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Rose JJ, Zhang MS, Pan J, Gauthier MC, Pizon AF, Saul MI, Nouraie SM. Heart-Brain 346-7 Score: the development and validation of a simple mortality prediction score for carbon monoxide poisoning utilizing deep learning. Clin Toxicol (Phila) 2023; 61:492-499. [PMID: 37417305 PMCID: PMC10529057 DOI: 10.1080/15563650.2023.2226817] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION Acute mortality from carbon monoxide poisoning is 1-3%. The long-term mortality risk of survivors of carbon monoxide poisoning is doubled compared to age-matched controls. Cardiac involvement also increases mortality risk. We built a clinical risk score to identify carbon monoxide-poisoned patients at risk for acute and long-term mortality. METHODS We performed a retrospective analysis. We identified 811 adult carbon monoxide-poisoned patients in the derivation cohort, and 462 adult patients in the validation cohort. We utilized baseline demographics, laboratory values, hospital charge transactions, discharge disposition, and clinical charting information in the electronic medical record in Stepwise Akaike's Information Criteria with Firth logistic regression to determine optimal parameters to create a prediction model. RESULTS In the derivation cohort, 5% had inpatient or 1-year mortality. Three variables following the final Firth logistic regression minimized Stepwise Akaike's Information Criteria: altered mental status, age, and cardiac complications. The following predict inpatient or 1-year mortality: age > 67, age > 37 with cardiac complications, age > 47 with altered mental status, or any age with cardiac complications and altered mental status. The sensitivity of the score was 82% (95% confidence interval: 65-92%), the specificity was 80% (95% confidence interval: 77-83%), negative predictive value was 99% (95% confidence interval: 98-100%), positive predictive value 17% (95% confidence interval: 12-23%), and the area under the receiver operating characteristic curve was 0.81 (95% confidence interval: 0.74-0.87). A score above the cut-off point of -2.9 was associated with an odds ratio of 18 (95% confidence interval: 8-40). In the validation cohort (462 patients), 4% had inpatient death or 1-year mortality. The score performed similarly in the validation cohort: sensitivity was 72% (95% confidence interval: 47-90%), specificity was 69% (95% confidence interval: 63-73%), negative predictive value was 98% (95% confidence interval: 96-99%), positive predictive value was 9% (95% confidence interval: 5-15%) and the area under the receiver operating characteristic curve was 0.70 (95% confidence interval: 60%-81%). CONCLUSIONS We developed and validated a simple, clinical-based scoring system, the Heart-Brain 346-7 Score to predict inpatient and long-term mortality based on the following: age > 67, age > 37 with cardiac complications, age > 47 with altered mental status, or any age with cardiac complications and altered mental status. With further validation, this score will hopefully aid decision-making to identify carbon monoxide-poisoned patients with higher mortality risk.
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Affiliation(s)
- Jason J. Rose
- University of Maryland School of Medicine, University of Maryland; Baltimore, MA, USA
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine; Pittsburgh, PA, USA
| | - Michael S. Zhang
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine; Pittsburgh, PA, USA
| | - Jerry Pan
- Department of Medicine, University of Pittsburgh; Pittsburgh, PA, USA
| | - Marc C. Gauthier
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine; Pittsburgh, PA, USA
| | - Anthony F. Pizon
- Department of Emergency Medicine, University of Pittsburgh School of Medicine; Pittsburgh, PA, USA
- Division of Medical Toxicology, University of Pittsburgh School of Medicine; Pittsburgh, PA, USA
| | - Melissa I. Saul
- Department of Medicine, University of Pittsburgh; Pittsburgh, PA, USA
| | - Seyed M. Nouraie
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine; Pittsburgh, PA, USA
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Sundermann AJ, Chen J, Kumar P, Ayres AM, Cho ST, Ezeonwuka C, Griffith MP, Miller JK, Mustapha MM, Pasculle AW, Saul MI, Shutt KA, Srinivasa V, Waggle K, Snyder DJ, Cooper VS, Van Tyne D, Snyder GM, Marsh JW, Dubrawski A, Roberts MS, Harrison LH. Whole Genome Sequencing Surveillance and Machine Learning of the Electronic Health Record for Enhanced Healthcare Outbreak Detection. Clin Infect Dis 2021; 75:476-482. [PMID: 34791136 PMCID: PMC9427134 DOI: 10.1093/cid/ciab946] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [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: 09/08/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Most hospitals use traditional infection prevention (IP) methods for outbreak detection. We developed the Enhanced Detection System for Healthcare-Associated Transmission (EDS-HAT), which combines whole genome sequencing (WGS) surveillance and machine learning (ML) of the electronic health record (EHR) to identify undetected outbreaks and the responsible transmission routes, respectively. METHODS We performed WGS surveillance of healthcare-associated bacterial pathogens from November 2016 to November 2018. EHR ML was used to identify the transmission routes for WGS-detected outbreaks, which were investigated by an IP expert. Potential infections prevented were estimated and compared to traditional IP practice during the same period. RESULTS Of 3,165 isolates, there were 2,752 unique patient isolates in 99 clusters involving 297 (10.8%) patient isolates were identified by WGS; clusters ranged from 2-14 patients. At least one transmission route was detected for 65.7% of clusters. During the same time, traditional IP investigation prompted WGS for 15 suspected outbreaks involving 133 patients, for which transmission events were identified for 5 (3.8%). If EDS-HAT had been running in real-time, 25-63 transmissions could have been prevented. EDS-HAT was found to be cost-saving and more effective than traditional IP practice, with overall savings of $192,408 - $692,532. CONCLUSION EDS-HAT detected multiple outbreaks not identified using traditional IP methods, correctly identified the transmission routes for most outbreaks, and would save the hospital substantial costs. Traditional IP practice misidentified outbreaks for which transmission did not occur. WGS surveillance combined with EHR ML has the potential to save costs and enhance patient safety.
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Affiliation(s)
- Alexander J Sundermann
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jieshi Chen
- Auton Lab, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Praveen Kumar
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashley M Ayres
- Department of Infection Control and Hospital Epidemiology, UPMC Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Shu-Ting Cho
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chinelo Ezeonwuka
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Marissa P Griffith
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - James K Miller
- Auton Lab, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Mustapha M Mustapha
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - A William Pasculle
- Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Melissa I Saul
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kathleen A Shutt
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Vatsala Srinivasa
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kady Waggle
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Daniel J Snyder
- Department of Microbiology and Molecular Genetics, and Center for Evolutionary Biology and Medicine, University of Pittsburgh School of Medicine, Pennsylvania, USA
| | - Vaughn S Cooper
- Department of Microbiology and Molecular Genetics, and Center for Evolutionary Biology and Medicine, University of Pittsburgh School of Medicine, Pennsylvania, USA
| | - Daria Van Tyne
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Graham M Snyder
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Infection Control and Hospital Epidemiology, UPMC Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Jane W Marsh
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Artur Dubrawski
- Auton Lab, Carnegie Mellon University, Pittsburgh, Pennsylvania, USA
| | - Mark S Roberts
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lee H Harrison
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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3
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Sundermann AJ, Chen J, Miller JK, Saul MI, Shutt KA, Griffith MP, Mustapha MM, Ezeonwuka C, Waggle K, Srinivasa V, Kumar P, Pasculle AW, Ayres AM, Snyder GM, Cooper VS, Van Tyne D, Marsh JW, Dubrawski AW, Harrison LH. Outbreak of Pseudomonas aeruginosa Infections from a Contaminated Gastroscope Detected by Whole Genome Sequencing Surveillance. Clin Infect Dis 2021; 73:e638-e642. [PMID: 33367518 DOI: 10.1093/cid/ciaa1887] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [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: 10/26/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Traditional methods of outbreak investigations utilize reactive whole genome sequencing (WGS) to confirm or refute the outbreak. We have implemented WGS surveillance and a machine learning (ML) algorithm for the electronic health record (EHR) to retrospectively detect previously unidentified outbreaks and to determine the responsible transmission routes. METHODS We performed WGS surveillance to identify and characterize clusters of genetically-related Pseudomonas aeruginosa infections during a 24-month period. ML of the EHR was used to identify potential transmission routes. A manual review of the EHR was performed by an infection preventionist to determine the most likely route and results were compared to the ML algorithm. RESULTS We identified a cluster of 6 genetically related P. aeruginosa cases that occurred during a 7-month period. The ML algorithm identified gastroscopy as a potential transmission route for 4 of the 6 patients. Manual EHR review confirmed gastroscopy as the most likely route for 5 patients. This transmission route was confirmed by identification of a genetically-related P. aeruginosa incidentally cultured from a gastroscope used on 4of the 5 patients. Three infections, 2 of which were blood stream infections, could have been prevented if the ML algorithm had been running in real-time. CONCLUSIONS WGS surveillance combined with a ML algorithm of the EHR identified a previously undetected outbreak of gastroscope-associated P. aeruginosa infections. These results underscore the value of WGS surveillance and ML of the EHR for enhancing outbreak detection in hospitals and preventing serious infections.
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Affiliation(s)
- Alexander J Sundermann
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh.,Division of Infectious Diseases, University of Pittsburgh School of Medicine
| | - Jieshi Chen
- Anton Laboratory, Carnegie Mellon University
| | | | - Melissa I Saul
- Department of Medicine, University of Pittsburgh School of Medicine
| | - Kathleen A Shutt
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh.,Division of Infectious Diseases, University of Pittsburgh School of Medicine
| | - Marissa P Griffith
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh.,Division of Infectious Diseases, University of Pittsburgh School of Medicine
| | - Mustapha M Mustapha
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh.,Division of Infectious Diseases, University of Pittsburgh School of Medicine
| | - Chinelo Ezeonwuka
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh.,Division of Infectious Diseases, University of Pittsburgh School of Medicine
| | - Kady Waggle
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh.,Division of Infectious Diseases, University of Pittsburgh School of Medicine
| | - Vatsala Srinivasa
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh.,Division of Infectious Diseases, University of Pittsburgh School of Medicine
| | - Praveen Kumar
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh
| | | | - Ashley M Ayres
- Department of Infection Prevention and Control, University of Pittsburgh Medical Center
| | - Graham M Snyder
- Division of Infectious Diseases, University of Pittsburgh School of Medicine.,Department of Infection Prevention and Control, University of Pittsburgh Medical Center
| | - Vaughn S Cooper
- Department of Microbiology and Molecular Genetics, and Center for Evolutionary Biology and Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Daria Van Tyne
- Division of Infectious Diseases, University of Pittsburgh School of Medicine
| | - Jane W Marsh
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh.,Division of Infectious Diseases, University of Pittsburgh School of Medicine
| | | | - Lee H Harrison
- Microbial Genomic Epidemiology Laboratory, Center for Genomic Epidemiology, University of Pittsburgh.,Division of Infectious Diseases, University of Pittsburgh School of Medicine
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Anderson A, Matsumoto M, Secrest A, Saul MI, Ho J, Ferris LK. Cost of Treatment of Benign and Premalignant Lesions During Skin Cancer Screening. JAMA Dermatol 2021; 157:876-879. [PMID: 34106213 DOI: 10.1001/jamadermatol.2021.1953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alyce Anderson
- Department of Dermatology, Northwestern University, Chicago, Illinois
| | - Martha Matsumoto
- Department of Dermatology, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - Aaron Secrest
- Department of Dermatology, University of Utah, Salt Lake City
| | - Melissa I Saul
- Department of Medicine, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - Jonhan Ho
- Department of Dermatology, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - Laura K Ferris
- Department of Dermatology, University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
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Sundermann AJ, Babiker A, Marsh JW, Shutt KA, Mustapha MM, Pasculle AW, Ezeonwuka C, Saul MI, Pacey MP, Van Tyne D, Ayres AM, Cooper VS, Snyder GM, Harrison LH. Outbreak of Vancomycin-resistant Enterococcus faecium in Interventional Radiology: Detection Through Whole-genome Sequencing-based Surveillance. Clin Infect Dis 2021; 70:2336-2343. [PMID: 31312842 DOI: 10.1093/cid/ciz666] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [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: 04/23/2019] [Accepted: 07/15/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Vancomycin-resistant enterococci (VRE) are a major cause of hospital-acquired infections. The risk of infection from interventional radiology (IR) procedures is not well documented. Whole-genome sequencing (WGS) surveillance of clinical bacterial isolates among hospitalized patients can identify previously unrecognized outbreaks. METHODS We analyzed WGS surveillance data from November 2016 to November 2017 for evidence of VRE transmission. A previously unrecognized cluster of 10 genetically related VRE (Enterococcus faecium) infections was discovered. Electronic health record review identified IR procedures as a potential source. An outbreak investigation was conducted. RESULTS Of the 10 outbreak patients, 9 had undergone an IR procedure with intravenous (IV) contrast ≤22 days before infection. In a matched case-control study, preceding IR procedure and IR procedure with contrast were associated with VRE infection (matched odds ratio [MOR], 16.72; 95% confidence interval [CI], 2.01 to 138.73; P = .009 and MOR, 39.35; 95% CI, 7.85 to infinity; P < .001, respectively). Investigation of IR practices and review of the manufacturer's training video revealed sterility breaches in contrast preparation. Our investigation also supported possible transmission from an IR technician. Infection prevention interventions were implemented, and no further IR-associated VRE transmissions have been observed. CONCLUSIONS A prolonged outbreak of VRE infections related to IR procedures with IV contrast resulted from nonsterile preparation of injectable contrast. The fact that our VRE outbreak was discovered through WGS surveillance and the manufacturer's training video that demonstrated nonsterile technique raise the possibility that infections following invasive IR procedures may be more common than previously recognized.
