascular conditions. It is important to note that influenza vaccination coverage levels overall and in this population remain well below national goals and are marked by disparities across different age and ethnic groups. One of the barriers to vaccination for patients with cardiovascular disease is that cardiology practices frequently do not stock and administer influenza vaccine. Healthcare providers who treat individuals with cardiovascular disease can help improve influenza vaccination coverage rates by providing and strongly recommending vaccination to their patients before and throughout the influenza season.

Influenza vaccination as secondary prevention for cardiovascular disease: a science advisory from the American Heart Association/American College of Cardiology

Evidence from cohort studies and a randomized clinical trial indicates that annual vaccination against seasonal influenza prevents cardiovascular morbidity and all-cause mortality in patients with cardiovascular conditions. The American Heart Association and American College of Cardiology recommend influenza immunization with inactivated vaccine (administered intramuscularly) as part of comprehensive secondary prevention in persons with coronary and other atherosclerotic vascular disease (Class I, Level B). Immunization with live, attenuated vaccine (administered intranasally) is not currently recommended [corrected] for persons with cardiovascular conditions. It is important to note that influenza vaccination coverage levels overall and in this population remain well below national goals and are marked by disparities across different age and ethnic groups. One of the barriers to vaccination for patients with cardiovascular disease is that cardiology practices frequently do not stock and administer influenza vaccine. Healthcare providers who treat individuals with cardiovascular disease can help improve influenza vaccination coverage rates by providing and strongly recommending vaccination to their patients before and throughout the influenza season.

Qualitative analysis of mothers' decision-making about vaccines for infants: the importance of trust

BACKGROUND

The high visibility of controversies regarding vaccination makes it increasingly important to understand how parents decide whether to vaccinate their infants.

OBJECTIVE

The purpose of this research was to investigate decision-making about vaccinations for infants.

DESIGN

We conducted qualitative, open-ended interviews.

PARTICIPANTS

Subjects included mothers 1 to 3 days postpartum and again at 3 to 6 months.

RESULTS

We addressed 3 topics: attitudes to vaccination, knowledge about vaccination, and decision-making. Mothers who intended to have their infants vaccinated ("vaccinators," n = 25) either agreed with or did not question vaccination or they accepted vaccination but had significant concerns. Mothers who did not intend to vaccinate ("nonvaccinators," n = 8) either completely rejected vaccination or they purposely delayed vaccinating/chose only some vaccines. Knowledge about which vaccines are recommended for children was poor among both vaccinators and nonvaccinators. The theme of trust in the medical profession was the central concept that underpinned all of the themes about decision-making. Promoters of vaccination included trusting the pediatrician, feeling satisfied by the pediatrician's discussion about vaccines, not wanting to diverge from the cultural norm, and wanting to adhere to the social contact. Inhibitors included feeling alienated by or unable to trust the pediatrician, having a trusting relationship with an influential homeopath/naturopath or other person who did not believe in vaccinating, worry about permanent side effects, beliefs that vaccine-preventable diseases are not serious, and feeling that since other children are vaccinated their child is not at risk.

CONCLUSION

Trust or lack of trust and a relationship with a pediatrician or another influential person were pivotal for decision-making of new mothers about vaccinating their children. Attempts to work with mothers who are concerned about vaccinating their infants should focus not only on providing facts about vaccines but also on developing trusting and positive relationships.

Validity of using an electronic medical record for assessing quality of care in an outpatient setting

OBJECTIVE

We sought to evaluate the validity of retrieving data from a commercial, outpatient electronic medical record (EMR) to assess the management of pharyngitis, an important measure of quality of healthcare in pediatrics and a new measure for the Health Plan Employer Data and Information Set (HEDIS).

METHODS

For children ages 3-18 years, we electronically identified clinical encounters with diagnoses of pharyngitis using 3 different strategies (an EMR-based strategy, an administrative data-based strategy, and a reference strategy which used medical record review). By each strategy, we calculated the proportion of episodes of pharyngitis during 1 year for which management of pharyngitis adhered to published guidelines.

RESULTS

Among 479 total episodes of pharyngitis, 434 (91%) were from the EMR-based strategy and 281 (59%) from the administrative data-based strategy. Review of the records (the reference strategy) found that 391 of 479 (82%) were confirmed episodes of pharyngitis. A diagnostic test for group A streptococcus (GAS) was performed at 310 of 434 (71%) of episodes identified by the EMR-based strategy and at 214 of 281 (76%) of episodes by the administrative data-based strategy (P = 0.045). By the reference strategy, a diagnostic test was done in 301 of 391 (77%); more than at episodes found by the EMR-based strategy (71%, P < 0.001).

CONCLUSIONS

The EMR-based strategy resulted in a statistically different proportion of episodes having diagnostic testing for GAS compared with a reference strategy. Complete evaluations to validate strategies for extracting data from electronic databases are necessary before assuming that measures of quality of care will be the same regardless of the source of data.

