Watching Hands in the Cookie Jar: A Project for Improving Medication Charge Capture in the Operating Room

Introduction: With the high cost of healthcare in the United States, there have been attempts to identify waste (1). In our anesthesia department, vials or syringes of non-controlled medications are not checked out individually from a pharmacist. Rather, they are removed from a medication housing machine (BD Pyxis Anesthesia Station ED™) before and during a case based on an honor system. The provider logs into the Pyxis system and then has access to any medication in that reservoir. When an individual medication is removed, a button has to be pressed on a screen to register its removal. Anyone who has electronic access to the Pyxis system may log in and withdraw a medication, potentially without documenting the removal. Our current system tracks medication use based on those documented as being removed from the Pyxis, and thus if a medication has not been “checked out”, it will not be billed. Feedback and Audit is a tool that can be utilized to change provider behavior (3) and potentially decrease medication discrepancies. Below, we describe the results of implementing such a tool, evaluating change in behavior, and the cost savings of doing so. Problem: For the calendar year of 2018, there were 20,421 cases performed with an estimated loss per case of $11.49. There is currently no incentive for correct practice, nor repercussion for failing to “check out” a medication from the Pyxis machine. Our pharmacy department follows these costs and losses, and has provided feedback to determine overall lost revenue. Methodology: Using the electronic anesthesia record, all non-controlled medications that were documented as administered to the patient were analyzed, regardless of amount of medication that was administered. Any provider who was documented as a care provider on the chart was listed as a person that may have administered the drug. We included cases performed in the operating rooms of the main hospital, labor and delivery, BBRP (pediatric), and the Outpatient Surgical and Imaging Center (OSIS) for a total of 31 anesthetic sites. Exclusion criteria included emergency cases (ASA class “E”), controlled medications, as well as anesthetics provided in sites other than those listed above (e.g. SRMC or CCOR). Data was extracted using name-identified information. Using the average wholesale price (AWP) of the medications for the month of September 2019, we calculated the estimated lost revenue. We then calculated the mean percentage of medication dispensing discrepancy, and compared this with the habits of all anesthesia providers. Starting in January of 2019, this information was published on a slideshow that is displayed on an electronic announcement board in the anesthesiology break room, enabling providers to see how their practices compared with their peers’. After three months, there was a plateau in behavior. The residency director and director of the Advanced Practice Providers were then asked to send individual emails to the providers whose compliance was two standard deviations below the mean behavior in an attempt to improve compliance. Results: For the calendar year of 2018, there were 20,421 cases performed in the above-mentioned operating rooms. The estimated loss per case was$11.49. For the months of November and December of 2018, there was an average provider baseline compliance rate of 77.76% for checking out medications. For the calendar year 2019, there were 21,290 cases performed in those operating rooms, with an estimated loss per case of $5.06. From November to December of 2019, there was an average provider compliance rate of 82.16$127,000. Discussion: It is estimated that the cost of United States healthcare approaches 18% gross domestic product, and up to 30% of this may be waste (2). In the field of anesthesiology, other institutions have looked at ways to reduce waste and overall expenditure (1), and have attempted to utilize a similar Feedback and Audit tool (5). Changing provider behavior can be difficult. Some of the most effective methods for changing behavior can also be the most effective (3). A Cochrane review looking at the effects on professional practice when using an Audit and Feedback system showed a median risk difference of 4.3% (4). Using an electronic slideshow with the published names of anesthesia providers and their compliance rates, we were able to demonstrate a similar improvement of dispensing practice of 4.4%, which correlated to a cost savings of $6.54 per case, averaged over 21,290 cases, and an estimated calendar-year cost savings of$127,000. It is interesting to note that this degree of improvement correlated with a cost savings of 38.9%. One possible explanation for the initial poor compliance rate of 77.76% is the design of the Pyxis system, and the need for multiple steps to register removal of a medication. This problem would best be addressed from a machine that was designed to follow expected provider behavior and workflow naturally. Limitations of this analysis include unintentional exclusion of certain medications that are commonly utilized, as well as including medications that are not stored in the Pyxis dispenser. Limitations to this review include sustainability, as one institution that utilized an Audit and Feedback tool demonstrated a downward trend in compliance in the post-intervention time frame (5). References: Rinehardt E, Sivarajan M. Costs and wastes in anesthesia care. Current Opinion in Anaesthesiology. 2002;25(2):221-225 Chrank W, Rogstad T, Parekh N. Waste in the US Health Care System: Estimated Costs and Potential for Savings. Journal of the American Medical Association. 2019;322(15):1501-1509 Trowbridge R, Weingarten S. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Chapter 54. Educational Techniques Used in Changing Provider Behavior. https://archive.ahrq.gov/clinic/ptsafety/chap54.htm Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, O\u27Brien MA, Johansen M, Grimshaw J, Oxman AD. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews 2012, Issue 6. Bowdle T, Jelacic S, Nair B, et al. Improve Anesthesia Provider Compliance with a Barcode-Based Drug Safety System. Anesthesia and Analgesia. 2019:129(2)418-425

