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Derington CG, Goodrich GK, Xu S, Clark NP, Reynolds K, An J, Witt DM, Smith DH, O’Keeffe-Rosetti M, Lang DT, Ho PM, Cheetham TC, Comer AC, King JB. Association of Direct Oral Anticoagulation Management Strategies With Clinical Outcomes for Adults With Atrial Fibrillation. JAMA Netw Open 2023; 6:e2321971. [PMID: 37410461 PMCID: PMC10326649 DOI: 10.1001/jamanetworkopen.2023.21971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/19/2023] [Indexed: 07/07/2023] Open
Abstract
Importance Anticoagulation management services (AMSs; ie, warfarin clinics) have evolved to include patients treated with direct oral anticoagulants (DOACs), but it is unknown whether DOAC therapy management services improve outcomes for patients with atrial fibrillation (AF). Objective To compare outcomes associated with 3 DOAC care models for preventing adverse anticoagulation-related outcomes among patients with AF. Design, Setting, and Participants This retrospective cohort study included 44 746 adult patients with a diagnosis of AF who initiated oral anticoagulation (DOAC or warfarin) between August 1, 2016, and December 31, 2019, in 3 Kaiser Permanente (KP) regions. Statistical analysis was conducted from August 2021 through May 2023. Exposures Each KP region used an AMS to manage warfarin but used distinct approaches to DOAC care: (1) usual care (UC) by the prescribing clinician, (2) UC plus an automated population management tool (PMT), or (3) pharmacist-managed AMS care. Propensity scores and inverse probability of treatment weights (IPTWs) were estimated. Direct oral anticoagulant care models were first indirectly compared using warfarin as a common comparator within each region and then directly compared across regions. Main Outcomes and Measures Patients were followed up until the first occurrence of an outcome (composite of thromboembolic stroke, intracranial hemorrhage, other major bleeding, or death), discontinuation of KP membership, or December 31, 2020. Results Overall, 44 746 patients were included: 6182 in the UC care model (3297 DOAC; 2885 warfarin), 33 625 in the UC plus PMT care model (21 891 DOAC; 11 734 warfarin), and 4939 in the AMS care model (2089 DOAC; 2850 warfarin). Baseline characteristics (mean [SD] age, 73.1 [10.6] years, 56.1% male, 67.2% non-Hispanic White, median CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes, stroke, vascular disease, age 65-74 years, female sex] score of 3 [IQR, 2-5]) were well balanced after IPTW. Over a median follow-up of 2 years, patients who received the UC plus PMT or AMS care model did not have significantly better outcomes than those who received UC. The incidence rate of the composite outcome was 5.4% per year for DOAC and 9.1% per year for warfarin for those in the UC group, 6.1% per year for DOAC and 10.5% per year for those in the UC plus PMT group, and 5.1% per year for DOAC and 8.0% per year for those in the AMS group. The IPTW-adjusted hazard ratios (HRs) for the composite outcome comparing DOAC vs warfarin were 0.91 (95% CI, 0.79-1.05) in the UC group, 0.85 (95% CI, 0.79-0.90) in the UC plus PMT group, and 0.84 (95% CI, 0.72-0.99) in the AMS group (P = .62 for heterogeneity across care models). When directly comparing patients receiving DOAC, the IPTW-adjusted HR was 1.06 (95% CI, 0.85-1.34) for the UC plus PMT group vs the UC group and 0.85 (95% CI, 0.71-1.02) for the AMS group vs the UC group. Conclusions and Relevance This cohort study did not find appreciably better outcomes for patients receiving DOAC who were managed by either a UC plus PMT or AMS care model compared with UC.
