The steps that hospitalists can take to effect change in their home institutions will be the focus of Tuesday morning’s session at 10:35–11:15 a.m., “Overcoming a Culture Overrun with Overuse.”
“Overuse is one of the [biggest] issues that we’re facing right now in health care,” said presenter Christopher Moriates, MD, assistant dean for health care value at the University of Texas at Austin. “The estimates are that about a third of what we do in health care is unnecessary. If you look at areas like lab testing in hospitals, it might be even more than that.”
Dr. Christopher MoriatesAlthough it is clearly imperative for hospitalists to provide high-value care, there has been relatively limited progress toward truly decreasing overuse, Dr. Moriates said. Creating lists and guidelines from the Choosing Wisely campaign, which questions unnecessary medical tests and procedures, is “incredibly important but insufficient.”
“We must also address our medical culture that, through many different mechanisms, reinforces overuse,” he added. “The way we’re trained, the way we think about addressing problems in the hospital, the way that hospitals are set up and organized – all of these things contribute to us ordering more tests or doing more things.”
The session will discuss culture change as a general concept and introduce a framework for understanding and targeting culture change. The presentation also will demonstrate how culture contributes to overuse and low-value care, describe specific interventions that support culture change, and define opportunities to ensure the delivery of high-value care to patients.
One initiative to be discussed is Caring Wisely, which Dr. Moriates helped implement in 2012 at the University of California, San Francisco. The program takes the ideals of Choosing Wisely and, by crowdsourcing among front-line hospital staff, looks for ways to cut health care waste.
“We will highlight specific examples for how hospitalists can lead programs and work with others to decrease overuse, even within other departments,” Dr. Moriates said. “For example, we will discuss a successful resident-led program to decrease phlebotomy rates in the hospital, which can be replicated by other medical center or resident groups.”
Hospitalists at any level, in any setting, can help contribute to culture change, either by mimicking programs like Caring Wisely or by implementing simple changes in the way we speak to patients and each other.
“Every time we make decisions and we have conversations with patients, trainees, or consultants, we have the ability to either contribute to or take away from that culture of overuse,” Dr. Moriates said. “We’ll also discuss how hospitalists can lead efforts to organize multidisciplinary teams around decreasing common areas of overuse.”
On all levels, hospitalists have an important role to play. “We should all recognize that we lead from where we stand, no matter what our position or title may be,” Dr. Moriates said.
Overcoming a Culture Overrun with Overuse Tuesday, 10:35 a.m.-11:15 a.m.
The steps that hospitalists can take to effect change in their home institutions will be the focus of Tuesday morning’s session at 10:35–11:15 a.m., “Overcoming a Culture Overrun with Overuse.”
“Overuse is one of the [biggest] issues that we’re facing right now in health care,” said presenter Christopher Moriates, MD, assistant dean for health care value at the University of Texas at Austin. “The estimates are that about a third of what we do in health care is unnecessary. If you look at areas like lab testing in hospitals, it might be even more than that.”
Dr. Christopher MoriatesAlthough it is clearly imperative for hospitalists to provide high-value care, there has been relatively limited progress toward truly decreasing overuse, Dr. Moriates said. Creating lists and guidelines from the Choosing Wisely campaign, which questions unnecessary medical tests and procedures, is “incredibly important but insufficient.”
“We must also address our medical culture that, through many different mechanisms, reinforces overuse,” he added. “The way we’re trained, the way we think about addressing problems in the hospital, the way that hospitals are set up and organized – all of these things contribute to us ordering more tests or doing more things.”
The session will discuss culture change as a general concept and introduce a framework for understanding and targeting culture change. The presentation also will demonstrate how culture contributes to overuse and low-value care, describe specific interventions that support culture change, and define opportunities to ensure the delivery of high-value care to patients.
One initiative to be discussed is Caring Wisely, which Dr. Moriates helped implement in 2012 at the University of California, San Francisco. The program takes the ideals of Choosing Wisely and, by crowdsourcing among front-line hospital staff, looks for ways to cut health care waste.
“We will highlight specific examples for how hospitalists can lead programs and work with others to decrease overuse, even within other departments,” Dr. Moriates said. “For example, we will discuss a successful resident-led program to decrease phlebotomy rates in the hospital, which can be replicated by other medical center or resident groups.”
Hospitalists at any level, in any setting, can help contribute to culture change, either by mimicking programs like Caring Wisely or by implementing simple changes in the way we speak to patients and each other.
“Every time we make decisions and we have conversations with patients, trainees, or consultants, we have the ability to either contribute to or take away from that culture of overuse,” Dr. Moriates said. “We’ll also discuss how hospitalists can lead efforts to organize multidisciplinary teams around decreasing common areas of overuse.”
On all levels, hospitalists have an important role to play. “We should all recognize that we lead from where we stand, no matter what our position or title may be,” Dr. Moriates said.
Overcoming a Culture Overrun with Overuse Tuesday, 10:35 a.m.-11:15 a.m.
The steps that hospitalists can take to effect change in their home institutions will be the focus of Tuesday morning’s session at 10:35–11:15 a.m., “Overcoming a Culture Overrun with Overuse.”
“Overuse is one of the [biggest] issues that we’re facing right now in health care,” said presenter Christopher Moriates, MD, assistant dean for health care value at the University of Texas at Austin. “The estimates are that about a third of what we do in health care is unnecessary. If you look at areas like lab testing in hospitals, it might be even more than that.”
Dr. Christopher MoriatesAlthough it is clearly imperative for hospitalists to provide high-value care, there has been relatively limited progress toward truly decreasing overuse, Dr. Moriates said. Creating lists and guidelines from the Choosing Wisely campaign, which questions unnecessary medical tests and procedures, is “incredibly important but insufficient.”
“We must also address our medical culture that, through many different mechanisms, reinforces overuse,” he added. “The way we’re trained, the way we think about addressing problems in the hospital, the way that hospitals are set up and organized – all of these things contribute to us ordering more tests or doing more things.”
The session will discuss culture change as a general concept and introduce a framework for understanding and targeting culture change. The presentation also will demonstrate how culture contributes to overuse and low-value care, describe specific interventions that support culture change, and define opportunities to ensure the delivery of high-value care to patients.
One initiative to be discussed is Caring Wisely, which Dr. Moriates helped implement in 2012 at the University of California, San Francisco. The program takes the ideals of Choosing Wisely and, by crowdsourcing among front-line hospital staff, looks for ways to cut health care waste.
“We will highlight specific examples for how hospitalists can lead programs and work with others to decrease overuse, even within other departments,” Dr. Moriates said. “For example, we will discuss a successful resident-led program to decrease phlebotomy rates in the hospital, which can be replicated by other medical center or resident groups.”
Hospitalists at any level, in any setting, can help contribute to culture change, either by mimicking programs like Caring Wisely or by implementing simple changes in the way we speak to patients and each other.
“Every time we make decisions and we have conversations with patients, trainees, or consultants, we have the ability to either contribute to or take away from that culture of overuse,” Dr. Moriates said. “We’ll also discuss how hospitalists can lead efforts to organize multidisciplinary teams around decreasing common areas of overuse.”
On all levels, hospitalists have an important role to play. “We should all recognize that we lead from where we stand, no matter what our position or title may be,” Dr. Moriates said.
Overcoming a Culture Overrun with Overuse Tuesday, 10:35 a.m.-11:15 a.m.
As clinicians who have been in practice for even a relatively short period of time know, patient compliance is an integral aspect of achieving optimal patient outcomes. However, studies show that patient compliance with treatment of many dermatologic disorders, including acne and psoriasis, is often poor.1,2
In 2007, Feldman showed that patients are more likely to use their products in the days before and the days after their dermatologist visit.3 He suggested that more frequent office visits would boost compliance. I have found that this is true and I recommend seeing patients every 4 weeks when implementing a new treatment regimen. I have also found that combining prescription medications with the proper corresponding skin care products helps decrease side effects and speed results when patients apply the products correctly.
Dr. Leslie S. Baumann
To increase the chance of patients using the products correctly, they should be educated about how and when to use the products. I cannot overemphasize the importance of this, as illustrated by the following story of a patient who came in with facial redness and irritation. Upon questioning, I learned that she was using her facial cleanser but was not washing it off and left it on all day. She said, “No one told me to wash it off!” While washing a cleanser off may seem obvious, cultural, gender, ethnic, and geographical differences can lead to misunderstandings.
The problem with patient education is that it takes time. It is best if education is provided by staff, but keeping them trained and up to date is also difficult. Most dermatologists only have 3-5 minutes per patient so streamlining the process of designing a treatment plan and educating the patient and recruiting your staff to help is crucial. Before I discuss how to streamline the process, let’s first look at our goals for patients.
To achieve good patient outcomes, the patient needs to:
Understand what medications and products to use.
Understand when and how to use the products.
Understand the order in which to use the products (step 1, step 2, etc.).
Purchase the products (from you or elsewhere).
Tell you if they do not purchase the products, for whatever reason (insurance will not cover, too expensive, could not find them, etc.).
Use the products consistently.
Inform you if they do not use the products (too busy, did not have them on a trip, etc.).
Report any side effects so you can adjust the therapy accordingly.
You can see why it is so difficult to get patients to be compliant. Many factors – such as time, memory, education level, understanding, motivation, cost, convenience, and insurance coverage – can get in the way of these important components. Giving patients a printed regimen with instructions, selling the products in your practice, and providing some sort of interaction to keep patients engaged is key. In my June 2015 Dermatology News column, I discussed why you should consider selling products in your practice. In the future, I will discuss ways to engage your patients, but for now, let’s focus on how to quickly and effectively provide your patients with printed regimens and patient instructions without increasing office visit times.
Streamlining the Process of Generating a Skin Care Regimen That Includes Prescription Medications
Identify patients’ phenotypes
Divide patients into phenotypes based on skin care needs to save yourself time with the recommendation process.
Many doctors do this with a disease-based approach, such as acne, rosacea, eczema, psoriasis, etc. I prefer to classify my patients according to 16 Baumann Skin Types based on four parameters: hydration status, propensity for inflammation; presence or absence of uneven pigmentation; and presence of lifestyle habits, such as sun exposure, that increase an individual’s risk of skin aging.4,5,6 To quickly diagnose the patient as a particular Baumann Skin Type, I use a tablet-based validated questionnaire called the Baumann Skin Type Indicator (BSTI).7 This questionnaire is self-administered by the patient in the waiting room and serves several purposes that facilitate my practice:
To collect historical and current data.
To diagnose skin type.
To ask specifically about skin allergies.
To learn preferences such as tinted vs. nontinted, or chemical vs. physical sunscreen.
To inquire about what issues the patient wants to discuss, such as thinning eyelashes, hair loss, dry body skin, toenail fungus, warts, eczema, and other topics that might not come up during the appointment.
To learn and document habits that affect the skin, such as tanning bed exposure, sun exposure, and smoking.
To stimulate the patient to think about how daily actions such as sunscreen use and sun exposure affect their skin health.
Whether you choose to use my questionnaire or one of your own, using a validated method that can be initiated by staff in the waiting room saves time in the exam room.
Include prescription medications in the skin care regimen
Often, we think of skin care regimens and prescription medications as two different entities. In actuality, these should be combined.
For example, when treating acne, every item the patient uses plays a role. For example, if they are washing the face with Ivory soap and then applying benzoyl peroxide and a retinoid they will experience dryness and irritation. Then they will buy a moisturizer that might cause acne. (It is very hard for them to know which moisturizers and sunscreens will not worsen acne). By providing them with the exact names of cleansers, moisturizers, and sunscreens to use, they will be better able to tolerate their prescription acne medications.
The same is true with psoriasis, eczema, seborrheic dermatitis, contact dermatitis, and most of the other ailments that dermatologists treat. You must also tell them the order to use them in. For example, I always have patients apply the retinoid over the noncomedogenic moisturizer for the first few weeks to help them adjust to the retinoid. Later, once they have passed the high-risk period of retinoid dermatitis, I move the retinoid to under the moisturizer.
Psoriasis treatment (topical) is another good example. If they are going to use a surfactant-laden soap on their skin, they will impair their barrier and absorb more of the topically applied drug. Conversely, if they use a barrier repair moisturizer, they will absorb less. Telling the patients exactly which body cleansers and moisturizers to use with topical psoriasis medications will help standardize the response. For this reason, giving patients printed regimens is not limited to treatment of acne, rosacea, and photoaging, but rather should be done for patients with all skin issues and phenotypes.
Have informational material for each phenotype at your fingertips
You can have a plan for each patient phenotype that is designed ahead of time. You will save yourself hours of time if you have preprinted instructions sheets made for each of these phenotypes. You can use Touch MD, The Canfield Visia Camera Patient Portal, your EMR, or other systems to organize this material and deliver it to patients.
I personally use the Skin Type Solutions Software System (STSFranchise.com) that I developed and patented to house and export my patient instructions. Using a standardized methodology to provide educational information through video, preprinted sheets, emails, and other methods allows you to educate your patients at their pace and in the media with which they are most comfortable. To have this flexibility, the educational information must be developed prior to the patient visit. Categorizing the education information by phenotype makes this possible.
What the informational material should contain
Educational information should include important information about the phenotype, the do’s and don’ts for the phenotype, an exact skin care regimen containing clear steps that include product names including brand names, prescription medications, the order in which the products should be applied, and clear instructions on how to use the products.
The patient should be informed about what to do if anticipated adverse events occur, such as redness and peeling from retinoids or dryness from benzoyl peroxide. The same is true about injectable biologic medications for psoriasis. The patients need information on where to inject the product, how often, how to clean the skin beforehand, and what to put on the skin after the injections. It is always important with any skin issue for the patient to know when to contact the office. The American Academy of Dermatology and other organizations offer educational brochures for patients, but they cannot be customized. Patients prefer a customized approach to educational material. They don’t want to read information that does not apply to them. I have found that dividing patients into 16 distinct Baumann Skin Types helps target the right information to the corresponding skin phenotypes.
Summary
Patients need education and guidance to be compliant and improve their outcomes. Your staff needs to be a part of the education process, but taking the time to train your staff and educate your patients is always an issue. Developing a standardized methodology will help overcome these hurdles and solve this problem. The methodology should provide directed education and clear communication with written instructions delivered in the media of the patient’s choice. Doing this will yield better compliance and outcomes.
If you have any questions, suggestions or ideas of how to solve these issues, please share them with me at [email protected].
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
As clinicians who have been in practice for even a relatively short period of time know, patient compliance is an integral aspect of achieving optimal patient outcomes. However, studies show that patient compliance with treatment of many dermatologic disorders, including acne and psoriasis, is often poor.1,2
In 2007, Feldman showed that patients are more likely to use their products in the days before and the days after their dermatologist visit.3 He suggested that more frequent office visits would boost compliance. I have found that this is true and I recommend seeing patients every 4 weeks when implementing a new treatment regimen. I have also found that combining prescription medications with the proper corresponding skin care products helps decrease side effects and speed results when patients apply the products correctly.
Dr. Leslie S. Baumann
To increase the chance of patients using the products correctly, they should be educated about how and when to use the products. I cannot overemphasize the importance of this, as illustrated by the following story of a patient who came in with facial redness and irritation. Upon questioning, I learned that she was using her facial cleanser but was not washing it off and left it on all day. She said, “No one told me to wash it off!” While washing a cleanser off may seem obvious, cultural, gender, ethnic, and geographical differences can lead to misunderstandings.
The problem with patient education is that it takes time. It is best if education is provided by staff, but keeping them trained and up to date is also difficult. Most dermatologists only have 3-5 minutes per patient so streamlining the process of designing a treatment plan and educating the patient and recruiting your staff to help is crucial. Before I discuss how to streamline the process, let’s first look at our goals for patients.
To achieve good patient outcomes, the patient needs to:
Understand what medications and products to use.
Understand when and how to use the products.
Understand the order in which to use the products (step 1, step 2, etc.).
Purchase the products (from you or elsewhere).
Tell you if they do not purchase the products, for whatever reason (insurance will not cover, too expensive, could not find them, etc.).
Use the products consistently.
Inform you if they do not use the products (too busy, did not have them on a trip, etc.).
Report any side effects so you can adjust the therapy accordingly.
You can see why it is so difficult to get patients to be compliant. Many factors – such as time, memory, education level, understanding, motivation, cost, convenience, and insurance coverage – can get in the way of these important components. Giving patients a printed regimen with instructions, selling the products in your practice, and providing some sort of interaction to keep patients engaged is key. In my June 2015 Dermatology News column, I discussed why you should consider selling products in your practice. In the future, I will discuss ways to engage your patients, but for now, let’s focus on how to quickly and effectively provide your patients with printed regimens and patient instructions without increasing office visit times.
Streamlining the Process of Generating a Skin Care Regimen That Includes Prescription Medications
Identify patients’ phenotypes
Divide patients into phenotypes based on skin care needs to save yourself time with the recommendation process.
Many doctors do this with a disease-based approach, such as acne, rosacea, eczema, psoriasis, etc. I prefer to classify my patients according to 16 Baumann Skin Types based on four parameters: hydration status, propensity for inflammation; presence or absence of uneven pigmentation; and presence of lifestyle habits, such as sun exposure, that increase an individual’s risk of skin aging.4,5,6 To quickly diagnose the patient as a particular Baumann Skin Type, I use a tablet-based validated questionnaire called the Baumann Skin Type Indicator (BSTI).7 This questionnaire is self-administered by the patient in the waiting room and serves several purposes that facilitate my practice:
To collect historical and current data.
To diagnose skin type.
To ask specifically about skin allergies.
To learn preferences such as tinted vs. nontinted, or chemical vs. physical sunscreen.
To inquire about what issues the patient wants to discuss, such as thinning eyelashes, hair loss, dry body skin, toenail fungus, warts, eczema, and other topics that might not come up during the appointment.
To learn and document habits that affect the skin, such as tanning bed exposure, sun exposure, and smoking.
To stimulate the patient to think about how daily actions such as sunscreen use and sun exposure affect their skin health.
Whether you choose to use my questionnaire or one of your own, using a validated method that can be initiated by staff in the waiting room saves time in the exam room.
Include prescription medications in the skin care regimen
Often, we think of skin care regimens and prescription medications as two different entities. In actuality, these should be combined.
For example, when treating acne, every item the patient uses plays a role. For example, if they are washing the face with Ivory soap and then applying benzoyl peroxide and a retinoid they will experience dryness and irritation. Then they will buy a moisturizer that might cause acne. (It is very hard for them to know which moisturizers and sunscreens will not worsen acne). By providing them with the exact names of cleansers, moisturizers, and sunscreens to use, they will be better able to tolerate their prescription acne medications.
The same is true with psoriasis, eczema, seborrheic dermatitis, contact dermatitis, and most of the other ailments that dermatologists treat. You must also tell them the order to use them in. For example, I always have patients apply the retinoid over the noncomedogenic moisturizer for the first few weeks to help them adjust to the retinoid. Later, once they have passed the high-risk period of retinoid dermatitis, I move the retinoid to under the moisturizer.
