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  • 1
    In: Medical Care, Ovid Technologies (Wolters Kluwer Health), Vol. 56, No. 7 ( 2018-07), p. 626-633
    Abstract: Electronic health records provide the opportunity to assess system-wide quality measures. Veterans Affairs Pharmacy Benefits Management Center for Medication Safety uses medication use evaluation (MUE) through manual review of the electronic health records. Objective: To compare an electronic MUE approach versus human/manual review for extraction of antibiotic use (choice and duration) and severity metrics. Research Design: Retrospective. Subjects: Hospitalizations for uncomplicated pneumonia occurring during 2013 at 30 Veterans Affairs facilities. Measures: We compared summary statistics, individual hospitalization-level agreement, facility-level consistency, and patterns of variation between electronic and manual MUE for initial severity, antibiotic choice, daily clinical stability, and antibiotic duration. Results: Among 2004 hospitalizations, electronic and manual abstraction methods showed high individual hospitalization-level agreement for initial severity measures (agreement=86%–98%, κ=0.5–0.82), antibiotic choice (agreement=89%–100%, κ=0.70–0.94), and facility-level consistency for empiric antibiotic choice (anti-MRSA r =0.97, P 〈 0.001; antipseudomonal r =0.95, P 〈 0.001) and therapy duration ( r =0.77, P 〈 0.001) but lower facility-level consistency for days to clinical stability ( r =0.52, P =0.006) or excessive duration of therapy ( r =0.55, P =0.005). Both methods identified widespread facility-level variation in antibiotic choice, but we found additional variation in manual estimation of excessive antibiotic duration and initial illness severity. Conclusions: Electronic and manual MUE agreed well for illness severity, antibiotic choice, and duration of therapy in pneumonia at both the individual and facility levels. Manual MUE showed additional reviewer-level variation in estimation of initial illness severity and excessive antibiotic use. Electronic MUE allows for reliable, scalable tracking of national patterns of antimicrobial use, enabling the examination of system-wide interventions to improve quality.
    Type of Medium: Online Resource
    ISSN: 0025-7079
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
    detail.hit.zdb_id: 2045939-7
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  • 2
    Online Resource
    Online Resource
    Oxford University Press (OUP) ; 2022
    In:  Open Forum Infectious Diseases Vol. 9, No. Supplement_2 ( 2022-12-15)
    In: Open Forum Infectious Diseases, Oxford University Press (OUP), Vol. 9, No. Supplement_2 ( 2022-12-15)
    Abstract: Bacterial co-infection has been reported with COVID-19, but the extent of co-infection nationally is unclear. We sought to describe the temporal and spatial trends in bacterial co-infection across the US among COVID-19 positive admissions to Veterans Affairs (VA) hospitals. Methods This retrospective cohort study included patients admitted to VA hospitals from March 1, 2020 through May 31, 2022 with a positive COVID-19 test within the previous 14 days and up to 2 days after admission. We summarized temporal and spatial patterns of bacterial co-infection, defined as a positive clinical microbiology culture for the bacterial pathogens listed in Table 1, defined as either community-onset (COI, within 2 calendar days of admission), or hospital-onset (HOI, & gt; 2 calendar days after admission). We performed a univariate analysis including facility and patient factors and generated descriptive statistics to describe the frequency of occurrence over time and space overall, and within each organism. Organisms Table 1:List of organisms included in our study Results By the end of June 2021, there were 35,299 hospitalizations observed from 33,383 patients admitted with positive COVID-19 tests in VA. Co-infection was detected among 7.4% of hospitalizations (2.9% for COI and 4.7% for HOI). VA patients older than 70, Asian or unknown race, higher Charlson Comorbidity Index were more likely to experience HOI and COI. Facility-level rates of HOI and COI over the study period presented substantial geographic variability, ranging from 0 to 45.5 per 1000 patient days and from 0 to 6.98 per 100 hospitalizations for HOI and COI, respectively [Fig 1]. Between March 2020 and June 2021, monthly facility-level rates of HOI and COI also varied substantially within and between facilities [Fig 2] . Average monthly co-infection rates increased in the first three months of the pandemic, with HOIs subsequently declining gradually and COIs remaining stable across VA. The correlation coefficients between hospital mortality and facility-level co-infection rates for HOI and COI ranged from –0.5 to 0.7 [Fig 3]. Spatial variation Fig 1:Plot for spatial distribution across VA facilities of HOIs and COIs, measured as Co-Infections per 100 patient hospitalizations Temporal variation Fig 2:Plot for temporal distribution across VA facilities of HOI and COI, measured as Co-Infections per 100 patient hospitalizations Mortality correlation Fig 3:Plot for spatial distribution of the correlation coefficients between hospital mortality and HOI and COI Conclusion Bacterial co-infection was infrequent during hospitalization with COVID-19 in the VA healthcare system, and has mild to moderate association with hospital mortality. However, substantial geographic and temporal variation was observed. Disclosures Karim Khader, PhD, BioFire Diagnostics: Grant/Research Support.