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Affiliation(s)
- Alexander J Sundermann
- Microbial Genomic Epidemiology Laboratory, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pennsylvania.,Department of Infection Control and Hospital Epidemiology, University of Pittsburgh Medical Center, Pennsylvania
| | - Ahmed Babiker
- Microbial Genomic Epidemiology Laboratory, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pennsylvania.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pennsylvania
| | - Jane W Marsh
- Microbial Genomic Epidemiology Laboratory, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pennsylvania.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pennsylvania
| | - Kathleen A Shutt
- Microbial Genomic Epidemiology Laboratory, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pennsylvania.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pennsylvania
| | - Mustapha M Mustapha
- Microbial Genomic Epidemiology Laboratory, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pennsylvania.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pennsylvania
| | | | - Chinelo Ezeonwuka
- Microbial Genomic Epidemiology Laboratory, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pennsylvania.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pennsylvania
| | - Melissa I Saul
- Microbial Genomic Epidemiology Laboratory, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pennsylvania
| | - Marissa P Pacey
- Microbial Genomic Epidemiology Laboratory, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pennsylvania.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pennsylvania
| | - Daria Van Tyne
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pennsylvania
| | - Ashley M Ayres
- Department of Infection Control and Hospital Epidemiology, University of Pittsburgh Medical Center, Pennsylvania
| | - Vaughn S Cooper
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pennsylvania
| | - Graham M Snyder
- Department of Infection Control and Hospital Epidemiology, University of Pittsburgh Medical Center, Pennsylvania.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pennsylvania
| | - Lee H Harrison
- Microbial Genomic Epidemiology Laboratory, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pennsylvania.,Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pennsylvania
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Sun R, Burke LE, Korytkowski MT, Saul MI, Li D, Sereika SM. A longitudinal examination of patient portal use on glycemic control among patients with uncontrolled type 2 diabetes. Diabetes Res Clin Pract 2020; 170:108483. [PMID: 33038473 DOI: 10.1016/j.diabres.2020.108483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 08/23/2020] [Accepted: 09/25/2020] [Indexed: 01/22/2023]
Abstract
AIM This study examined glycemia level over a 2-year period between portal users and non-users. METHODS This retrospective cohort study used data from electronic health records (EHRs) of a large academic medical center and its ancillary patient portal. A total of 15,528 patients with uncontrolled type 2 diabetes mellitus (T2DM) were included. Using propensity score matching (PSM), portal users and non-users were balanced on demographic and clinical characteristics. Mixed-effects polynomial regression modeling was employed to evaluate the HbA1c change over time between groups. RESULTS The patient sample was 85.9% (13,333) white and 52.5% (7375) male. On average, patients were 62.8 (SD, 11.7) years old and with obesity (mean BMI: 34.2 ± 7.2 kg/m2) with uncontrolled T2DM (initial HbA1c: 8.5 ± 1.5%). After PSM, portal users (n = 4924) and non-users (n = 4924) were matched on all variables except for the insurance. The mixed-effects modeling showed a nonlinear decrease of HbA1c in both groups over time. A significant interaction was observed with a greater decline, followed by a smaller rise of HbA1c in portal users than non-users. CONCLUSIONS The use of the patient portal was significantly associated with a lower HbA1c. This finding supports patient portals as a promising tool for improving clinical outcomes in patients with uncontrolled T2DM.
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Affiliation(s)
- Ran Sun
- Department of Health & Community Systems, University of Pittsburgh School of Nursing, 3500 Victoria St, Pittsburgh, PA 15213, USA.
| | - Lora E Burke
- Department of Health & Community Systems, University of Pittsburgh School of Nursing, 3500 Victoria St, Pittsburgh, PA 15213, USA
| | - Mary T Korytkowski
- Department of Medicine, University of Pittsburgh School of Medicine, 3550 Terrace St, Pittsburgh, PA 15213, USA
| | - Melissa I Saul
- University of Pittsburgh School of Health and Rehabilitation Sciences, 3600 Atwood St, Pittsburgh, PA 15260, USA
| | - Dan Li
- Department of Health & Community Systems, University of Pittsburgh School of Nursing, 3500 Victoria St, Pittsburgh, PA 15213, USA
| | - Susan M Sereika
- Department of Health & Community Systems, University of Pittsburgh School of Nursing, 3500 Victoria St, Pittsburgh, PA 15213, USA
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7
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Evans DR, Griffith MP, Sundermann AJ, Shutt KA, Saul MI, Mustapha MM, Marsh JW, Cooper VS, Harrison LH, Van Tyne D. Systematic detection of horizontal gene transfer across genera among multidrug-resistant bacteria in a single hospital. eLife 2020; 9:53886. [PMID: 32285801 PMCID: PMC7156236 DOI: 10.7554/elife.53886] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 03/14/2020] [Indexed: 12/16/2022] Open
Abstract
Multidrug-resistant bacteria pose a serious health threat, especially in hospitals. Horizontal gene transfer (HGT) of mobile genetic elements (MGEs) facilitates the spread of antibiotic resistance, virulence, and environmental persistence genes between nosocomial pathogens. We screened the genomes of 2173 bacterial isolates from healthcare-associated infections from a single hospital over 18 months, and identified identical nucleotide regions in bacteria belonging to distinct genera. To further resolve these shared sequences, we performed long-read sequencing on a subset of isolates and generated highly contiguous genomes. We then tracked the appearance of ten different plasmids in all 2173 genomes, and found evidence of plasmid transfer independent from bacterial transmission. Finally, we identified two instances of likely plasmid transfer within individual patients, including one plasmid that likely transferred to a second patient. This work expands our understanding of HGT in healthcare settings, and can inform efforts to limit the spread of drug-resistant pathogens in hospitals.
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Affiliation(s)
- Daniel R Evans
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, United States.,Department of Infectious Diseases and Microbiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, United States
| | - Marissa P Griffith
- Microbial Genomic Epidemiology Laboratory, Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, United States
| | - Alexander J Sundermann
- Microbial Genomic Epidemiology Laboratory, Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, United States
| | - Kathleen A Shutt
- Microbial Genomic Epidemiology Laboratory, Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, United States
| | - Melissa I Saul
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, United States
| | - Mustapha M Mustapha
- Microbial Genomic Epidemiology Laboratory, Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, United States
| | - Jane W Marsh
- Microbial Genomic Epidemiology Laboratory, Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, United States
| | - Vaughn S Cooper
- Department of Microbiology and Molecular Genetics, and Center for Evolutionary Biology and Medicine, University of Pittsburgh, Pittsburgh, United States
| | - Lee H Harrison
- Microbial Genomic Epidemiology Laboratory, Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, United States
| | - Daria Van Tyne
- Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, United States
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8
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Abstract
Background: Patient portals empower patients by providing access to their health information and facilitating communication with care providers. This study aimed to examine the usage patterns of a patient portal offered as part of an electronic health record and to identify predictors of portal use among patients with type 2 diabetes (T2DM). Methods: A 2-year retrospective cohort study was performed using outpatient data from the health care system and its patient portal. Demographic and clinical data from 38,399 T2DM patients were analyzed. Descriptive statistics were used to summarize portal usage patterns. Binary logistic regression was employed to examine predictors and two-way interactions associated with portal use. Results: Almost one-third of patients (n = 12,615; 32.9%, 95% confidence interval: [32.38%-33.32%]) had used the portal for a mean 2.5 ± 1.9 years before the study period. Portal use was higher on weekdays than on weekends (P < 0.001). An increase in portal use was observed in response to e-mail reminders. A nonlinear relationship between age and portal use was observed and depended on several other predictors (P's < 0.05). Patients living in more rural areas with low income were at lower odds to use the portal (P = 0.021), and this finding also applied to nonwhites with low income (P < 0.001). More chronic conditions and a higher initial glycated hemoglobin value were associated with portal use (P = 0.014). Conclusions: The patient portal usage remained relatively stable over the 2-year period. A combination of factors was associated with an individual's patient portal use. Patient engagement in portal use can be facilitated through a proactive approach by health care providers.
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Affiliation(s)
- Ran Sun
- Department of Health & Community Systems, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lora E Burke
- Department of Health & Community Systems, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melissa I Saul
- Department of Health Information Management, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mary T Korytkowski
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dan Li
- Department of Health & Community Systems, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Susan M Sereika
- Department of Health & Community Systems, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
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9
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Miller JK, Chen J, Sundermann A, Marsh JW, Saul MI, Shutt KA, Pacey M, Mustapha MM, Harrison LH, Dubrawski A. Statistical outbreak detection by joining medical records and pathogen similarity. J Biomed Inform 2019; 91:103126. [PMID: 30771483 PMCID: PMC6424617 DOI: 10.1016/j.jbi.2019.103126] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 01/05/2019] [Accepted: 02/06/2019] [Indexed: 01/08/2023]
Abstract
We present a statistical inference model for the detection and characterization of outbreaks of hospital associated infection. The approach combines patient exposures, determined from electronic medical records, and pathogen similarity, determined by whole-genome sequencing, to simultaneously identify probable outbreaks and their root-causes. We show how our model can be used to target isolates for whole-genome sequencing, improving outbreak detection and characterization even without comprehensive sequencing. Additionally, we demonstrate how to learn model parameters from reference data of known outbreaks. We demonstrate model performance using semi-synthetic experiments.
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Affiliation(s)
- James K Miller
- Auton Lab, Carnegie Mellon University, Pittsburgh, PA, United States.
| | - Jieshi Chen
- Auton Lab, Carnegie Mellon University, Pittsburgh, PA, United States
| | - Alexander Sundermann
- Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, PA, United States; Department of Infection Control and Hospital Epidemiology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Jane W Marsh
- Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, PA, United States
| | - Melissa I Saul
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Kathleen A Shutt
- Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, PA, United States
| | - Marissa Pacey
- Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, PA, United States
| | - Mustapha M Mustapha
- Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, PA, United States
| | - Lee H Harrison
- Infectious Diseases Epidemiology Research Unit, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, PA, United States
| | - Artur Dubrawski
- Auton Lab, Carnegie Mellon University, Pittsburgh, PA, United States
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10
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Genuardi MV, Ogilvie RP, Saand AR, DeSensi RS, Saul MI, Magnani JW, Patel SR. Association of Short Sleep Duration and Atrial Fibrillation. Chest 2019; 156:544-552. [PMID: 30825445 DOI: 10.1016/j.chest.2019.01.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 12/18/2018] [Accepted: 01/31/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Short sleep may be a risk factor for atrial fibrillation. However, previous investigations have been limited by lack of objective sleep measurement and small sample size. We sought to determine the association between objectively measured sleep duration and atrial fibrillation. METHODS All 31,079 adult patients undergoing diagnostic polysomnography from 1999 to 2015 at multiple sites within a large hospital network were identified from electronic medical records. Prevalent atrial fibrillation was identified by continuous ECG during polysomnography. Incident atrial fibrillation was identified by diagnostic codes and 12-lead ECGs. Logistic regression and Cox proportional hazards modeling were used to examine the association of sleep duration and atrial fibrillation prevalence and incidence, respectively, adjusting for age, sex, BMI, hypertension, coronary artery disease, cerebrovascular disease, peripheral vascular disease, heart failure, and sleep apnea severity. RESULTS We identified 404 cases of prevalent atrial fibrillation among 30,061 individuals (mean age ± SD, 51.0 ± 14.5 years; 51.6% women) undergoing polysomnography. After adjustment, each 1-h reduction in sleep duration was associated with a 1.17-fold (95% CI, 1.11-1.30) increased risk of prevalent atrial fibrillation. Among 27,589 patients without atrial fibrillation at baseline, we identified 1,820 cases of incident atrial fibrillation over 4.6 years median follow-up. After adjustment, each 1-h reduction in sleep duration was associated with a 1.09-fold (95% CI, 1.05-1.13) increased risk for incident atrial fibrillation. CONCLUSIONS Short sleep duration is independently associated with prevalent and incident atrial fibrillation. Further research is needed to determine whether interventions to extend sleep can lower atrial fibrillation risk.