Psoriasis treatment (topical) is another good example. If they are going to use a surfactant-laden soap on their skin, they will impair their barrier and absorb more of the topically applied drug. Conversely, if they use a barrier repair moisturizer, they will absorb less. Telling the patients exactly which body cleansers and moisturizers to use with topical psoriasis medications will help standardize the response. For this reason, giving patients printed regimens is not limited to treatment of acne, rosacea, and photoaging, but rather should be done for patients with all skin issues and phenotypes.
Have informational material for each phenotype at your fingertips
You can have a plan for each patient phenotype that is designed ahead of time. You will save yourself hours of time if you have preprinted instructions sheets made for each of these phenotypes. You can use Touch MD, The Canfield Visia Camera Patient Portal, your EMR, or other systems to organize this material and deliver it to patients.
I personally use the Skin Type Solutions Software System (STSFranchise.com) that I developed and patented to house and export my patient instructions. Using a standardized methodology to provide educational information through video, preprinted sheets, emails, and other methods allows you to educate your patients at their pace and in the media with which they are most comfortable. To have this flexibility, the educational information must be developed prior to the patient visit. Categorizing the education information by phenotype makes this possible.
What the informational material should contain
Educational information should include important information about the phenotype, the do’s and don’ts for the phenotype, an exact skin care regimen containing clear steps that include product names including brand names, prescription medications, the order in which the products should be applied, and clear instructions on how to use the products.
The patient should be informed about what to do if anticipated adverse events occur, such as redness and peeling from retinoids or dryness from benzoyl peroxide. The same is true about injectable biologic medications for psoriasis. The patients need information on where to inject the product, how often, how to clean the skin beforehand, and what to put on the skin after the injections. It is always important with any skin issue for the patient to know when to contact the office. The American Academy of Dermatology and other organizations offer educational brochures for patients, but they cannot be customized. Patients prefer a customized approach to educational material. They don’t want to read information that does not apply to them. I have found that dividing patients into 16 distinct Baumann Skin Types helps target the right information to the corresponding skin phenotypes.
Summary
Patients need education and guidance to be compliant and improve their outcomes. Your staff needs to be a part of the education process, but taking the time to train your staff and educate your patients is always an issue. Developing a standardized methodology will help overcome these hurdles and solve this problem. The methodology should provide directed education and clear communication with written instructions delivered in the media of the patient’s choice. Doing this will yield better compliance and outcomes.
If you have any questions, suggestions or ideas of how to solve these issues, please share them with me at [email protected].
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
As clinicians who have been in practice for even a relatively short period of time know, patient compliance is an integral aspect of achieving optimal patient outcomes. However, studies show that patient compliance with treatment of many dermatologic disorders, including acne and psoriasis, is often poor.1,2
In 2007, Feldman showed that patients are more likely to use their products in the days before and the days after their dermatologist visit.3 He suggested that more frequent office visits would boost compliance. I have found that this is true and I recommend seeing patients every 4 weeks when implementing a new treatment regimen. I have also found that combining prescription medications with the proper corresponding skin care products helps decrease side effects and speed results when patients apply the products correctly.
Dr. Leslie S. Baumann
To increase the chance of patients using the products correctly, they should be educated about how and when to use the products. I cannot overemphasize the importance of this, as illustrated by the following story of a patient who came in with facial redness and irritation. Upon questioning, I learned that she was using her facial cleanser but was not washing it off and left it on all day. She said, “No one told me to wash it off!” While washing a cleanser off may seem obvious, cultural, gender, ethnic, and geographical differences can lead to misunderstandings.
The problem with patient education is that it takes time. It is best if education is provided by staff, but keeping them trained and up to date is also difficult. Most dermatologists only have 3-5 minutes per patient so streamlining the process of designing a treatment plan and educating the patient and recruiting your staff to help is crucial. Before I discuss how to streamline the process, let’s first look at our goals for patients.
To achieve good patient outcomes, the patient needs to:
Understand what medications and products to use.
Understand when and how to use the products.
Understand the order in which to use the products (step 1, step 2, etc.).
Purchase the products (from you or elsewhere).
Tell you if they do not purchase the products, for whatever reason (insurance will not cover, too expensive, could not find them, etc.).
Use the products consistently.
Inform you if they do not use the products (too busy, did not have them on a trip, etc.).
Report any side effects so you can adjust the therapy accordingly.
You can see why it is so difficult to get patients to be compliant. Many factors – such as time, memory, education level, understanding, motivation, cost, convenience, and insurance coverage – can get in the way of these important components. Giving patients a printed regimen with instructions, selling the products in your practice, and providing some sort of interaction to keep patients engaged is key. In my June 2015 Dermatology News column, I discussed why you should consider selling products in your practice. In the future, I will discuss ways to engage your patients, but for now, let’s focus on how to quickly and effectively provide your patients with printed regimens and patient instructions without increasing office visit times.
Streamlining the Process of Generating a Skin Care Regimen That Includes Prescription Medications
Identify patients’ phenotypes
Divide patients into phenotypes based on skin care needs to save yourself time with the recommendation process.
Many doctors do this with a disease-based approach, such as acne, rosacea, eczema, psoriasis, etc. I prefer to classify my patients according to 16 Baumann Skin Types based on four parameters: hydration status, propensity for inflammation; presence or absence of uneven pigmentation; and presence of lifestyle habits, such as sun exposure, that increase an individual’s risk of skin aging.4,5,6 To quickly diagnose the patient as a particular Baumann Skin Type, I use a tablet-based validated questionnaire called the Baumann Skin Type Indicator (BSTI).7 This questionnaire is self-administered by the patient in the waiting room and serves several purposes that facilitate my practice:
To collect historical and current data.
To diagnose skin type.
To ask specifically about skin allergies.
To learn preferences such as tinted vs. nontinted, or chemical vs. physical sunscreen.
To inquire about what issues the patient wants to discuss, such as thinning eyelashes, hair loss, dry body skin, toenail fungus, warts, eczema, and other topics that might not come up during the appointment.
To learn and document habits that affect the skin, such as tanning bed exposure, sun exposure, and smoking.
To stimulate the patient to think about how daily actions such as sunscreen use and sun exposure affect their skin health.
Whether you choose to use my questionnaire or one of your own, using a validated method that can be initiated by staff in the waiting room saves time in the exam room.
Include prescription medications in the skin care regimen
Often, we think of skin care regimens and prescription medications as two different entities. In actuality, these should be combined.
For example, when treating acne, every item the patient uses plays a role. For example, if they are washing the face with Ivory soap and then applying benzoyl peroxide and a retinoid they will experience dryness and irritation. Then they will buy a moisturizer that might cause acne. (It is very hard for them to know which moisturizers and sunscreens will not worsen acne). By providing them with the exact names of cleansers, moisturizers, and sunscreens to use, they will be better able to tolerate their prescription acne medications.
The same is true with psoriasis, eczema, seborrheic dermatitis, contact dermatitis, and most of the other ailments that dermatologists treat. You must also tell them the order to use them in. For example, I always have patients apply the retinoid over the noncomedogenic moisturizer for the first few weeks to help them adjust to the retinoid. Later, once they have passed the high-risk period of retinoid dermatitis, I move the retinoid to under the moisturizer.
Psoriasis treatment (topical) is another good example. If they are going to use a surfactant-laden soap on their skin, they will impair their barrier and absorb more of the topically applied drug. Conversely, if they use a barrier repair moisturizer, they will absorb less. Telling the patients exactly which body cleansers and moisturizers to use with topical psoriasis medications will help standardize the response. For this reason, giving patients printed regimens is not limited to treatment of acne, rosacea, and photoaging, but rather should be done for patients with all skin issues and phenotypes.
Have informational material for each phenotype at your fingertips
You can have a plan for each patient phenotype that is designed ahead of time. You will save yourself hours of time if you have preprinted instructions sheets made for each of these phenotypes. You can use Touch MD, The Canfield Visia Camera Patient Portal, your EMR, or other systems to organize this material and deliver it to patients.
I personally use the Skin Type Solutions Software System (STSFranchise.com) that I developed and patented to house and export my patient instructions. Using a standardized methodology to provide educational information through video, preprinted sheets, emails, and other methods allows you to educate your patients at their pace and in the media with which they are most comfortable. To have this flexibility, the educational information must be developed prior to the patient visit. Categorizing the education information by phenotype makes this possible.
What the informational material should contain
Educational information should include important information about the phenotype, the do’s and don’ts for the phenotype, an exact skin care regimen containing clear steps that include product names including brand names, prescription medications, the order in which the products should be applied, and clear instructions on how to use the products.
The patient should be informed about what to do if anticipated adverse events occur, such as redness and peeling from retinoids or dryness from benzoyl peroxide. The same is true about injectable biologic medications for psoriasis. The patients need information on where to inject the product, how often, how to clean the skin beforehand, and what to put on the skin after the injections. It is always important with any skin issue for the patient to know when to contact the office. The American Academy of Dermatology and other organizations offer educational brochures for patients, but they cannot be customized. Patients prefer a customized approach to educational material. They don’t want to read information that does not apply to them. I have found that dividing patients into 16 distinct Baumann Skin Types helps target the right information to the corresponding skin phenotypes.
Summary
Patients need education and guidance to be compliant and improve their outcomes. Your staff needs to be a part of the education process, but taking the time to train your staff and educate your patients is always an issue. Developing a standardized methodology will help overcome these hurdles and solve this problem. The methodology should provide directed education and clear communication with written instructions delivered in the media of the patient’s choice. Doing this will yield better compliance and outcomes.
If you have any questions, suggestions or ideas of how to solve these issues, please share them with me at [email protected].
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
AMSTERDAM – Prolonged oral treatment with norfloxacin improved the survival of patients with Child-Pugh class C liver disease versus no antibiotic prophylaxis in a randomized, double-blind, placebo-controlled, phase III multicenter trial.
Fewer patients (15.3% vs. 24.5%) treated with norfloxacin for 6 months died by the 6-month mortality primary endpoint than did those treated with placebo, with a hazard ratio of 0.59 (95% confidence interval, 0.35-0.99; P = .047) favoring prolonged antibiotic treatment. Adjustments for the concomitant use of nonselective beta-blockers and corticosteroids did not greatly alter the significance of the findings (adjusted HR, 0.58; 95% CI, 0.34-0.98; P = .042).
Dr. Richard MoreauThe survival benefit was lost by 1 year of follow-up, however, suggesting that perhaps treatment needs to continue beyond 12 months, according to author Richard Moreau, MD, of Hôpital Beaujon, Clichy, France, who reported the results at a meeting sponsored by the European Association for the Study of the Liver.
“The results of this study provide evidence that 6 months of norfloxacin therapy reduces the risk of death in the short term, but not in the long term,” he observed in an official EASL press release.
The occurrence of infections at 6 months and 12 months were secondary outcomes of the study and showed that fewer infections overall (23.9% vs. 35.0%, P = .04) had occurred in the norfloxacin group versus the placebo group at 6 months, which was sustained at 12 months, suggesting an overhanging effect of the antibiotic treatment.
There was no difference between the groups in the incidence of other secondary endpoints including septic shock, systolic blood pressure, liver transplantation, kidney dysfunction, encephalopathy, and variceal bleeding at 6 months, Dr. Moreau reported on behalf of the NORFLOCIR study group.
Norfloxacin is a fluoroquinolone antibiotic and earlier data (Gastroenterology 2007;133:818-24) had suggested that its prolonged use could improve survival in patients with advanced cirrhosis significantly at 3 months and nonsignificantly at 12 months. This was a small study, however, and although several other small-sized trials followed, the long-term use of fluoroquinolone therapy to improve outcomes in patients cirrhosis remained debated,” Dr. Moreau said during his presentation of the study’s findings.
There was also the concern that such prolonged antibiotic use might up the risk for infection with gram-positive bacteria, he observed, but the current study’s finding showed that this was not the case. The cumulative incidence of gram-positive (3.4% vs. 8.1%, P = .08) infections was numerically although not significantly lower in the antibiotic-treated patients at 6 months while the cumulative incidence of gram-negative infections was significantly lowered (3.2% vs. 13.0%, P less than .005).
The study does have its limitations, Dr. Moreau conceded. Fewer patients were recruited than anticipated, 291 rather than a planned sample size of 392 patients, which was caused by a combination of factors – slow recruitment, termination of funding, and time expiry of the trial drug. Nevertheless, the study findings are strengthened by the fact it was conducted in 18 centers throughout France and that liver transplantation was taken into account as a potential competing risk.
During the trial, 144 patients with Child-Pugh class C cirrhosis were randomized to receive oral norfloxacin at a dose of 400 mg/day and 147 were randomized to a matching placebo daily for 6 months. Patients were followed for 6 additional months.
Just 3% of patients were lost to follow-up by the time of the primary endpoint assessment at 6 months, with just over half (55%) modifying their consent and almost half (46%) discontinuing the study because of death (15%), liver transplant (9%), elevated systolic blood pressure (9%), or patient decision (12%).
Patients included in the study were mostly middle-aged (55 years or older), male (more than 65%), and had alcoholic cirrhosis (greater than 74%) or alcoholic hepatitis (39%), with around 88% having ascites.
Dr. Moreau had nothing to disclose. The study was sponsored by the French government.
AMSTERDAM – Prolonged oral treatment with norfloxacin improved the survival of patients with Child-Pugh class C liver disease versus no antibiotic prophylaxis in a randomized, double-blind, placebo-controlled, phase III multicenter trial.
Fewer patients (15.3% vs. 24.5%) treated with norfloxacin for 6 months died by the 6-month mortality primary endpoint than did those treated with placebo, with a hazard ratio of 0.59 (95% confidence interval, 0.35-0.99; P = .047) favoring prolonged antibiotic treatment. Adjustments for the concomitant use of nonselective beta-blockers and corticosteroids did not greatly alter the significance of the findings (adjusted HR, 0.58; 95% CI, 0.34-0.98; P = .042).
Dr. Richard MoreauThe survival benefit was lost by 1 year of follow-up, however, suggesting that perhaps treatment needs to continue beyond 12 months, according to author Richard Moreau, MD, of Hôpital Beaujon, Clichy, France, who reported the results at a meeting sponsored by the European Association for the Study of the Liver.
“The results of this study provide evidence that 6 months of norfloxacin therapy reduces the risk of death in the short term, but not in the long term,” he observed in an official EASL press release.
The occurrence of infections at 6 months and 12 months were secondary outcomes of the study and showed that fewer infections overall (23.9% vs. 35.0%, P = .04) had occurred in the norfloxacin group versus the placebo group at 6 months, which was sustained at 12 months, suggesting an overhanging effect of the antibiotic treatment.
There was no difference between the groups in the incidence of other secondary endpoints including septic shock, systolic blood pressure, liver transplantation, kidney dysfunction, encephalopathy, and variceal bleeding at 6 months, Dr. Moreau reported on behalf of the NORFLOCIR study group.
Norfloxacin is a fluoroquinolone antibiotic and earlier data (Gastroenterology 2007;133:818-24) had suggested that its prolonged use could improve survival in patients with advanced cirrhosis significantly at 3 months and nonsignificantly at 12 months. This was a small study, however, and although several other small-sized trials followed, the long-term use of fluoroquinolone therapy to improve outcomes in patients cirrhosis remained debated,” Dr. Moreau said during his presentation of the study’s findings.
There was also the concern that such prolonged antibiotic use might up the risk for infection with gram-positive bacteria, he observed, but the current study’s finding showed that this was not the case. The cumulative incidence of gram-positive (3.4% vs. 8.1%, P = .08) infections was numerically although not significantly lower in the antibiotic-treated patients at 6 months while the cumulative incidence of gram-negative infections was significantly lowered (3.2% vs. 13.0%, P less than .005).
The study does have its limitations, Dr. Moreau conceded. Fewer patients were recruited than anticipated, 291 rather than a planned sample size of 392 patients, which was caused by a combination of factors – slow recruitment, termination of funding, and time expiry of the trial drug. Nevertheless, the study findings are strengthened by the fact it was conducted in 18 centers throughout France and that liver transplantation was taken into account as a potential competing risk.
During the trial, 144 patients with Child-Pugh class C cirrhosis were randomized to receive oral norfloxacin at a dose of 400 mg/day and 147 were randomized to a matching placebo daily for 6 months. Patients were followed for 6 additional months.
Just 3% of patients were lost to follow-up by the time of the primary endpoint assessment at 6 months, with just over half (55%) modifying their consent and almost half (46%) discontinuing the study because of death (15%), liver transplant (9%), elevated systolic blood pressure (9%), or patient decision (12%).
Patients included in the study were mostly middle-aged (55 years or older), male (more than 65%), and had alcoholic cirrhosis (greater than 74%) or alcoholic hepatitis (39%), with around 88% having ascites.
Dr. Moreau had nothing to disclose. The study was sponsored by the French government.
AMSTERDAM – Prolonged oral treatment with norfloxacin improved the survival of patients with Child-Pugh class C liver disease versus no antibiotic prophylaxis in a randomized, double-blind, placebo-controlled, phase III multicenter trial.
Fewer patients (15.3% vs. 24.5%) treated with norfloxacin for 6 months died by the 6-month mortality primary endpoint than did those treated with placebo, with a hazard ratio of 0.59 (95% confidence interval, 0.35-0.99; P = .047) favoring prolonged antibiotic treatment. Adjustments for the concomitant use of nonselective beta-blockers and corticosteroids did not greatly alter the significance of the findings (adjusted HR, 0.58; 95% CI, 0.34-0.98; P = .042).
Dr. Richard MoreauThe survival benefit was lost by 1 year of follow-up, however, suggesting that perhaps treatment needs to continue beyond 12 months, according to author Richard Moreau, MD, of Hôpital Beaujon, Clichy, France, who reported the results at a meeting sponsored by the European Association for the Study of the Liver.
“The results of this study provide evidence that 6 months of norfloxacin therapy reduces the risk of death in the short term, but not in the long term,” he observed in an official EASL press release.
The occurrence of infections at 6 months and 12 months were secondary outcomes of the study and showed that fewer infections overall (23.9% vs. 35.0%, P = .04) had occurred in the norfloxacin group versus the placebo group at 6 months, which was sustained at 12 months, suggesting an overhanging effect of the antibiotic treatment.
There was no difference between the groups in the incidence of other secondary endpoints including septic shock, systolic blood pressure, liver transplantation, kidney dysfunction, encephalopathy, and variceal bleeding at 6 months, Dr. Moreau reported on behalf of the NORFLOCIR study group.
Norfloxacin is a fluoroquinolone antibiotic and earlier data (Gastroenterology 2007;133:818-24) had suggested that its prolonged use could improve survival in patients with advanced cirrhosis significantly at 3 months and nonsignificantly at 12 months. This was a small study, however, and although several other small-sized trials followed, the long-term use of fluoroquinolone therapy to improve outcomes in patients cirrhosis remained debated,” Dr. Moreau said during his presentation of the study’s findings.