Delivering pneumococcal vaccine to a high risk population: the Navajo experience

High rates of preventable diseases such as pneumococcal disease occur among the Navajo despite their universal health insurance through the Indian Health Service. The objective of this study was to determine the proportion of Navajo adults vaccinated with pneumococcal polysaccharide vaccine and to examine key features of vaccination programs of the Navajo Indian Health Service. For this cross-sectional study, medical charts of Navajo patients with vaccine indications were randomly selected and reviewed to determine who had been vaccinated as of January 1, 1999. Among 480 Navajo>or=65 years old, 73% were vaccinated (95% confidence interval [CI]: 69%-77%). Among 111 Navajo 18-64 years old with vaccine indications, 54% were vaccinated (95% CI: 45% -63%). Vaccination programs utilized extensive public health nursing, home visits, standing orders, and "express lane" clinics. In spite of excellent delivery systems and universal healthcare, the proportion of Navajo persons vaccinated was still below the goals for Healthy People 2010 of having 90% of persons>or=65 years old vaccinated and 60% of high-risk persons 18-64 years old vaccinated.

Validation of a system for quality improvement: preliminary data

Electronic Health Records (EHRs) are designed for patient-centered care and not for cross-patient analyses. Thus to ensure that measurements of quality of care derived from data extracted from EHRs are meaningful, they must be validated.1 We present preliminary data regarding validation of measurements of quality of care in a pediatric clinic.

Invasive Pneumococcal Disease among Navajo Adults, 1989–1998

Compared with white and black persons in the United States, some Native American groups are at increased risk for invasive pneumococcal disease (IPD). To characterize the epidemiology of IPD among Navajo adults, we conducted active surveillance for IPD on the Navajo Nation and reviewed medical records of patients with IPD. For 1997-1998, the annual incidence (cases per 100,000 persons) was 56 for Navajos aged 18-64 years and 190 for Navajos aged > or =65 years. The corresponding rates were 10 and 57 for white and 44 and 82 for black persons in the United States. The case-fatality rate was 14%. Eighty percent of cases were caused by serotypes included in the 23-valent pneumococcal polysaccharide vaccine. Navajo adults have rates of IPD that are 3-5-fold higher than those of the general US population. Additional research is needed to understand the reasons for this elevated risk and to develop prevention strategies.

Reasons physicians accepted or declined smallpox vaccine, February through April, 2003

From February to April 2003, we performed an e-mail-based survey to assess responses of physicians at Yale University to being offered smallpox vaccine. Of 58 respondents, 3 (5%) had been or intended to be vaccinated. Reasons cited for declining vaccination included: belief that benefits did not outweigh risks (55%), belief that the vaccination program was unnecessary (18%), desire to wait and see what side effects occurred in vaccinees (11%), and worries about compensation or liability (7%). Most (94%) considered risks to themselves, family, or patients in their decision. Only 3% thought a smallpox attack in the next 5 years was likely or very likely. Physicians did not accept the smallpox vaccine because they did not believe the potential benefits were sufficient.

Improving diagnostic testing and reducing overuse of antibiotics for children with pharyngitis: a useful role for the electronic medical record

BACKGROUND

Because of rising resistance to antibiotics, appropriate use of antibiotics is an important measure of quality of care. The purpose of this study was to use an electronic medical record (EMR) to assess use of diagnostic testing and of antibiotics for pharyngitis in a pediatric outpatient setting and to target areas for improvement.

METHODS

Using data retrieved from the EMR, we analyzed visits from March 1, 2001 to February 28, 2002 for children 3 to 18 years old diagnosed with pharyngitis. We determined the proportion of episodes with a diagnostic test for group A streptococci, the proportion for which a prescription for an antibiotic was dispensed and factors that predicted prescribing and testing.

RESULTS

Of 391 episodes of pharyngitis, a test was ordered for 303 (78%). Antibiotics were prescribed for 90 (23%); for 76 of 90 (84%) a test was ordered. Clinicians were less likely to order tests late in the week [relative risk (RR), 0.76; 95% confidence interval (CI), 0.66, 0.87)], more likely to order tests for patients with an exudate (RR 1.2; 95% CI 1.1, 1.3) and more likely to prescribe an antibiotic for patients with an exudate (RR 1.5; 95% CI 1.1, 2.1). When prescribing an antibiotic clinicians were less likely to order tests late in the week (RR 0.1; 95% CI 0.02, 0.5) and for patients diagnosed with scarlet fever (RR 0.07; 95% CI 0.01, 0.4).

CONCLUSION

Using data from the EMR, we could assess adherence to the guidelines for antibiotic use and identify areas to target for improving diagnostic testing and reducing overuse of antibiotics in our clinic.