    Type of Medium: Online Resource
    ISSN: 2328-8957
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2022
    detail.hit.zdb_id: 2757767-3
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  • 3
    In: Open Forum Infectious Diseases, Oxford University Press (OUP), Vol. 4, No. suppl_1 ( 2017), p. S170-S171
    Type of Medium: Online Resource
    ISSN: 2328-8957
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2017
    detail.hit.zdb_id: 2757767-3
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  • 4
    In: Infection Control & Hospital Epidemiology, Cambridge University Press (CUP), Vol. 40, No. 7 ( 2019-07), p. 761-766
    Abstract: Determine the effectiveness of a personal protective equipment (PPE)-free zone intervention on healthcare personnel (HCP) entry hand hygiene (HH) and PPE donning compliance in rooms of patients in contact precautions. Design: Quasi-experimental, multicenter intervention, before-and-after study with concurrent controls. Setting: All patient rooms on contact precautions on 16 units (5 medical-surgical, 6 intensive care, 5 specialty care units) at 3 acute-care facilities (2 academic medical centers, 1 Veterans Affairs hospital). Observations of PPE donning and entry HH compliance by HCP were conducted during both study phases. Surveys of HCP perceptions of the PPE-free zone were distributed in both study phases. Intervention: A PPE-free zone, where a low-risk area inside door thresholds of contact precautions rooms was demarcated by red tape on the floor. Inside this area, HCP were not required to wear PPE. Results: We observed 3,970 room entries. HH compliance did not change between study phases among intervention units (relative risk [RR], 0.92; P = .29) and declined in control units (RR, 0.70; P = .005); however, the PPE-free zone did not significantly affect compliance ( P = .07). The PPE-free zone effect on HH was significant only for rooms on enteric precautions ( P = .008). PPE use was not significantly different before versus after the intervention ( P = .15). HCP perceived the zone positively; 65% agreed that it facilitated communication and 66.8% agreed that it permitted checking on patients more frequently. Conclusions: HCP viewed the PPE-free zone favorably and it did not adversely affect PPE or HH compliance. Future infection prevention interventions should consider the complex sociotechnical system factors influencing behavior change.
    Type of Medium: Online Resource
    ISSN: 0899-823X , 1559-6834
    Language: English
    Publisher: Cambridge University Press (CUP)
    Publication Date: 2019
    detail.hit.zdb_id: 2106319-9
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  • 5
    In: JAMA Internal Medicine, American Medical Association (AMA), Vol. 180, No. 4 ( 2020-04-01), p. 552-
    Type of Medium: Online Resource
    ISSN: 2168-6106
    Language: English
    Publisher: American Medical Association (AMA)
    Publication Date: 2020
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  • 6
    In: Open Forum Infectious Diseases, Oxford University Press (OUP), Vol. 9, No. Supplement_2 ( 2022-12-15)
    Abstract: Bacterial co-infection has been reported with COVID-19, but risk factors for bacterial co-infection remain unclear due to limited large scale studies. We seek to identify predictive factors associated with risk of co-infection with multidrug-resistant organisms for patients hospitalized at Veterans Affairs (VA) hospitals with COVID-19. Methods This retrospective cohort study included Veterans admitted to VA hospitals from March 1, 2020 through May 31, 2022 with a confirmed positive COVID-19 test within the previous 14 days and up to 2 days after admission. Outcomes