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Affiliation(s)
- Catherine G. Derington
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles University of Utah School of Medicine, Salt Lake City
| | | | - Stanley Xu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Jaejin An
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Daniel M. Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City
| | - David H. Smith
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | | | - Daniel T. Lang
- Southern California Permanente Medical Group, Los Angeles
| | - P. Michael Ho
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora
- Cardiology Section, Veterans Affairs Eastern Colorado Health Care System, Aurora
| | | | - Angela C. Comer
- Institute for Health Research, Kaiser Permanente Colorado, Denver
| | - Jordan B. King
- Intermountain Healthcare Department of Population Health Sciences, Spencer Fox Eccles University of Utah School of Medicine, Salt Lake City
- Institute for Health Research, Kaiser Permanente Colorado, Denver
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Steiner JF, Zeng C, Comer AC, Barrow JC, Langer JN, Steffen DA, Steiner CA. Factors Associated With Opting Out of Automated Text and Telephone Messages Among Adult Members of an Integrated Health Care System. JAMA Netw Open 2021; 4:e213479. [PMID: 33769509 PMCID: PMC7998073 DOI: 10.1001/jamanetworkopen.2021.3479] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Health care systems deliver automated text or telephone messages to remind patients of appointments and to provide health information. Patients who receive multiple messages may demonstrate message fatigue by opting out of future messages. OBJECTIVE To assess whether the volume of automated text or interactive voice response (IVR) telephone messages is associated with the likelihood of patients requesting to opt out of future messages. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted at Kaiser Permanente Colorado (KPCO), an integrated health care system. All adult members who received 1 or more automated text or IVR message between October 1, 2018, and September 30, 2019, were included. EXPOSURES Receipt of automated text or IVR messages. MAIN OUTCOMES AND MEASURES Message volume and opt-out rates obtained from messaging systems over 1 year. RESULTS Of the 428 242 adults included in this study, 59.7% were women, and 66.5% were White; the mean (SD) age was 52.3 (17.7) years. During the study period, 84.1% received 1 or more text messages (median, 4 messages; interquartile range, 2-8 messages) and 67.8% received 1 or more IVR messages (median, 3 messages; interquartile range, 1-6 messages). A total of 8929 individuals (2.5%) opted out of text messages, and 4392 (1.5%) opted out of IVR messages. In multivariable analyses, individuals who received 10 to 19.9 or 20 or more text messages per year had higher opt-out rates for text messages compared with those who received fewer than 2 messages per year (adjusted odds ratio [aOR]: 10-19.9 vs <2 messages, 1.27 [95% CI, 1.17-1.38]; ≥20 vs <2 messages, 3.58 [95% CI, 3.28-3.91]), whereas opt-out rates increased progressively in association with IVR message volume, with the highest rates among individuals who received 10.0 to 19.9 messages (aOR, 11.11; 95% CI, 9.43-13.08) or 20.0 messages or more (aOR, 49.84; 95% CI, 42.33-58.70). Individuals opting out of text messages were more likely to opt out of IVR messages (aOR, 4.07; 95% CI, 3.65-4.55), and those opting out of IVR messages were more likely to opt out of text messages (aOR, 5.92; 95% CI, 5.29-6.61). CONCLUSIONS AND RELEVANCE In this cohort study among adult members of an integrated health care system, requests to discontinue messages were associated with greater message volume. These findings suggest that, to preserve the benefits of automated outreach, health care systems should use these messages judiciously to reduce message fatigue.
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Affiliation(s)
- John F. Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Chan Zeng
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Angela C. Comer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | | | - Jonah N. Langer
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - David A. Steffen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
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Fratta KA, Bouland AJ, Lawner BJ, Comer AC, Halliday MH, Levy MJ, Seaman KG. Barriers to bystander CPR: Evaluating socio-economic and cultural factors influencing students attending community CPR training. Am J Emerg Med 2019; 37:159-161. [DOI: 10.1016/j.ajem.2018.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 05/10/2018] [Accepted: 05/13/2018] [Indexed: 11/27/2022] Open
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Dezman ZDW, Comer AC, Smith GS, Hu PF, Mackenzie CF, Scalea TM, Hirshon JM. Repeat lactate level predicts mortality better than rate of clearance. Am J Emerg Med 2018; 36:2005-2009. [PMID: 29544906 DOI: 10.1016/j.ajem.2018.03.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/06/2018] [Accepted: 03/06/2018] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Lactate clearance has been developed into a marker of resuscitation in trauma, but no study has compared the predictive power of the various clearance calculations. Our objective was to determine which method of calculating lactate clearance best predicted 24-hour and in-hospital mortality after injury. STUDY DESIGN Retrospective chart review of patients admitted to a Level-1 trauma center directly from the scene of injury from 2010 to 2013 who survived >15min, had an elevated lactate at admission (≥3mmol/L), followed by another measurement within 24h of admission. Lactate clearance was calculated using five models: actual value of the repeat level, absolute clearance, relative clearance, absolute rate, and relative rate. Models were compared using the areas under the respective receiver operating curves (AUCs), with an endpoint of death at 24h and in-hospital mortality. RESULTS 3910 patients had an elevated admission lactate concentration on admission (mean=5.6±3.0mmol/L) followed by a second measurement (2.7±1.8mmol/L). Repeat absolute measurement best predicted 24-hour (AUC=0.85, 95% CI: 0.84-0.86) and in-hospital death (AUC=0.77; 95% CI, 0.76-0.78). Relative clearance was the best model of lactate clearance (AUC=0.77, 95% CI: 0.75-0.78 and AUC=0.705, 95% CI: 0.69-72, respectively) (p<0.0001 for each). A sensitivity analysis using a range of initial lactate measures yielded similar results. CONCLUSIONS The absolute value of the repeat lactate measurement had the greatest ability to predict mortality in injured patients undergoing resuscitation.
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Affiliation(s)
- Zachary D W Dezman
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Angela C Comer
- Children's Hospital Colorado, Denver, CO, United States.
| | - Gordon S Smith
- Department of Epidemiology, West Virginia University, Morgantown, WV, United States.
| | - Peter F Hu
- Shock Trauma Anaesthesia Organized Research Center (STAR-ORC), University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Colin F Mackenzie
- Shock Trauma Anaesthesia Organized Research Center (STAR-ORC), University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, United States.
| | - Jon Mark Hirshon
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States.