Dementia and Traffic Accidents:A Danish Register-Based Cohort Study

BACKGROUND: As a consequence of a rapid growth of an ageing population, more people with dementia are expected on the roads. Little is known about whether these people are at increased risk of road traffic-related accidents. OBJECTIVE: Our study aims to investigate the risk of road traffic-related accidents for people aged 65 years or older with a diagnosis of dementia in Denmark. METHODS: We will conduct a nationwide population-based cohort study consisting of Danish people aged 65 or older living in Denmark as of January 1, 2008. The cohort is followed for 7 years (2008-2014). Individual’s personal data are available in Danish registers and can be linked using a unique personal identification number. A person is identified with dementia if the person meets at least one of the following criteria: (1) a diagnosis of the disease in the Danish National Patient Register or in the Danish Psychiatric Central Research Register, and/or (2) at least one dementia diagnosis-related drug prescription registration in the Danish National Prescription Registry. Police-, hospital-, and emergency room-reported road traffic-related accidents occurred within the study follow-up are defined as the study outcome. Cox proportional hazard regression models are used for the main analysis. RESULTS: Our study protocol has 3 phases including data collection, data analysis, and reporting. The first phase of register-based data collection of 853,228 individual’s personal information was completed in August, 2016. The next phase is data analysis, which is expected to be finished before December 2016, and thereafter writing publications based on the findings. The study started in January 2016 and will end in December 2018. DISCUSSION: This study covers the entire elderly population of Denmark, and thereby will avoid selection bias due to nonparticipation and loss to follow-up. Furthermore, this ensures that the study results are reliable and generalizable. However, underreporting of traffic-related accidents may occur, which will limit estimation of absolute risks

Upregulation of Mrps18a in breast cancer identified by selecting phage antibody libraries on breast tissue sections

Abstract Background One of the hallmarks of cancer is an altered energy metabolism, and here, mitochondria play a central role. Previous studies have indicated that some mitochondrial ribosomal proteins change their expression patterns upon transformation. Method In this study, we have used the selection of recombinant antibody libraries displayed on the surface of filamentous bacteriophage as a proteomics discovery tool for the identification of breast cancer biomarkers. A small subpopulation of breast cells expressing both cytokeratin 19 and cytokeratin 14 was targeted using a novel selection procedure. Results We identified the mitochondrial ribosomal protein s18a (Mrps18a) as a protein which is upregulated in breast cancer. However, Mrps18a was not homogeneously upregulated in all cancer cells, suggesting the existence of sub-populations within the tumor. The upregulation was not confined to cytokeratin 19 and cytokeratin 14 double positive cells. Conclusion This study illustrates how phage display can be applied towards the discovery of proteins which exhibit changes in their expression patterns. We identified the mitochondrial protein Mrps18a as being upregulated in human breast cancer cells compared to normal breast cells

Klimabedingte Zwangsmigration: Ein Blick aus der Praxis

IHC controls. a–c, Example of control staining with secondary antibody Anti-C-Myc-Cy3 (red) alone, on cancer tissue (P757). From left to right the pictures show immunofluorescence in the blue, green and red range respectively. d–e, Example of control staining with the scFv antibody epsilon, which also was used as a negative control during screening and validation of selected antibodies. From left to right the pictures show immunofluorescence in the blue, green and red range respectively. (TIF 4987 kb