of interest were hospital-onset co-infection (HOI, & gt; 2 calendar days after admission) and community-onset co-infection (COI, within 2 calendar days of admission). Potential risk factors included both patient- (e.g. vital sign, medication use) and facility-level covariates (e.g. bed size, antibiotic use rate). We compared the covariate distributions for patients with and without HOI and COI. Our analytical approaches included variance inflation factors to detect the presence of multicollinearity among these factors, and Least Absolute Shrinkage and Selection Operator to identify the subset of factors associated with HOI and COI. We conducted a two-stage analysis, first performing feature selection among the individual-level risk factors followed by identification of facility-level risk factors. Optimal models were identified using 10-fold cross validation. Results By July 2021, 33,383 patients were admitted to VA with positive COVID-19 test. We found that medications for ventilator induction (OR with 95% CI: 2.9 (2.2, 3.9)), norepinephrine (OR with 95% CI: 1.6 (1.2, 2.2)) and antimicrobial therapies for gram-positive infections (OR with 95% CI: 4.5 (3.6, 5.6)) [Table 1] were associated with the increased risk of HOI and patients in facilities with high C difficile infection rates were more likely to have COI detected (OR with 95% CI: 1.14 (1.11, 1.18)) [Table 2] . Homeless Veterans had higher risk of developing an HOI (OR with 95% CI: 1.5 (1.1, 2.0)), but not a COI. Conclusion Risk factors for HOI and COI in COVID-19 were distinct, with specific classes of medications and antibiotics as well as patient factors resulting in increased risk for HOI. Further work is needed to better understand the risk factors for COI. Disclosures Karim Khader, PhD, BioFire Diagnostics: Grant/Research Support.
    Type of Medium: Online Resource
    ISSN: 2328-8957
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2022
    detail.hit.zdb_id: 2757767-3
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  • 7
    In: The Journal of Rheumatology, The Journal of Rheumatology, Vol. 41, No. 10 ( 2014-10), p. 1935-1943
    Abstract: Limited evidence exists comparing the persistence, effectiveness, and costs of biologic therapies for rheumatoid arthritis in clinical practice. Comparative effectiveness studies are needed to understand real-world experience with these agents. We evaluated treatment patterns, costs, and effectiveness of tumor necrosis factor inhibitor (TNFi) agents in patients enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry. Methods. Observational data from the VARA registry and linked administrative databases were analyzed. Longitudinal data from VARA patients initiating adalimumab (ADA), etanercept (ETN), or infliximab (IFX) from 2003 (the date all agents were available within the Veteran Affairs) to 2010 were analyzed. Outcomes included Disease Activity Score using 28 joints (DAS28), treatment persistence, dose escalation, and direct costs of drugs and drug administration. Results. For 563 eligible patients, baseline DAS28, DAS28 improvements, and persistence on initial treatment were similar across agents. Fewer patients receiving ETN (n = 5/290; 2%) underwent dose escalation than did patients taking ADA (n = 32/204; 16%) or IFX (n = 44/69; 64%). Annual costs for first course of TNFi therapy were lower for injectable ADA ($13,100 US) and ETN ($13,500 US) than for intravenously administered IFX ($16,900 US). Conclusion. Despite similar persistence and clinical disease activity for these TNFi agents, rates of dose escalation were highest with ADA and IFX. Higher overall costs were noted for IFX without increases in effectiveness.