There was also the concern that such prolonged antibiotic use might up the risk for infection with gram-positive bacteria, he observed, but the current study’s finding showed that this was not the case. The cumulative incidence of gram-positive (3.4% vs. 8.1%, P = .08) infections was numerically although not significantly lower in the antibiotic-treated patients at 6 months while the cumulative incidence of gram-negative infections was significantly lowered (3.2% vs. 13.0%, P less than .005).
The study does have its limitations, Dr. Moreau conceded. Fewer patients were recruited than anticipated, 291 rather than a planned sample size of 392 patients, which was caused by a combination of factors – slow recruitment, termination of funding, and time expiry of the trial drug. Nevertheless, the study findings are strengthened by the fact it was conducted in 18 centers throughout France and that liver transplantation was taken into account as a potential competing risk.
During the trial, 144 patients with Child-Pugh class C cirrhosis were randomized to receive oral norfloxacin at a dose of 400 mg/day and 147 were randomized to a matching placebo daily for 6 months. Patients were followed for 6 additional months.
Just 3% of patients were lost to follow-up by the time of the primary endpoint assessment at 6 months, with just over half (55%) modifying their consent and almost half (46%) discontinuing the study because of death (15%), liver transplant (9%), elevated systolic blood pressure (9%), or patient decision (12%).
Patients included in the study were mostly middle-aged (55 years or older), male (more than 65%), and had alcoholic cirrhosis (greater than 74%) or alcoholic hepatitis (39%), with around 88% having ascites.
Dr. Moreau had nothing to disclose. The study was sponsored by the French government.
Key clinical point: Prolonged antibiotic therapy proved beneficial in patients with advanced cirrhosis.
Major finding: Mortality at 6 months was significantly reduced with norfloxacin vs. placebo treatment (adjusted HR, 0.58; 95% CI, 0.34-0.98; P = .042).
Data source: A phase III, multicenter, randomized, double-blind, placebo-controlled trial of 291 patients with Child-Pugh class C cirrhosis who received either 400 mg of norfloxacin or placebo orally, once daily, for 6 months.
Disclosures: Dr. Moreau had nothing to disclose. The study was sponsored by the French government.
With patient co-management arrangements between hospitalists and other surgical and medical subspecialists becoming more common, HM17 attendees won’t want to miss Tuesday afternoon’s session at 3:15–4:20 p.m., “Redefining Co-management in Hospital Medicine.”
“We’ll provide hospitalists effective co-management programs at their respective hospitals,” said copresenter William Atchley Jr., MD, FACP, SFHM, a hospitalist with Sentara Heart Hospital in Norfolk, Va.
Dr. William Atchley Jr.The session will review the history of co-management research and the metrics studied, discuss the practice management benefits of co-management, look at real-world examples, and glimpse into future directions and implications for practice.
More hospital medicine groups are getting involved in co-management, the presenters said. There are two primary models: one in which the hospitalist is the attending of record and the subspecialist is the co-manager and another in which the subspecialist is the attending of record and the hospitalist serves as the co-manager. “Either model can work with the right agreements put in place,” Dr. Atchley said.
Dr. Corey Karlin-ZysmanThere are several drivers for these agreements, added co-presenter Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at North Shore University Hospital, Manhasset, N.Y., and Long Island (N.Y.) Jewish Medical Center, which has multiple co-management arrangements in place in areas including orthopedics, urology, otolaryngology, trauma, neurosurgery, cardiology, and psychiatry. “Sometimes surgical co-managers want help and someone to take shared responsibility of the patient so they can focus on their area of expertise. Sometimes the driver is administrative, where someone reviews a subspecialty’s performance or throughput metrics and notes opportunities to work together to reduce hospital length of stay or readmissions.” With the average age of surgical patients rising, surgical subspecialists are becoming more reliant on hospitalists to manage co-morbidities to prevent them from being exacerbated perioperatively.
“We’ll go through some of what we feel are the undiscovered benefits of having a co-management service,” said copresenter Mark Goldin, MD, FACP, a hospitalist at Long Island Jewish Medical Center. “I think a lot of people will be interested to hear that because research on co-management has been mixed, up to this point.” For example, he said, SHM engagement surveys have indicated that hospitalists who do co-management may be at reduced risk of burnout.
Dr. Mark GoldinFor co-management to work well, said Dr. Goldin, “have a very clear, mutually agreed-upon service agreement that details who does what for the patient. That way, you can avoid a lot of the pitfalls of having a mission creep, with hospitalists taking on more and more responsibility.”
Also important is creating a metrics dashboard and monitoring and updating it regularly, Dr. Karlin-Zysman added. “Not only does it keep both sides honest, but it’s how you garner support from the C-suite.”
The Society of Hospital Medicine has resources available to help, Dr. Atchley said. The SHM website includes a white paper on co-management. There also is a listserv called HMS Exchange, in which hospitalists can discuss comanagement topics.
“Co-management is not going away. It’s something that hospitalists are going to be involved with,” Dr. Atchley said. “It’s important to come up with the right agreement and, at the same time, work with everybody in collaboration to improve patient care.”
Redefining Co-management in Hospital Medicine Tuesday, 3:15–4:20 p.m.
With patient co-management arrangements between hospitalists and other surgical and medical subspecialists becoming more common, HM17 attendees won’t want to miss Tuesday afternoon’s session at 3:15–4:20 p.m., “Redefining Co-management in Hospital Medicine.”
“We’ll provide hospitalists effective co-management programs at their respective hospitals,” said copresenter William Atchley Jr., MD, FACP, SFHM, a hospitalist with Sentara Heart Hospital in Norfolk, Va.
Dr. William Atchley Jr.The session will review the history of co-management research and the metrics studied, discuss the practice management benefits of co-management, look at real-world examples, and glimpse into future directions and implications for practice.
More hospital medicine groups are getting involved in co-management, the presenters said. There are two primary models: one in which the hospitalist is the attending of record and the subspecialist is the co-manager and another in which the subspecialist is the attending of record and the hospitalist serves as the co-manager. “Either model can work with the right agreements put in place,” Dr. Atchley said.
Dr. Corey Karlin-ZysmanThere are several drivers for these agreements, added co-presenter Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at North Shore University Hospital, Manhasset, N.Y., and Long Island (N.Y.) Jewish Medical Center, which has multiple co-management arrangements in place in areas including orthopedics, urology, otolaryngology, trauma, neurosurgery, cardiology, and psychiatry. “Sometimes surgical co-managers want help and someone to take shared responsibility of the patient so they can focus on their area of expertise. Sometimes the driver is administrative, where someone reviews a subspecialty’s performance or throughput metrics and notes opportunities to work together to reduce hospital length of stay or readmissions.” With the average age of surgical patients rising, surgical subspecialists are becoming more reliant on hospitalists to manage co-morbidities to prevent them from being exacerbated perioperatively.
“We’ll go through some of what we feel are the undiscovered benefits of having a co-management service,” said copresenter Mark Goldin, MD, FACP, a hospitalist at Long Island Jewish Medical Center. “I think a lot of people will be interested to hear that because research on co-management has been mixed, up to this point.” For example, he said, SHM engagement surveys have indicated that hospitalists who do co-management may be at reduced risk of burnout.
Dr. Mark GoldinFor co-management to work well, said Dr. Goldin, “have a very clear, mutually agreed-upon service agreement that details who does what for the patient. That way, you can avoid a lot of the pitfalls of having a mission creep, with hospitalists taking on more and more responsibility.”
Also important is creating a metrics dashboard and monitoring and updating it regularly, Dr. Karlin-Zysman added. “Not only does it keep both sides honest, but it’s how you garner support from the C-suite.”
The Society of Hospital Medicine has resources available to help, Dr. Atchley said. The SHM website includes a white paper on co-management. There also is a listserv called HMS Exchange, in which hospitalists can discuss comanagement topics.
“Co-management is not going away. It’s something that hospitalists are going to be involved with,” Dr. Atchley said. “It’s important to come up with the right agreement and, at the same time, work with everybody in collaboration to improve patient care.”
Redefining Co-management in Hospital Medicine Tuesday, 3:15–4:20 p.m.
With patient co-management arrangements between hospitalists and other surgical and medical subspecialists becoming more common, HM17 attendees won’t want to miss Tuesday afternoon’s session at 3:15–4:20 p.m., “Redefining Co-management in Hospital Medicine.”
“We’ll provide hospitalists effective co-management programs at their respective hospitals,” said copresenter William Atchley Jr., MD, FACP, SFHM, a hospitalist with Sentara Heart Hospital in Norfolk, Va.
Dr. William Atchley Jr.The session will review the history of co-management research and the metrics studied, discuss the practice management benefits of co-management, look at real-world examples, and glimpse into future directions and implications for practice.
More hospital medicine groups are getting involved in co-management, the presenters said. There are two primary models: one in which the hospitalist is the attending of record and the subspecialist is the co-manager and another in which the subspecialist is the attending of record and the hospitalist serves as the co-manager. “Either model can work with the right agreements put in place,” Dr. Atchley said.
Dr. Corey Karlin-ZysmanThere are several drivers for these agreements, added co-presenter Corey Karlin-Zysman, MD, FHM, FACP, chief of the division of hospital medicine at North Shore University Hospital, Manhasset, N.Y., and Long Island (N.Y.) Jewish Medical Center, which has multiple co-management arrangements in place in areas including orthopedics, urology, otolaryngology, trauma, neurosurgery, cardiology, and psychiatry. “Sometimes surgical co-managers want help and someone to take shared responsibility of the patient so they can focus on their area of expertise. Sometimes the driver is administrative, where someone reviews a subspecialty’s performance or throughput metrics and notes opportunities to work together to reduce hospital length of stay or readmissions.” With the average age of surgical patients rising, surgical subspecialists are becoming more reliant on hospitalists to manage co-morbidities to prevent them from being exacerbated perioperatively.
“We’ll go through some of what we feel are the undiscovered benefits of having a co-management service,” said copresenter Mark Goldin, MD, FACP, a hospitalist at Long Island Jewish Medical Center. “I think a lot of people will be interested to hear that because research on co-management has been mixed, up to this point.” For example, he said, SHM engagement surveys have indicated that hospitalists who do co-management may be at reduced risk of burnout.
Dr. Mark GoldinFor co-management to work well, said Dr. Goldin, “have a very clear, mutually agreed-upon service agreement that details who does what for the patient. That way, you can avoid a lot of the pitfalls of having a mission creep, with hospitalists taking on more and more responsibility.”
Also important is creating a metrics dashboard and monitoring and updating it regularly, Dr. Karlin-Zysman added. “Not only does it keep both sides honest, but it’s how you garner support from the C-suite.”
The Society of Hospital Medicine has resources available to help, Dr. Atchley said. The SHM website includes a white paper on co-management. There also is a listserv called HMS Exchange, in which hospitalists can discuss comanagement topics.
“Co-management is not going away. It’s something that hospitalists are going to be involved with,” Dr. Atchley said. “It’s important to come up with the right agreement and, at the same time, work with everybody in collaboration to improve patient care.”
Redefining Co-management in Hospital Medicine Tuesday, 3:15–4:20 p.m.
The Food and Drug Administration has approved midostaurin for the treatment of FLT3 mutation–positive acute myeloid leukemia (FLT3+ AML) in adult patients in combination with standard cytarabine and daunorubicin induction and cytarabine consolidation.
Approval was based on results from a randomized, double-blind, placebo-controlled trial of 717 patients with previously untreated FLT3+ AML. The hazard ratio for overall survival in patients receiving midostaurin, compared with a placebo, was 0.77 (P = .016). A companion diagnostic tool, the LeukoStrat CDx FLT3 Mutation Assay manufactured by Invivoscribe Technologies, was also approved.
Febrile neutropenia, nausea, mucositis, vomiting, headache, petechiae, musculoskeletal pain, epistaxis, device-related infection, hyperglycemia, and upper respiratory tract infection were the most common side effects of treatment with midostaurin, occurring in at least 20% of patients, the FDA said in a written statement.
Midostaurin was also approved for the treatment of aggressive systemic mastocytosis, SM with associated hematological neoplasm, or mast cell leukemia. This indication approval was based on a single-arm, open-label study of midostaurin 100 mg, taken orally twice daily. Complete plus incomplete remission rates were 38% for ASM and 16% for SM with associated hematological neoplasm. Common adverse events included nausea, vomiting, diarrhea, edema, musculoskeletal pain, abdominal pain, fatigue, upper respiratory tract infection, fever, headache, and dyspnea.
The recommended dose of midostaurin in AML is 50 mg twice daily with food on days 8 to 21 of each cycle of induction and consolidation chemotherapy followed by 50 mg with food as a single agent for up to 12 months. The recommended dose for the treatment of adults with aggressive SM, SM with associated hematological neoplasm, or mast cell leukemia is 100 mg twice daily with food, the FDA said.
Midostaurin will be marketed as Rydapt by Novartis Pharmaceuticals.
The Food and Drug Administration has approved midostaurin for the treatment of FLT3 mutation–positive acute myeloid leukemia (FLT3+ AML) in adult patients in combination with standard cytarabine and daunorubicin induction and cytarabine consolidation.
Approval was based on results from a randomized, double-blind, placebo-controlled trial of 717 patients with previously untreated FLT3+ AML. The hazard ratio for overall survival in patients receiving midostaurin, compared with a placebo, was 0.77 (P = .016). A companion diagnostic tool, the LeukoStrat CDx FLT3 Mutation Assay manufactured by Invivoscribe Technologies, was also approved.
Febrile neutropenia, nausea, mucositis, vomiting, headache, petechiae, musculoskeletal pain, epistaxis, device-related infection, hyperglycemia, and upper respiratory tract infection were the most common side effects of treatment with midostaurin, occurring in at least 20% of patients, the FDA said in a written statement.
Midostaurin was also approved for the treatment of aggressive systemic mastocytosis, SM with associated hematological neoplasm, or mast cell leukemia. This indication approval was based on a single-arm, open-label study of midostaurin 100 mg, taken orally twice daily. Complete plus incomplete remission rates were 38% for ASM and 16% for SM with associated hematological neoplasm. Common adverse events included nausea, vomiting, diarrhea, edema, musculoskeletal pain, abdominal pain, fatigue, upper respiratory tract infection, fever, headache, and dyspnea.
The recommended dose of midostaurin in AML is 50 mg twice daily with food on days 8 to 21 of each cycle of induction and consolidation chemotherapy followed by 50 mg with food as a single agent for up to 12 months. The recommended dose for the treatment of adults with aggressive SM, SM with associated hematological neoplasm, or mast cell leukemia is 100 mg twice daily with food, the FDA said.
Midostaurin will be marketed as Rydapt by Novartis Pharmaceuticals.
The Food and Drug Administration has approved midostaurin for the treatment of FLT3 mutation–positive acute myeloid leukemia (FLT3+ AML) in adult patients in combination with standard cytarabine and daunorubicin induction and cytarabine consolidation.
Approval was based on results from a randomized, double-blind, placebo-controlled trial of 717 patients with previously untreated FLT3+ AML. The hazard ratio for overall survival in patients receiving midostaurin, compared with a placebo, was 0.77 (P = .016). A companion diagnostic tool, the LeukoStrat CDx FLT3 Mutation Assay manufactured by Invivoscribe Technologies, was also approved.
Febrile neutropenia, nausea, mucositis, vomiting, headache, petechiae, musculoskeletal pain, epistaxis, device-related infection, hyperglycemia, and upper respiratory tract infection were the most common side effects of treatment with midostaurin, occurring in at least 20% of patients, the FDA said in a written statement.
Midostaurin was also approved for the treatment of aggressive systemic mastocytosis, SM with associated hematological neoplasm, or mast cell leukemia. This indication approval was based on a single-arm, open-label study of midostaurin 100 mg, taken orally twice daily. Complete plus incomplete remission rates were 38% for ASM and 16% for SM with associated hematological neoplasm. Common adverse events included nausea, vomiting, diarrhea, edema, musculoskeletal pain, abdominal pain, fatigue, upper respiratory tract infection, fever, headache, and dyspnea.
The recommended dose of midostaurin in AML is 50 mg twice daily with food on days 8 to 21 of each cycle of induction and consolidation chemotherapy followed by 50 mg with food as a single agent for up to 12 months. The recommended dose for the treatment of adults with aggressive SM, SM with associated hematological neoplasm, or mast cell leukemia is 100 mg twice daily with food, the FDA said.
Midostaurin will be marketed as Rydapt by Novartis Pharmaceuticals.
Aggressive resection to negative margins, combined with neoadjuvant chemotherapy and postsurgical radiation, resulted in a 96% 5-year locoregional recurrence-free survival in nonmetastatic inflammatory breast cancer, Kelly Rosso, MD, reported.
Dr. Rosso of MD Anderson Cancer Center, Houston, and her colleagues identified 277 women diagnosed with inflammatory breast cancer between 2007 and 2015 from a prospective database; 114 of those had nonmetastatic disease and received aggressive trimodality therapy with curative intent.
Dr. Kelly RossoTrimodality therapy at MD Anderson is defined as neoadjuvant chemotherapy and targeted systemic therapies followed by aggressive surgical resection to negative surgical margins and specific radiotherapy, Dr. Rosso said.
Median age at diagnosis was 52 years and all patients were diagnosed at Stage III; 55% presented with N2 disease while 45% presented with N3. Patients were followed for a median 3.6 years.
“Historically, prognosis for patients with inflammatory breast cancer has been very poor,” Dr. Rosso said at a press conference in advance of the annual meeting of the American Society of Breast Surgeons. “Data from our institution has failed to identify any significant improvement in survival from the 1970s to the 2000s.”
In this study, 29 patients died and 4 experienced a locoregional recurrence (3.5%) during follow-up. The 2-year probability of locoregional recurrence was low, at 3.19%, while the 2-year probability of recurrence or distant metastasis was 23.1%. The 5-year disease-free survival was 72.5%, significantly lower than local/regional recurrence-free survival because some patients developed metastatic cancer in other organs, Dr. Rosso reported.
Diminished overall survival and increased risk for recurrence or metastasis were more likely in women over the age of 65 years and those with HER2-negative status, limited clinical response to chemotherapy, and absence of a pathologically complete response. Recurrence or metastasis also were more likely in women with Stage IIIC disease and more lymphovascular involvement.
“It is encouraging to see the high 5-year breast cancer specific survival rates reported in this cohort,” Judy C. Boughey, MD, professor of surgery and vice chair of research at the Mayo Clinic, Rochester, Minn., said in a statement. “This study supports that the current management of these patients with neoadjuvant chemotherapy, mastectomy and post-mastectomy radiation is the optimal multimodal approach for inflammatory breast cancer. The improvements in systemic therapy, with increased use of directed therapy, being used in breast cancer, together with appropriate local-regional therapies, is likely responsible for the improvement in survival over historical cohorts.”