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Affiliation(s)
- Michael V Genuardi
- Division of Cardiology, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA; Center for Sleep and Cardiovascular Outcomes Research, Department of Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Rachel P Ogilvie
- Center for Sleep and Cardiovascular Outcomes Research, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA
| | - Aisha Rasool Saand
- Center for Sleep and Cardiovascular Outcomes Research, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Division of Pulmonary, Allergy, and Critical Care Medicine, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA
| | - Rebecca S DeSensi
- Center for Sleep and Cardiovascular Outcomes Research, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Melissa I Saul
- Center for Sleep and Cardiovascular Outcomes Research, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Jared W Magnani
- Division of Cardiology, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA; Center for Sleep and Cardiovascular Outcomes Research, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Sanjay R Patel
- Center for Sleep and Cardiovascular Outcomes Research, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Division of Pulmonary, Allergy, and Critical Care Medicine, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA
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11
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Zou RH, Nouraie M, Chen X, Saul MI, Kaminski N, Gibson KF, Kass DJ, Lindell KO. Assessing Patterns of Palliative Care Referral and Location of Death in Patients with Idiopathic Pulmonary Fibrosis: A Sixteen-Year Single-Center Retrospective Cohort Study. J Palliat Med 2019; 22:538-544. [PMID: 30615545 DOI: 10.1089/jpm.2018.0400] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 01/21/2023] Open
Abstract
Background: Idiopathic pulmonary fibrosis (IPF) is a progressive and fatal lung disease with an unpredictable course and a median survival of three to four years. This timeline challenges providers to approach diagnosis, oxygen therapy, rehabilitation, transplantation, and end-of-life discussions in limited encounters. There is currently no widely accepted guideline for determining when IPF patients should be referred to palliative care (PC). Objective: We sought to describe the patient and clinical factors associated with PC referral, as well as its impact on mortality and location of death. We also aimed to examine temporal trends in PC referral in this population. Materials and Methods: Patient data were retrospectively extracted from the health system repository of our specialty referral center for all new IPF patients evaluated between 2000 and 2016 (n = 828). Exclusion criteria included transplant recipients and patients who did not have IPF. Results: One hundred twelve (13.5%) IPF patients received formal PC referral. Recipients were older at diagnosis (72 years vs. 69 years, p < 0.001), had higher frequency of Charlson Comorbidity Index ≥1 (55% vs. 42%, p = 0.011), resided closer to our institution (16 miles vs. 54 miles, p < 0.001), and had a higher number of total outpatient visits (7 vs. 4, p < 0.001). PC was associated with less in-hospital death (44% vs. 60%, p = 0.006) and more in-home and hospice death (56% vs. 40%, p = 0.006). Conclusions: IPF patients referred to PC were older with more severe comorbidities, resided closer to our specialty referral center, and had more outpatient follow-up. This was associated with more in-home and hospice deaths. The patient-provider relationship and frequency of follow-up visits likely play important roles in the introduction of end-of-life discussions.
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Affiliation(s)
- Richard H Zou
- 1 Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mehdi Nouraie
- 2 Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease at the University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania.,3 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xiaoping Chen
- 3 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melissa I Saul
- 1 Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Naftali Kaminski
- 4 Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Kevin F Gibson
- 2 Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease at the University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania.,3 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daniel J Kass
- 2 Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease at the University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania.,3 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kathleen O Lindell
- 2 Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease at the University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania.,3 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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12
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Sun R, Korytkowski MT, Sereika SM, Saul MI, Li D, Burke LE. Patient Portal Use in Diabetes Management: Literature Review. JMIR Diabetes 2018; 3:e11199. [PMID: 30401665 PMCID: PMC6246970 DOI: 10.2196/11199] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 10/08/2018] [Accepted: 10/08/2018] [Indexed: 01/22/2023] Open
Abstract
Background Health information technology tools (eg, patient portals) have the potential to promote engagement, improve patient-provider communication, and enhance clinical outcomes in the management of chronic disorders such as diabetes mellitus (DM). Objectives The aim of this study was to report the findings of a literature review of studies reporting patient portal use by individuals with type 1 or type 2 DM. We examined the association of the patient portal use with DM-related outcomes and identified opportunities for further improvement in DM management. Methods Electronic literature search was conducted through PubMed and PsycINFO databases. The keywords used were “patient portal*,” “web portal,” “personal health record,” and “diabetes.” Inclusion criteria included (1) published in the past 10 years, (2) used English language, (3) restricted to age ≥18 years, and (4) available in full text. Results This review included 6 randomized controlled trials, 16 observational, 4 qualitative, and 4 mixed-methods studies. The results of these studies revealed that 29% to 46% of patients with DM have registered for a portal account, with 27% to 76% of these patients actually using the portal at least once during the study period. Portal use was associated with the following factors: personal traits (eg, sociodemographics, clinical characteristics, health literacy), technology (eg, functionality, usability), and provider engagement. Inconsistent findings were observed regarding the association of patient portal use with DM-related clinical and psychological outcomes. Conclusions Barriers to use of the patient portal were identified among patients and providers. Future investigations into strategies that engage both physicians and patients in use of a patient portal to improve patient outcomes are needed.
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Affiliation(s)
- Ran Sun
- Department of Health & Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, PA, United States
| | - Mary T Korytkowski
- Division of Endocrinology and Metabolism, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Susan M Sereika
- Department of Health & Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, PA, United States
| | - Melissa I Saul
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Dan Li
- Department of Health & Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, PA, United States
| | - Lora E Burke
- Department of Health & Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, PA, United States
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13
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Anderson AM, Matsumoto M, Saul MI, Secrest AM, Ferris LK. Accuracy of Skin Cancer Diagnosis by Physician Assistants Compared With Dermatologists in a Large Health Care System. JAMA Dermatol 2018; 154:569-573. [PMID: 29710082 PMCID: PMC6128496 DOI: 10.1001/jamadermatol.2018.0212] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/25/2018] [Indexed: 11/14/2022]
Abstract
Importance Physician assistants (PAs) are increasingly used in dermatology practices to diagnose skin cancers, although, to date, their diagnostic accuracy compared with board-certified dermatologists has not been well studied. Objective To compare diagnostic accuracy for skin cancer of PAs with that of dermatologists. Design, Setting, and Participants Medical record review of 33 647 skin cancer screening examinations in 20 270 unique patients who underwent screening at University of Pittsburgh Medical Center-affiliated dermatology offices from January 1, 2011, to December 31, 2015. International Classification of Diseases, Ninth Revision code V76.43 and International Classification of Diseases and Related Health Problems, Tenth Revision code Z12.83 were used to identify pathology reports from skin cancer screening examinations by dermatologists and PAs. Exposure Examination performed by a PA or dermatologist. Main Outcomes and Measures Number needed to biopsy (NNB) to diagnose skin cancer (nonmelanoma, invasive melanoma, or in situ melanoma). Results Of 20 270 unique patients, 12 722 (62.8%) were female, mean (SD) age at the first visit was 52.7 (17.4) years, and 19 515 patients (96.3%) self-reported their race/ethnicity as non-Hispanic white. To diagnose 1 case of skin cancer, the NNB was 3.9 for PAs and 3.3 for dermatologists (P < .001). Per diagnosed melanoma, the NNB was 39.4 for PAs and 25.4 for dermatologists (P = .007). Patients screened by a PA were significantly less likely than those screened by a dermatologist to be diagnosed with melanoma in situ (1.1% vs 1.8% of visits, P = .02), but differences were not significant for invasive melanoma (0.7% vs 0.8% of visits, P = .83) or nonmelanoma skin cancer (6.1% vs 6.1% of visits, P = .98). Conclusions and Relevance Compared with dermatologists, PAs performed more skin biopsies per case of skin cancer diagnosed and diagnosed fewer melanomas in situ, suggesting that the diagnostic accuracy of PAs may be lower than that of dermatologists. Although the availability of PAs may help increase access to care and reduce waiting times for appointments, these findings have important implications for the training, appropriate scope of practice, and supervision of PAs and other nonphysician practitioners in dermatology.
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Affiliation(s)
- Alyce M. Anderson
- Medical student, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Martha Matsumoto
- Department of Dermatology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melissa I. Saul
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Aaron M. Secrest
- Department of Dermatology, University of Utah, Salt Lake City
- Department of Population Health Sciences, University of Utah, Salt Lake City
| | - Laura K. Ferris
- Department of Dermatology, University of Pittsburgh, Pittsburgh, Pennsylvania
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14
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Matsumoto M, Secrest A, Anderson A, Saul MI, Ho J, Kirkwood JM, Ferris LK. Estimating the cost of skin cancer detection by dermatology providers in a large health care system. J Am Acad Dermatol 2018; 78:701-709.e1. [PMID: 29180093 PMCID: PMC5963718 DOI: 10.1016/j.jaad.2017.11.033] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 11/06/2017] [Accepted: 11/12/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Data on the cost and efficiency of skin cancer detection through total body skin examination are scarce. OBJECTIVE To determine the number needed to screen (NNS) and biopsy (NNB) and cost per skin cancer diagnosed in a large dermatology practice in patients undergoing total body skin examination. METHODS This is a retrospective observational study. RESULTS During 2011-2015, a total of 20,270 patients underwent 33,647 visits for total body skin examination; 9956 lesion biopsies were performed yielding 2763 skin cancers, including 155 melanomas. The NNS to detect 1 skin cancer was 12.2 (95% confidence interval [CI] 11.7-12.6) and 1 melanoma was 215 (95% CI 185-252). The NNB to detect 1 skin cancer was 3.0 (95% CI 2.9-3.1) and 1 melanoma was 27.8 (95% CI 23.3-33.3). In a multivariable model for NNS, age and personal history of melanoma were significant factors. Age switched from a protective factor to a risk factor at 51 years of age. The estimated cost per melanoma detected was $32,594 (95% CI $27,326-$37,475). LIMITATIONS Data are from a single health care system and based on physician coding. CONCLUSION Melanoma detection through total body skin examination is most efficient in patients ≥50 years of age and those with a personal history of melanoma. Our findings will be helpful in modeling the cost effectiveness of melanoma screening by dermatologists.
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Affiliation(s)
- Martha Matsumoto
- University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - Aaron Secrest
- Department of Dermatology, University of Utah, Salt Lake City, Utah
| | - Alyce Anderson
- University of Pittsburgh, School of Medicine, Pittsburgh, Pennsylvania
| | - Melissa I Saul
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jonhan Ho
- Department of Dermatology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John M Kirkwood
- Department of Medicine, Division of Medical Oncology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Laura K Ferris
- Department of Dermatology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
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15
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Altawalbeh SM, Saul MI, Seybert AL, Thorpe JM, Kane-Gill SL. Intensive care unit drug costs in the context of total hospital drug expenditures with suggestions for targeted cost containment efforts. J Crit Care 2017; 44:77-81. [PMID: 29073536 DOI: 10.1016/j.jcrc.2017.10.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 07/17/2017] [Revised: 10/13/2017] [Accepted: 10/18/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess costs of intensive care unit (ICU) related pharmacotherapy relative to hospital drug expenditures, and to identify potential targets for cost-effectiveness investigations. We offer the unique advantage of comparing ICU drug costs with previously published data a decade earlier to describe changes over time. MATERIALS AND METHODS Financial transactions for all ICU patients during fiscal years (FY) 2009-2012 were retrieved from the hospital's data repository. ICU drug costs were evaluated for each FY. ICU departments' charges were also retrieved and calculated as percentages of total ICU charges. RESULTS Albumin, prismasate (dialysate), voriconazole, factor VII and alteplase denoted the highest percentages of ICU drug costs. ICU drug costs contributed to an average of 31% (SD 1.0%) of the hospital's total drug costs. ICU drug costs per patient day increased by 5.8% yearly versus 7.8% yearly for non-ICU drugs. This rate was higher for ICU drugs costs at 12% a decade previous. Pharmacy charges contributed to 17.7% of the total ICU charges. CONCLUSIONS Growth rates of costs per year have declined but still drug expenditures in the ICU are consistently a significant driver in this resource intensive environment with a high impact on hospital drug expenditures.
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Affiliation(s)
- Shoroq M Altawalbeh
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States; Department of Clinical Pharmacy, School of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Melissa I Saul
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Amy L Seybert
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States; UPMC, Department of Pharmacy, Pittsburgh, PA, United States
| | - Joshua M Thorpe
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States; UPMC, Department of Pharmacy, Pittsburgh, PA, United States.
