Antibiotic Stewardship Implementation and Antibiotic Use at Hospitals With and Without On-site Infectious Disease Specialists.

BackgroundMany US hospitals lack infectious disease (ID) specialists, which may hinder antibiotic stewardship efforts. We sought to compare patient-level antibiotic exposure at Veterans Health Administration (VHA) hospitals with and without an on-site ID specialist, defined as an ID physician and/or ID pharmacist.MethodsThis retrospective VHA cohort included all acute-care patient admissions during 2016. A mandatory survey was used to identify hospitals' antibiotic stewardship processes and their access to an on-site ID specialist. Antibiotic use was quantified as days of therapy per days present and categorized based on National Healthcare Safety Network definitions. A negative binomial regression model with risk adjustment was used to determine the association between presence of an on-site ID specialist and antibiotic use at the level of patient admissions.ResultsEighteen of 122 (14.8%) hospitals lacked an on-site ID specialist; there were 525 451 (95.8%) admissions at ID hospitals and 23 007 (4.2%) at non-ID sites. In the adjusted analysis, presence of an ID specialist was associated with lower total inpatient antibacterial use (odds ratio, 0.92; 95% confidence interval, .85-.99). Presence of an ID specialist was also associated with lower use of broad-spectrum antibacterials (0.61; .54-.70) and higher narrow-spectrum β-lactam use (1.43; 1.22-1.67). Total antibacterial exposure (inpatient plus postdischarge) was lower among patients at ID versus non-ID sites (0.92; .86-.99).ConclusionsPatients at hospitals with an ID specialist received antibiotics in a way more consistent with stewardship principles. The presence of an ID specialist may be important to effective antibiotic stewardship

Antibiotic stewardship implementation and patient-level antibiotic use at hospitals with and without on-site Infectious Disease specialists.

Many US hospitals lack Infectious Disease (ID) specialists, which may hinder antibiotic stewardship efforts. We sought to compare patient-level antibiotic exposure at Veterans Health Administration (VHA) hospitals with and without an on-site ID specialist, defined as an ID physician and/or ID pharmacist. This retrospective VHA cohort included all acute-care patient-admissions during 2016. A mandatory survey was used to identify hospitals' antibiotic stewardship processes and their access to an on-site ID specialist. Antibiotic use was quantified as days of therapy (DOT) per days-present and categorized based on National Healthcare Safety Network definitions. A negative binomial regression model with risk adjustment was used to determine the association between presence of an on-site ID specialist and antibiotic use at the level of patient-admissions. Eighteen of 122 (14.8%) hospitals lacked an on-site ID specialist; there were 525,451 (95.8%) admissions at ID hospitals and 23,007 (4.2%) at non-ID sites. In the adjusted analysis, presence of an ID specialist was associated with lower total inpatient antibacterial use [OR 0.92, (95% CI, 0.85-0.99)]. Presence of an ID specialist was also associated with lower use of broad-spectrum antibacterials [OR 0.61 (95% CI, 0.54-0.70)] and higher narrow-spectrum beta-lactam use [OR 1.43 (95% CI, 1.22-1.67)]. Total antibacterial exposure (inpatient plus post-discharge) was lower among patients at ID versus non-ID sites [OR 0.92 (95% CI, 0.86-0.99)]. Patients at hospitals with an ID specialist received antibiotics in a way more consistent with stewardship principles. The presence of an ID specialist may be important to effective antibiotic stewardship

The short-term impact of the alcohol act on alcohol-related deaths and hospital admissions in Scotland: a natural experiment

Background and aim: The introduction of the Alcohol Act in Scotland on 1 October 2011, which included a ban on multi-buy promotions, was likely associated with a fall in off-trade alcohol sales in the year after its implementation. The aim of this study was to test if the same legislation was associated with reduced levels of alcohol-related deaths and hospital admissions in the 3-year period after its introduction. Design: A natural experiment design using time series data to assess the impact of the Alcohol Act legislation in Scotland. Comparisons were made with unexposed populations in the rest of Great Britain. Setting Scotland with comparable data obtained for geographical control groups in other parts of Great Britain. Participants: For alcohol-related deaths, a total of 17,732 in Scotland and 88,001 in England/Wales across 169 four-week periods between January 2001 and December 2013. For alcohol-related hospital admissions, a total of 121,314 in Scotland and 696,892 in England across 182 four-week periods between January 2001 and December 2014. Measurements: Deaths and hospital admissions in Scotland and control groups that were wholly attributable to alcohol for consecutive four-week periods between January 2001 and December 2014. Data were obtained by age, sex and area-based socioeconomic position. Findings: There was no evidence to suggest that the Alcohol Act was associated with changes in the overall rate of alcohol-related deaths [incidence rate ratio (IRR) 0.99, 95% confidence interval (0.91 to 1.07)] or hospital admissions [IRR 0.98 (0.95 to 1.02)] in Scotland. In control group analyses, the pseudo intervention variable was not associated with a change in alcohol-related death rates in England/Wales [IRR 0.99 (0.95 to 1.02)], but was associated with an increase in alcohol-related hospital admission rates in England [IRR 1.05 (1.03 to 1.07)]. In combined models, the interaction analysis did not provide support for a ‘net effect’ of the legislation on alcohol-related deaths in Scotland compared with England/Wales [IRR 0.99 (0.95 to 1.04)], but suggested a net reduction in hospital admissions for Scotland compared with England [IRR 0.93 (0.87 to 0.98)]. Conclusion: The implementation of the Alcohol Act in Scotland has not been associated clearly with a reduction in alcohol-related deaths or hospital admissions in the 3-year period after it was implemented in October 2011