Aggressive resection to negative margins, combined with neoadjuvant chemotherapy and postsurgical radiation, resulted in a 96% 5-year locoregional recurrence-free survival in nonmetastatic inflammatory breast cancer, Kelly Rosso, MD, reported.
Dr. Rosso of MD Anderson Cancer Center, Houston, and her colleagues identified 277 women diagnosed with inflammatory breast cancer between 2007 and 2015 from a prospective database; 114 of those had nonmetastatic disease and received aggressive trimodality therapy with curative intent.
Dr. Kelly RossoTrimodality therapy at MD Anderson is defined as neoadjuvant chemotherapy and targeted systemic therapies followed by aggressive surgical resection to negative surgical margins and specific radiotherapy, Dr. Rosso said.
Median age at diagnosis was 52 years and all patients were diagnosed at Stage III; 55% presented with N2 disease while 45% presented with N3. Patients were followed for a median 3.6 years.
“Historically, prognosis for patients with inflammatory breast cancer has been very poor,” Dr. Rosso said at a press conference in advance of the annual meeting of the American Society of Breast Surgeons. “Data from our institution has failed to identify any significant improvement in survival from the 1970s to the 2000s.”
In this study, 29 patients died and 4 experienced a locoregional recurrence (3.5%) during follow-up. The 2-year probability of locoregional recurrence was low, at 3.19%, while the 2-year probability of recurrence or distant metastasis was 23.1%. The 5-year disease-free survival was 72.5%, significantly lower than local/regional recurrence-free survival because some patients developed metastatic cancer in other organs, Dr. Rosso reported.
Diminished overall survival and increased risk for recurrence or metastasis were more likely in women over the age of 65 years and those with HER2-negative status, limited clinical response to chemotherapy, and absence of a pathologically complete response. Recurrence or metastasis also were more likely in women with Stage IIIC disease and more lymphovascular involvement.
“It is encouraging to see the high 5-year breast cancer specific survival rates reported in this cohort,” Judy C. Boughey, MD, professor of surgery and vice chair of research at the Mayo Clinic, Rochester, Minn., said in a statement. “This study supports that the current management of these patients with neoadjuvant chemotherapy, mastectomy and post-mastectomy radiation is the optimal multimodal approach for inflammatory breast cancer. The improvements in systemic therapy, with increased use of directed therapy, being used in breast cancer, together with appropriate local-regional therapies, is likely responsible for the improvement in survival over historical cohorts.”
Aggressive resection to negative margins, combined with neoadjuvant chemotherapy and postsurgical radiation, resulted in a 96% 5-year locoregional recurrence-free survival in nonmetastatic inflammatory breast cancer, Kelly Rosso, MD, reported.
Dr. Rosso of MD Anderson Cancer Center, Houston, and her colleagues identified 277 women diagnosed with inflammatory breast cancer between 2007 and 2015 from a prospective database; 114 of those had nonmetastatic disease and received aggressive trimodality therapy with curative intent.
Dr. Kelly RossoTrimodality therapy at MD Anderson is defined as neoadjuvant chemotherapy and targeted systemic therapies followed by aggressive surgical resection to negative surgical margins and specific radiotherapy, Dr. Rosso said.
Median age at diagnosis was 52 years and all patients were diagnosed at Stage III; 55% presented with N2 disease while 45% presented with N3. Patients were followed for a median 3.6 years.
“Historically, prognosis for patients with inflammatory breast cancer has been very poor,” Dr. Rosso said at a press conference in advance of the annual meeting of the American Society of Breast Surgeons. “Data from our institution has failed to identify any significant improvement in survival from the 1970s to the 2000s.”
In this study, 29 patients died and 4 experienced a locoregional recurrence (3.5%) during follow-up. The 2-year probability of locoregional recurrence was low, at 3.19%, while the 2-year probability of recurrence or distant metastasis was 23.1%. The 5-year disease-free survival was 72.5%, significantly lower than local/regional recurrence-free survival because some patients developed metastatic cancer in other organs, Dr. Rosso reported.
Diminished overall survival and increased risk for recurrence or metastasis were more likely in women over the age of 65 years and those with HER2-negative status, limited clinical response to chemotherapy, and absence of a pathologically complete response. Recurrence or metastasis also were more likely in women with Stage IIIC disease and more lymphovascular involvement.
“It is encouraging to see the high 5-year breast cancer specific survival rates reported in this cohort,” Judy C. Boughey, MD, professor of surgery and vice chair of research at the Mayo Clinic, Rochester, Minn., said in a statement. “This study supports that the current management of these patients with neoadjuvant chemotherapy, mastectomy and post-mastectomy radiation is the optimal multimodal approach for inflammatory breast cancer. The improvements in systemic therapy, with increased use of directed therapy, being used in breast cancer, together with appropriate local-regional therapies, is likely responsible for the improvement in survival over historical cohorts.”
BIRMINGHAM, ENGLAND – One in five people with ankylosing spondylitis could have comorbid fibromyalgia, according to data from the British Society for Rheumatology Biologics Register for Ankylosing Spondylitis (BSRBR-AS).
The analysis, which included more than 880 patients with axial spondyloarthritis (SpA), found that 20.7% met 2011 research criteria for the chronic pain condition.
The prevalence of fibromyalgia was similar when the modified New York (mNY) criteria were used to diagnose SpA, at 19.7%, but slightly higher at 25.2% when SpA patients met the Assessment of SpondyloArthritis international Society (ASAS) imaging criteria but not mNY criteria, and substantially lower at 9.5% when SpA patients met ASAS clinical criteria only.
Courtesy Dr. Gary J. Macfarlane
Dr. Gary J. Macfarlane“The background is that some patients with axial SpA are recognized clinically to have comorbid fibromyalgia,” Gary J. Macfarlane, MD, PhD, said at the British Society for Rheumatology annual conference.
Dr. Macfarlane, chief investigator of the BSRBR-AS and professor and chair of clinical epidemiology at the University of Aberdeen (Scotland), added that having comorbid fibromyalgia might “distort the responses of some of the key patient-reported measures and that may lead to some patients having inappropriate therapy.”
So the aim of the present analysis was to provide data on the frequency of SpA and fibromyalgia co-occurrence, characterize which patients might be more likely to have both conditions, and also provide information that would inform future studies looking at the optimal management of such patients.
“The patients most likely to meet fibromyalgia criteria were female, either HLA-B27 negative or untested, and there was a particularly strong association with higher levels of [social] deprivation,” Dr. Macfarlane reported.
Patients who had both SpA and fibromyalgia also were found to be more likely to have been treated with a biologic than those who had SpA alone (51% vs. 32%), and there also was an associated with the time missed (15.1% vs. 2.5%) or impaired (50.8% vs. 22.8%) at work.
In a comparison of the characteristics of patients with SpA who met the fibromyalgia research criteria with those who did not, Dr. Macfarlane observed that they had worse disease activity, function, metrology, and global scores as measured using Bath Ankylosing Spondylitis disease indices:
• Disease activity scores were a respective 6.7 and 3.6, giving a difference of 3.1 (95% confidence interval, 2.9-3.3).
• Function scores were a respective 6.6 and 3.7, with a difference of 2.9 (95% CI, 2.6-3.3).
• Metrology scores were a respective 4.2 and 3.6, with a difference of 0.6 (95% CI, 0.3-0.9).
• Global scores were a respective 6.9 and 3.7, with a different of 3.2 (95% CI, 2.9-3.6).
Dr. Macfarlane reported that there were “extremely large differences” on the patient-reported measures of quality of life, depression, and anxiety. Other common problems in the group meeting the fibromyalgia criteria were sleeping difficulties and high levels of fatigue, he said.
Patients with both SpA and fibromyalgia fared worse on quality of life scores measured using the disease-specific Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire where they scored a mean of 7.1 points (95% CI, 6.4-7.7) higher than did those with SpA alone.
The mean differences in depression and anxiety, both measured using the Hospital Anxiety and Depression Scale (HADS), was 4.8 (95% CI, 4.3-5.2) and 4.7 (95% CI, 4.1-5.2).
The mean difference in the sleep disturbance scale was 5.3 (95% CI, 4.5-6.0), and the mean difference in Chalder Fatigue Scale scores was 4.0 (95% CI, 3.5-4.4).
In contrast, there was no difference in the proportion of patients who had levels of C-reactive protein above 1 mg/dL or in the number of proportion of patients who had extraspinal manifestations of SpA, with the exception of tender or swollen joint counts.
Dr. Macfarlane noted that the fibromyalgia research criteria had not been validated for use in patients with axial SpA but that a grant had been awarded by Arthritis Research UK to look at this and also to look into optimizing options for managing patients with both conditions.
The BSRBR-AS is currently the newest of the biologics registries and began recruiting patients with axial SpA as of December 2012 from 82 centers across the United Kingdom. The register enrolls patients who have not previously been treated with a tumor necrosis factor inhibitor drug and are then followed-up for a 5-year period. The 2011 fibromyalgia research criteria have been used as part of the baseline assessment since September 2015, and clinicians also are asked to report whether they think that patients have fibromyalgia.
The BSRBR-AS is funded by the British Society for Rheumatology, which receives funds from AbbVie, Pfizer, and UCB. Dr. Macfarlane did not report having any conflicts of interest.
BIRMINGHAM, ENGLAND – One in five people with ankylosing spondylitis could have comorbid fibromyalgia, according to data from the British Society for Rheumatology Biologics Register for Ankylosing Spondylitis (BSRBR-AS).
The analysis, which included more than 880 patients with axial spondyloarthritis (SpA), found that 20.7% met 2011 research criteria for the chronic pain condition.
The prevalence of fibromyalgia was similar when the modified New York (mNY) criteria were used to diagnose SpA, at 19.7%, but slightly higher at 25.2% when SpA patients met the Assessment of SpondyloArthritis international Society (ASAS) imaging criteria but not mNY criteria, and substantially lower at 9.5% when SpA patients met ASAS clinical criteria only.
Courtesy Dr. Gary J. Macfarlane
Dr. Gary J. Macfarlane“The background is that some patients with axial SpA are recognized clinically to have comorbid fibromyalgia,” Gary J. Macfarlane, MD, PhD, said at the British Society for Rheumatology annual conference.
Dr. Macfarlane, chief investigator of the BSRBR-AS and professor and chair of clinical epidemiology at the University of Aberdeen (Scotland), added that having comorbid fibromyalgia might “distort the responses of some of the key patient-reported measures and that may lead to some patients having inappropriate therapy.”
So the aim of the present analysis was to provide data on the frequency of SpA and fibromyalgia co-occurrence, characterize which patients might be more likely to have both conditions, and also provide information that would inform future studies looking at the optimal management of such patients.
“The patients most likely to meet fibromyalgia criteria were female, either HLA-B27 negative or untested, and there was a particularly strong association with higher levels of [social] deprivation,” Dr. Macfarlane reported.
Patients who had both SpA and fibromyalgia also were found to be more likely to have been treated with a biologic than those who had SpA alone (51% vs. 32%), and there also was an associated with the time missed (15.1% vs. 2.5%) or impaired (50.8% vs. 22.8%) at work.
In a comparison of the characteristics of patients with SpA who met the fibromyalgia research criteria with those who did not, Dr. Macfarlane observed that they had worse disease activity, function, metrology, and global scores as measured using Bath Ankylosing Spondylitis disease indices:
• Disease activity scores were a respective 6.7 and 3.6, giving a difference of 3.1 (95% confidence interval, 2.9-3.3).
• Function scores were a respective 6.6 and 3.7, with a difference of 2.9 (95% CI, 2.6-3.3).
• Metrology scores were a respective 4.2 and 3.6, with a difference of 0.6 (95% CI, 0.3-0.9).
• Global scores were a respective 6.9 and 3.7, with a different of 3.2 (95% CI, 2.9-3.6).
Dr. Macfarlane reported that there were “extremely large differences” on the patient-reported measures of quality of life, depression, and anxiety. Other common problems in the group meeting the fibromyalgia criteria were sleeping difficulties and high levels of fatigue, he said.
Patients with both SpA and fibromyalgia fared worse on quality of life scores measured using the disease-specific Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire where they scored a mean of 7.1 points (95% CI, 6.4-7.7) higher than did those with SpA alone.
The mean differences in depression and anxiety, both measured using the Hospital Anxiety and Depression Scale (HADS), was 4.8 (95% CI, 4.3-5.2) and 4.7 (95% CI, 4.1-5.2).
The mean difference in the sleep disturbance scale was 5.3 (95% CI, 4.5-6.0), and the mean difference in Chalder Fatigue Scale scores was 4.0 (95% CI, 3.5-4.4).
In contrast, there was no difference in the proportion of patients who had levels of C-reactive protein above 1 mg/dL or in the number of proportion of patients who had extraspinal manifestations of SpA, with the exception of tender or swollen joint counts.
Dr. Macfarlane noted that the fibromyalgia research criteria had not been validated for use in patients with axial SpA but that a grant had been awarded by Arthritis Research UK to look at this and also to look into optimizing options for managing patients with both conditions.
The BSRBR-AS is currently the newest of the biologics registries and began recruiting patients with axial SpA as of December 2012 from 82 centers across the United Kingdom. The register enrolls patients who have not previously been treated with a tumor necrosis factor inhibitor drug and are then followed-up for a 5-year period. The 2011 fibromyalgia research criteria have been used as part of the baseline assessment since September 2015, and clinicians also are asked to report whether they think that patients have fibromyalgia.
The BSRBR-AS is funded by the British Society for Rheumatology, which receives funds from AbbVie, Pfizer, and UCB. Dr. Macfarlane did not report having any conflicts of interest.
BIRMINGHAM, ENGLAND – One in five people with ankylosing spondylitis could have comorbid fibromyalgia, according to data from the British Society for Rheumatology Biologics Register for Ankylosing Spondylitis (BSRBR-AS).
The analysis, which included more than 880 patients with axial spondyloarthritis (SpA), found that 20.7% met 2011 research criteria for the chronic pain condition.
The prevalence of fibromyalgia was similar when the modified New York (mNY) criteria were used to diagnose SpA, at 19.7%, but slightly higher at 25.2% when SpA patients met the Assessment of SpondyloArthritis international Society (ASAS) imaging criteria but not mNY criteria, and substantially lower at 9.5% when SpA patients met ASAS clinical criteria only.
Courtesy Dr. Gary J. Macfarlane
Dr. Gary J. Macfarlane“The background is that some patients with axial SpA are recognized clinically to have comorbid fibromyalgia,” Gary J. Macfarlane, MD, PhD, said at the British Society for Rheumatology annual conference.
Dr. Macfarlane, chief investigator of the BSRBR-AS and professor and chair of clinical epidemiology at the University of Aberdeen (Scotland), added that having comorbid fibromyalgia might “distort the responses of some of the key patient-reported measures and that may lead to some patients having inappropriate therapy.”
So the aim of the present analysis was to provide data on the frequency of SpA and fibromyalgia co-occurrence, characterize which patients might be more likely to have both conditions, and also provide information that would inform future studies looking at the optimal management of such patients.
“The patients most likely to meet fibromyalgia criteria were female, either HLA-B27 negative or untested, and there was a particularly strong association with higher levels of [social] deprivation,” Dr. Macfarlane reported.
Patients who had both SpA and fibromyalgia also were found to be more likely to have been treated with a biologic than those who had SpA alone (51% vs. 32%), and there also was an associated with the time missed (15.1% vs. 2.5%) or impaired (50.8% vs. 22.8%) at work.
In a comparison of the characteristics of patients with SpA who met the fibromyalgia research criteria with those who did not, Dr. Macfarlane observed that they had worse disease activity, function, metrology, and global scores as measured using Bath Ankylosing Spondylitis disease indices:
• Disease activity scores were a respective 6.7 and 3.6, giving a difference of 3.1 (95% confidence interval, 2.9-3.3).
• Function scores were a respective 6.6 and 3.7, with a difference of 2.9 (95% CI, 2.6-3.3).
• Metrology scores were a respective 4.2 and 3.6, with a difference of 0.6 (95% CI, 0.3-0.9).
• Global scores were a respective 6.9 and 3.7, with a different of 3.2 (95% CI, 2.9-3.6).
Dr. Macfarlane reported that there were “extremely large differences” on the patient-reported measures of quality of life, depression, and anxiety. Other common problems in the group meeting the fibromyalgia criteria were sleeping difficulties and high levels of fatigue, he said.
Patients with both SpA and fibromyalgia fared worse on quality of life scores measured using the disease-specific Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire where they scored a mean of 7.1 points (95% CI, 6.4-7.7) higher than did those with SpA alone.
The mean differences in depression and anxiety, both measured using the Hospital Anxiety and Depression Scale (HADS), was 4.8 (95% CI, 4.3-5.2) and 4.7 (95% CI, 4.1-5.2).
The mean difference in the sleep disturbance scale was 5.3 (95% CI, 4.5-6.0), and the mean difference in Chalder Fatigue Scale scores was 4.0 (95% CI, 3.5-4.4).
In contrast, there was no difference in the proportion of patients who had levels of C-reactive protein above 1 mg/dL or in the number of proportion of patients who had extraspinal manifestations of SpA, with the exception of tender or swollen joint counts.
Dr. Macfarlane noted that the fibromyalgia research criteria had not been validated for use in patients with axial SpA but that a grant had been awarded by Arthritis Research UK to look at this and also to look into optimizing options for managing patients with both conditions.
The BSRBR-AS is currently the newest of the biologics registries and began recruiting patients with axial SpA as of December 2012 from 82 centers across the United Kingdom. The register enrolls patients who have not previously been treated with a tumor necrosis factor inhibitor drug and are then followed-up for a 5-year period. The 2011 fibromyalgia research criteria have been used as part of the baseline assessment since September 2015, and clinicians also are asked to report whether they think that patients have fibromyalgia.
The BSRBR-AS is funded by the British Society for Rheumatology, which receives funds from AbbVie, Pfizer, and UCB. Dr. Macfarlane did not report having any conflicts of interest.
Key clinical point:Fibromyalgia can coexist in patients with axial spondyloarthritis and appears associated with worse disease activity and quality of life.
Major finding: Of more than 880 patients with axial SpA, 20.7% met 2011 research criteria for the chronic pain condition.
Data source: British Society for Rheumatology Biologics Register for Ankylosing Spondylitis (BSRBR-AS).
Disclosures: The BSRBR-AS is funded by the British Society for Rheumatology, which receives funds from AbbVie, Pfizer, and UCB. Dr. Macfarlane did not report having any conflicts of interest.
BOSTON – Both the soon-to-be chair and vice chair of the AGA Center for GI Innovation and Technology, which sponsors the AGA Tech Summit, are looking forward to building upon the successes of this year’s meeting.
“Giving folks a road map and seeing physicians come to the meeting to network and meet the right people, that is the really satisfying part for me,” V. Raman Muthusamy, MD, the incoming chair of the committee, said in an interview.
“I was honored to be asked to take over this position,” he said. “I have been contemplating . . .where we are and where we’ve been and where we need to go next.”