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16
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Ferris LK, Saul MI, Lin Y, Ding F, Weinstock MA, Geller AC, Yuan JM, Neuren E, Maddukuri S, Solano FX, Kirkwood JM. A Large Skin Cancer Screening Quality Initiative: Description and First-Year Outcomes. JAMA Oncol 2017; 3:1112-1115. [PMID: 28241191 DOI: 10.1001/jamaoncol.2016.6779] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The lack of prospective randomized clinical trials demonstrating that full-body skin examination (FBSE) reduces melanoma morbidity or mortality has prompted an "I" rating from the United States Preventive Services Task Force for population-based skin cancer screening. More data on these screening programs are needed. Objectives To describe a skin cancer screening quality initiative in a large health care system and to determine if the intervention was associated with screening of a demographically higher-risk population than previous screening programs and if melanoma incidence and thickness differed in screened vs unscreened patients. Design, Setting, and Participants This observational evaluation of a prospectively implemented quality initiative was conducted in a large health care system in western Pennsylvania (University of Pittsburgh Medical Center, UPMC) among adults seen in an office visit by a UPMC-employed primary care physician (PCP) in 2014. Interventions Implementation of a campaign promoting annual skin cancer screening by FBSE, including training of PCPs, promotion of the initiative to physicians and patients, and modification of the electronic health record (EHR) to include FBSE as a recommended preventive service for patients 35 years or older. Main Outcomes and Measures Characteristics of screened and unscreened patients and melanomas detected among them. Results Of 333 735 adult patients seen in an office visit by PCPs in 2014, 53 196 patients (15.9% of the screen-eligible population) received an FBSE, and 280 539 did not. Screened patients were slightly older (median age, 60 vs 57 years; P < .001) but did not differ significantly by sex (43.2% vs 43.1% men; P = .49) from the unscreened population. Fifty melanomas were diagnosed in screened patients and 104 melanomas were diagnosed in unscreened patients. Screened patients were more likely than unscreened patients to be diagnosed with melanoma (adjusted risk ratio [RR], 2.4; 95% CI, 1.7-3.4; P < .001) and to have a thinner invasive melanoma (median thickness, 0.37 mm vs 0.65 mm; P < .001). The incidence of melanoma lesions 1 mm or thicker was similar in screened vs unscreened patients (adjusted RR, 0.7; 95% CI, 02.-2.2; P = .52). Conclusions and Relevance Large-scale screening for melanoma within a United States health care system is feasible and can result in increased detection of thinner melanomas. This intervention also resulted in screening of a higher proportion of men and an older patient population than previous screening interventions in which younger individuals and women predominated.
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Affiliation(s)
| | | | - Yan Lin
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Fei Ding
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Martin A Weinstock
- Providence VA Medical Center, Brown University, Providence, Rhode Island
| | - Alan C Geller
- Harvard Chan School of Public Health, Boston, Massachusetts
| | | | - Erica Neuren
- University of Pittsburgh, Pittsburgh, Pennsylvania.,Hofstra University School of Medicine, East Garden City, New York
| | - Spandana Maddukuri
- University of Pittsburgh, Pittsburgh, Pennsylvania.,Rutgers University School of Medicine, Newark, New Jersey
| | - Francis X Solano
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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17
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Umapathy C, Raina A, Saligram S, Tang G, Papachristou GI, Rabinovitz M, Chennat J, Zeh H, Zureikat AH, Hogg ME, Lee KK, Saul MI, Whitcomb DC, Slivka A, Yadav D. Natural History After Acute Necrotizing Pancreatitis: a Large US Tertiary Care Experience. J Gastrointest Surg 2016; 20:1844-1853. [PMID: 27619808 DOI: 10.1007/s11605-016-3264-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [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: 05/16/2016] [Accepted: 08/24/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Most studies of acute necrotizing pancreatitis (ANP) focus on short-term outcomes. We evaluated long-term survival and outcomes following ANP. METHODS Patients treated for ANP at the University of Pittsburgh Medical Center from 2001 to 2008 were studied. Data on presentation and course during initial hospitalization and follow-up (median 34 months) was extracted. RESULTS Mean age of patients (n = 167) was 53 ± 16 years; 70 % were male, 94 % white, 71 % transfers, 52 % biliary etiology, and 78 % had first-attack of acute pancreatitis. Majority had severe disease with high Acute Physiology and Chronic Health Evaluation II (APACHE-II) score (median 11), length of stay (median 26 days), intensive care unit (ICU) admission (87 %), presence of systemic inflammatory response syndrome (SIRS) (90 %), persistent organ failure (60 %), and infected necrosis (50 %). Intervention was needed in 74 %. Eighteen (10.8 %) patients died during index hospitalization, 9 (5.4 %) during the first year, and 13 (7.8 %) after 1 year. Median survival was significantly shorter when compared with age- and sex-matched US general population (9.1 vs. 26.1 years, p < 0.001). Increasing age (HR 1.05), persistent organ failure (HR 4.5), and >50 % necrosis (HR 3.8) were independent predictors of death at 1 year. In eligible patients, new-onset diabetes, oral pancreatic enzyme replacement therapy, and disability were noted in 45, 25, and 53 %, respectively. CONCLUSION ANP significantly impacts long-term survival. A high proportion of patients develop functional derangement and disability following ANP.
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Affiliation(s)
| | - Amit Raina
- Division of Gastroenterology, Hepatology, and Nutrition, East Carolina University, Greenville, NC, USA
| | - Shreyas Saligram
- Division of Gastroenterology, Hepatology, and Motility, University of Kansas Medical Center, Kansas City, KS, USA
| | - Gong Tang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Georgios I Papachristou
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA
| | - Mordechai Rabinovitz
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA
| | - Jennifer Chennat
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA
| | - Herbert Zeh
- Division of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Amer H Zureikat
- Division of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melissa E Hogg
- Division of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kenneth K Lee
- Division of Surgical Oncology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Melissa I Saul
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - David C Whitcomb
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA
| | - Adam Slivka
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA
| | - Dhiraj Yadav
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, M-2, C-Wing, Pittsburgh, PA, 15213, USA.
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18
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Liang Z, Hoffman LA, Nouraie M, Kass DJ, Donahoe MP, Gibson KF, Saul MI, Lindell KO. Referral to Palliative Care Infrequent in Patients with Idiopathic Pulmonary Fibrosis Admitted to an Intensive Care Unit. J Palliat Med 2016; 20:134-140. [PMID: 27754815 DOI: 10.1089/jpm.2016.0258] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [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: 01/23/2023] Open
Abstract
BACKGROUND Palliative care has been recommended as a means to assist patients with idiopathic pulmonary fibrosis (IPF) in managing symptom burden and advanced care planning. Timing of referral is important because although most patients display a gradually progressive course, a minority experience acute deterioration, an outcome associated with high mortality. AIM To describe characteristics of IPF patients referred to a specialty lung disease center over a 10-year period who experienced acute deterioration and subsequent intensive care unit (ICU) admission, including frequency and timing of referral to palliative care. DESIGN Retrospective review. SETTING/PARTICIPANTS We identified 106 patients admitted to the ICU with acute deterioration due to a respiratory or nonrespiratory cause. Variables examined included demographics, date of first center visit, forced vital capacity, diffusing capacity of the lung for carbon monoxide (DLCO), and palliative care referral. RESULTS ICU admission occurred early (median 9.5 months) and, for 34%, within four months of their first center visit. For nearly one-half of these patients, ICU admission occurred before their third clinic visit. Only 4 (3.8%) patients received a palliative care referral before ICU admission. The majority (77%) died during ICU admission. With exception of the relationship between DLCO% predicted at first visit and time to ICU admission (r = 0.32, p = 0.005), no variables identified those most likely to experience acute deterioration. CONCLUSION Due to high mortality associated with ICU admission, patients and families should be informed about palliative care early following diagnosis of IPF.
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Affiliation(s)
- Zhan Liang
- 1 University of South Florida College of Nursing , Tampa, Florida
| | - Leslie A Hoffman
- 2 University of Pittsburgh School of Nursing , Pittsburgh, Pennsylvania
| | - Mehdi Nouraie
- 3 Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania.,4 The University of Pittsburgh Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease at UPMC , Pittsburgh, Pennsylvania
| | - Daniel J Kass
- 3 Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania.,4 The University of Pittsburgh Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease at UPMC , Pittsburgh, Pennsylvania
| | - Michael P Donahoe
- 3 Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania.,5 Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Kevin F Gibson
- 3 Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania.,4 The University of Pittsburgh Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease at UPMC , Pittsburgh, Pennsylvania
| | - Melissa I Saul
- 5 Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Kathleen O Lindell
- 3 Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania.,4 The University of Pittsburgh Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease at UPMC , Pittsburgh, Pennsylvania
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Kane-Gill SL, MacLasco AM, Saul MI, Politz Smith TR, Kloet MA, Kim C, Anthes AM, Smithburger PL, Seybert AL. Use of Text Searching for Trigger Words in Medical Records to Identify Adverse Drug Reactions within an Intensive Care Unit Discharge Summary. Appl Clin Inform 2016; 7:660-71. [PMID: 27453336 DOI: 10.4338/aci-2016-03-ra-0031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [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: 03/14/2016] [Accepted: 06/08/2016] [Indexed: 01/29/2023] Open
Abstract
PURPOSE To evaluate the performance of using trigger words (e.g. clues to an adverse drug reaction) in unstructured, narrative text to detect adverse drug reactions (ADRs) and compare the use of these trigger words to a targeted chart review for ADR detection within the intensive care unit (ICU) discharge summary note. MATERIALS A retrospective medical record review was conducted. Evaluation of ADRs occurred in two phases - targeted chart review of the ICU discharge summary notes in Phase 1 and targeted chart review using specific words and phrases as triggers for ADRs in Phase 2. RESULTS Four hundred ADRs were documented in 223 patients for Phase 1. For Phase 2, there were 219 ADRs identified in 120 patients. 138 real or accurate ADRs were identified from Phase 1 and 47 duplicate events. 34 ADRs from Phase 2 were not identified in Phase 1. Fifteen of the ADRs were inaccurately presumed in Phase 2. Fifty-eight of 127 text triggers identified at least one ADR. Low and moderate frequency trigger words were more likely to have PPVs > 5%. CONCLUSIONS Targeted chart review using specific words and phrases as triggers for ADRs is a reasonable approach to identify ADRs and may save time compared to other methods after further refinement leads to a more accurately performing trigger word list.
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Affiliation(s)
- Sandra L Kane-Gill
- Sandra L. Kane-Gill, PharmD, MSc, FCCM, FCCP, University of Pittsburgh, School of Pharmacy, 918 Salk Hall, 3501 Terrace St., Pittsburgh, PA 15261, , Phone: 412-624-5150
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Weinstock MA, Ferris LK, Saul MI, Geller AC, Risica PM, Siegel JA, Solano FX, Kirkwood JM. Downstream consequences of melanoma screening in a community practice setting: First results. Cancer 2016; 122:3152-3156. [PMID: 27391802 DOI: 10.1002/cncr.30177] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [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: 10/26/2015] [Revised: 02/10/2016] [Accepted: 02/12/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND Population-based screening for the early detection of melanoma holds great promise for reducing melanoma mortality, but evidence is needed to determine whether benefits outweigh risks. Skin surgeries and dermatology visits after screening were assessed to indicate potential physical, psychological, and financial consequences. METHODS Targeted primary care providers (PCPs) at the University of Pittsburgh Medical Center were trained to detect early melanoma using the INFORMED (INternet course FOR Melanoma Early Detection) program. The authors analyzed aggregated administrative data describing 3 groups of patients aged ≥35 years who had received an annual physical examination by PCPs: group A1 included patients of PCPs from the group with the highest percentage of INFORMED-trained providers, group A2 included patients of PCPs from the group with a lower percentage of INFORMED-trained providers, and group B included patients of PCPs without INFORMED training. RESULTS INFORMED-trained PCPs screened 1572 of 16,472 patients in groups A1 or A2 and none of the 56,261 patients in group B. In group A1, there was a 79% increase (95% confidence interval, 15%-138%) in melanoma diagnoses noted; no increase was observed for the other groups, and no substantial increase in skin surgeries or dermatology visits occurred in any group. CONCLUSIONS A large-scale melanoma screening using the INFORMED program was conducted in Pennsylvania. To the best of the authors' knowledge, the current study is the first analysis of downstream results and the findings indicate increased melanoma diagnoses but little impact on skin surgeries or dermatology visits. This result provides some reassurance that such efforts can be conducted without major adverse consequences, at least as measured by these parameters, and therefore should be considered for more widespread use. Cancer 2016;122:3152-6. © 2016 American Cancer Society.