    Type of Medium: Online Resource
    ISSN: 0315-162X , 1499-2752
    RVK:
    Language: English
    Publisher: The Journal of Rheumatology
    Publication Date: 2014
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  • 8
    In: Clinical Infectious Diseases, Oxford University Press (OUP), Vol. 72, No. Supplement_1 ( 2021-01-29), p. S59-S67
    Abstract: The 2019 American Thoracic Society/Infectious Diseases Society of America guidelines for community-acquired pneumonia (CAP) revised recommendations for culturing and empiric broad-spectrum antibiotics. We simulated guideline adoption in Veterans Affairs (VA) inpatients. Methods For all VA acute hospitalizations for CAP from 2006–2016 nationwide, we compared observed with guideline-expected proportions of hospitalizations with initial blood and respiratory cultures obtained, empiric antibiotic therapy with activity against methicillin-resistant Staphylococcus aureus (anti-MRSA) or Pseudomonas aeruginosa (antipseudomonal), empiric “overcoverage” (receipt of anti-MRSA/antipseudomonal therapy without eventual detection of MRSA/P. aeruginosa on culture), and empiric “undercoverage” (lack of anti-MRSA/antipseudomonal therapy with eventual detection on culture). Results Of 115 036 CAP hospitalizations over 11 years, 17 877 (16%) were admitted to an intensive care unit (ICU). Guideline adoption would slightly increase respiratory culture (30% to 36%) and decrease blood culture proportions (93% to 36%) in hospital wards and increase both respiratory (40% to 100%) and blood (95% to 100%) cultures in ICUs. Adoption would decrease empiric selection of anti-MRSA (ward: 27% to 1%; ICU: 61% to 8%) and antipseudomonal (ward: 25% to 1%; ICU: 54% to 9%) therapies. This would correspond to greatly decreased MRSA overcoverage (ward: 27% to 1%; ICU: 56% to 8%), slightly increased MRSA undercoverage (ward: 0.6% to 1.3%; ICU: 0.5% to 3.3%), with similar findings for P. aeruginosa. For all comparisons, P  & lt; .001. Conclusions Adoption of the 2019 CAP guidelines in this population would substantially change culturing and empiric antibiotic selection practices, with a decrease in overcoverage and slight increase in undercoverage for MRSA and P. aeruginosa.
    Type of Medium: Online Resource
    ISSN: 1058-4838 , 1537-6591
    RVK:
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2021
    detail.hit.zdb_id: 2002229-3
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  • 9
    In: Advances in Therapy, Springer Science and Business Media LLC, Vol. 33, No. 8 ( 2016-8), p. 1347-1359
    Type of Medium: Online Resource
    ISSN: 0741-238X , 1865-8652
    Language: English
    Publisher: Springer Science and Business Media LLC
    Publication Date: 2016
    detail.hit.zdb_id: 2421646-X
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  • 10
    Online Resource
    Online Resource
    Cambridge University Press (CUP) ; 2020
    In:  Infection Control & Hospital Epidemiology Vol. 41, No. S1 ( 2020-10), p. s222-s224
    In: Infection Control & Hospital Epidemiology, Cambridge University Press (CUP), Vol. 41, No. S1 ( 2020-10), p. s222-s224
    Abstract: Background: Contamination of healthcare workers and patient environments likely play a role in the spread of antibiotic-resistant organisms. The mechanisms that contribute to the distribution of organisms within and between patient rooms are not well understood, but they may include movement patterns and patient interactions of healthcare workers. We used an innovative technology for tracking healthcare worker movement and patient interactions in ICUs. Methods: The Kinect system, a device developed by Microsoft, was used to detect the location of a person’s hands and head over time, each represented with 3-dimensional coordinates. The Kinects were deployed in 2 intensive care units (ICUs), at 2 different hospitals, and they collected data from 5 rooms in a high-acuity 20-bed cardiovascular ICU (unit 1) and 3 rooms in a 10-bed medical-surgical ICU (unit 2). The length of the Kinect deployment varied by room (range, 15–48 days). The Kinect data were processed to included date, time, and location of head and hands for all individuals. Based on the coordinates of the bed, we defined events indicating bed touch, distance 30 cm (1 foot) from the bed, and distance 1 m (3 feet) from the bed. The processed Kinect data were then used to generate heat maps showing density of person locations within a room and summarizing bed touches and time spent in different locations within the room. Results: The Kinect systems captured In total, 2,090 hours of room occupancy by at least 1 person within ~1 m of the bed (Table 1). Approximately half of the time spent within ~1 m from the bed was at the bedside (within ~30 cm). The estimated number of bed touches per hour when within ~1 m was 13–23. Patients spent more time on one side of the bed, which varied by room and facility (Fig. 1A, 1B). Additionally, we observed temporal variation in intensity measured by person time in the room (Fig. 1C, 1D). Conclusions: High occupancy tends to be on the far side (away from the door) of the patient bed where the computers are, and the bed touch rate is relatively high. These results can be used to help us understand the potential for room contamination, which can contribute to both transmission and infection, and they highlight critical times and locations in the room, with a potential for focused deep cleaning. Funding: None Disclosures: None
    Type of Medium: Online Resource
    ISSN: 0899-823X , 1559-6834
    Language: English
    Publisher: Cambridge University Press (CUP)
    Publication Date: 2020
    detail.hit.zdb_id: 2106319-9
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