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Bouland AJ, Halliday MH, Comer AC, Levy MJ, Seaman KG, Lawner BJ. Evaluating Barriers to Bystander CPR among Laypersons before and after Compression-only CPR Training. PREHOSP EMERG CARE 2017; 21:662-669. [PMID: 28422540 DOI: 10.1080/10903127.2017.1308605] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Bystander CPR is an essential part of out-of-hospital cardiac arrest (OHCA) survival. EMS and public safety jurisdictions have embraced initiatives to teach compression-only CPR to laypersons in order to increase rates of bystander CPR. We examined barriers to bystander CPR amongst laypersons participating in community compression-only CPR training and the ability of the training to alleviate these barriers. The barriers analyzed include fear of litigation, risk of disease transmission, fear of hurting someone as a result of doing CPR when unnecessary, and fear of hurting someone as a result of doing CPR incorrectly. METHODS Laypersons attending community compression-only CPR training were administered surveys before and after community CPR training. Data were analyzed via standard statistical analyses. RESULTS A total of 238 surveys were collected and analyzed between September 2015 and January 2016. The most common reported motivation for attending CPR training was "to be prepared/just in case" followed by "infant or child at home." Respondents reported that they were significantly more likely to perform CPR on a family member than a stranger in both pre-and post-training responses. Nevertheless, reported self-confidence in and likelihood of doing CPR on both family and strangers increased from pre-training to post-training. There was a statistically significant decrease in reported likelihood of all four barriers to prevent respondents from performing bystander CPR when pre-training responses were compared to post-training responses. Previous CPR training and history of having witnessed a sudden cardiac arrest (SCA) were both associated with decreased barriers to CPR, but previous training had no effect on reported likelihood of or confidence in performing CPR. CONCLUSION The training initiative studied significantly reduced the reported likelihood of all barriers studied to prevent respondents from performing bystander CPR and also increased the reported confidence in doing CPR and likelihood of doing CPR on both strangers and family. However, it did not alleviate the pre-training discrepancy between likelihood of performing CPR on strangers versus family. Previous CPR training or certification had no impact on likelihood of or confidence in performing CPR.
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Saleh HM, Elsabagh AE, Elewa MG, Fawzy AA, Hassan OM, Comer AC, Abdelmonem IM, Hirshon JM, El-Shinawi M. Admission delays' magnitude of traumatized patients in the emergency department of a hospital in Egypt: a cross-sectional study. Eur J Trauma Emerg Surg 2017; 44:225-230. [PMID: 28255612 DOI: 10.1007/s00068-017-0762-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 01/07/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Injury is an escalating public health problem, representing about 9% of global mortality, which disproportionately impacts lower- and middle-income countries. There are approximately 12,000 annual fatalities from road traffic injuries in Egypt, but a little information about delays in seeking emergent care is available. OBJECTIVES To measure the time interval between sustaining an injury and presentation to the emergency department of Ain Shams University Surgery Hospital and to identify possible causes of these delays. METHODS We conducted a cross-sectional, facilitated survey of a convenience sample of trauma patients presenting to the emergency department of Ain Shams University Surgery Hospital from 1 February to 31 May 2014. Data obtained included: demographic information, trauma incident details, and injury assessment. RESULTS The average reported transport time for patients from injury to hospital arrival was 3.8 h, while the mean ambulance response time was 45 min. Referral from other hospitals was revealed to be a significant cause of delay (P = 0.004), while ignorance of the local ambulance phone number could not be confirmed as a cause (P = 0.2). CONCLUSION This study demonstrated that trauma patients at our hospital experience more than 3 h of delay until they reach the ED. It also identified the possible causes accounting for that delay. However, additional nationwide research is needed to establish the clear causation or association of these causes with the delay intervals.
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Affiliation(s)
- H M Saleh
- Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11566, Egypt.