Effectiveness of the 23-valent polysaccharide vaccine against invasive pneumococcal disease in Navajo adults

Invasive pneumococcal disease occurs 2-3-fold more often among Navajo adults than among adults in the general United States population. The objective of this observational study was to determine the effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPV23) among Navajo adults. Active surveillance identified cases of invasive pneumococcal disease during 1996-1997. Three control patients per case patient were matched according to underlying medical conditions, sex, age, and location of medical care. Effectiveness was calculated by regression analysis of case-control sets and by indirect cohort methodology. Diabetes and alcoholism occurred in 41% and 43% of 108 case patients, respectively; 62% of case patients and 64% of control patients were immunized. Overall vaccine effectiveness was 26% (95% confidence interval [CI], -29% to 58%); 15% (95% CI, -116% to 67%) for patients with diabetes and -5% (95% CI, -141% to 54%) for patients with alcoholism. Overall vaccine effectiveness, as determined by use of the indirect cohort methodology, was 35% (95% CI, -33% to 69%). PPV23 was not significantly effective among Navajo adults and may be inadequate to prevent serious pneumococcal disease in this population.

Trends in legionnaires disease, 1980-1998: declining mortality and new patterns of diagnosis

New diagnostic tests and empirical therapy for pneumonia may have important ramifications for the identification, treatment, and control of legionnaires disease (LD). To determine trends in the epidemiology of LD, we analyzed data for 1980-1998 from the passive surveillance system of the Centers for Disease Control and Prevention. During this time period, there were 6757 confirmed cases of LD (median annual number, 360 cases/year). Diagnosis by culture and by direct fluorescent antibody and serologic testing decreased significantly; diagnosis by urine antigen testing increased from 0% to 69%. The frequency of isolates other than Legionella pneumophila serogroup 1 (LP1) decreased from 38% to 4% (P=.003). The case-fatality rate decreased significantly, from 34% to 12% (P<.001) for all cases, from 46% to 14% (P<.0001) for nosocomial cases, and from 26% to 10% (P=.05) for community-acquired cases. LD-related mortality has decreased dramatically. The decrease in culture-based diagnosis limits the recognition of non-LP1 disease and impairs outbreak investigation, because fewer Legionella isolates are provided for further examination.

An outbreak of travel-associated Legionnaires disease and Pontiac fever: the need for enhanced surveillance of travel-associated legionellosis in the United States

Travel-associated outbreaks of legionnaires disease (LD) and combined outbreaks of LD and Pontiac fever (PF) are rarely identified. During one travel-associated combined outbreak at a hotel, a cohort study of potentially exposed persons and an environmental investigation were performed. Two LD and 22 PF cases were identified. Legionella pneumophila serogroup 6 (Lp6) isolates from the index patient and the hotel whirlpool spa were found to be identical by amplified fragment-length polymorphism typing. Disease occurred in 10 of 26 guests who were exposed to the spa versus 2 of 29 guests who were exposed only to the pool area (38% vs. 7%; P=.005). Immunoglobulin M (IgM) antibody to the outbreak Lp6 strain was more common among persons with PF (4 of 9) than among non-ill persons (2 of 32) (44% vs. 6%; P=.02). Spa exposure correlated with disease (P=.001) and IgM seropositivity (P=.007). New laboratory techniques facilitate outbreak investigation; to expedite outbreak interruption and measure the impact of travel-associated legionellosis, surveillance must be improved.

High concentrations of heavy metals in neighborhoods near ore smelters in northern Mexico

In developing countries, rapid industrialization without environmental controls has resulted in heavy metal contamination of communities. We hypothesized that residential neighborhoods located near ore industries in three northern Mexican cities would be heavily polluted with multiple contaminants (arsenic, cadmium, and lead) and that these sites would be point sources for the heavy metals. To evaluate these hypotheses, we obtained samples of roadside surface dust from residential neighborhoods within 2 m of metal smelters [Torreón (n = 19)] and Chihuahua (n = 19)] and a metal refinery [Monterrey (n = 23)]. Heavy metal concentrations in dust were mapped with respect to distance from the industrial sites. Correlation between dust metal concentration and distance was estimated with least-squares regression using log-transformed data. Median dust arsenic, cadmium, and lead concentrations were 32, 10, and 277 microg/g, respectively, in Chihuahua; 42, 2, and 467 microg/g, respectively, in Monterrey, and 113, 112, and 2,448 microg/g, respectively, in Torreón. Dust concentrations of all heavy metals were significantly higher around the active smelter in Torreón, where more than 90% of samples exceeded Superfund cleanup goals. At all sites, dust concentrations were inversely related to distance from the industrial source, implicating these industries as the likely source of the contamination. We concluded that residential neighborhoods around metal smelting and refining sites in these three cities are contaminated by heavy metals at concentrations likely to pose a health threat to people living nearby. Evaluations of human exposure near these sites should be conducted. Because multiple heavy metal pollutants may exist near smelter sites, researchers should avoid attributing toxicity to one heavy metal unless others have been measured and shown not to coexist.