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Affiliation(s)
- Martin A Weinstock
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, Rhode Island. .,Departments of Dermatology and Epidemiology, Brown University, Providence, Rhode Island.
| | - Laura K Ferris
- Department of Dermatology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Melissa I Saul
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alan C Geller
- Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts
| | - Patricia M Risica
- Department of Epidemiology, Brown University, Providence, Rhode Island
| | - Julia A Siegel
- Center for Dermatoepidemiology, Providence VA Medical Center, Providence, Rhode Island
| | - Francis X Solano
- Physician Services Division, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John M Kirkwood
- Melanoma and Skin Cancer Program, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Lindell KO, Liang Z, Hoffman LA, Rosenzweig MQ, Saul MI, Pilewski JM, Gibson KF, Kaminski N. Palliative care and location of death in decedents with idiopathic pulmonary fibrosis. Chest 2015; 147:423-429. [PMID: 25187973 DOI: 10.1378/chest.14-1127] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Palliative care, integrated early, may reduce symptom burden in patients with idiopathic pulmonary fibrosis (IPF). However, limited information exists on timing and clinical practice. The purpose of this study was to describe the time course of events prior to death in patients with IPF managed at a specialty center with a focus on location of death and timing of referral for palliative care. METHODS Data were retrospectively extracted from the health system's data repository and obituary listings. The sample included all decedents, excluding lung transplant recipients, who had their first visit to the center between 2000 and 2012. RESULTS Median survival for 404 decedents was 3 years from diagnosis and 1 year from first center visit. Of 277 decedents whose location of death could be determined, > 50% died in the hospital (57%). Only 38 (13.7%) had a formal palliative care referral and the majority (71%) was referred within 1 month of their death. Decedents who died in the academic medical center ICU were significantly younger than those who died in a community hospital ward (P = .04) or hospice (P = .001). CONCLUSIONS The majority of patients with IPF died in a hospital setting and only a minority received a formal palliative care referral. Referral to palliative care occurred late in the disease. These findings indicate the need to study adequacy of end-of-life management in IPF and promote earlier discussion and referral to palliative care.
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Affiliation(s)
- Kathleen O Lindell
- The University of Pittsburgh Dorothy P. & Richard P. Simmons Center for Interstitial Lung Disease at UPMC, School of Medicine, Pittsburgh, PA; Division of Pulmonary, Allergy, and Critical Care Medicine, School of Medicine, Pittsburgh, PA.
| | - Zhan Liang
- School of Nursing, School of Medicine, Pittsburgh, PA
| | | | | | - Melissa I Saul
- Department of Biomedical Informatics, School of Medicine, Pittsburgh, PA
| | - Joseph M Pilewski
- Division of Pulmonary, Allergy, and Critical Care Medicine, School of Medicine, Pittsburgh, PA
| | - Kevin F Gibson
- The University of Pittsburgh Dorothy P. & Richard P. Simmons Center for Interstitial Lung Disease at UPMC, School of Medicine, Pittsburgh, PA; Division of Pulmonary, Allergy, and Critical Care Medicine, School of Medicine, Pittsburgh, PA
| | - Naftali Kaminski
- Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, CT
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Dunn MA, Behari J, Rogal SS, O'Connell MR, Furlan A, Aghayev A, Gumus S, Saul MI, Bae KT. Hepatic steatosis in diabetic patients does not predict adverse liver-related or cardiovascular outcomes. Liver Int 2013; 33:1575-82. [PMID: 23944954 DOI: 10.1111/liv.12285] [Citation(s) in RCA: 18] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 07/24/2013] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Steatosis is a defining feature of nonalcoholic fatty liver disease (NAFLD). However, evidence that severity of steatosis can predict adverse outcomes in NAFLD or nonalcoholic steatohepatitis (NASH) is lacking. The aim of this study was to determine whether steatosis assessed by computed tomography (CT) imaging predicts adverse outcomes in diabetic patients at risk for NAFLD/NASH. METHODS We studied deaths, liver-related and cardiovascular adverse outcomes in a 5-year retrospective observational cohort of 2343 type 2 diabetic patients in a large care network who had noncontrast CT imaging for clinical indications. We measured steatosis by subtraction of spleen from liver attenuation, a method that showed low sensitivity (0.417) and high specificity (0.882) compared with histopathological scoring. We evaluated outcomes prediction using multivariate Cox proportional hazards modelling of steatosis both as a categorical (≥ 30%) and continuous variable. RESULTS Steatosis ≥ 30% was present in 233 (9.9%) of the cohort at baseline. Over 5 years, there were 372 total deaths, 18 liver-related and 99 cardiovascular deaths, 48 liver transplants, 51 occurrences of hepatic encephalopathy, 41 hepatocellular carcinomas, 653 myocardial infarctions, 66 strokes, 180 occurrences of angina, 735 occurrences of arrhythmia and 772 occurrences of congestive heart failure. Steatosis had no predictive value for any adverse outcome. Patients with steatosis averaged 8 years younger than those without it. Age had a strong covariate influence on occurrence of total deaths, cardiovascular deaths, myocardial infarctions, arrhythmias and congestive heart failure. CONCLUSION Although steatosis on imaging is often the abnormality that triggers diagnosis and assessment of NAFLD/NASH, it lacks predictive value for adverse clinical outcomes.
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Affiliation(s)
- Michael A Dunn
- Center for Liver Diseases, Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
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Sorbero ME, Saul MI, Liu H, Resnick NM. Are geriatricians more efficient than other physicians at managing inpatient care for elderly patients? J Am Geriatr Soc 2012; 60:869-76. [PMID: 22587852 DOI: 10.1111/j.1532-5415.2012.03934.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare outcomes and measures of efficiency for hospitalized elderly adults managed by geriatricians with those managed by other physicians. DESIGN Secondary data analysis using a system that integrates clinical and financial information for inpatient and outpatient services delivered throughout the University of Pittsburgh Medical Center (UPMC). Propensity scores were developed based on participant sociodemographic and clinical characteristics and used to match participants based on the attending physician's specialty (geriatrician, n = 701; nongeriatrician, n = 11,549). Multivariate analyses using generalized estimating equations methods were performed. SETTING Two UPMC hospitals in Pittsburgh, Pennsylvania. PARTICIPANTS Patients aged 65 and older admitted in 2002 in a medical diagnosis-related group (DRG). MEASUREMENTS Outcomes (inpatient mortality, 30-day mortality, readmission) and efficiency measures (length of stay, total costs, and surplus, which is the difference between hospital costs and payment received for an admission). RESULTS Elderly adults managed by geriatricians were significantly older (P < .001) and more likely to be male (P < .001) and had more diagnoses (P < .001). Propensity scores successfully balanced characteristics managed by the two groups. Patients of geriatricians had shorter length of stay (P < .001), lower costs per admission (P < .001), and greater surplus (P < .001) with no differences in outcomes. In multivariate analyses, there were not significant differences in outcomes, but patients of geriatricians had significantly shorter length of stay and lower costs per admission and generated more surplus for the hospitals. CONCLUSION Geriatricians were more efficient than other physicians in managing hospitalized elderly adults with medical DRGs frequently managed by geriatricians. This efficiency did not compromise patient outcomes.
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Stamm JA, McVerry BJ, Mathier MA, Donahoe MP, Saul MI, Gladwin MT. Doppler-defined pulmonary hypertension in medical intensive care unit patients: Retrospective investigation of risk factors and impact on mortality. Pulm Circ 2011; 1:95-102. [PMID: 22034595 PMCID: PMC3198625 DOI: 10.4103/2045-8932.78104] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Pulmonary hypertension (PH) is poorly characterized in the critically ill. No prior studies describe the burden of or outcomes associated with PH in a general medical intensive care unit population. We hypothesize that PH is an important comorbidity prevalent in the modern medical intensive care unit. We undertook a preliminary investigation to define the consequences of Doppler-defined PH in the critically ill. A single-center retrospective case–control study of medical intensive care patients admitted over a 1-year period was conducted. Eligible patients had an echocardiogram within 4 days of admission. PH was defined to include both pulmonary arterial and venous hypertension and required a tricuspid regurgitant jet velocity ≥3 m/sec. Cases and controls were compared for comorbidities, illness severity, diagnoses, and mortality. Multivariable regression was performed to identify clinical features associated with PH and mortality. 299 (21% of admissions) patients had an eligible echocardiogram. Patients with PH (N=126) had a higher unadjusted mortality than did controls (N=173) (37% vs. 25%, P=0.04) and PH remained significantly associated with mortality after controlling for other clinical factors (HR=1.59, 95% CI=1.03–2.44, P=0.036). Low ejection fraction (OR=2.21, 95% CI=1.19–4.11, P=0.012) and pulmonary embolism (OR=4.28, 95% CI=1.59–11.5, P=0.004) were independently associated with PH. Doppler-defined PH is associated with mortality in the critically ill. Prospective studies are needed to define the prevalence of pulmonary venous hypertension versus pulmonary arterial hypertension, and the clinical consequences of each, in a general medical intensive care unit population.
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Affiliation(s)
- Jason A Stamm
- Department of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Dedhia RC, Smith KJ, Weissfeld JL, Saul MI, Lee SC, Myers EN, Johnson JT. Cost-identification analysis of total laryngectomy: an itemized approach to hospital costs. Otolaryngol Head Neck Surg 2011; 144:220-4. [PMID: 21493420 DOI: 10.1177/0194599810393117] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To understand the contribution of intraoperative and postoperative hospital costs to total hospital costs, examine the costs associated with specific hospital services in the postoperative period, and recognize the impact of patient factors on hospital costs. STUDY DESIGN Case series with chart review. SETTING Large tertiary care teaching hospital system. SUBJECTS AND METHODS Using the Pittsburgh Head and Neck Organ-Specific Database, 119 patients were identified as having total laryngectomy with bilateral selective neck dissection and primary closure from 1999 to 2009. Cost data were obtained for 112 patients. Costs include fixed and variable costs, adjusted to 2010 US dollars using the Consumer Price Index. RESULTS Mean total hospital costs were $29,563 (range, $10,915 to $120,345). Operating room costs averaged 24% of total hospital costs, whereas room charges, respiratory therapy, laboratory, pharmacy, and radiology accounted for 38%, 14%, 8%, 7%, and 3%, respectively. Median length of stay was 9 days (range, 6-43), and median Charlson comorbidity index score was 8 (2-16). Patients with ≥1 day in the intensive care unit had significantly higher hospital costs ($46,831 vs $24,601, P < .01). The authors found no significant cost differences with stratification based on previous radiation therapy ($27,598 vs $29,915 with no prior radiation, P = .62) or hospital readmission within 30 days ($29,483 vs $29,609 without readmission, P = .97). CONCLUSION This is one of few studies in surgery and the first in otolaryngology to analyze hospital costs for a relatively standardized procedure. Further work will include cost analysis from multiple centers with investigation of global cost drivers.
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Affiliation(s)
- Raj C Dedhia
- Department of Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA.
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Kane-Gill SL, Visweswaran S, Saul MI, Wong AKI, Penrod LE, Handler SM. Computerized detection of adverse drug reactions in the medical intensive care unit. Int J Med Inform 2011; 80:570-8. [PMID: 21621453 DOI: 10.1016/j.ijmedinf.2011.04.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 02/21/2011] [Accepted: 04/22/2011] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Clinical event monitors are a type of active medication monitoring system that can use signals to alert clinicians to possible adverse drug reactions. The primary goal was to evaluate the positive predictive values of select signals used to automate the detection of ADRs in the medical intensive care unit. METHOD This is a prospective, case series of adult patients in the medical intensive care unit during a six-week period who had one of five signals presents: an elevated blood urea nitrogen, vancomycin, or quinidine concentration, or a low sodium or glucose concentration. Alerts were assessed using 3 objective published adverse drug reaction determination instruments. An event was considered an adverse drug reaction when 2 out of 3 instruments had agreement of possible, probable or definite. Positive predictive values were calculated as the proportion of alerts that occurred, divided by the number of times that alerts occurred and adverse drug reactions were confirmed. RESULTS 145 patients were eligible for evaluation. For the 48 patients (50% male) having an alert, the mean±SD age was 62±19 years. A total of 253 alerts were generated. Positive predictive values were 1.0, 0.55, 0.38 and 0.33 for vancomycin, glucose, sodium, and blood urea nitrogen, respectively. A quinidine alert was not generated during the evaluation. CONCLUSIONS Computerized clinical event monitoring systems should be considered when developing methods to detect adverse drug reactions as part of intensive care unit patient safety surveillance systems, since they can automate the detection of these events using signals that have good performance characteristics by processing commonly available laboratory and medication information.
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Affiliation(s)
- Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, School of Pharmacy, University Pittsburgh, Pittsburgh, PA 15261, United States.
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Salangsang JAM, Harrison LH, Brooks MM, Shutt KA, Saul MI, Muto CA. Patient-associated risk factors for acquisition of methicillin-resistant Staphylococcus aureus in a tertiary care hospital. Infect Control Hosp Epidemiol 2011; 31:1139-47. [PMID: 20923281 DOI: 10.1086/656595] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [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 Determining risk factors for acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in hospitals is important for defining infection-control measures that may lead to fewer hospital-acquired infections. OBJECTIVE To determine patient-associated risk factors for acquisition of MRSA in a tertiary care hospital with the goal of identifying modifiable risk factors. METHODS A retrospective matched case-control study was performed. Case patients who acquired MRSA during hospitalization and 2 matched control patients were selected among inpatients admitted to target units during the period from 2001 through 2008. The odds of exposure to potential risk factors were compared between case patients and control patients, using matched univariate conditional logistic regression. A single multivariate conditional logistic regression model identifying independent patient-specific risk factors was generated. RESULTS A total of 451 case patients and 866 control patients were analyzed. Factors positively associated with MRSA acquisition were as follows: target unit stay before index culture; primary diagnosis of respiratory disease, digestive tract disease, injury or trauma, or other diagnosis compared with cardiocirculatory disease; peripheral vascular disease; mechanical ventilation with pneumonia; ventricular shunting or ventriculostomy; and ciprofloxacin use. Factors associated with decreased risk were receipt of a solid-organ transplant and use of penicillins, cephalosporins, rifamycins, daptomycin or linezolid, and proton pump inhibitors. CONCLUSION Among the factors associated with increased risk, few are modifiable. Patients with at-risk conditions could be targeted for intensive surveillance to detect acquisition sooner. The association of MRSA acquisition with target unit exposure argues for rigorous application of hand hygiene, appropriate barriers, environmental control, and strict aseptic technique for all procedures performed on such patients. Our findings support focusing efforts to prevent MRSA transmission and restriction of ciprofloxacin use.