| | - A E Elsabagh
- Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11566, Egypt
| | - M G Elewa
- Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11566, Egypt
| | - A A Fawzy
- Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11566, Egypt
| | - O M Hassan
- Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11566, Egypt
| | - A C Comer
- Charles McC. Mathias, Jr. National Study Center for Trauma and EMS, University of Maryland School of Medicine, Baltimore, USA
| | - I M Abdelmonem
- Faculty of Medicine, Ain Shams University, Ramses Street, Cairo, 11566, Egypt
| | - J M Hirshon
- Charles McC. Mathias, Jr. National Study Center for Trauma and EMS, University of Maryland School of Medicine, Baltimore, USA.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, USA.,Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - M El-Shinawi
- Department of General Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Millin MG, Comer AC, Nable JV, Johnston PV, Lawner BJ, Woltman N, Levy MJ, Seaman KG, Hirshon JM. Patients without ST elevation after return of spontaneous circulation may benefit from emergent percutaneous intervention: A systematic review and meta-analysis. Resuscitation 2016; 108:54-60. [PMID: 27640933 DOI: 10.1016/j.resuscitation.2016.09.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 08/30/2016] [Accepted: 09/05/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The American Heart Association recommends that post-arrest patients with evidence of ST elevation myocardial infarction (STEMI) on electrocardiogram (ECG) be emergently taken to the catheterization lab for percutaneous coronary intervention (PCI). However, recommendations regarding the utility of emergent PCI for patients without ST elevation are less specific. This review examined the literature on the utility of PCI in post-arrest patients without ST elevation compared to patients with STEMI. METHODS A systematic review of the English language literature was performed for all years to March 1, 2015 to examine the hypothesis that a percentage of post-cardiac arrest patients without ST elevation will benefit from emergent PCI as defined by evidence of an acute culprit coronary lesion. RESULTS Out of 1067 articles reviewed, 11 articles were identified that allowed for analysis of data to examine our study hypothesis. These studies show that patients presenting post cardiac arrest with STEMI are thirteen times more likely to be emergently taken to the catheterization lab than patients without STEMI; OR 13.8 (95% CI 4.9-39.0). Most importantly, the cumulative data show that when taken to the catheterization lab as much as 32.2% of patients without ST elevation had an acute culprit lesion requiring intervention, compared to 71.9% of patients with STEMI; OR 0.15 (95% CI 0.06-0.34). CONCLUSION The results of this systematic review demonstrate that nearly one third of patients who have been successfully resuscitated from cardiopulmonary arrest without ST elevation on ECG have an acute lesion that would benefit from emergent percutaneous coronary intervention.
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Affiliation(s)
- Michael G Millin
- Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Angela C Comer
- National Study Center for the Study of Trauma and EMS Baltimore, MD, United States.
| | - Jose V Nable
- MedStar Georgetown University Hospital, United States.
| | - Peter V Johnston
- Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Benjamin J Lawner
- University of Maryland School of Medicine Baltimore, MD, United States.
| | - Nathan Woltman
- Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Matthew J Levy
- Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Kevin G Seaman
- Maryland Institute for Emergency Medical Services Systems, Baltimore, MD, United States.
| | - Jon Mark Hirshon
- University of Maryland School of Medicine Baltimore, MD, United States.
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Dezman ZD, Comer AC, Narayan M, Scalea TM, Hirshon JM, Smith GS. Alcohol consumption decreases lactate clearance in acutely injured patients. Injury 2016; 47:1908-12. [PMID: 27025567 PMCID: PMC5482221 DOI: 10.1016/j.injury.2016.03.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 03/06/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Alcohol, a common risk factor for injury, has direct toxic effects on the liver. The use of lactate clearance has been well described as an indicator of the adequacy of resuscitation in injured patients. We investigated whether acutely injured patients with positive blood alcohol content (+BAC) had less lactate clearance than sober patients. METHODS We conducted a retrospective cohort study of acutely injured patients treated at an urban Level 1 trauma centre between January 2010 and December 2012. Blood alcohol and venous lactate levels were measured on all patients at the time of arrival. Study subjects were patients transported directly from the scene of injury, who had an elevated lactate concentration on arrival (≥3.0mmol/L) and at least one subsequent lactate measurement within 24h after admission. Lactate clearance ([Lactate1-Lactate2]/Lactate1) was calculated for all patients. Chi-squared tests were used to compare values from sober and intoxicated subjects. Lactate clearance was plotted against alcohol levels and stratified by age and Injury Severity Score (ISS). RESULTS Serial lactate concentration measurements were obtained in 3910 patients; 1674 of them had +BAC. Patients with +BAC were younger (mean age: 36.6 [SD 14.7] vs 41.0 [SD 19.9] years [p=0.0001]), were more often male (83.4% vs 75.9% [p=0.0001]), had more minor injuries (ISS<9) (33.8% vs 27.1% [p=0.0001]), had a lower in-hospital mortality rate (1.4% vs 3.9% [p=0.0001]), but also had lower average lactate clearance (37.8% vs 47.6% [p=0.0001]). The lactate clearance of the sober patients (47.6 [SD 33.5]) was twice that of those with +BAC >400 (23.5 [SD 6.5]). Lactate clearance decreased with increasing BAC irrespective of age and ISS. CONCLUSIONS In a large group of acutely injured patients, a dose-dependent decrease in lactate clearance was seen in those with elevated BAC. This relationship will cause a falsely elevated lactate reading or prolong lactate clearance and should be taken into account when evaluating patients with +BAC.