Dr. Muthusamy, director of interventional endoscopy and general GI endoscopy and current professor of medicine at the University of California, Los Angeles, is keenly interested in the intersection of technical innovation and gastroenterology, especially concerning endoscopic technology.
The committee’s incoming vice chair, Srinadh Komanduri, MD, of Northwestern University’s Feinberg School of Medicine, Chicago, takes a deep interest in innovative medical technologies that are applicable to gastroenterology. “A lot of what I’m doing at Northwestern is cutting-edge techniques and looking for new innovation, especially for early cancers in the GI tract,” Dr. Komanduri said.
Dr. Muthusamy and Dr. Komanduri will assume their new roles June 1 when Michael L. Kochman, MD, AGAF, of the University of Pennsylvania, Philadelphia, retires from his position as executive chairman of the committee, shortly after the close of this year’s AGA Tech Summit. “It’s been an honor and humbling to have been entrusted with running the CGIT over the past term; we solidified a number of critical relationships and added new programs. I am thrilled that Raman and Sri will be taking the reins as the plans that they have will build on the foundation and take the CGIT to a new level.”
The meeting, according to the incoming chairs, offers a great opportunity for physician-innovators to share their interests and ideas.
“The Tech Summit is unlike any other meeting I’ve gone to. It is a time to see the business of science and the gaps in technology as well as the technicalities of business that are not part of the standard medical training,” said Dr. Muthusamy, who moderated this year’s “Shark Tank” session, considered the highlight event of the meeting during which entrepreneurs present their ideas to a panel of doctors and business leaders to gain a diverse range of insight on how to take their projects to the next level.
Learn more about the AGA Center for GI Innovation and Technology at www.gastro.org/CGIT.
BOSTON – Both the soon-to-be chair and vice chair of the AGA Center for GI Innovation and Technology, which sponsors the AGA Tech Summit, are looking forward to building upon the successes of this year’s meeting.
“Giving folks a road map and seeing physicians come to the meeting to network and meet the right people, that is the really satisfying part for me,” V. Raman Muthusamy, MD, the incoming chair of the committee, said in an interview.
“I was honored to be asked to take over this position,” he said. “I have been contemplating . . .where we are and where we’ve been and where we need to go next.”
Dr. Muthusamy, director of interventional endoscopy and general GI endoscopy and current professor of medicine at the University of California, Los Angeles, is keenly interested in the intersection of technical innovation and gastroenterology, especially concerning endoscopic technology.
The committee’s incoming vice chair, Srinadh Komanduri, MD, of Northwestern University’s Feinberg School of Medicine, Chicago, takes a deep interest in innovative medical technologies that are applicable to gastroenterology. “A lot of what I’m doing at Northwestern is cutting-edge techniques and looking for new innovation, especially for early cancers in the GI tract,” Dr. Komanduri said.
Dr. Muthusamy and Dr. Komanduri will assume their new roles June 1 when Michael L. Kochman, MD, AGAF, of the University of Pennsylvania, Philadelphia, retires from his position as executive chairman of the committee, shortly after the close of this year’s AGA Tech Summit. “It’s been an honor and humbling to have been entrusted with running the CGIT over the past term; we solidified a number of critical relationships and added new programs. I am thrilled that Raman and Sri will be taking the reins as the plans that they have will build on the foundation and take the CGIT to a new level.”
The meeting, according to the incoming chairs, offers a great opportunity for physician-innovators to share their interests and ideas.
“The Tech Summit is unlike any other meeting I’ve gone to. It is a time to see the business of science and the gaps in technology as well as the technicalities of business that are not part of the standard medical training,” said Dr. Muthusamy, who moderated this year’s “Shark Tank” session, considered the highlight event of the meeting during which entrepreneurs present their ideas to a panel of doctors and business leaders to gain a diverse range of insight on how to take their projects to the next level.
Learn more about the AGA Center for GI Innovation and Technology at www.gastro.org/CGIT.
BOSTON – Both the soon-to-be chair and vice chair of the AGA Center for GI Innovation and Technology, which sponsors the AGA Tech Summit, are looking forward to building upon the successes of this year’s meeting.
“Giving folks a road map and seeing physicians come to the meeting to network and meet the right people, that is the really satisfying part for me,” V. Raman Muthusamy, MD, the incoming chair of the committee, said in an interview.
“I was honored to be asked to take over this position,” he said. “I have been contemplating . . .where we are and where we’ve been and where we need to go next.”
Dr. Muthusamy, director of interventional endoscopy and general GI endoscopy and current professor of medicine at the University of California, Los Angeles, is keenly interested in the intersection of technical innovation and gastroenterology, especially concerning endoscopic technology.
The committee’s incoming vice chair, Srinadh Komanduri, MD, of Northwestern University’s Feinberg School of Medicine, Chicago, takes a deep interest in innovative medical technologies that are applicable to gastroenterology. “A lot of what I’m doing at Northwestern is cutting-edge techniques and looking for new innovation, especially for early cancers in the GI tract,” Dr. Komanduri said.
Dr. Muthusamy and Dr. Komanduri will assume their new roles June 1 when Michael L. Kochman, MD, AGAF, of the University of Pennsylvania, Philadelphia, retires from his position as executive chairman of the committee, shortly after the close of this year’s AGA Tech Summit. “It’s been an honor and humbling to have been entrusted with running the CGIT over the past term; we solidified a number of critical relationships and added new programs. I am thrilled that Raman and Sri will be taking the reins as the plans that they have will build on the foundation and take the CGIT to a new level.”
The meeting, according to the incoming chairs, offers a great opportunity for physician-innovators to share their interests and ideas.
“The Tech Summit is unlike any other meeting I’ve gone to. It is a time to see the business of science and the gaps in technology as well as the technicalities of business that are not part of the standard medical training,” said Dr. Muthusamy, who moderated this year’s “Shark Tank” session, considered the highlight event of the meeting during which entrepreneurs present their ideas to a panel of doctors and business leaders to gain a diverse range of insight on how to take their projects to the next level.
Learn more about the AGA Center for GI Innovation and Technology at www.gastro.org/CGIT.
Supply of the only U.S.-licensed yellow fever vaccine will be depleted by mid-2017 because of manufacturing issues, according to the Centers for Disease Control and Prevention.
Sanofi Pasteur, the manufacturer of the YF-VAX vaccine, notified the CDC and the Food and Drug Administration in 2016 there could be a shortage this year after the manufacturing complications during a factory switch over led to the loss of a large amount of vaccine supply, according to an article published online in the Morbidity and Mortality Weekly Report.
The shortage is expected to affect government workers and military personnel as well as private travelers, 8 million of whom traveled to at least one of 42 countries with endemic yellow fever virus transmission in 2015 (MMWR. 2017 Apr 28. doi: 10.15585/mmwr.mm6617e2).
The CDC, Sanofi Pasteur, and the FDA are working to supplement the shortage. The manufacturer submitted an expanded investigational new drug (eIND) application to the FDA in September 2016 for marketing permission for Stamaril, an alternative vaccine manufactured by Sanofi Pasteur France and used in around 70 countries.
The application included planning for strategic distribution sites, which the CDC is determining using a tiered system based on volume of doses ordered in 2016.
As of April 2017, 250 civilian sites have been invited to participate in the eIND program, significantly less than the 4,000 currently distributing YF-VAX.
The CDC will “monitor for critical gaps in vaccine access and collaborate to address any issues, including considering the possibility of recruiting additional clinics to participate as necessary,” according to a statement.
Supply of the only U.S.-licensed yellow fever vaccine will be depleted by mid-2017 because of manufacturing issues, according to the Centers for Disease Control and Prevention.
Sanofi Pasteur, the manufacturer of the YF-VAX vaccine, notified the CDC and the Food and Drug Administration in 2016 there could be a shortage this year after the manufacturing complications during a factory switch over led to the loss of a large amount of vaccine supply, according to an article published online in the Morbidity and Mortality Weekly Report.
The shortage is expected to affect government workers and military personnel as well as private travelers, 8 million of whom traveled to at least one of 42 countries with endemic yellow fever virus transmission in 2015 (MMWR. 2017 Apr 28. doi: 10.15585/mmwr.mm6617e2).
The CDC, Sanofi Pasteur, and the FDA are working to supplement the shortage. The manufacturer submitted an expanded investigational new drug (eIND) application to the FDA in September 2016 for marketing permission for Stamaril, an alternative vaccine manufactured by Sanofi Pasteur France and used in around 70 countries.
The application included planning for strategic distribution sites, which the CDC is determining using a tiered system based on volume of doses ordered in 2016.
As of April 2017, 250 civilian sites have been invited to participate in the eIND program, significantly less than the 4,000 currently distributing YF-VAX.
The CDC will “monitor for critical gaps in vaccine access and collaborate to address any issues, including considering the possibility of recruiting additional clinics to participate as necessary,” according to a statement.
Supply of the only U.S.-licensed yellow fever vaccine will be depleted by mid-2017 because of manufacturing issues, according to the Centers for Disease Control and Prevention.
Sanofi Pasteur, the manufacturer of the YF-VAX vaccine, notified the CDC and the Food and Drug Administration in 2016 there could be a shortage this year after the manufacturing complications during a factory switch over led to the loss of a large amount of vaccine supply, according to an article published online in the Morbidity and Mortality Weekly Report.
The shortage is expected to affect government workers and military personnel as well as private travelers, 8 million of whom traveled to at least one of 42 countries with endemic yellow fever virus transmission in 2015 (MMWR. 2017 Apr 28. doi: 10.15585/mmwr.mm6617e2).
The CDC, Sanofi Pasteur, and the FDA are working to supplement the shortage. The manufacturer submitted an expanded investigational new drug (eIND) application to the FDA in September 2016 for marketing permission for Stamaril, an alternative vaccine manufactured by Sanofi Pasteur France and used in around 70 countries.
The application included planning for strategic distribution sites, which the CDC is determining using a tiered system based on volume of doses ordered in 2016.
As of April 2017, 250 civilian sites have been invited to participate in the eIND program, significantly less than the 4,000 currently distributing YF-VAX.
The CDC will “monitor for critical gaps in vaccine access and collaborate to address any issues, including considering the possibility of recruiting additional clinics to participate as necessary,” according to a statement.
Association of inpatient antimicrobial utilization measures with antimicrobial stewardship activities and facility characteristics of Veterans Affairs medical centers
The deleterious impact of inappropriate and/or excessive antimicrobial usage is well recognized. In the United States, the Centers for Disease Control and Prevention (CDC) estimates that at least 2 million people become infected with antimicrobial-resistant bacteria with 23,000 subsequent deaths and at least $1 billion in excess medical costs per year.1
In response, many healthcare organizations have developed antimicrobial stewardship programs (ASPs). Guidelines co-sponsored by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America, as well as recent statements from the CDC and the Transatlantic Taskforce on Antimicrobial Resistance,all recommend core ASP elements.2-5 The guidelines provide general recommendations on ASP structure, strategies, and activities. The recommended ASP structure is a team of physicians and pharmacists that collaborates with facility governing committees and other stakeholders to optimize antimicrobial use. While personnel with expertise in infectious diseases (ID) often lead ASPs, hospitalists are also recognized as key contributors, especially in quality improvement.6,7 Recommended strategies include prospective audit of antimicrobial use with intervention and feedback and formulary restriction with preauthorization. Recommended activities include education, creation of guidelines, clinical pathways, and order forms, and programs to promote de-escalation and conversion from parenteral (IV) to oral (PO) antimicrobial therapy. However, limited evidence exists regarding the effectiveness of these ASP core elements.8,9 While Cochrane reviews found clear evidence that particular stewardship strategies (eg, audit and feedback, formulary restriction, guidelines implemented with or without feedback, protocols, computerized decision support) can be effective in reducing antimicrobial usage and improving clinical outcomes over the long term, little evidence exists favoring 1 strategy over another.8 Furthermore, most individual studies of ASPs are single-center, making their conclusions less generalizable.
In 2012, the VA National Antimicrobial Stewardship Task Force (ASTF), in conjunction with the VA Healthcare Analysis and Information Group (HAIG) administered a survey on the characteristics of ASPs at all 130 acute care VA facilities (Appendix A). We used these survey results to build an implementation model and then assess associations between facility-level variables and 4 antimicrobial utilization measures.
METHODS
Survey and Data
In 2011, the ASTF was chartered to develop, deploy, and monitor a strategic plan for optimizing antimicrobial therapy management. Monthly educational webinars and sample policies were offered to all facilities, including a sample business plan for stewardship and policies to encourage de-escalation from broad-spectrum antimicrobials, promote conversion from parenteral to oral antimicrobial therapy, avoid unnecessary double anaerobic coverage, and mitigate unnecessary antimicrobial usage in the context of Clostridium difficile infection.10
At the time that ASTF was chartered, the understanding of how ASP structures across VA facilities operated was limited. Hence, to capture baseline institutional characteristics and stewardship activities, ASTF and HAIG developed an inventory assessment of ASPs that was distributed online in November 2012. All 130 VA facilities providing inpatient acute care services responded.
We derived 57 facility characteristics relevant to antimicrobial utilization and conducted a series of factor analyses to simplify the complex dataset, and identify underlying latent constructs. We categorized resulting factors into domains of evidence, context, or facilitation as guided by the Promoting Action on Research Implementation in Health Services framework.11 Briefly, the evidence domain describes how the facility uses codified and noncodified sources of knowledge (eg, research evidence, clinical experience). Organizational context comprises a facility’s characteristics that ensure a more conducive environment to put evidence into practice (eg, supportive leadership, organizational structure, evaluative systems). Facilitation emphasizes a facility personnel’s “state of preparedness” and receptivity to implementation.
Using factor analysis to identify facility factors as correlates of the outcomes, we first examined polychoric correlations among facility characteristics to assess multicollinearity. We performed independent component analysis to create latent constructs of variables that were defined by factor loadings (that indicated the proportion of variance accounted for by the construct) and uniqueness factors (that determined how well the variables were interpreted by the construct). Factors retained included variables that had uniqueness values of less than 0.7 and factor loadings greater than 0.3. Those associated with uniqueness values greater than 0.7 were left as single items, as were characteristics deemed a priori to be particularly important to antimicrobial stewardship. Factor scales that had only 2 items were converted into indices, while factor scores were generated for those factors that contained 3 or more items.12-15
Data for facility-level antimicrobial utilization measures were obtained from the VA Corporate Data Warehouse from calendar year 2012. The analysis was conducted within the VA Informatics and Computing Infrastructure. All study procedures were approved by the VA Central Institutional Review Board.
Measures
Four utilization measures were defined as dependent measures: overall antimicrobial use; antimicrobial use in patients with non-infectious discharge diagnoses; missed opportunities to convert from parenteral to oral antimicrobial therapy; and missed opportunities to avoid double anaerobic coverage with metronidazole.
Overall antimicrobial use was defined as total acute care (ie, medical/surgical/intensive care) antibacterial use for each facility aggregated as per CDC National Healthcare Safety Network Antimicrobial Use Option guidelines (antimicrobial days per 1000 patient days present). A subanalysis of overall antimicrobial use was restricted to antimicrobial use among patients without an infection-related discharge diagnosis, as we surmised that this measure may capture a greater proportion of potentially unnecessary antimicrobial use. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)16 codes for infectious processes were identified by a combination of those classified previously in the literature,17 and those identified by finding the descendants of all infections named in the Systematized Nomenclature of Medicine--Clinical Terms.18 Next, all remaining codes for principal discharge diagnoses for which antimicrobials were administered were reviewed for potential indications for systemic antibacterial use. Discharges were considered noninfectious if no codes were identified when systemic antimicrobials were or could be indicated. For this measure, antimicrobial days were not counted if administered on or 1 day after the calendar day of surgery warranting antimicrobial prophylaxis.
Missed opportunities for conversion from parenteral to oral (IV to PO) formulations of highly bioavailable oral antimicrobials (ciprofloxacin, levofloxacin, moxifloxacin, azithromycin, clindamycin, linezolid, metronidazole, and fluconazole) were defined as the percentage of days of unnecessary IV therapy that were given when PO therapy could have been used among patients who were not in intensive care units at the time of antimicrobial administration who were receiving other oral medications, using previously described methodology.19Missed opportunities for avoiding redundant anaerobic coverage with metronidazole were defined as the percentage of days in which patients receiving metronidazole also receivedantibiotics with activity against anaerobic bacteria, specifically beta-lactam/beta-lactamase inhibitors, carbapenems, cefotetan/cefoxitin, clindamycin, moxifloxacin, or tigecycline), using previously described methodology.20 Patients for whom C. difficile testing was either ordered or positive within the prior 28 days (indicating potential clinical concern for C. difficile infection) were excluded from this endpoint.
Analysis
The variables derived above were entered into a multivariable model for each of the 4 antimicrobial utilization measures. The least absolute shrinkage and selection operator (LASSO) regression was used to determine significant associations between variables and individual utilization measures.21 LASSO was chosen because it offers advantages over traditional subset selection approaches in large multivariable analyses by assessing covariates simultaneously rather than sequentially, supporting prediction rather than estimation of effect.22P values were not reported as they are not useful in determining statistical significance in this methodology. A tuning parameter of 0.025 was determined for the model based on a cross-validation approach. Significant variables remaining in the model were reported with the percent change in each utilization measure per unit change in the variable of interest. For binary factors, percent change was reported according to whether the variable was present or not. For ordinal variables, percent change was reported according to incremental increase in ordinal score. For continuous variables or variables represented by factor or index scores, percent change was reported per each 25% increase in the range of the score.
RESULTS
Inpatient Facility Antimicrobial Stewardship Characteristics and Antimicrobial Utilization
Frequencies of key facility characteristics that contributed to variable development are included in Table 1. Full survey results across all facilities are included in Appendix B. Factor analysis reduced the total number of variables to 32; however, we also included hospital size and VA complexity score. Thus, 34 variables were evaluated for association with antimicrobial utilization measures: 4 in the evidence domain, 23 in the context domain, and 7 in the facilitation domain (Table 2).
Table 1
Table 1 (continued)
Median facility antimicrobial use was 619 antimicrobial days per 1000 days present (interquartile range [IQR], 554-700; overall range, 346-974). Median facility noninfectious antimicrobial use was 236 per 1000 days present (IQR, 200-286). Missed opportunities for conversion from IV to PO antimicrobial therapy were common, with a median facility value of 40.4% (391/969) of potentially eligible days of therapy (IQR, 32.2-47.8%). Missed opportunities to avoid double anaerobic coverage were less common (median 15.3% (186/1214) of potentially eligible days of therapy (IQR, 11.8%-20.2%; Figure).
Overall Antimicrobial Use
Four variables were associated with decreased overall antimicrobial use, although with small magnitude of change: presence of postgraduate physician/pharmacy training programs (0.03% decrease per quarter increase in factor score; on the order of 0.2 antimicrobial days per 1000 patient days present), presence of pharmacists and/or ID attendings on general medicine ward teams (0.02% decrease per quarter increase in index score), frequency of systematic de-escalation review (0.01% decrease per ordinal increase in score), and degree of involvement of ID physicians and/or fellows in antimicrobial approvals (0.007% decrease per quarter increase in index score). No variables were associated with increased overall antimicrobial use.