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Affiliation(s)
- Jo-anne M Salangsang
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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Lavsa SM, Fabian TJ, Saul MI, Corman SL, Coley KC. Influence of medications and diagnoses on fall risk in psychiatric inpatients. Am J Health Syst Pharm 2010; 67:1274-80. [DOI: 10.2146/ajhp090611] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Stacey M. Lavsa
- University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
| | - Tanya J. Fabian
- Schools of Pharmacy and Medicine, University of Pittsburgh (UP), Pittsburgh, and Director of Pharmacy Research and Pharmacy Services, Western Psychiatric Institute and Clinic, UPMC
| | | | - Shelby L. Corman
- School of Pharmacy, UP, and Clinical Specialist, Drug Information, UPMC
| | - Kim C. Coley
- University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
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Harbrecht BG, Delgado E, Tuttle RP, Cohen-Melamed MH, Saul MI, Valenta CA. Improved outcomes with routine respiratory therapist evaluation of non-intensive-care-unit surgery patients. Respir Care 2009; 54:861-7. [PMID: 19558737 DOI: 10.4187/002013209793800457] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Respiratory therapist (RT) driven protocols decrease ventilator days and resource utilization in the intensive care unit (ICU). Protocols have been studied in non-ICU settings, but their effect on mortality has been incompletely studied. METHODS In our neurosurgery step-down, trauma/surgery step-down, and trauma/surgery general units we initiated an RT-driven evaluate-and-treat protocol that included a standardized, quantitative, RT-driven patient-assessment scale and protocolized interventions. Before and after initiation of the protocol we collected data on non-ICU patients at risk for pulmonary complications. RESULTS The patient groups before (n = 2,230) and after (n = 2,805) protocol initiation were well matched in age, sex, Charlson score, and admitting service. Most of the patients, whether assessed by a physician or an RT, were deemed to have low risk of pulmonary complications and did not require any respiratory treatments. The number of respiratory treatments increased after protocol initiation, but the patients who received respiratory treatments after protocol initiation had shorter ICU stay and hospital stay, and lower total hospital costs than those who received respiratory treatments before protocol initiation. There was a nonsignificant trend toward lower mortality after protocol initiation. CONCLUSIONS Our RT-evaluate-and-treat protocol for non-ICU surgery patients was associated with more patients receiving respiratory treatments but decreased ICU and hospital stay and lower total hospital costs. Routine RT-driven assessment of non-ICU patients may reduce pulmonary complications in high-risk patients.
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Affiliation(s)
- Brian G Harbrecht
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292, USA.
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Curry SR, Marsh JW, Shutt KA, Muto CA, O'Leary MM, Saul MI, Pasculle AW, Harrison LH. High frequency of rifampin resistance identified in an epidemic Clostridium difficile clone from a large teaching hospital. Clin Infect Dis 2009; 48:425-9. [PMID: 19140738 DOI: 10.1086/596315] [Citation(s) in RCA: 126] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Rifampin is used as adjunctive therapy for Clostridium difficile-associated disease, and the drug's derivative, rifaximin, has emerged as an attractive antimicrobial for treatment of C. difficile-associated disease. Rifampin resistance in C. difficile strains has been reported to be uncommon. METHODS We examined the prevalence of rifampin resistance among 470 C. difficile isolates (51.1% during 2001-2002 and 48.9% during 2005) from a large teaching hospital. Rifampin sensitivity was performed using E-test. The epidemic BI/NAP1 C. difficile clone was identified by tcdC genotyping and multilocus variable number of tandem repeats analysis. A 200-base pair fragment of the rpoB gene was sequenced for 102 isolates. Data on rifamycin exposures were obtained for all patients. RESULTS Rifampin resistance was observed in 173 (36.8%) of 470 recovered isolates and 167 (81.5%) of 205 of epidemic clone isolates (P < .001). Six rpoB genotypes were associated with rifampin resistance. Of 8 patients exposed to rifamycins, 7 had rifampin-resistant C. difficile, compared with 166 of 462 unexposed patients (relative risk, 2.4; 95% confidence interval, 1.8-3.3). CONCLUSIONS Rifampin resistance is common among epidemic clone C. difficile isolates at our institution. Exposure to rifamycins before the development of C. difficile-associated disease was a risk factor for rifampin-resistant C. difficile infection. The use of rifaximin may be limited for treatment of C. difficile-associated disease at our institution.
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Affiliation(s)
- Scott R Curry
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Handler SM, Hanlon JT, Perera S, Saul MI, Fridsma DB, Visweswaran S, Studenski SA, Roumani YF, Castle NG, Nace DA, Becich MJ. Assessing the performance characteristics of signals used by a clinical event monitor to detect adverse drug reactions in the nursing home. AMIA Annu Symp Proc 2008; 2008:278-282. [PMID: 18998853 PMCID: PMC2656060] [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] [Subscribe] [Scholar Register] [Received: 03/13/2008] [Revised: 06/30/2008] [Indexed: 05/27/2023]
Abstract
Adverse drug reactions (ADRs) are a common cause of morbidity and mortality in the nursing home (NH) setting. Traditional non-automated mechanisms for ADR detection are time-consuming, costly, and fail to detect the majority of ADRs. We describe the implementation and pharmacist evaluation of a clinical event monitor using signals previously developed by our research team to detect potential ADRs in the NH. The overall positive predictive value (PPV) for all signals combined was 81% (54/67), with individual signal PPVs ranging from 0-100%. The PPVs were 53% (10/19) for the antidote signals category and 96% (44/46) for the laboratory/ medication combination signals category. The majority 75% (12/16) of the preventable ADRs were laboratory/medication combination signals. The results suggest that ADRs can be detected in the NH setting with a high degree of accuracy using a clinical event monitor that employs a set of signals derived by expert consensus.
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Affiliation(s)
- Steven M Handler
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Wadhwa R, Fridsma DB, Saul MI, Penrod LE, Visweswaran S, Cooper GF, Chapman W. Analysis of a failed clinical decision support system for management of congestive heart failure. AMIA Annu Symp Proc 2008; 2008:773-777. [PMID: 18999183 PMCID: PMC2655961] [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] [Subscribe] [Scholar Register] [Received: 03/14/2008] [Revised: 07/11/2008] [Indexed: 05/27/2023]
Abstract
In order to increase compliance with The Joint Commission's Congestive Heart Failure Core Measures, a rule based clinical decision support system (CDSS) was developed and deployed at a community hospital in our health system. We evaluated the performance of the CDSS in identifying patients with primary congestive heart failure (CHF)and identified problems encountered with its introduction. Performance of the CDSS was compared against a manual review of records of patients with diagnosis of primary CHF. The CDSS had a sensitivity of 0.79 and PPV of 0.11. The CDSS issued multiple alerts for majority of the patients(74%). The number of alerts issued for patients without primary CHF was large, and for a majority of patients (63%) physicians did not respond to alerts the first time. The CDSS performed poorly and was eventually withdrawn but provided insight into a subsequently successful method for managing CHF.
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Affiliation(s)
- Rajiv Wadhwa
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, USA
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Coley KC, Fabian TJ, Kim E, Ammerman DK, Scipio TM, Saul MI, Kim MS, Whitehead R, Ganguli R. Predictors of aripiprazole treatment continuation in hospitalized patients. J Clin Psychiatry 2008; 69:1393-7. [PMID: 19012819 DOI: 10.4088/jcp.v69n0906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Accepted: 07/15/2008] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Aripiprazole is a second-generation antipsychotic that is increasingly prescribed in a variety of psychiatric disorders. The goal of this study was to investigate patient and treatment factors associated with aripiprazole treatment continuation on hospital discharge in psychiatric inpatients. METHOD This was a retrospective cohort analysis of patients admitted to a psychiatric hospital between January 1, 2003, and June 30, 2006, and treated with aripiprazole. The goal was to determine factors associated with continuation of aripiprazole throughout the hospital stay and on discharge from the hospital. Covariates assessed included patient demographics, prior psychiatric hospitalizations, diagnoses, prior antipsychotic use, and concomitant psychotropic medications. Aripiprazole-specific covariates were starting and maximum dose and dose titration pattern. Diagnoses were identified using ICD-9-CM codes. RESULTS There were 1957 aripiprazole-treated patients included in this study, and 1573 (80%) continued aripiprazole treatment at the time of hospital discharge. Median starting doses were lower (5 mg/day) for younger and older patients, and patients with psychotic disorders received higher doses than other patients. Approximately 58% of patients had at least 1 aripiprazole dose titration while hospitalized, and most (73%) of those patients had a dose titration within 3 days of admission. Predictors of treatment continuation in this broad patient population were younger age, a diagnosis of bipolar or major depressive disorder, higher maximum aripiprazole doses, and upward dose titration within 3 days of admission. Patients receiving concomitant anticholinergics or antipsychotics were less likely to continue treatment as were those receiving aripiprazole at the time of hospitalization. CONCLUSION In this acute inpatient psychiatric setting, continuation of aripiprazole treatment on discharge was achieved in most patients. Demographic, diagnostic, and treatment factors predicting aripiprazole treatment effectiveness were identified.
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Affiliation(s)
- Kim C Coley
- Department of Pharmacy and Therapeutics, School of Pharmacy, 921 Salk Hall, University of Pittsburgh, Pittsburgh, PA 15261, USA.
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Handler SM, Hanlon JT, Perera S, Roumani YF, Nace DA, Fridsma DB, Saul MI, Castle NG, Studenski SA. Consensus list of signals to detect potential adverse drug reactions in nursing homes. J Am Geriatr Soc 2008; 56:808-15. [PMID: 18363678 DOI: 10.1111/j.1532-5415.2008.01665.x] [Citation(s) in RCA: 41] [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: 11/30/2022]
Abstract
OBJECTIVES To develop a consensus list of agreed-upon laboratory, pharmacy, and Minimum Data Set signals that a computer system can use in the nursing home to detect potential adverse drug reactions (ADRs). DESIGN Literature search for potential ADR signals, followed by an internet-based, a two-round, modified Delphi survey. SETTING A nationally representative survey of experts in geriatrics. PARTICIPANTS Panel of 13 physicians, 10 pharmacists, and 13 advanced practitioners. MEASUREMENTS Mean score and 95% confidence interval (CI) for each of 80 signals rated on a 5-point Likert scale (5=strong agreement with likelihood of indicating potential ADRs). Consensus agreement indicated by a lower-limit 95% CI of 4.0 or greater. RESULTS Panelists reached consensus agreement on 40 signals: 15 laboratory and medication combinations, 12 medication concentrations, 10 antidotes, and three Resident Assessment Protocols (RAPs). Highest consensus scores (4.6, 95% CI=4.4-4.9 or 4.4-4.8) were for naloxone when taking opioid analgesics; phytonadione when taking warfarin; dextrose, glucagon, or liquid glucose when taking hypoglycemic agents; medication-induced hypoglycemia; supratherapeutic international normalized ratio when taking warfarin; and triggering the Falls RAP when taking certain medications. CONCLUSION A multidisciplinary expert panel was able to reach consensus agreement on a list of signals to detect potential ADRs in nursing home residents. The results of this study can be used to prioritize an initial list of signals to be included in paper- or computer-based methods for potential ADR detection.
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Affiliation(s)
- Steven M Handler
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA.
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Coley KC, Saul MI, Seybert AL. Economic burden of not recognizing panic disorder in the emergency department. J Emerg Med 2007; 36:3-7. [PMID: 17933481 DOI: 10.1016/j.jemermed.2007.06.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2006] [Revised: 02/07/2007] [Accepted: 03/21/2007] [Indexed: 12/21/2022]
Abstract
The objective of this cohort study was to examine the diagnostic patterns and resource utilization of patients presenting to the Emergency Department with chest pain of unknown origin who may be experiencing a panic attack. Patients were excluded if they had coronary artery disease. In the 155 patients meeting study criteria, unspecified chest pain (78%) was the most common diagnostic code assigned. Total charges for the index hospitalization were $1,263,391 (median/visit = $7340). During the 1-year follow-up, 41% of patients had at least one repeat hospital visit and generated $1.6 million in charges. Patients on Medicare or Medicaid were more likely to have multiple hospital visits during the follow-up (odds ratio = 11.7). In conclusion, Emergency Department patients admitted with non-cardiac chest pain account for a significant amount of hospital resource use.