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Affiliation(s)
- Zachary D.W. Dezman
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA,National Study Center for Trauma and Emergency Medical Systems, University of Maryland, Baltimore, MD, USA,Corresponding author at: Department of Emergency Medicine, University of Maryland School of Medicine, 110 S Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA. Tel.: +1 410 328 5085; fax: +1 410 328 8026. (Zachary D.W. Dezman)
| | - Angela C. Comer
- National Study Center for Trauma and Emergency Medical Systems, University of Maryland, Baltimore, MD, USA
| | - Mayur Narayan
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - Thomas M. Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA
| | - Jon Mark Hirshon
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA,National Study Center for Trauma and Emergency Medical Systems, University of Maryland, Baltimore, MD, USA
| | - Gordon S. Smith
- National Study Center for Trauma and Emergency Medical Systems, University of Maryland, Baltimore, MD, USA
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Halliday MH, Bouland AJ, Lawner BJ, Comer AC, Ramos DC, Fletcher M. The Medical Duty Officer: An Attempt to Mitigate the Ambulance At-Hospital Interval. West J Emerg Med 2016; 17:662-8. [PMID: 27625737 PMCID: PMC5017857 DOI: 10.5811/westjem.2016.7.30266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 06/13/2016] [Accepted: 07/05/2016] [Indexed: 11/21/2022] Open
Abstract
Introduction A lack of coordination between emergency medical services (EMS), emergency departments (ED) and systemwide management has contributed to extended ambulance at-hospital times at local EDs. In an effort to improve communication within the local EMS system, the Baltimore City Fire Department (BCFD) placed a medical duty officer (MDO) in the fire communications bureau. It was hypothesized that any real-time intervention suggested by the MDO would be manifested in a decrease in the EMS at-hospital time. Methods The MDO was implemented on November 11, 2013. A senior EMS paramedic was assigned to the position and was placed in the fire communication bureau from 9 a.m. to 9 p.m., seven days a week. We defined the pre-intervention period as August 2013 – October 2013 and the post-intervention period as December 2013 – February 2014. We also compared the post-intervention period to the “seasonal match control” one year earlier to adjust for seasonal variation in EMS volume. The MDO was tasked with the prospective management of city EMS resources through intensive monitoring of unit availability and hospital ED traffic. The MDO could suggest alternative transport destinations in the event of ED crowding. We collected and analyzed data from BCFD computer-aided dispatch (CAD) system for the following: ambulance response times, ambulance at-hospital interval, hospital diversion and alert status, and “suppression wait time” (defined as the total time suppression units remained on scene until ambulance arrival). The data analysis used a pre/post intervention design to examine the MDO impact on the BCFD EMS system. Results There were a total of 15,567 EMS calls during the pre-intervention period, 13,921 in the post-intervention period and 14,699 in the seasonal match control period one year earlier. The average at-hospital time decreased by 1.35 minutes from pre- to post-intervention periods and 4.53 minutes from the pre- to seasonal match control, representing a statistically significant decrease in this interval. There was also a statistically significant decrease in hospital alert time (approximately 1,700 hour decrease pre- to post-intervention periods) and suppression wait time (less than one minute decrease from pre- to post- and pre- to seasonal match control periods). The decrease in ambulance response time was not statistically significant. Conclusion Proactive deployment of a designated MDO was associated with a small, contemporaneous reduction in at-hospital time within an urban EMS jurisdiction. This project emphasized the importance of better communication between EMS systems and area hospitals as well as uniform reporting of variables for future iterations of this and similar projects.
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Affiliation(s)
| | | | - Benjamin J Lawner
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore Maryland; Baltimore City Fire Department, Division of EMS, Baltimore, Maryland
| | - Angela C Comer
- National Study Center for Emergency Medical Systems and Trauma, Baltimore Maryland
| | - Daniel C Ramos
- Baltimore City Department of Social Services, Baltimore, Maryland
| | - Mark Fletcher
- Baltimore City Fire Department, Division of EMS, Baltimore, Maryland
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Lawner BJ, Hirshon JM, Comer AC, Nable JV, Kelly J, Alcorta RL, Pimentel L, Tupe CL, Vanhoy MA, Browne BJ. The impact of a freestanding ED on a regional emergency medical services system. Am J Emerg Med 2016; 34:1342-6. [DOI: 10.1016/j.ajem.2015.11.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Indexed: 11/28/2022] Open
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11
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Grasso MA, Dezman ZDW, Comer AC, Jerrard DA. The Decline in Hydrocodone/Acetaminophen Prescriptions in Emergency Departments in the Veterans Health Administration Between 2009 to 2015. West J Emerg Med 2016; 17:396-403. [PMID: 27482304 PMCID: PMC4957666 DOI: 10.5811/westjem.2016.5.29924] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 04/14/2016] [Accepted: 05/05/2016] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION The purpose of the study was to measure national prescribing patterns for hydrocodone/acetaminophen among veterans seeking emergency medical care, and to see if patterns have changed since this medication became a Schedule II controlled substance. METHODS We conducted a retrospective cohort study of emergency department (ED) visits within the Veterans Health Administration (VA) between January 2009 and June 2015. We looked at demographics, comorbidities, utilization measures, diagnoses, and prescriptions. RESULTS During the study period, 1,709,545 individuals participated in 6,270,742 ED visits and received 471,221 prescriptions for hydrocodone/acetaminophen (7.5% of all visits). The most common diagnosis associated with a prescription was back pain. Prescriptions peaked at 80,776 in 2011 (8.7% of visits), and declined to 35,031 (5.6%) during the first half of 2015 (r=-0.99, p<0.001). The percentage of hydrocodone/acetaminophen prescriptions limited to 12 pills increased from 22% (13,949) in 2009 to 31% (11,026) in the first half of 2015. A prescription was more likely written for patients with a pain score≥7 (OR 3.199, CI [3.192-3.205]), a musculoskeletal (OR 1.622, CI [1.615-1.630]) or soft tissue (OR 1.656, CI [1.649-1.664]) diagnosis, and those below the first quartile for total ED visits (OR 1.282, CI [1.271-1.293]) and total outpatient ICD 9 codes (OR 1.843, CI [1.833-1.853]). CONCLUSION Hydrocodone/acetaminophen is the most frequently prescribed ED medication in the VA. The rate of prescribing has decreased since 2011, with the rate of decline remaining unchanged after it was classified as a Schedule II controlled substance. The proportion of prescriptions falling within designated guidelines has increased but is not at goal.