Circumcision of Male Children for Reduction of Future Risk for HIV: Acceptability among HIV Serodiscordant Couples in Kampala, Uganda

The ultimate success of medical male circumcision for HIV prevention may depend on targeting male infants and children as well as adults, in order to maximally reduce new HIV infections into the future.We conducted a cross-sectional study among heterosexual HIV serodiscordant couples (a population at high risk for HIV transmission) attending a research clinic in Kampala, Uganda on perceptions and attitudes about medical circumcision for male children for HIV prevention. Correlates of willingness to circumcise male children were assessed using generalized estimating equations methods.318 HIV serodiscordant couples were interviewed, 51.3% in which the female partner was HIV uninfected. Most couples were married and cohabiting, and almost 50% had at least one uncircumcised male child of ≤18 years of age. Overall, 90.2% of male partners and 94.6% of female partners expressed interest in medical circumcision for their male children for reduction of future risk for HIV infection, including 79.9% of men and 87.6% of women who had an uncircumcised male child. Among both men and women, those who were knowledgeable that circumcision reduces men's risk for HIV (adjusted prevalence ratio [APR] 1.34 and 1.14) and those who had discussed the HIV prevention effects of medical circumcision with their partner (APR 1.08 and 1.07) were significantly (p≤0.05) more likely to be interested in male child circumcision for HIV prevention. Among men, those who were circumcised (APR 1.09, p = 0.004) and those who were HIV seropositive (APR 1.09, p = 0.03) were also more likely to be interested in child circumcision for HIV prevention.A high proportion of men and women in Ugandan heterosexual HIV serodiscordant partnerships were willing to have their male children circumcised for eventual HIV prevention benefits. Engaging both parents may increase interest in medical male circumcision for HIV prevention

Healthy Cities Phase V evaluation: further synthesizing realism

In this article we reflect on the quality of a realist synthesis paradigm applied to the evaluation of Phase V of the WHO European Healthy Cities Network. The programmatic application of this approach has led to very high response rates and a wealth of important data. All articles in this Supplement report that cities in the network move from small-scale, time-limited projects predominantly focused on health lifestyles to the significant inclusion of policies and programmes on systems and values for good health governance. The evaluation team felt that, due to time and resource limitations, it was unable to fully exploit the potential of realist synthesis. In particular, the synthetic integration of different strategic foci of Phase V designation areas did not come to full fruition. We recommend better and more sustained integration of realist synthesis in the practice of Healthy Cities in future Phase

First Reported Prairie Dog–to-Human Tularemia Transmission, Texas, 2002

A tularemia outbreak, caused by Francisella tularensis type B, occurred among wild-caught, commercially traded prairie dogs. F. tularensis microagglutination titers in one exposed person indicated recent infection. These findings represent the first evidence for prairie-dog-to-human tularemia transmission and demonstrate potential human health risks of the exotic pet trade

Laboratory Analysis of Tularemia in Wild-Trapped, Commercially Traded Prairie Dogs, Texas, 2002

Oropharyngeal tularemia was identified as the cause of a die-off in captured wild prairie dogs at a commercial exotic animal facility in Texas. From this point source, Francisella tularensis–infected prairie dogs were traced to animals distributed to the Czech Republic and to a Texas pet shop. F. tularensis culture isolates were recovered tissue specimens from 63 prairie dogs, including one each from the secondary distribution sites. Molecular and biochemical subtyping indicated that all isolates were F. tularensis subsp. holarctica (Type B). Microagglutination assays detected antibodies against F. tularensis, with titers as great as 1:4,096 in some live animals. All seropositive animals remained culture positive, suggesting that prairie dogs may act as chronic carriers of F. tularensis. These findings demonstrate the need for additional studies of tularemia in prairie dogs, given the seriousness of the resulting disease, the fact that prairie dogs are sold commercially as pets, and the risk for pet-to-human transmission