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Affiliation(s)
- Kim C Coley
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania 15261, USA
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Handler SM, Altman RL, Perera S, Hanlon JT, Studenski SA, Bost JE, Saul MI, Fridsma DB. A systematic review of the performance characteristics of clinical event monitor signals used to detect adverse drug events in the hospital setting. J Am Med Inform Assoc 2007; 14:451-8. [PMID: 17460130 PMCID: PMC2244905 DOI: 10.1197/jamia.m2369] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [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] [Received: 01/06/2007] [Accepted: 04/10/2007] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE Despite demonstrated benefits, few healthcare organizations have implemented clinical event monitors to detect adverse drug events (ADEs). The objective of this study was to conduct a systematic review of pharmacy and laboratory signals used by clinical event monitors to detect ADEs in hospitalized adults. DESIGN We performed a comprehensive search of MEDLINE, CINHAL and EMBASE to identify studies published between 1985 through 2006. Studies were included if they: described a clinical event monitor to detect ADEs in an adult hospital setting; described laboratory or pharmacy ADE signals; and, provided positive predictive values (PPVs) or information to allow the calculation of PPVs for individual ADE signals. MEASUREMENTS We calculated overall estimates of PPVs and 95% confidence intervals (CIs) for signals reported in 2 or more studies and contained no evidence heterogeneity. Results were examined by signal category: medication levels, laboratory tests, or antidotes. RESULTS We identified 12 observational studies describing 36 unique ADE signals. Fifteen signals (3 antidotes, 4 medication levels, and 8 laboratory values) contained no evidence of heterogeneity. The pooled PPVs for these individual signals ranged from 0.03 [CI=0.03-0.03] for hypokalemia, to 0.50 [CI=0.39-0.61] for supratherapeutic quinidine level. In general, antidotes (range=0.09-0.11) had the lowest PPVs, followed by laboratory values (0.03-0.27), and medication levels (0.03-0.50). CONCLUSION Results from this study should help clinical information system and computerized decision support producers develop or improve existing clinical event monitors to detect ADEs in their own hospitals by prioritizing those signals with the highest PPVs [corrected]
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Affiliation(s)
- Steven M Handler
- Department of Medicine, Division of Geriatric Medicine, University of Pittsburgh, 3471 Fifth Ave, Suite 500, Pittsburgh, PA 15213, USA.
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Watson K, Seybert AL, Saul MI, Lee JS, Kane-Gill SL. Comparison of patient outcomes with bivalirudin versus unfractionated heparin in percutaneous coronary intervention. Pharmacotherapy 2007; 27:647-56. [PMID: 17461699 DOI: 10.1592/phco.27.5.647] [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] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare clinical outcomes and glycoprotein IIb-IIIa inhibitor use in patients undergoing percutaneous coronary intervention (PCI) who received bivalirudin or unfractionated heparin (UFH) in a real-world setting. DESIGN Retrospective cohort analysis. SETTING University-affiliated medical center. PATIENTS One thousand seventy-five adult patients who underwent PCI and received either bivalirudin (539 patients) or UFH (536 patients) from April 1, 2003-April 1, 2004. MEASUREMENT AND MAIN RESULTS Patient data on demographics, comorbidities, laboratory values, and reports of radiologic examinations, cardiac catheterizations, and discharge summaries were obtained. Outcomes evaluated included rates of in-hospital mortality, myocardial infarction, revascularization, and length of stay (LOS), as well as Randomized Evaluation of PCI Linking Angiomax to Reduced Clinical Events (REPLACE-2) and Thrombosis in Myocardial Infarction (TIMI) bleeding categorization. Bivalirudin use was associated with a significant reduction in TIMI major (5.0% vs 9.7%, p=0.003), REPLACE-2 major (5.4% vs 12.9%, p<0.001), and TIMI minor (1.7% vs 6%, p<0.001) bleeding complications compared with UFH use. Significantly fewer patients in the bivalirudin group received glycoprotein IIb-IIIa inhibitors (27.3% vs 62.7%, p<0.001). Patients receiving bivalirudin had significantly fewer myocardial infarctions after catheterization (10.7% [40/375] vs 18.0% [51/284], p=0.007). No differences were noted in mortality and revascularization rates between groups. A shortened LOS was observed in the bivalirudin group. CONCLUSIONS This real-world analysis that included high-risk patients provides further evidence that bivalirudin is an attractive alternative to UFH because of a decrease in bleeding events without compromising efficacy.
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Affiliation(s)
- Kristin Watson
- Department of Pharmacy Practice and Sciences, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
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Kane-Gill SL, Seybert AL, Lazar J, Shatzer MB, Saul MI, Kirisci L, Murali S. Resource Use in Decompensated Heart Failure by Disease Progression Categories. ACTA ACUST UNITED AC 2007; 13:22-8. [PMID: 17268207 DOI: 10.1111/j.1527-5299.2007.06268.x] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The purpose of this study was to quantify the total hospital resource use for decompensated heart failure according to disease progression categories. Clinical and cost information was obtained from an electronic data repository and chart review. During the 1-year period from June 2002 to June 2003, qualified patients were categorized based on disease progression as (1) new onset, (2) known heart failure, or (3) readmission. The primary outcome variables were total hospital resource use and resource use by services. Analysis of variance, Scheffé analysis for pairwise comparisons, and chi-square analysis were performed to determine differences among groups. Total hospitalization costs are similar whether it is a new diagnosis of heart failure, known diagnosis, or readmission. Among the 3 categories, 5 services contained statistically significant differences in costs (P<.05): echocardiography, electrophysiology, neurodiagnostic, nuclear cardiology, and pharmacy. Careful analysis of hospital resource use by services for heart failure patients provides opportunities for institutional cost containment.
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Affiliation(s)
- Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, PA 15261, USA.
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Weisbord SD, Chen H, Stone RA, Kip KE, Fine MJ, Saul MI, Palevsky PM. Associations of increases in serum creatinine with mortality and length of hospital stay after coronary angiography. J Am Soc Nephrol 2006; 17:2871-7. [PMID: 16928802 DOI: 10.1681/asn.2006030301] [Citation(s) in RCA: 164] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The absence of a universally accepted definition of radiocontrast nephropathy (RCN) has hampered efforts to characterize effectively the incidence and the clinical significance of this condition. The objective of this study was to identify a clinically relevant definition of RCN by assessment of the relationships between increases in serum creatinine (Scr) of varying magnitude after coronary angiography and clinical outcomes. An electronic medical database was used to identify all patients who underwent coronary angiography at the University of Pittsburgh Medical Center during a 12-yr period and abstract Scr levels before and after angiography, as well as demographic characteristics and comorbid conditions. Changes in Scr after angiography were categorized into mutually exclusive categories on the basis of absolute and relative changes from baseline levels, with a separate category denoting "unknown" change. Discrete proportional odds models were used to examine the association between increases in Scr and 30-d in-hospital mortality and length of stay. A total of 27,608 patients who underwent coronary angiography were evaluated. Small absolute (0.25 to 0.5 mg/dl) and relative (25 to 50%) increases in Scr were associated with risk-adjusted odds ratios for in-hospital mortality of 1.83 and 1.39, respectively. Larger increases in Scr generally were associated with greater risks for these clinical outcomes. Small increases in Scr after the administration of intravascular radiocontrast are associated with adverse patient outcomes. This observation will help guide the post-procedure care of patients who undergo coronary angiography and has important implications for future studies that investigate RCN.
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Affiliation(s)
- Steven D Weisbord
- VA Pittsburgh Healthcare System, Mailstop 111F-U, 7E Room 120, Pittsburgh, PA 15240, USA.
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Coons JC, Seybert AL, Saul MI, Kirisci L, Kane-Gill SL. Outcomes and costs of abciximab versus eptifibatide for percutaneous coronary intervention. Ann Pharmacother 2005; 39:1621-6. [PMID: 16105872 DOI: 10.1345/aph.1g129] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Patients undergoing percutaneous coronary intervention (PCI) with stent placement are often prescribed glycoprotein IIb/IIIa inhibitors. However, drug selection is often based on clinicians' preference and cost because few studies have directly compared abciximab and eptifibatide. OBJECTIVE To compare clinical outcomes and total hospital costs of abciximab and eptifibatide in patients undergoing stent placement during PCI in a real-world setting. METHODS A retrospective cohort analysis was conducted of 960 patients administered abciximab or eptifibatide for intracoronary stent placement between 1999 and 2001 at a tertiary care hospital. The primary outcome was bleeding, defined as major, moderate, or minor according to published criteria. Secondary outcomes included in-hospital death, myocardial infarction, revascularization, and the triple composite endpoint of those outcomes, thrombocytopenia, length-of-stay, and total hospital costs. Pearson's chi(2) analysis, Fisher's exact test, and ANOVA were used for statistical analysis. RESULTS The frequency of bleeding complications based on severity was similar between abciximab and eptifibatide: major (2.4% vs 2.8%), moderate (12.4% vs 10.5%), and minor (4.0% vs 3.9%), respectively (p = 0.86). Secondary clinical outcomes were also similar between groups (p > 0.05). Total costs for hospitalization were significantly greater for abciximab compared with eptifibatide ($16,383 +/- 6799 vs $14,115 +/- 6285; p < 0.001). Drug acquisition costs were also significantly greater for abciximab compared with eptifibatide ($508 +/- 159 vs $465 +/- 263; p = 0.003). CONCLUSIONS In patients undergoing stent placement during PCI, abciximab and eptifibatide are comparable in terms of safety and effectiveness despite significant differences in hospitalization and acquisition costs.
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Affiliation(s)
- James C Coons
- Cardiology Specialty Resident, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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Weisbord SD, Bruns FJ, Saul MI, Palevsky PM. Provider Use of Preventive Strategies for Radiocontrast Nephropathy in High-Risk Patients. ACTA ACUST UNITED AC 2004; 96:c56-62. [PMID: 14988599 DOI: 10.1159/000076400] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [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] [Received: 04/03/2003] [Accepted: 11/06/2003] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Radiocontrast nephropathy (RCN) is a common and costly form of acute renal failure. Current preventative strategies include the use of intravenous (IV) fluids and the discontinuation of nephrotoxic medications at the time of radiocontrast administration. We sought to determine whether providers employ these strategies in high-risk patients to limit the development of RCN. METHODS High-risk patients undergoing procedures using radiocontrast media over a 12-month period were identified. Medical records were reviewed for all subjects who developed RCN and a randomly selected 25% of patients without RCN. Patients with a contraindication to IV volume expansion were excluded. Medical records of the remaining patients were reviewed to determine whether IV fluids were administered and whether NSAIDs or COX-2 inhibitors were prescribed at the time of contrast administration. RESULTS RCN developed in 8% of patients overall. Of 144 patients eligible for IV volume expansion, 16% failed to receive any IV fluids. When IV fluids were employed, their dose and timing of administration varied significantly by treating specialty and procedure. NSAIDs and COX-2 inhibitors were prescribed to 8% of patients. CONCLUSIONS Commonly accepted strategies for the prevention of RCN are underutilized. Quality improvement efforts are needed to increase the use of these two simple prophylactic measures.
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Affiliation(s)
- Steven D Weisbord
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pa, USA.
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Hravnak M, Hoffman LA, Saul MI, Zullo TG, Cuneo JF, Pellegrini RV. Short-term complications and resource utilization in matched subjects after on-pump or off-pump primary isolated coronary artery bypass. Am J Crit Care 2004; 13:499-507; discussion 508. [PMID: 15568655 PMCID: PMC3655795] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
BACKGROUND Studies suggest that patients who undergo off-pump coronary artery bypass grafting (OPCABG) have fewer short-term complications and use fewer inpatient resources than do patients who undergo standard coronary artery bypass grafting (CABG) with extracorporeal circulation. However, dissimilarity between groups in risk factors for complications has hindered interpretation of results. OBJECTIVES To compare the prevalence of selected complications (atrial fibrillation, stroke, reoperation, and bleeding) and inpatient resource utilization (length of stay, discharge disposition, total charges) between subjects undergoing primary isolated CABG or OPCABG who were matched with respect to key risk factors. METHODS Retrospective, causal-comparative survey conducted in 1 center for 18 months. Patients who underwent primary isolated CABG or OPCABG were matched for sex, age (within 2 years), left ventricular ejection fraction (within 0.05), and graft-patient ratio (exact match) and compared for prevalence of new-onset atrial fibrillation, stroke, reoperation within 24 hours, and bleeding. Statistical analysis included Wilcoxon and t tests for paired comparisons. RESULTS The sample (107 matched pairs) was 63% male, with a mean age of 66 (SD 9.5) years, a mean left ventricular ejection fraction of 0.51 (SD 0.13), and a mean graft-patient ratio of 3.41 (SD 0.74). The 2 groups did not differ significantly in New York Heart Association class (P = .43), Acute Physiology and Chronic Health Evaluation III score (P = .22), postoperative beta-blocker use (P = .73), or comorbid conditions. None of the complications examined differed significantly between pairs. CONCLUSION Patients with comparable risk profiles have similar prevalences of selected complications after CABG and OPCABG.