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Affiliation(s)
- Michael A Grasso
- University of Maryland, Department of Emergency Medicine, Baltimore, Maryland
| | - Zachary D W Dezman
- University of Maryland, Department of Emergency Medicine, Baltimore, Maryland
| | - Angela C Comer
- University of Maryland, National Study Center for Trauma and EMS, Maryland
| | - David A Jerrard
- University of Maryland, Department of Emergency Medicine, Baltimore, Maryland
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Furuno JP, Comer AC, Johnson JK, Rosenberg JH, Moore SL, MacKenzie TD, Hall KK, Hirshon JM. Using antibiograms to improve antibiotic prescribing in skilled nursing facilities. Infect Control Hosp Epidemiol 2016; 35 Suppl 3:S56-61. [PMID: 25222899 DOI: 10.1086/677818] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown. OBJECTIVE To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing. DESIGN AND SETTING Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs. METHODS Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities. RESULTS We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant ([Formula: see text]). CONCLUSIONS Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.
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Affiliation(s)
- Jon P Furuno
- Department of Pharmacy Practice, Oregon State University/Oregon Health and Science University College of Pharmacy, Portland, Oregon
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13
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Grasso MA, Comer AC, DiRenzo DD, Yesha Y, Rishe ND. Using Big Data to Evaluate the Association between Periodontal Disease and Rheumatoid Arthritis. AMIA Annu Symp Proc 2015; 2015:589-593. [PMID: 26958193 PMCID: PMC4765642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
An association between periodontal disease and rheumatoid arthritis is believed to exist. Most investigations into a possible relationship have been case-control studies with relatively low sample sizes. The advent of very large clinical repositories has created new opportunities for data-driven research. We conducted a retrospective cohort study to measure the association between periodontal disease and rheumatoid arthritis in a population of 25 million patients. We demonstrated that subjects with periodontal disease were roughly 1.4 times more likely to have rheumatoid arthritis. These results compare favorably with those of previous studies on smaller cohorts. Additional work is needed to identify the mechanisms behind this association and to determine if aggressive treatment of periodontal disease can alter the course of rheumatoid arthritis.
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Affiliation(s)
| | - Angela C Comer
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Dana D DiRenzo
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Yelena Yesha
- University of Maryland Baltimore County, Baltimore, Maryland
| | - Naphtali D Rishe
- Florida International University and NOA Data Science Institute Inc, Miami, Florida
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14
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Albrecht JS, Gruber-Baldini AL, Hirshon JM, Brown CH, Goldberg R, Rosenberg JH, Comer AC, Furuno JP. Hospital discharge instructions: comprehension and compliance among older adults. J Gen Intern Med 2014; 29:1491-8. [PMID: 25015430 PMCID: PMC4238191 DOI: 10.1007/s11606-014-2956-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 04/20/2014] [Accepted: 06/27/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little is known regarding the prevalence or risk factors for non-comprehension and non-compliance with discharge instructions among older adults. OBJECTIVE To quantify the prevalence of non-comprehension and non-compliance with discharge instructions and to identify associated patient characteristics. RESEARCH DESIGN Prospective cohort study. SUBJECTS Four hundred and fifty adults aged ≥ 65 admitted to medical and surgical units of a tertiary care facility and meeting inclusion criteria. MEASURES We collected information on demographics, psycho-social factors, discharge diagnoses, and medications using surveys and patient medical records. Domains within discharge instructions included medications, follow-up appointments, diet, and exercise. At 5 days post-discharge, we assessed comprehension by asking patients about their discharge instructions, and compared responses to written instructions from medical charts. We assessed compliance among patients who understood their instructions. RESULTS Prevalence of non-comprehension was 5 % for follow-up appointments, 27 % for medications, 48 % for exercise and 50 % for diet recommendations. Age was associated with non-comprehension of medication [odds ratio (OR) 1.07; 95 % confidence interval (CI) 1.04, 1.12] and follow-up appointment (OR 1.08; 95 % CI 1.00, 1.17) instructions. Male sex was associated with non-comprehension of diet instructions (OR 1.91; 95 % CI 1.10, 3.31). Social isolation was associated with non-comprehension of exercise instructions (OR 9.42; 95 % CI 1.50, 59.11) Depression was associated with non-compliance with medication (OR 2.29; 95 % CI 1.02, 5.10) and diet instructions (OR 3.30; 95 % CI 1.24, 8.83). CONCLUSIONS Non-comprehension of discharge instructions among older adults is prevalent, multi-factorial, and varies by domain.