Table 2
Table 2 (continued)
Antimicrobial Use among Discharges without Infectious Diagnoses
Six variables were associated with decreased antimicrobial use in patients without infectious discharge diagnoses, while 4 variables were associated with increased use. Variables associated with the greatest magnitude of decreased use included facility educational programs for prudent antimicrobial use (1.8% on the order of 4 antimicrobial days per 1000 patient days present), frequency of systematic de-escalation review (1.5% per incremental increase in score), and whether a facility’s lead antimicrobial stewardship pharmacist had ID training (1.3%). Also significantly associated with decreased use was a factor summarizing the presence of 4 condition-specific stewardship processes (de-escalation policies, policies for addressing antimicrobial use in the context of C. difficile infection, blood culture review, and automatic ID consults for certain conditions) (0.6% per quarter increase in factor score range), the extent to which postgraduate physician/pharmacy training programs were present (0.6% per quarter increase in factor score range), and the number of electronic antimicrobial-specific order sets present (0.4% per order set). The variables associated with increased use of antimicrobials included the presence of antimicrobial stop orders (4.6%), the degree to which non-ID physicians were involved in antimicrobial approvals (0.7% per increase in ordinal score), the level engagement with ASTF online resources (0.6% per quarter increase in factor score range), and hospital size (0.6% per 50-bed increase).
Figure
Missed Opportunities for Parenteral to Oral Antimicrobial Conversion
Missed opportunities for IV to PO antimicrobial conversion had the largest number of significant associations with organizational variables: 14 variables were associated with fewer missed opportunities, while 5 were associated with greater missed opportunities. Variables associated with the largest reductions in missed opportunities for IV to PO conversion included having guidelines for antimicrobial duration (12.8%), participating in regional stewardship collaboratives (8.1%), number of antimicrobial-specific order sets (6.0% per order set), ID training of the ASP pharmacist (4.9%), and VA facility complexity designation (4.2% per quarter increase in score indicating greater complexity).23 Variables associated with more missed opportunities included stop orders (11.7%), overall perceived receptiveness to antimicrobial stewardship among clinical services (9.4%), the degree of engagement with ASTF online resources (6.9% per quarter increase in factor score range), educational programs for prudent antimicrobial use (4.1%), and hospital size (1.0% per 50-bed increase).
Missed Opportunities for Avoidance of Double Anaerobic Coverage
Four variables were associated with more avoidance of double anaerobic coverage: ID training of the lead ASP pharmacist (8.8%), presence of pharmacists and/or ID attendings on acute care ward teams (6.2% per quarter increase in index score), degree of ID pharmacist involvement in antimicrobial approvals, ranging from not at all (score=0) to both weekdays and nights/weekends (score=2; 4.3% per ordinal increase), and the number of antimicrobial-specific order sets (1.5% per order set). No variables were associated with less avoidance of double anaerobic coverage.
Variables Associated with Multiple Favorable or Unfavorable Antimicrobial Utilization Measures
To better assess the consistency of the relationship between organizational variables and measures of antimicrobial use, we tabulated variables that were associated with at least 3 potentially favorable (ie, reduced overall or noninfectious antimicrobial use or fewer missed opportunities) measures. Altogether, 5 variables satisfied this criterion: the presence of postgraduate physician/pharmacy training programs, the number of antimicrobial-specific order sets, frequency of systematic de-escalation review, the presence of pharmacists and/or ID attendings on acute care ward teams, and formal ID training of the lead ASP pharmacist (Table 3). Three other variables were associated with at least 2 unfavorable measures: hospital size, the degree to which the facility engaged with ASTF online resources, and presence of antimicrobial stop orders.
Table 3
DISCUSSION
Variability in ASP implementation across VA allowed us to assess the relationship between ASP and facility elements and baseline patterns of antimicrobial utilization. Hospitalists and hospital policy-makers are becoming more and more engaged in inpatient antimicrobial stewardship. While our results suggest that having pharmacists and/or physicians with formal ID training participate in everyday inpatient activities can favorably improve antimicrobial utilization, considerable input into stewardship can be made by hospitalists and policy makers. In particular, based on this work, the highest yield from an organizational standpoint may be in working to develop order sets within the electronic medical record and systematic efforts to promote de-escalation of broad-spectrum therapy, as well as encouraging hospital administration to devote specific physician and pharmacy salary support to stewardship efforts.
While we noted that finding the ASTF online resources helpful was associated with potentially unfavorable antimicrobial utilization, we speculate that this may represent reverse causality due to facilities recognizing that their antimicrobial usage is suboptimal and thus seeking out sample ASTF policies to implement. The association between the presence of automatic stop orders and potentially unfavorable antimicrobial utilization is less clear since the timeframe was not specified in the survey; it may be that setting stop orders too far in advance may promote an environment in which critical thinking about antimicrobial de-escalation is not encouraged or timely. The larger magnitude of association between ASP characteristics and antimicrobial usage among patients without infectious discharge diagnoses versus overall antimicrobial usage also suggests that clinical situations where infection was of low enough suspicion to not even have the providers eventually list an infectious diagnosis on their discharge summaries may be particularly malleable to ASP interventions, though further exploration is needed in determining how useful this utilization measure may be as a marker for inappropriate antimicrobial use.
Our results complement those of Pakyz et al.24 who surveyed 44 academic medical facilities in March 2013 to develop an ASP intensity score and correlate this score and its specific components to overall and targeted antimicrobial use. This study found that the overall ASP intensity score was not significantly associated with total or targeted antimicrobial use. However, ASP strategies were more associated with decreased total and targeted antimicrobial use than were specific ASP resources. In particular, the presence of a preauthorization strategy was associated with decreased targeted antimicrobial use. Our particular findings that order set establishment and de-escalation efforts are associated with multiple antibiotic outcomes also line up with the findings of Schuts et al,who performed a meta-analysis of the effects of meeting antimicrobial stewardship objectives and found that achieving guideline concordance (such as through establishment of order sets) and successfully de-escalating antimicrobial therapy was associated with reduced mortality.25,26 This meta-analysis, however, was limited by low rigor of its studies and potential for reverse causality. While our study has the advantages of capturing an entire national network of 130 acute care facilities with a 100% response rate, it, too, is limited by a number of issues, most notably by the fact that the survey was not specifically designed for the analysis of antimicrobial utilization measures, patient-level risk stratification was not available, the VA population does not reflect the U.S. population at-large, recall bias, and that antimicrobial prescribing and stewardship practices have evolved in VA since 2012. Furthermore, all of the antimicrobial utilization measures studied are imperfect at capturing inappropriate antibiotic use; in particular, our reliance on principal ICD-9 codes for noninfectious outcomes requires prospective validation. Many survey questions were subjective and subject to misinterpretation; other unmeasured confounders may also be present. Causality cannot be inferred from association. Nevertheless, our findings support many core indicators for hospital ASP recommended by the CDC and the Transatlantic Taskforce on Antimicrobial Resistance,3,4 most notably, having personnel with ID training involved in stewardship and establishing a formal procedure for ASP review for the appropriateness of an antimicrobial at or after 48 hours from the initial order.
In summary, the VA has made efforts to advance the practice of antimicrobial stewardship system-wide, including a 2014 directive that all VA facilities have an ASP,27 since the 2012 HAIG assessment reported considerable variability in antimicrobial utilization and antimicrobial stewardship activities. Our study identifies areas of stewardship that may correlate with, positively or negatively, antimicrobial utilization measures that will require further investigation. A repeat and more detailed antimicrobial stewardship survey was recently completed and will help VA gauge ongoing effects of ASTF activities. We hope to re-evaluate our model with newer data when available.
Acknowledgments
The authors wish to thank Michael Fletcher, Jaime Lopez, and Catherine Loc-Carrillo for their administrative and organizational support of the project and Allison Kelly, MD, for her pivotal role in survey development and distribution. This work was supported by the VA Health Services Research and Development Service Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) Initiative; Cognitive Support Informatics for Antimicrobial Stewardshipproject (CRE 12-313).
Disclosure
The authors report no financial conflicts of interest.
1. Antibiotic resistance threats in the United States, 2013. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/drugresistance/threat-report-2013/. Published 2013. Accessed January 7, 2016. 2. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44(2):159-177. PubMed 3. Centers for Disease Control and Prevention. Core elements of hospital antibiotic stewardship programs. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Published 2015. Accessed January 7, 2016. 4. Pollack LA, Plachouras D, Gruhler H, Sinkowitz-Cochran R. Transatlantic taskforce on antimicrobial resistance (TATFAR) summary of the modified Delphi process for common structure and process indicators for hospital antimicrobial stewardship programs. http://www.cdc.gov/drugresistance/pdf/summary_of_tatfar_recommendation_1.pdf. Published 2015. Accessed January 7, 2016. 5. Barlam TF, Cosgrove SE, Abbo LM, MacDougal C, Schuetz AN, Septimus EJ, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62(10):e51-e77. PubMed 6. Rohde JM, Jacobsen D, Rosenberg DJ. Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther. 2013;35(6):751-757. PubMed 7. Mack MR, Rohde JM, Jacobsen D, Barron JR, Ko C, Goonewardene M, et al. Engaging hospitalists in antimicrobial stewardship: lessons from a multihosopital collaborative. J Hosp Med. 2016;11(8):576-580. PubMed 8. Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2013;4:CD003543. PubMed 9. Filice G, Drekonja D, Wilt TJ, Greer N, Butler M, Wagner B. Antimicrobial stewardship programs in inpatient settings: a systematic review. Washington, DC: Department of Veterans Affairs Health Services Research and Development. http://www.hsrd.research.va.gov/publications/esp/antimicrobial.pdf. Published 2013. Accessed January 7, 2016. 10. Graber CJ, Madaras-Kelly K, Jones MM, Neuhauser MM, Goetz MB. Unnecessary antimicrobial use in the context of Clostridium difficile infection: a call to arms for the Veterans Affairs Antimicrobial Stewardship Task Force. Infect Control Hosp Epidemiol. 2013(6);34:651-653. PubMed 11. Rycroft-Malone J. The PARIHS framework--a framework for guiding the implementation of evidence-based practice. J Nurs Care Qual. 2004;19(4):297-304. PubMed 12. Chou AF, Graber CJ, Jones MM, Zhang Y, Goetz MB, Madaras-Kelly K, et al. Specifying an implementation framework for VA antimicrobial stewardship programs. Oral presentation at the VA HSR&D/QUERI National Conference, July 8-9, 2015. Washington, DC: U.S. Department of Veterans Affairs. http://www.hsrd.research.va.gov/meetings/2015/abstract-display.cfm?RecordID=862. Accessed July 5, 2016. 13. Bartholomew DJ. Factor analysis for categorical data. J R Stat Soc. 1980;42:293-321. 14. Flanagan M, Ramanujam R, Sutherland J, Vaughn T, Diekema D, Doebbeling BN. Development and validation of measures to assess prevention and control of AMR in hospitals. Med Care. 2007;45(6): 537-544. PubMed 15. Kline P. An easy guide to factor analysis. New York: Routledge, 1994. 16. Centers for Disease Control and Prevention, National Center for Health Statistics. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Atlanta GA: Centers for Disease Control and Prevention. http://www.cdc.gov/nchs/icd/icd9cm.htm. Published 2013. Accessed January 7, 2016. 17. Huttner B, Jones M, Huttner A, Rubin M, Samore MH. Antibiotic prescription practices for pneumonia, skin and soft tissue infections and urinary tract infections throughout the US Veterans Affairs system. J Antimicrob Chemother. 2013;68(10):2393-2399. PubMed 18. National Institutes of Health. SNOMED Clinical Terms (SNOMED CT). Bethesda, MD: U.S. National Library of Medicine. https://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html. NIH website. Published 2009. Accessed January 7. 2016. 19. Jones M, Huttner B, Madaras-Kelly K, Nechodom K, Nielson C, Bidwell Goetz M, et al. Parenteral to oral conversion of fluoroquinolones: low-hanging fruit for antimicrobial stewardship programs? Infect Control Hosp Epidemiol 2012;33(4): 362-367. PubMed 20. Huttner B, Jones M, Rubin MA, Madaras-Kelly K, Nielson C, Goetz MB, et al. Double trouble: how big a problem is redundant anaerobic antibiotic coverage in Veterans Affairs medical centres? J Antimicrob Chemother. 2012;67(6):1537-1539. PubMed 21. Tibshirani R. Regression shrinkage and selection via the lasso. J R Stat Soc B. 1996;58:267-288. 22. Taylor J, Tibshirani RJ. Statistical learning and selective inference. Proc Natl Acad Sci U S A. 2015;112(25):7629-7634. PubMed 23. VHA Office of Productivity, Efficiency, and Staffing. Facility Complexity Levels. Department of Veterans Affairs website. http://opes.vssc.med.va.gov/FacilityComplexityLevels/Pages/default.aspx. Published 2008. Accessed January 7, 2016. 24. Pakyz AL, Moczygemba LR, Wang H, Stevens MP, Edmond MB. An evaluation of the association between an antimicrobial stewardship score and antimicrobial usage. J Antimicrob Chemother. 2015;70(5):1588-1591. PubMed 25. Schuts EC, Hulscher ME, Mouton JW, Verduin CM, Stuart JW, Overdiek HW, et al. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis. 2016;16(7):847-856. PubMed 26. Graber CJ, Goetz MB. Next steps for antimicrobial stewardship. Lancet Infect Dis. 2016;16(7):764-765. PubMed 27. Petzel RA. VHA Directive 1031: Antimicrobial stewardship programs (ASP). Washington, DC: Department of Veterans Affairs.http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2964. Published January 22, 2014. Accessed July 5, 2016.
The deleterious impact of inappropriate and/or excessive antimicrobial usage is well recognized. In the United States, the Centers for Disease Control and Prevention (CDC) estimates that at least 2 million people become infected with antimicrobial-resistant bacteria with 23,000 subsequent deaths and at least $1 billion in excess medical costs per year.1
In response, many healthcare organizations have developed antimicrobial stewardship programs (ASPs). Guidelines co-sponsored by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America, as well as recent statements from the CDC and the Transatlantic Taskforce on Antimicrobial Resistance,all recommend core ASP elements.2-5 The guidelines provide general recommendations on ASP structure, strategies, and activities. The recommended ASP structure is a team of physicians and pharmacists that collaborates with facility governing committees and other stakeholders to optimize antimicrobial use. While personnel with expertise in infectious diseases (ID) often lead ASPs, hospitalists are also recognized as key contributors, especially in quality improvement.6,7 Recommended strategies include prospective audit of antimicrobial use with intervention and feedback and formulary restriction with preauthorization. Recommended activities include education, creation of guidelines, clinical pathways, and order forms, and programs to promote de-escalation and conversion from parenteral (IV) to oral (PO) antimicrobial therapy. However, limited evidence exists regarding the effectiveness of these ASP core elements.8,9 While Cochrane reviews found clear evidence that particular stewardship strategies (eg, audit and feedback, formulary restriction, guidelines implemented with or without feedback, protocols, computerized decision support) can be effective in reducing antimicrobial usage and improving clinical outcomes over the long term, little evidence exists favoring 1 strategy over another.8 Furthermore, most individual studies of ASPs are single-center, making their conclusions less generalizable.
In 2012, the VA National Antimicrobial Stewardship Task Force (ASTF), in conjunction with the VA Healthcare Analysis and Information Group (HAIG) administered a survey on the characteristics of ASPs at all 130 acute care VA facilities (Appendix A). We used these survey results to build an implementation model and then assess associations between facility-level variables and 4 antimicrobial utilization measures.
METHODS
Survey and Data
In 2011, the ASTF was chartered to develop, deploy, and monitor a strategic plan for optimizing antimicrobial therapy management. Monthly educational webinars and sample policies were offered to all facilities, including a sample business plan for stewardship and policies to encourage de-escalation from broad-spectrum antimicrobials, promote conversion from parenteral to oral antimicrobial therapy, avoid unnecessary double anaerobic coverage, and mitigate unnecessary antimicrobial usage in the context of Clostridium difficile infection.10
At the time that ASTF was chartered, the understanding of how ASP structures across VA facilities operated was limited. Hence, to capture baseline institutional characteristics and stewardship activities, ASTF and HAIG developed an inventory assessment of ASPs that was distributed online in November 2012. All 130 VA facilities providing inpatient acute care services responded.
We derived 57 facility characteristics relevant to antimicrobial utilization and conducted a series of factor analyses to simplify the complex dataset, and identify underlying latent constructs. We categorized resulting factors into domains of evidence, context, or facilitation as guided by the Promoting Action on Research Implementation in Health Services framework.11 Briefly, the evidence domain describes how the facility uses codified and noncodified sources of knowledge (eg, research evidence, clinical experience). Organizational context comprises a facility’s characteristics that ensure a more conducive environment to put evidence into practice (eg, supportive leadership, organizational structure, evaluative systems). Facilitation emphasizes a facility personnel’s “state of preparedness” and receptivity to implementation.
Using factor analysis to identify facility factors as correlates of the outcomes, we first examined polychoric correlations among facility characteristics to assess multicollinearity. We performed independent component analysis to create latent constructs of variables that were defined by factor loadings (that indicated the proportion of variance accounted for by the construct) and uniqueness factors (that determined how well the variables were interpreted by the construct). Factors retained included variables that had uniqueness values of less than 0.7 and factor loadings greater than 0.3. Those associated with uniqueness values greater than 0.7 were left as single items, as were characteristics deemed a priori to be particularly important to antimicrobial stewardship. Factor scales that had only 2 items were converted into indices, while factor scores were generated for those factors that contained 3 or more items.12-15
Data for facility-level antimicrobial utilization measures were obtained from the VA Corporate Data Warehouse from calendar year 2012. The analysis was conducted within the VA Informatics and Computing Infrastructure. All study procedures were approved by the VA Central Institutional Review Board.
Measures
Four utilization measures were defined as dependent measures: overall antimicrobial use; antimicrobial use in patients with non-infectious discharge diagnoses; missed opportunities to convert from parenteral to oral antimicrobial therapy; and missed opportunities to avoid double anaerobic coverage with metronidazole.
Overall antimicrobial use was defined as total acute care (ie, medical/surgical/intensive care) antibacterial use for each facility aggregated as per CDC National Healthcare Safety Network Antimicrobial Use Option guidelines (antimicrobial days per 1000 patient days present). A subanalysis of overall antimicrobial use was restricted to antimicrobial use among patients without an infection-related discharge diagnosis, as we surmised that this measure may capture a greater proportion of potentially unnecessary antimicrobial use. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)16 codes for infectious processes were identified by a combination of those classified previously in the literature,17 and those identified by finding the descendants of all infections named in the Systematized Nomenclature of Medicine--Clinical Terms.18 Next, all remaining codes for principal discharge diagnoses for which antimicrobials were administered were reviewed for potential indications for systemic antibacterial use. Discharges were considered noninfectious if no codes were identified when systemic antimicrobials were or could be indicated. For this measure, antimicrobial days were not counted if administered on or 1 day after the calendar day of surgery warranting antimicrobial prophylaxis.