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Affiliation(s)
- Marilyn Hravnak
- Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, Pa., USA
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Hravnak M, Hoffman LA, Saul MI, Zullo TG, Cuneo JF, Pellegrini RV. Short-Term Complications and Resource Utilization in Matched Subjects After On-Pump or Off-Pump Primary Isolated Coronary Artery Bypass. Am J Crit Care 2004. [DOI: 10.4037/ajcc2004.13.6.499] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
• Background Studies suggest that patients who undergo off-pump coronary artery bypass grafting (OPCABG) have fewer short-term complications and use fewer inpatient resources than do patients who undergo standard coronary artery bypass grafting (CABG) with extracorporeal circulation. However, dissimilarity between groups in risk factors for complications has hindered interpretation of results.• Objectives To compare the prevalence of selected complications (atrial fibrillation, stroke, reoperation, and bleeding) and inpatient resource utilization (length of stay, discharge disposition, total charges) between subjects undergoing primary isolated CABG or OPCABG who were matched with respect to key risk factors.• Methods Retrospective, causal-comparative survey conducted in 1 center for 18 months. Patients who underwent primary isolated CABG or OPCABG were matched for sex, age (within 2 years), left ventricular ejection fraction (within 0.05), and graft-patient ratio (exact match) and compared for prevalence of new-onset atrial fibrillation, stroke, reoperation within 24 hours, and bleeding. Statistical analysis included Wilcoxon and t tests for paired comparisons.• Results The sample (107 matched pairs) was 63% male, with a mean age of 66 (SD 9.5) years, a mean left ventricular ejection fraction of 0.51 (SD 0.13), and a mean graft-patient ratio of 3.41 (SD 0.74). The 2 groups did not differ significantly in New York Heart Association class (P = .43), Acute Physiology and Chronic Health Evaluation III score (P = .22), postoperative β-blocker use (P = .73), or comorbid conditions. None of the complications examined differed significantly between pairs.• Conclusion Patients with comparable risk profiles have similar prevalences of selected complications after CABG and OPCABG.
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Affiliation(s)
- Marilyn Hravnak
- The Department of Acute/Tertiary Care, School of Nursing (MH, LAH, TGZ, JFC), Center for Biomedical Informatics (MIS), and Department of Cardiothoracic Surgery, School of Medicine (RVP), University of Pittsburgh, Pittsburgh, Pa
| | - Leslie A. Hoffman
- The Department of Acute/Tertiary Care, School of Nursing (MH, LAH, TGZ, JFC), Center for Biomedical Informatics (MIS), and Department of Cardiothoracic Surgery, School of Medicine (RVP), University of Pittsburgh, Pittsburgh, Pa
| | - Melissa I. Saul
- The Department of Acute/Tertiary Care, School of Nursing (MH, LAH, TGZ, JFC), Center for Biomedical Informatics (MIS), and Department of Cardiothoracic Surgery, School of Medicine (RVP), University of Pittsburgh, Pittsburgh, Pa
| | - Thomas G. Zullo
- The Department of Acute/Tertiary Care, School of Nursing (MH, LAH, TGZ, JFC), Center for Biomedical Informatics (MIS), and Department of Cardiothoracic Surgery, School of Medicine (RVP), University of Pittsburgh, Pittsburgh, Pa
| | - Julie F. Cuneo
- The Department of Acute/Tertiary Care, School of Nursing (MH, LAH, TGZ, JFC), Center for Biomedical Informatics (MIS), and Department of Cardiothoracic Surgery, School of Medicine (RVP), University of Pittsburgh, Pittsburgh, Pa
| | - Ronald V. Pellegrini
- The Department of Acute/Tertiary Care, School of Nursing (MH, LAH, TGZ, JFC), Center for Biomedical Informatics (MIS), and Department of Cardiothoracic Surgery, School of Medicine (RVP), University of Pittsburgh, Pittsburgh, Pa
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Abstract
• Background Studies of resource utilization by patients with new-onset atrial fibrillation after coronary artery bypass grafting have addressed only length of stay and bed charges.• Objective To compare resource utilization between patients with new-onset atrial fibrillation and patients without atrial fibrillation after isolated coronary artery bypass grafting.• Methods Retrospective review of clinical and administrative electronic databases for 720 subjects who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass in 25 months at one medical center. The prevalence of atrial fibrillation was determined, and resource utilization in various hospital cost centers was compared between subjects with and without atrial fibrillation.• Results The prevalence of new-onset atrial fibrillation was 33.1%. Compared with subjects without atrial fibrillation, subjects with atrial fibrillation had a longer stay (5.8 ± 2.4 vs 4.4 ± 1.2 days, P< .001), more days receiving mechanical ventilation (P=.002) and oxygen therapy (P< .001), and higher rates of readmission to the intensive care unit (4.6% vs 0.2%, P< .001). Subjects with atrial fibrillation also had more laboratory tests (P< .001) and more days receiving cardiac drugs, heparin, diuretics, and electrolytes. Subjects with atrial fibrillation had higher total postoperative charges ($57261 ± $17 101 vs $50 905 ± $10 062, P = .001), a mean difference of $6356. The mean differences were greatest for bed charges ($1642), laboratory charges ($1215), pharmacy ($989), and respiratory care ($582).• Conclusions The economic impact of atrial fibrillation after coronary artery bypass grafting has been underestimated.
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Affiliation(s)
- Marilyn Hravnak
- The Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh (MH, LAH, TGZ, GRW) and Medical Archival Retrieval System, Inc. (MIS), University of Pittsburgh Medical Center–Health System, Pittsburgh, Pa
| | - Leslie A. Hoffman
- The Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh (MH, LAH, TGZ, GRW) and Medical Archival Retrieval System, Inc. (MIS), University of Pittsburgh Medical Center–Health System, Pittsburgh, Pa
| | - Melissa I. Saul
- The Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh (MH, LAH, TGZ, GRW) and Medical Archival Retrieval System, Inc. (MIS), University of Pittsburgh Medical Center–Health System, Pittsburgh, Pa
| | - Thomas G. Zullo
- The Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh (MH, LAH, TGZ, GRW) and Medical Archival Retrieval System, Inc. (MIS), University of Pittsburgh Medical Center–Health System, Pittsburgh, Pa
| | - Gayle R. Whitman
- The Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh (MH, LAH, TGZ, GRW) and Medical Archival Retrieval System, Inc. (MIS), University of Pittsburgh Medical Center–Health System, Pittsburgh, Pa
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Hravnak M, Hoffman LA, Saul MI, Zullo TG, Whitman GR. Resource utilization related to atrial fibrillation after coronary artery bypass grafting. Am J Crit Care 2002; 11:228-38. [PMID: 12022486 PMCID: PMC3674411] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
BACKGROUND Studies of resource utilization by patients with new-onset atrialfibrillation after coronary artery bypass grafting have addressed only length of stay and bed charges. OBJECTIVE To compare resource utilization between patients with new-onset atrial fibrillation and patients without atrialfibrillation after isolated coronary artery bypass grafting. METHODS Retrospective review of clinical and administrative electronic databases for 720 subjects who underwent isolated coronary artery bypass grafting with cardiopulmonary bypass in 25 months at one medical center The prevalence of atrial fibrillation was determined, and resource utilization in various hospital cost centers was compared between subjects with and without atrialfibrillation. RESULTS The prevalence of new-onset atrial fibrillation was 33.1%. Compared with subjects without atrialfibrillation, subjects with atrialfibrillation had a longer stay (5.8 +/- 2.4 vs. 4.4+/-1.2 days, P<.001), more days receiving mechanical ventilation (P =.002) and oxygen therapy (P<.001), and higher rates of readmission to the intensive care unit (4.6% vs. 0.2%, P<.001). Subjects with atrial fibrillation also had more laboratory tests (P<.001) and more days receiving cardiac drugs, heparin, diuretics, and electrolytes. Subjects with atrialfibrillation had higher total postoperative charges ($57261 +/- $17101 vs. $50905 +/- $10062, P = .001), a mean difference of $6356. The mean differences were greatest for bed charges ($1642), laboratory charges ($1215), pharmacy ($989), and respiratory care ($582). CONCLUSION The economic impact of atrialfibrillation after coronary artery bypass grafting has been underestimated.
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Affiliation(s)
- Marilyn Hravnak
- Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, PA, USA
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Abstract
OBJECTIVE Although an extensive number of studies have attempted to identify predictors of new-onset atrial fibrillation (AFIB) after coronary artery bypass grafting (CABG), a strong predictive model does not exist. Prior studies have included patients recruited from multiple centers with variant AFIB prevalence rates and those who underwent CABG in combination with other surgical procedures. Also, most studies have focused on pre- and perioperative characteristics, with less attention given to the initial postoperative period. The purpose of this study was to comprehensively examine pre-, peri-, and postoperative characteristics that might predict new-onset AFIB in a large sample of patients undergoing isolated CABG in a single medical center, utilizing data readily available to clinicians in electronic data repositories. In addition, length of stay and selected postoperative complications and disposition were compared in patients with AFIB and no AFIB. DESIGN Retrospective, comparative survey. SETTING University-affiliated tertiary care hospital. PATIENTS Patients with new-onset AFIB who underwent isolated standard CABG or minimally invasive direct vision coronary artery bypass were identified from an electronic clinical data repository. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The prevalence of AFIB in the total sample (n = 814) was 31.9%. Predictors of AFIB included age (p =.0004), number of vessels bypassed (p =.013), vessel location (diagonal [p <.003] or posterior descending artery [p <.001]), and net fluid balance on the operative day (p =.015). Forward stepwise regression analysis produced a model that correctly predicted AFIB in only 24% of cases, with age (14%) and body surface area (9%) providing the most prediction. The incidence of embolic stroke was higher in AFIB (n = 8) vs. no AFIB (n = 4) patients, but stroke preceded AFIB onset in seven of eight cases. Subjects with AFIB had a longer stay (p =.0004), more intensive care unit readmissions (p =.0004), and required more assistance at hospital discharge (p =.017). CONCLUSIONS Despite attempts to examine comprehensively predictors of new-onset AFIB, we were unable to identify a robust predictive model. Our findings, in combination with prior work, imply that it may not be feasible to predict the development of new-onset AFIB after CABG using data readily available to the bedside clinician. In this sample, stroke was uncommon and, when it occurred, preceded AFIB in all but one case. As anticipated, AFIB increased length of stay, and patients with this complication required more assistance at discharge.
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Affiliation(s)
- Marilyn Hravnak
- Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
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Hravnak M, Hoffman LA, Saul MI, Zullo TG, Cuneo JF, Whitman GR, Clochesy JM, Griffith BP. Atrial fibrillation: prevalence after minimally invasive direct and standard coronary artery bypass. Ann Thorac Surg 2001; 71:1491-5. [PMID: 11383788 DOI: 10.1016/s0003-4975(01)02477-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND This study identified and compared the prevalence of new-onset atrial fibrillation (AFIB) following standard coronary artery bypass grafting (SCABG) with cardiopulmonary bypass (CPB) and minimally invasive direct vision coronary artery bypass grafting (MIDCAB) without CPB. A further comparison was made between AFIB prevalence in SCABG and MIDCAB subjects with two or fewer bypasses. METHODS This is a retrospective, comparative survey. Patients with new-onset AFIB who underwent SCABG or MIDCAB alone were identified electronically using a triangulated method (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9 CM] code; clinical database word search; and pharmacy database drug search). RESULTS The total sample (n = 814; 94 MIDCAB, 720 SCABG) exhibited a trend toward lower AFIB prevalence in MIDCAB (23.4%) versus SCABG (33.1%) subjects (p = 0.059). AFIB prevalence in the SCABG subset with two or less vessel bypasses (n = 98; n = 18 single vessel, n = 80 double vessels) and MIDCAB subjects (n = 94; n = 90 single vessels, n = 4 double vessels) was almost identical (SCABG subset 24.5% versus MIDCAB 23.4%, p = 0.860). Slightly more than half (56.9%) of new-onset AFIB subjects were identified by ICD-9 CM codes, with the remainder by word search (37.7%) or procainamide query (5.4%). CONCLUSIONS In this sample, the number of vessels bypassed seemed to have a greater influence on AFIB prevalence than the application of CPB or the surgical approach. Retrospective identification of AFIB cases by ICD-9 CM code grossly underestimated AFIB prevalence.
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Affiliation(s)
- M Hravnak
- Department of Acute/Technical Care, School of Nursing, Medical Archival System, Inc, University of Pittsburgh, Pennsylvania, USA.
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