Evaluating a discharge medication delivery service: a return on investment study and a pilot trial

Background: Many patients discharged from the hospital do not appropriately fill their discharge medications. At Boston Medical Center, an urban safety net facility, a bedside discharge medication delivery service was pilot tested in 2012 to ensure pediatric patients with asthma left in possession of their new medications. The service was expanded to all pediatric discharges in 2013. It is unknown whether beside delivery increases the proportion of written prescriptions captured by the hospital-owned pharmacy or if the service achieves a positive return on investment. Whether such a service improves patients’ satisfaction, medication adherence, or clinical outcomes is also unknown. Methods: Two primary methodologies were used to evaluate the impact of this novel service. The first evaluated the relative risk of filling a prescription in the hospital- owned pharmacy after the expansion of delivery eligibility criteria using two years of discharge prescription information, corresponding pharmacy fill data, and a hierarchical model with generalized estimating equations (GEE) to account for non-independent events. Initial patient-level impacts of the delivery service were evaluated through a pilot randomized controlled trial to test logistics and obtain empiric estimates of study parameters. Results: Patients were 1.44 times more likely to fill a medication at the hospital- owned pharmacy providing the delivery service after the intervention (95%CI 1.3-1.59). The increased profit generated by prescriptions captured as a result of offering the delivery service is estimated to be equivalent to 8-15% of a pharmacist full-time- equivalent (FTE), whereas only 3% of an FTE was required to provide the service, indicating a positive return on investment. Pilot study data suggest families did not differ significantly with regards to perceived satisfaction or reported outcomes whether randomized to usual care or delivery. Conclusion: A service to deliver discharge medications can yield a positive return on investment, allowing an institution to offset uncompensated care. To further study the intervention, a trial with randomization at the level of the ward or institution is needed.2017-10-02T00:00:00

A Reinforcement Learning Approach to Weaning of Mechanical Ventilation in Intensive Care Units

The management of invasive mechanical ventilation, and the regulation of sedation and analgesia during ventilation, constitutes a major part of the care of patients admitted to intensive care units. Both prolonged dependence on mechanical ventilation and premature extubation are associated with increased risk of complications and higher hospital costs, but clinical opinion on the best protocol for weaning patients off of a ventilator varies. This work aims to develop a decision support tool that uses available patient information to predict time-to-extubation readiness and to recommend a personalized regime of sedation dosage and ventilator support. To this end, we use off-policy reinforcement learning algorithms to determine the best action at a given patient state from sub-optimal historical ICU data. We compare treatment policies from fitted Q-iteration with extremely randomized trees and with feedforward neural networks, and demonstrate that the policies learnt show promise in recommending weaning protocols with improved outcomes, in terms of minimizing rates of reintubation and regulating physiological stability

Comparative Effectiveness of Step-up Therapies in Children with Asthma Prescribed Inhaled Corticosteroids : A Historical Cohort Study

This work was supported by the Respiratory Effectiveness Group. Acknowledgments We thank the Respiratory Effectiveness Group for funding this work, Annie Burden for assistance with statistics, and Simon Van Rysewyk and Lisa Law for assistance with medical writing.Peer reviewedPostprin

An evaluation of exact matching and propensity score methods as applied in a comparative effectiveness study of inhaled corticosteroids in asthma

Peer reviewedPublisher PD

A structural equation model of adverse events and length of stay in hospitals

Adverse events in hospitals cause significant morbidity and mortality, and considerable effort has been invested into analysing their incidence and preventability. An unresolved issue in models of medical adverse events is potential endogeneity of length of stay (LOS): whilst the probability of suffering a medical adverse event during the episode is likely to increase as a patient stays longer, there are a range of unobservable patient and hospital factors affecting both the occurrence of adverse events and LOS, such as unobserved patient complexity and hospital management. Therefore, statistical models of adverse events which do not account for the potential endogeneity of LOS may generate biased estimates. Our objective is to examine the effects of risk factors on the incidence of adverse events using structural equation models and accounting for endogeneity of LOS. We estimate separate models for three of the most common and serious types of medical adverse events: adverse drug reactions, hospital acquired infections, and pressure ulcers. We use episode level administrative hospital data from public hospitals in the state of Victoria, Australia, for the years 2004/05 and 2005/06 with detailed information on patients, in particular medical complexity and adverse events suffered during admission. We use days and months of discharge as instruments for LOS. Our research helps assessing the costs and benefits of additional days spent in hospital. For example, it can contribute to identifying the ideal time of discharge of patients, or inform whether 'hospital at home' programs reduce rates of hospital acquired infections.Medical errors, complications of care, adverse drug reactions, infections, ulcers, hospital quality