Missed opportunities for conversion from parenteral to oral (IV to PO) formulations of highly bioavailable oral antimicrobials (ciprofloxacin, levofloxacin, moxifloxacin, azithromycin, clindamycin, linezolid, metronidazole, and fluconazole) were defined as the percentage of days of unnecessary IV therapy that were given when PO therapy could have been used among patients who were not in intensive care units at the time of antimicrobial administration who were receiving other oral medications, using previously described methodology.19Missed opportunities for avoiding redundant anaerobic coverage with metronidazole were defined as the percentage of days in which patients receiving metronidazole also receivedantibiotics with activity against anaerobic bacteria, specifically beta-lactam/beta-lactamase inhibitors, carbapenems, cefotetan/cefoxitin, clindamycin, moxifloxacin, or tigecycline), using previously described methodology.20 Patients for whom C. difficile testing was either ordered or positive within the prior 28 days (indicating potential clinical concern for C. difficile infection) were excluded from this endpoint.
Analysis
The variables derived above were entered into a multivariable model for each of the 4 antimicrobial utilization measures. The least absolute shrinkage and selection operator (LASSO) regression was used to determine significant associations between variables and individual utilization measures.21 LASSO was chosen because it offers advantages over traditional subset selection approaches in large multivariable analyses by assessing covariates simultaneously rather than sequentially, supporting prediction rather than estimation of effect.22P values were not reported as they are not useful in determining statistical significance in this methodology. A tuning parameter of 0.025 was determined for the model based on a cross-validation approach. Significant variables remaining in the model were reported with the percent change in each utilization measure per unit change in the variable of interest. For binary factors, percent change was reported according to whether the variable was present or not. For ordinal variables, percent change was reported according to incremental increase in ordinal score. For continuous variables or variables represented by factor or index scores, percent change was reported per each 25% increase in the range of the score.
RESULTS
Inpatient Facility Antimicrobial Stewardship Characteristics and Antimicrobial Utilization
Frequencies of key facility characteristics that contributed to variable development are included in Table 1. Full survey results across all facilities are included in Appendix B. Factor analysis reduced the total number of variables to 32; however, we also included hospital size and VA complexity score. Thus, 34 variables were evaluated for association with antimicrobial utilization measures: 4 in the evidence domain, 23 in the context domain, and 7 in the facilitation domain (Table 2).
Table 1
Table 1 (continued)
Median facility antimicrobial use was 619 antimicrobial days per 1000 days present (interquartile range [IQR], 554-700; overall range, 346-974). Median facility noninfectious antimicrobial use was 236 per 1000 days present (IQR, 200-286). Missed opportunities for conversion from IV to PO antimicrobial therapy were common, with a median facility value of 40.4% (391/969) of potentially eligible days of therapy (IQR, 32.2-47.8%). Missed opportunities to avoid double anaerobic coverage were less common (median 15.3% (186/1214) of potentially eligible days of therapy (IQR, 11.8%-20.2%; Figure).
Overall Antimicrobial Use
Four variables were associated with decreased overall antimicrobial use, although with small magnitude of change: presence of postgraduate physician/pharmacy training programs (0.03% decrease per quarter increase in factor score; on the order of 0.2 antimicrobial days per 1000 patient days present), presence of pharmacists and/or ID attendings on general medicine ward teams (0.02% decrease per quarter increase in index score), frequency of systematic de-escalation review (0.01% decrease per ordinal increase in score), and degree of involvement of ID physicians and/or fellows in antimicrobial approvals (0.007% decrease per quarter increase in index score). No variables were associated with increased overall antimicrobial use.
Table 2
Table 2 (continued)
Antimicrobial Use among Discharges without Infectious Diagnoses
Six variables were associated with decreased antimicrobial use in patients without infectious discharge diagnoses, while 4 variables were associated with increased use. Variables associated with the greatest magnitude of decreased use included facility educational programs for prudent antimicrobial use (1.8% on the order of 4 antimicrobial days per 1000 patient days present), frequency of systematic de-escalation review (1.5% per incremental increase in score), and whether a facility’s lead antimicrobial stewardship pharmacist had ID training (1.3%). Also significantly associated with decreased use was a factor summarizing the presence of 4 condition-specific stewardship processes (de-escalation policies, policies for addressing antimicrobial use in the context of C. difficile infection, blood culture review, and automatic ID consults for certain conditions) (0.6% per quarter increase in factor score range), the extent to which postgraduate physician/pharmacy training programs were present (0.6% per quarter increase in factor score range), and the number of electronic antimicrobial-specific order sets present (0.4% per order set). The variables associated with increased use of antimicrobials included the presence of antimicrobial stop orders (4.6%), the degree to which non-ID physicians were involved in antimicrobial approvals (0.7% per increase in ordinal score), the level engagement with ASTF online resources (0.6% per quarter increase in factor score range), and hospital size (0.6% per 50-bed increase).
Figure
Missed Opportunities for Parenteral to Oral Antimicrobial Conversion
Missed opportunities for IV to PO antimicrobial conversion had the largest number of significant associations with organizational variables: 14 variables were associated with fewer missed opportunities, while 5 were associated with greater missed opportunities. Variables associated with the largest reductions in missed opportunities for IV to PO conversion included having guidelines for antimicrobial duration (12.8%), participating in regional stewardship collaboratives (8.1%), number of antimicrobial-specific order sets (6.0% per order set), ID training of the ASP pharmacist (4.9%), and VA facility complexity designation (4.2% per quarter increase in score indicating greater complexity).23 Variables associated with more missed opportunities included stop orders (11.7%), overall perceived receptiveness to antimicrobial stewardship among clinical services (9.4%), the degree of engagement with ASTF online resources (6.9% per quarter increase in factor score range), educational programs for prudent antimicrobial use (4.1%), and hospital size (1.0% per 50-bed increase).
Missed Opportunities for Avoidance of Double Anaerobic Coverage
Four variables were associated with more avoidance of double anaerobic coverage: ID training of the lead ASP pharmacist (8.8%), presence of pharmacists and/or ID attendings on acute care ward teams (6.2% per quarter increase in index score), degree of ID pharmacist involvement in antimicrobial approvals, ranging from not at all (score=0) to both weekdays and nights/weekends (score=2; 4.3% per ordinal increase), and the number of antimicrobial-specific order sets (1.5% per order set). No variables were associated with less avoidance of double anaerobic coverage.
Variables Associated with Multiple Favorable or Unfavorable Antimicrobial Utilization Measures
To better assess the consistency of the relationship between organizational variables and measures of antimicrobial use, we tabulated variables that were associated with at least 3 potentially favorable (ie, reduced overall or noninfectious antimicrobial use or fewer missed opportunities) measures. Altogether, 5 variables satisfied this criterion: the presence of postgraduate physician/pharmacy training programs, the number of antimicrobial-specific order sets, frequency of systematic de-escalation review, the presence of pharmacists and/or ID attendings on acute care ward teams, and formal ID training of the lead ASP pharmacist (Table 3). Three other variables were associated with at least 2 unfavorable measures: hospital size, the degree to which the facility engaged with ASTF online resources, and presence of antimicrobial stop orders.
Table 3
DISCUSSION
Variability in ASP implementation across VA allowed us to assess the relationship between ASP and facility elements and baseline patterns of antimicrobial utilization. Hospitalists and hospital policy-makers are becoming more and more engaged in inpatient antimicrobial stewardship. While our results suggest that having pharmacists and/or physicians with formal ID training participate in everyday inpatient activities can favorably improve antimicrobial utilization, considerable input into stewardship can be made by hospitalists and policy makers. In particular, based on this work, the highest yield from an organizational standpoint may be in working to develop order sets within the electronic medical record and systematic efforts to promote de-escalation of broad-spectrum therapy, as well as encouraging hospital administration to devote specific physician and pharmacy salary support to stewardship efforts.
While we noted that finding the ASTF online resources helpful was associated with potentially unfavorable antimicrobial utilization, we speculate that this may represent reverse causality due to facilities recognizing that their antimicrobial usage is suboptimal and thus seeking out sample ASTF policies to implement. The association between the presence of automatic stop orders and potentially unfavorable antimicrobial utilization is less clear since the timeframe was not specified in the survey; it may be that setting stop orders too far in advance may promote an environment in which critical thinking about antimicrobial de-escalation is not encouraged or timely. The larger magnitude of association between ASP characteristics and antimicrobial usage among patients without infectious discharge diagnoses versus overall antimicrobial usage also suggests that clinical situations where infection was of low enough suspicion to not even have the providers eventually list an infectious diagnosis on their discharge summaries may be particularly malleable to ASP interventions, though further exploration is needed in determining how useful this utilization measure may be as a marker for inappropriate antimicrobial use.
Our results complement those of Pakyz et al.24 who surveyed 44 academic medical facilities in March 2013 to develop an ASP intensity score and correlate this score and its specific components to overall and targeted antimicrobial use. This study found that the overall ASP intensity score was not significantly associated with total or targeted antimicrobial use. However, ASP strategies were more associated with decreased total and targeted antimicrobial use than were specific ASP resources. In particular, the presence of a preauthorization strategy was associated with decreased targeted antimicrobial use. Our particular findings that order set establishment and de-escalation efforts are associated with multiple antibiotic outcomes also line up with the findings of Schuts et al,who performed a meta-analysis of the effects of meeting antimicrobial stewardship objectives and found that achieving guideline concordance (such as through establishment of order sets) and successfully de-escalating antimicrobial therapy was associated with reduced mortality.25,26 This meta-analysis, however, was limited by low rigor of its studies and potential for reverse causality. While our study has the advantages of capturing an entire national network of 130 acute care facilities with a 100% response rate, it, too, is limited by a number of issues, most notably by the fact that the survey was not specifically designed for the analysis of antimicrobial utilization measures, patient-level risk stratification was not available, the VA population does not reflect the U.S. population at-large, recall bias, and that antimicrobial prescribing and stewardship practices have evolved in VA since 2012. Furthermore, all of the antimicrobial utilization measures studied are imperfect at capturing inappropriate antibiotic use; in particular, our reliance on principal ICD-9 codes for noninfectious outcomes requires prospective validation. Many survey questions were subjective and subject to misinterpretation; other unmeasured confounders may also be present. Causality cannot be inferred from association. Nevertheless, our findings support many core indicators for hospital ASP recommended by the CDC and the Transatlantic Taskforce on Antimicrobial Resistance,3,4 most notably, having personnel with ID training involved in stewardship and establishing a formal procedure for ASP review for the appropriateness of an antimicrobial at or after 48 hours from the initial order.
In summary, the VA has made efforts to advance the practice of antimicrobial stewardship system-wide, including a 2014 directive that all VA facilities have an ASP,27 since the 2012 HAIG assessment reported considerable variability in antimicrobial utilization and antimicrobial stewardship activities. Our study identifies areas of stewardship that may correlate with, positively or negatively, antimicrobial utilization measures that will require further investigation. A repeat and more detailed antimicrobial stewardship survey was recently completed and will help VA gauge ongoing effects of ASTF activities. We hope to re-evaluate our model with newer data when available.
Acknowledgments
The authors wish to thank Michael Fletcher, Jaime Lopez, and Catherine Loc-Carrillo for their administrative and organizational support of the project and Allison Kelly, MD, for her pivotal role in survey development and distribution. This work was supported by the VA Health Services Research and Development Service Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) Initiative; Cognitive Support Informatics for Antimicrobial Stewardshipproject (CRE 12-313).
Disclosure
The authors report no financial conflicts of interest.
The deleterious impact of inappropriate and/or excessive antimicrobial usage is well recognized. In the United States, the Centers for Disease Control and Prevention (CDC) estimates that at least 2 million people become infected with antimicrobial-resistant bacteria with 23,000 subsequent deaths and at least $1 billion in excess medical costs per year.1
In response, many healthcare organizations have developed antimicrobial stewardship programs (ASPs). Guidelines co-sponsored by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America, as well as recent statements from the CDC and the Transatlantic Taskforce on Antimicrobial Resistance,all recommend core ASP elements.2-5 The guidelines provide general recommendations on ASP structure, strategies, and activities. The recommended ASP structure is a team of physicians and pharmacists that collaborates with facility governing committees and other stakeholders to optimize antimicrobial use. While personnel with expertise in infectious diseases (ID) often lead ASPs, hospitalists are also recognized as key contributors, especially in quality improvement.6,7 Recommended strategies include prospective audit of antimicrobial use with intervention and feedback and formulary restriction with preauthorization. Recommended activities include education, creation of guidelines, clinical pathways, and order forms, and programs to promote de-escalation and conversion from parenteral (IV) to oral (PO) antimicrobial therapy. However, limited evidence exists regarding the effectiveness of these ASP core elements.8,9 While Cochrane reviews found clear evidence that particular stewardship strategies (eg, audit and feedback, formulary restriction, guidelines implemented with or without feedback, protocols, computerized decision support) can be effective in reducing antimicrobial usage and improving clinical outcomes over the long term, little evidence exists favoring 1 strategy over another.8 Furthermore, most individual studies of ASPs are single-center, making their conclusions less generalizable.
In 2012, the VA National Antimicrobial Stewardship Task Force (ASTF), in conjunction with the VA Healthcare Analysis and Information Group (HAIG) administered a survey on the characteristics of ASPs at all 130 acute care VA facilities (Appendix A). We used these survey results to build an implementation model and then assess associations between facility-level variables and 4 antimicrobial utilization measures.
METHODS
Survey and Data
In 2011, the ASTF was chartered to develop, deploy, and monitor a strategic plan for optimizing antimicrobial therapy management. Monthly educational webinars and sample policies were offered to all facilities, including a sample business plan for stewardship and policies to encourage de-escalation from broad-spectrum antimicrobials, promote conversion from parenteral to oral antimicrobial therapy, avoid unnecessary double anaerobic coverage, and mitigate unnecessary antimicrobial usage in the context of Clostridium difficile infection.10
At the time that ASTF was chartered, the understanding of how ASP structures across VA facilities operated was limited. Hence, to capture baseline institutional characteristics and stewardship activities, ASTF and HAIG developed an inventory assessment of ASPs that was distributed online in November 2012. All 130 VA facilities providing inpatient acute care services responded.
We derived 57 facility characteristics relevant to antimicrobial utilization and conducted a series of factor analyses to simplify the complex dataset, and identify underlying latent constructs. We categorized resulting factors into domains of evidence, context, or facilitation as guided by the Promoting Action on Research Implementation in Health Services framework.11 Briefly, the evidence domain describes how the facility uses codified and noncodified sources of knowledge (eg, research evidence, clinical experience). Organizational context comprises a facility’s characteristics that ensure a more conducive environment to put evidence into practice (eg, supportive leadership, organizational structure, evaluative systems). Facilitation emphasizes a facility personnel’s “state of preparedness” and receptivity to implementation.
Using factor analysis to identify facility factors as correlates of the outcomes, we first examined polychoric correlations among facility characteristics to assess multicollinearity. We performed independent component analysis to create latent constructs of variables that were defined by factor loadings (that indicated the proportion of variance accounted for by the construct) and uniqueness factors (that determined how well the variables were interpreted by the construct). Factors retained included variables that had uniqueness values of less than 0.7 and factor loadings greater than 0.3. Those associated with uniqueness values greater than 0.7 were left as single items, as were characteristics deemed a priori to be particularly important to antimicrobial stewardship. Factor scales that had only 2 items were converted into indices, while factor scores were generated for those factors that contained 3 or more items.12-15
Data for facility-level antimicrobial utilization measures were obtained from the VA Corporate Data Warehouse from calendar year 2012. The analysis was conducted within the VA Informatics and Computing Infrastructure. All study procedures were approved by the VA Central Institutional Review Board.
Measures
Four utilization measures were defined as dependent measures: overall antimicrobial use; antimicrobial use in patients with non-infectious discharge diagnoses; missed opportunities to convert from parenteral to oral antimicrobial therapy; and missed opportunities to avoid double anaerobic coverage with metronidazole.
Overall antimicrobial use was defined as total acute care (ie, medical/surgical/intensive care) antibacterial use for each facility aggregated as per CDC National Healthcare Safety Network Antimicrobial Use Option guidelines (antimicrobial days per 1000 patient days present). A subanalysis of overall antimicrobial use was restricted to antimicrobial use among patients without an infection-related discharge diagnosis, as we surmised that this measure may capture a greater proportion of potentially unnecessary antimicrobial use. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)16 codes for infectious processes were identified by a combination of those classified previously in the literature,17 and those identified by finding the descendants of all infections named in the Systematized Nomenclature of Medicine--Clinical Terms.18 Next, all remaining codes for principal discharge diagnoses for which antimicrobials were administered were reviewed for potential indications for systemic antibacterial use. Discharges were considered noninfectious if no codes were identified when systemic antimicrobials were or could be indicated. For this measure, antimicrobial days were not counted if administered on or 1 day after the calendar day of surgery warranting antimicrobial prophylaxis.
Missed opportunities for conversion from parenteral to oral (IV to PO) formulations of highly bioavailable oral antimicrobials (ciprofloxacin, levofloxacin, moxifloxacin, azithromycin, clindamycin, linezolid, metronidazole, and fluconazole) were defined as the percentage of days of unnecessary IV therapy that were given when PO therapy could have been used among patients who were not in intensive care units at the time of antimicrobial administration who were receiving other oral medications, using previously described methodology.19Missed opportunities for avoiding redundant anaerobic coverage with metronidazole were defined as the percentage of days in which patients receiving metronidazole also receivedantibiotics with activity against anaerobic bacteria, specifically beta-lactam/beta-lactamase inhibitors, carbapenems, cefotetan/cefoxitin, clindamycin, moxifloxacin, or tigecycline), using previously described methodology.20 Patients for whom C. difficile testing was either ordered or positive within the prior 28 days (indicating potential clinical concern for C. difficile infection) were excluded from this endpoint.
Analysis
The variables derived above were entered into a multivariable model for each of the 4 antimicrobial utilization measures. The least absolute shrinkage and selection operator (LASSO) regression was used to determine significant associations between variables and individual utilization measures.21 LASSO was chosen because it offers advantages over traditional subset selection approaches in large multivariable analyses by assessing covariates simultaneously rather than sequentially, supporting prediction rather than estimation of effect.22P values were not reported as they are not useful in determining statistical significance in this methodology. A tuning parameter of 0.025 was determined for the model based on a cross-validation approach. Significant variables remaining in the model were reported with the percent change in each utilization measure per unit change in the variable of interest. For binary factors, percent change was reported according to whether the variable was present or not. For ordinal variables, percent change was reported according to incremental increase in ordinal score. For continuous variables or variables represented by factor or index scores, percent change was reported per each 25% increase in the range of the score.