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Affiliation(s)
- J S Albrecht
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, 220 Arch Street, 12th floor, Room 01-234, Baltimore, MD, 21201, USA,
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Albrecht JS, Gruber-Baldini AL, Hirshon JM, Brown CH, Goldberg R, Rosenberg JH, Comer AC, Furuno JP. Depressive symptoms and hospital readmission in older adults. J Am Geriatr Soc 2014; 62:495-9. [PMID: 24512099 DOI: 10.1111/jgs.12686] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To quantify the risk of 30-day unplanned hospital readmission in adults aged 65 and older with depressive symptoms. DESIGN Prospective cohort study. SETTING University of Maryland Medical Center. PARTICIPANTS Individuals aged 65 and older admitted between July 1, 2011, and August 9, 2012, to the general medical and surgical units and followed for 31 days after hospital discharge (N = 750). MEASUREMENTS Primary exposure was depressive symptoms at admission, defined as a score of 6 or more on the 15-item Geriatric Depression Scale. Primary outcome was unplanned 30-day hospital readmission, defined as an unscheduled overnight stay at any inpatient facility not occurring in the emergency department. RESULTS Prevalence of depressive symptoms was 19% and incidence of 30-day unplanned hospital readmission was 19%. Depressive symptoms were not significantly associated with hospital readmission (relative risk (RR) = 1.20, 95% confidence interval (CI) = 0.83-1.72). Age, Charlson Comorbidity Index score, and number of hospitalizations within the past 6 months were significant predictors of unplanned 30-day hospital readmission. CONCLUSION Although not associated with hospital readmission, depressive symptoms were associated with other poor outcomes and may be underdiagnosed in hospitalized older adults. Hospitals interested in reducing readmission should focus on older adults with more comorbid illness and recent hospitalizations.
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Affiliation(s)
- Jennifer S Albrecht
- Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore, Mayland; Department of Pharmaceutical Health Services Research, School of Pharmacy, University of Maryland, Baltimore, Mayland
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Rosenberg JH, Albrecht JS, Fromme EK, Noble BN, McGregor JC, Comer AC, Furuno JP. Antimicrobial use for symptom management in patients receiving hospice and palliative care: a systematic review. J Palliat Med 2013; 16:1568-74. [PMID: 24151960 DOI: 10.1089/jpm.2013.0276] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Patients receiving hospice or palliative care often receive antimicrobial therapy; however the effectiveness of antimicrobial therapy for symptom management in these patients is unknown. OBJECTIVE The study's objective was to systematically review and summarize existing data on the prevalence and effectiveness of antimicrobial therapy to improve symptom burden among hospice or palliative care patients. DESIGN Systematic review of articles on microbial use in hospice and palliative care patients published from January 1, 2001 through June 30, 2011. MEASUREMENTS We extracted data on patients' underlying chronic condition and health care setting, study design, prevalence of antimicrobial use, whether symptom response following antimicrobial use was measured, and the method for measuring symptom response. RESULTS Eleven studies met our inclusion criteria in which prevalence of antimicrobial use ranged from 4% to 84%. Eight studies measured symptom response following antimicrobial therapy. Methods of symptom assessment were highly variable and ranged from clinical assessment from patients' charts to the Edmonton Symptom Assessment Scale. Symptom improvement varied by indication, and patients with urinary tract infections (two studies) appeared to experience the greatest improvement following antimicrobial therapy (range 67% to 92%). CONCLUSION Limited data are available on the use of antimicrobial therapy for symptom management among patients receiving palliative or hospice care. Future studies should systematically measure symptom response and control for important confounders to provide useful data to guide antimicrobial use in this population.