RESULTS
Inpatient Facility Antimicrobial Stewardship Characteristics and Antimicrobial Utilization
Frequencies of key facility characteristics that contributed to variable development are included in Table 1. Full survey results across all facilities are included in Appendix B. Factor analysis reduced the total number of variables to 32; however, we also included hospital size and VA complexity score. Thus, 34 variables were evaluated for association with antimicrobial utilization measures: 4 in the evidence domain, 23 in the context domain, and 7 in the facilitation domain (Table 2).
Table 1
Table 1 (continued)
Median facility antimicrobial use was 619 antimicrobial days per 1000 days present (interquartile range [IQR], 554-700; overall range, 346-974). Median facility noninfectious antimicrobial use was 236 per 1000 days present (IQR, 200-286). Missed opportunities for conversion from IV to PO antimicrobial therapy were common, with a median facility value of 40.4% (391/969) of potentially eligible days of therapy (IQR, 32.2-47.8%). Missed opportunities to avoid double anaerobic coverage were less common (median 15.3% (186/1214) of potentially eligible days of therapy (IQR, 11.8%-20.2%; Figure).
Overall Antimicrobial Use
Four variables were associated with decreased overall antimicrobial use, although with small magnitude of change: presence of postgraduate physician/pharmacy training programs (0.03% decrease per quarter increase in factor score; on the order of 0.2 antimicrobial days per 1000 patient days present), presence of pharmacists and/or ID attendings on general medicine ward teams (0.02% decrease per quarter increase in index score), frequency of systematic de-escalation review (0.01% decrease per ordinal increase in score), and degree of involvement of ID physicians and/or fellows in antimicrobial approvals (0.007% decrease per quarter increase in index score). No variables were associated with increased overall antimicrobial use.
Table 2
Table 2 (continued)
Antimicrobial Use among Discharges without Infectious Diagnoses
Six variables were associated with decreased antimicrobial use in patients without infectious discharge diagnoses, while 4 variables were associated with increased use. Variables associated with the greatest magnitude of decreased use included facility educational programs for prudent antimicrobial use (1.8% on the order of 4 antimicrobial days per 1000 patient days present), frequency of systematic de-escalation review (1.5% per incremental increase in score), and whether a facility’s lead antimicrobial stewardship pharmacist had ID training (1.3%). Also significantly associated with decreased use was a factor summarizing the presence of 4 condition-specific stewardship processes (de-escalation policies, policies for addressing antimicrobial use in the context of C. difficile infection, blood culture review, and automatic ID consults for certain conditions) (0.6% per quarter increase in factor score range), the extent to which postgraduate physician/pharmacy training programs were present (0.6% per quarter increase in factor score range), and the number of electronic antimicrobial-specific order sets present (0.4% per order set). The variables associated with increased use of antimicrobials included the presence of antimicrobial stop orders (4.6%), the degree to which non-ID physicians were involved in antimicrobial approvals (0.7% per increase in ordinal score), the level engagement with ASTF online resources (0.6% per quarter increase in factor score range), and hospital size (0.6% per 50-bed increase).
Figure
Missed Opportunities for Parenteral to Oral Antimicrobial Conversion
Missed opportunities for IV to PO antimicrobial conversion had the largest number of significant associations with organizational variables: 14 variables were associated with fewer missed opportunities, while 5 were associated with greater missed opportunities. Variables associated with the largest reductions in missed opportunities for IV to PO conversion included having guidelines for antimicrobial duration (12.8%), participating in regional stewardship collaboratives (8.1%), number of antimicrobial-specific order sets (6.0% per order set), ID training of the ASP pharmacist (4.9%), and VA facility complexity designation (4.2% per quarter increase in score indicating greater complexity).23 Variables associated with more missed opportunities included stop orders (11.7%), overall perceived receptiveness to antimicrobial stewardship among clinical services (9.4%), the degree of engagement with ASTF online resources (6.9% per quarter increase in factor score range), educational programs for prudent antimicrobial use (4.1%), and hospital size (1.0% per 50-bed increase).
Missed Opportunities for Avoidance of Double Anaerobic Coverage
Four variables were associated with more avoidance of double anaerobic coverage: ID training of the lead ASP pharmacist (8.8%), presence of pharmacists and/or ID attendings on acute care ward teams (6.2% per quarter increase in index score), degree of ID pharmacist involvement in antimicrobial approvals, ranging from not at all (score=0) to both weekdays and nights/weekends (score=2; 4.3% per ordinal increase), and the number of antimicrobial-specific order sets (1.5% per order set). No variables were associated with less avoidance of double anaerobic coverage.
Variables Associated with Multiple Favorable or Unfavorable Antimicrobial Utilization Measures
To better assess the consistency of the relationship between organizational variables and measures of antimicrobial use, we tabulated variables that were associated with at least 3 potentially favorable (ie, reduced overall or noninfectious antimicrobial use or fewer missed opportunities) measures. Altogether, 5 variables satisfied this criterion: the presence of postgraduate physician/pharmacy training programs, the number of antimicrobial-specific order sets, frequency of systematic de-escalation review, the presence of pharmacists and/or ID attendings on acute care ward teams, and formal ID training of the lead ASP pharmacist (Table 3). Three other variables were associated with at least 2 unfavorable measures: hospital size, the degree to which the facility engaged with ASTF online resources, and presence of antimicrobial stop orders.
Table 3
DISCUSSION
Variability in ASP implementation across VA allowed us to assess the relationship between ASP and facility elements and baseline patterns of antimicrobial utilization. Hospitalists and hospital policy-makers are becoming more and more engaged in inpatient antimicrobial stewardship. While our results suggest that having pharmacists and/or physicians with formal ID training participate in everyday inpatient activities can favorably improve antimicrobial utilization, considerable input into stewardship can be made by hospitalists and policy makers. In particular, based on this work, the highest yield from an organizational standpoint may be in working to develop order sets within the electronic medical record and systematic efforts to promote de-escalation of broad-spectrum therapy, as well as encouraging hospital administration to devote specific physician and pharmacy salary support to stewardship efforts.
While we noted that finding the ASTF online resources helpful was associated with potentially unfavorable antimicrobial utilization, we speculate that this may represent reverse causality due to facilities recognizing that their antimicrobial usage is suboptimal and thus seeking out sample ASTF policies to implement. The association between the presence of automatic stop orders and potentially unfavorable antimicrobial utilization is less clear since the timeframe was not specified in the survey; it may be that setting stop orders too far in advance may promote an environment in which critical thinking about antimicrobial de-escalation is not encouraged or timely. The larger magnitude of association between ASP characteristics and antimicrobial usage among patients without infectious discharge diagnoses versus overall antimicrobial usage also suggests that clinical situations where infection was of low enough suspicion to not even have the providers eventually list an infectious diagnosis on their discharge summaries may be particularly malleable to ASP interventions, though further exploration is needed in determining how useful this utilization measure may be as a marker for inappropriate antimicrobial use.
Our results complement those of Pakyz et al.24 who surveyed 44 academic medical facilities in March 2013 to develop an ASP intensity score and correlate this score and its specific components to overall and targeted antimicrobial use. This study found that the overall ASP intensity score was not significantly associated with total or targeted antimicrobial use. However, ASP strategies were more associated with decreased total and targeted antimicrobial use than were specific ASP resources. In particular, the presence of a preauthorization strategy was associated with decreased targeted antimicrobial use. Our particular findings that order set establishment and de-escalation efforts are associated with multiple antibiotic outcomes also line up with the findings of Schuts et al,who performed a meta-analysis of the effects of meeting antimicrobial stewardship objectives and found that achieving guideline concordance (such as through establishment of order sets) and successfully de-escalating antimicrobial therapy was associated with reduced mortality.25,26 This meta-analysis, however, was limited by low rigor of its studies and potential for reverse causality. While our study has the advantages of capturing an entire national network of 130 acute care facilities with a 100% response rate, it, too, is limited by a number of issues, most notably by the fact that the survey was not specifically designed for the analysis of antimicrobial utilization measures, patient-level risk stratification was not available, the VA population does not reflect the U.S. population at-large, recall bias, and that antimicrobial prescribing and stewardship practices have evolved in VA since 2012. Furthermore, all of the antimicrobial utilization measures studied are imperfect at capturing inappropriate antibiotic use; in particular, our reliance on principal ICD-9 codes for noninfectious outcomes requires prospective validation. Many survey questions were subjective and subject to misinterpretation; other unmeasured confounders may also be present. Causality cannot be inferred from association. Nevertheless, our findings support many core indicators for hospital ASP recommended by the CDC and the Transatlantic Taskforce on Antimicrobial Resistance,3,4 most notably, having personnel with ID training involved in stewardship and establishing a formal procedure for ASP review for the appropriateness of an antimicrobial at or after 48 hours from the initial order.
In summary, the VA has made efforts to advance the practice of antimicrobial stewardship system-wide, including a 2014 directive that all VA facilities have an ASP,27 since the 2012 HAIG assessment reported considerable variability in antimicrobial utilization and antimicrobial stewardship activities. Our study identifies areas of stewardship that may correlate with, positively or negatively, antimicrobial utilization measures that will require further investigation. A repeat and more detailed antimicrobial stewardship survey was recently completed and will help VA gauge ongoing effects of ASTF activities. We hope to re-evaluate our model with newer data when available.
Acknowledgments
The authors wish to thank Michael Fletcher, Jaime Lopez, and Catherine Loc-Carrillo for their administrative and organizational support of the project and Allison Kelly, MD, for her pivotal role in survey development and distribution. This work was supported by the VA Health Services Research and Development Service Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE) Initiative; Cognitive Support Informatics for Antimicrobial Stewardshipproject (CRE 12-313).
Disclosure
The authors report no financial conflicts of interest.
References
1. Antibiotic resistance threats in the United States, 2013. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/drugresistance/threat-report-2013/. Published 2013. Accessed January 7, 2016. 2. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44(2):159-177. PubMed 3. Centers for Disease Control and Prevention. Core elements of hospital antibiotic stewardship programs. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Published 2015. Accessed January 7, 2016. 4. Pollack LA, Plachouras D, Gruhler H, Sinkowitz-Cochran R. Transatlantic taskforce on antimicrobial resistance (TATFAR) summary of the modified Delphi process for common structure and process indicators for hospital antimicrobial stewardship programs. http://www.cdc.gov/drugresistance/pdf/summary_of_tatfar_recommendation_1.pdf. Published 2015. Accessed January 7, 2016. 5. Barlam TF, Cosgrove SE, Abbo LM, MacDougal C, Schuetz AN, Septimus EJ, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62(10):e51-e77. PubMed 6. Rohde JM, Jacobsen D, Rosenberg DJ. Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther. 2013;35(6):751-757. PubMed 7. Mack MR, Rohde JM, Jacobsen D, Barron JR, Ko C, Goonewardene M, et al. Engaging hospitalists in antimicrobial stewardship: lessons from a multihosopital collaborative. J Hosp Med. 2016;11(8):576-580. PubMed 8. Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2013;4:CD003543. PubMed 9. Filice G, Drekonja D, Wilt TJ, Greer N, Butler M, Wagner B. Antimicrobial stewardship programs in inpatient settings: a systematic review. Washington, DC: Department of Veterans Affairs Health Services Research and Development. http://www.hsrd.research.va.gov/publications/esp/antimicrobial.pdf. Published 2013. Accessed January 7, 2016. 10. Graber CJ, Madaras-Kelly K, Jones MM, Neuhauser MM, Goetz MB. Unnecessary antimicrobial use in the context of Clostridium difficile infection: a call to arms for the Veterans Affairs Antimicrobial Stewardship Task Force. Infect Control Hosp Epidemiol. 2013(6);34:651-653. PubMed 11. Rycroft-Malone J. The PARIHS framework--a framework for guiding the implementation of evidence-based practice. J Nurs Care Qual. 2004;19(4):297-304. PubMed 12. Chou AF, Graber CJ, Jones MM, Zhang Y, Goetz MB, Madaras-Kelly K, et al. Specifying an implementation framework for VA antimicrobial stewardship programs. Oral presentation at the VA HSR&D/QUERI National Conference, July 8-9, 2015. Washington, DC: U.S. Department of Veterans Affairs. http://www.hsrd.research.va.gov/meetings/2015/abstract-display.cfm?RecordID=862. Accessed July 5, 2016. 13. Bartholomew DJ. Factor analysis for categorical data. J R Stat Soc. 1980;42:293-321. 14. Flanagan M, Ramanujam R, Sutherland J, Vaughn T, Diekema D, Doebbeling BN. Development and validation of measures to assess prevention and control of AMR in hospitals. Med Care. 2007;45(6): 537-544. PubMed 15. Kline P. An easy guide to factor analysis. New York: Routledge, 1994. 16. Centers for Disease Control and Prevention, National Center for Health Statistics. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Atlanta GA: Centers for Disease Control and Prevention. http://www.cdc.gov/nchs/icd/icd9cm.htm. Published 2013. Accessed January 7, 2016. 17. Huttner B, Jones M, Huttner A, Rubin M, Samore MH. Antibiotic prescription practices for pneumonia, skin and soft tissue infections and urinary tract infections throughout the US Veterans Affairs system. J Antimicrob Chemother. 2013;68(10):2393-2399. PubMed 18. National Institutes of Health. SNOMED Clinical Terms (SNOMED CT). Bethesda, MD: U.S. National Library of Medicine. https://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html. NIH website. Published 2009. Accessed January 7. 2016. 19. Jones M, Huttner B, Madaras-Kelly K, Nechodom K, Nielson C, Bidwell Goetz M, et al. Parenteral to oral conversion of fluoroquinolones: low-hanging fruit for antimicrobial stewardship programs? Infect Control Hosp Epidemiol 2012;33(4): 362-367. PubMed 20. Huttner B, Jones M, Rubin MA, Madaras-Kelly K, Nielson C, Goetz MB, et al. Double trouble: how big a problem is redundant anaerobic antibiotic coverage in Veterans Affairs medical centres? J Antimicrob Chemother. 2012;67(6):1537-1539. PubMed 21. Tibshirani R. Regression shrinkage and selection via the lasso. J R Stat Soc B. 1996;58:267-288. 22. Taylor J, Tibshirani RJ. Statistical learning and selective inference. Proc Natl Acad Sci U S A. 2015;112(25):7629-7634. PubMed 23. VHA Office of Productivity, Efficiency, and Staffing. Facility Complexity Levels. Department of Veterans Affairs website. http://opes.vssc.med.va.gov/FacilityComplexityLevels/Pages/default.aspx. Published 2008. Accessed January 7, 2016. 24. Pakyz AL, Moczygemba LR, Wang H, Stevens MP, Edmond MB. An evaluation of the association between an antimicrobial stewardship score and antimicrobial usage. J Antimicrob Chemother. 2015;70(5):1588-1591. PubMed 25. Schuts EC, Hulscher ME, Mouton JW, Verduin CM, Stuart JW, Overdiek HW, et al. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis. 2016;16(7):847-856. PubMed 26. Graber CJ, Goetz MB. Next steps for antimicrobial stewardship. Lancet Infect Dis. 2016;16(7):764-765. PubMed 27. Petzel RA. VHA Directive 1031: Antimicrobial stewardship programs (ASP). Washington, DC: Department of Veterans Affairs.http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2964. Published January 22, 2014. Accessed July 5, 2016.
References
1. Antibiotic resistance threats in the United States, 2013. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/drugresistance/threat-report-2013/. Published 2013. Accessed January 7, 2016. 2. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44(2):159-177. PubMed 3. Centers for Disease Control and Prevention. Core elements of hospital antibiotic stewardship programs. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html. Published 2015. Accessed January 7, 2016. 4. Pollack LA, Plachouras D, Gruhler H, Sinkowitz-Cochran R. Transatlantic taskforce on antimicrobial resistance (TATFAR) summary of the modified Delphi process for common structure and process indicators for hospital antimicrobial stewardship programs. http://www.cdc.gov/drugresistance/pdf/summary_of_tatfar_recommendation_1.pdf. Published 2015. Accessed January 7, 2016. 5. Barlam TF, Cosgrove SE, Abbo LM, MacDougal C, Schuetz AN, Septimus EJ, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis. 2016;62(10):e51-e77. PubMed 6. Rohde JM, Jacobsen D, Rosenberg DJ. Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther. 2013;35(6):751-757. PubMed 7. Mack MR, Rohde JM, Jacobsen D, Barron JR, Ko C, Goonewardene M, et al. Engaging hospitalists in antimicrobial stewardship: lessons from a multihosopital collaborative. J Hosp Med. 2016;11(8):576-580. PubMed 8. Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2013;4:CD003543. PubMed 9. Filice G, Drekonja D, Wilt TJ, Greer N, Butler M, Wagner B. Antimicrobial stewardship programs in inpatient settings: a systematic review. Washington, DC: Department of Veterans Affairs Health Services Research and Development. http://www.hsrd.research.va.gov/publications/esp/antimicrobial.pdf. Published 2013. Accessed January 7, 2016. 10. Graber CJ, Madaras-Kelly K, Jones MM, Neuhauser MM, Goetz MB. Unnecessary antimicrobial use in the context of Clostridium difficile infection: a call to arms for the Veterans Affairs Antimicrobial Stewardship Task Force. Infect Control Hosp Epidemiol. 2013(6);34:651-653. PubMed 11. Rycroft-Malone J. The PARIHS framework--a framework for guiding the implementation of evidence-based practice. J Nurs Care Qual. 2004;19(4):297-304. PubMed 12. Chou AF, Graber CJ, Jones MM, Zhang Y, Goetz MB, Madaras-Kelly K, et al. Specifying an implementation framework for VA antimicrobial stewardship programs. Oral presentation at the VA HSR&D/QUERI National Conference, July 8-9, 2015. Washington, DC: U.S. Department of Veterans Affairs. http://www.hsrd.research.va.gov/meetings/2015/abstract-display.cfm?RecordID=862. Accessed July 5, 2016. 13. Bartholomew DJ. Factor analysis for categorical data. J R Stat Soc. 1980;42:293-321. 14. Flanagan M, Ramanujam R, Sutherland J, Vaughn T, Diekema D, Doebbeling BN. Development and validation of measures to assess prevention and control of AMR in hospitals. Med Care. 2007;45(6): 537-544. PubMed 15. Kline P. An easy guide to factor analysis. New York: Routledge, 1994. 16. Centers for Disease Control and Prevention, National Center for Health Statistics. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). 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Association of inpatient antimicrobial utilization measures with antimicrobial stewardship activities and facility characteristics of Veterans Affairs medical centers
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Association of inpatient antimicrobial utilization measures with antimicrobial stewardship activities and facility characteristics of Veterans Affairs medical centers
Address for correspondence and reprint requests: Christopher J. Graber, MD, MPH, Infectious Diseases Section, VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd, 111-F, Los Angeles, CA 90073; Telephone: 310-268-3763; Fax: 310 268-4928; E-mail: [email protected]
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