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Affiliation(s)
- Joseph H Rosenberg
- 1 Department of Epidemiology and Public Health, University of Maryland School of Medicine , Baltimore, Maryland
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17
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Albrecht JS, Hirshon JM, Goldberg R, Langenberg P, Day HR, Morgan DJ, Comer AC, Harris AD, Furuno JP. Serious mental illness and acute hospital readmission in diabetic patients. Am J Med Qual 2012; 27:503-8. [PMID: 22539798 PMCID: PMC3677605 DOI: 10.1177/1062860612436576] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients with serious mental illness (SMI), particularly those with other chronic illnesses, may be vulnerable to unplanned hospital readmission. The authors hypothesized that SMI would be associated with increased 30-day hospital readmission in a cohort of adult patients with comorbid diabetes admitted to a tertiary care facility from 2005 to 2009. SMI was defined by International Classification of Diseases, Ninth Revision, discharge diagnosis codes for schizophrenia, schizoaffective, bipolar, manic, or major depressive disorders, or other psychosis. The primary outcome was 30-day readmission to the index hospital. Among 26 878 eligible admissions, the prevalence of SMI was 6% and the incidence of 30-day hospital admission was 16%. Among patients aged <35 years, SMI was significantly associated with decreased odds of 30-day hospital readmission (odds ratio [OR] = 0.39; 95% confidence interval [CI] = 0.17, 0.91). However, among patients ≥35 years, SMI was not significantly associated with 30-day hospital readmission (OR = 1.11; 95% CI = 0.86, 1.42). SMI may not be associated with increased odds of 30-day hospital readmission in this population.
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Affiliation(s)
- Jennifer S. Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine
| | - Jon Mark Hirshon
- Department of Epidemiology and Public Health, University of Maryland School of Medicine
- Department of Emergency Medicine, University of Maryland School of Medicine
| | - Richard Goldberg
- Department of Psychiatry, University of Maryland School of Medicine
- VA Capitol Health Care Network (VISN 5) Mental Illness Research, Education, and Clinical Center
| | - Patricia Langenberg
- Department of Epidemiology and Public Health, University of Maryland School of Medicine
| | - Hannah R. Day
- Department of Epidemiology and Public Health, University of Maryland School of Medicine
| | - Daniel J. Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine
- VA Capitol Health Care Network (VISN 5) Mental Illness Research, Education, and Clinical Center
| | - Angela C. Comer
- Department of Epidemiology and Public Health, University of Maryland School of Medicine
| | - Anthony D. Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine
| | - Jon P. Furuno
- Department of Epidemiology and Public Health, University of Maryland School of Medicine
- Department of Pharmacy Practice, Oregon State University/Oregon Health and Science University College of Pharmacy
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Emerson CB, Eyzaguirre LM, Albrecht JS, Comer AC, Harris AD, Furuno JP. Healthcare-associated infection and hospital readmission. Infect Control Hosp Epidemiol 2012; 33:539-44. [PMID: 22561707 DOI: 10.1086/665725] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Hospital readmissions are a current target of initiatives to reduce healthcare costs. This study quantified the association between having a clinical culture positive for 1 of 3 prevalent hospital-associated organisms and time to hospital readmission. DESIGN Retrospective cohort study. PATIENTS AND SETTING Adults admitted to an academic, tertiary care referral center from January 1, 2001, through December 31, 2008. METHODS The primary exposure of interest was a clinical culture positive for methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), or Clostridium difficile obtained more than 48 hours after hospital admission during the index hospital stay. The primary outcome of interest was time to readmission to the index facility. Multivariable Cox proportional hazards models were used to model the adjusted association between positive clinical culture result and time to readmission and to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS Among 136,513 index admissions, the prevalence of hospital-associated positive clinical culture result for 1 of the 3 organisms of interest was 3%, and 35% of patients were readmitted to the index facility within 1 year after discharge. Patients with a positive clinical culture obtained more than 48 hours after hospital admission had an increased hazard of readmission (HR, 1.40; 95% CI, 1.33-1.46) after adjusting for age, sex, index admission length of stay, intensive care unit stay, Charlson comorbidity index, and year of hospital admission. CONCLUSIONS Patients with healthcare-associated infections may be at increased risk of hospital readmission. These findings may be used to impact health outcomes after discharge from the hospital and to encourage better infection prevention efforts.
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Affiliation(s)
- Carley B Emerson
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Harris AD, Johnson JK, Thom KA, Morgan DJ, McGregor JC, Ajao AO, Moore AC, Comer AC, Furuno JP. Risk factors for development of intestinal colonization with imipenem-resistant Pseudomonas aeruginosa in the intensive care unit setting. Infect Control Hosp Epidemiol 2011; 32:719-22. [PMID: 21666406 DOI: 10.1086/660763] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Risk factors for development of intestinal colonization by imipenem-resistant Pseudomonas aeruginosa (IRPA) may differ between those who acquire the organism via patient-to-patient transmission versus by antibiotic selective pressure. The aim of this study was to quantify potential risk factors for the development of IRPA not due to patient-to-patient transmission.
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Affiliation(s)
- Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
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