A Novel Approach to Evaluate Antibiotic Utilization Across the Spectrum of Inpatient and Ambulatory Care and Implications for Prioritization of Antibiotic Stewardship Efforts

2019 ◽  
Vol 70 (8) ◽  
pp. 1675-1682 ◽  
Author(s):  
Holly M Frost ◽  
Bryan C Knepper ◽  
Katherine C Shihadeh ◽  
Timothy C Jenkins
Keyword(s):  
Emergency Department ◽  
Critical Care ◽  
Ambulatory Care ◽  
Healthcare System ◽  
Antibiotic Stewardship ◽  
Antibiotic Use ◽  
Urgent Care ◽  
Outpatient Clinics ◽  
Integrated Healthcare ◽  
Gram Negative

Abstract Background Antibiotic overuse remains a significant problem. The objective of this study was to develop a methodology to evaluate antibiotic use across inpatient and ambulatory care sites in an integrated healthcare system to prioritize antibiotic stewardship efforts. Methods We conducted an epidemiologic study of antibiotic use across an integrated healthcare system on 12 randomly selected days from 2017 to 2018. For inpatients and perioperative patients, administrations of antibiotics were recorded, whereas prescriptions were recorded for outpatients. Results On the study days, 10.9% (95% confidence interval [CI], 10.6%–11.3%) of patients received antibiotics. Of all antibiotics, 54.1% were from ambulatory care (95% CI, 52.6%–55.7%), 38.0% were from the hospital (95% CI, 36.6%–39.5%), and 7.8% (95% CI, 7.1%–8.7%) were perioperative. The emergency department/urgent care centers, adult outpatient clinics, and adult non–critical care inpatient wards accounted for 26.4% (95% CI, 25.0%–27.7%), 23.8% (95% CI, 22.6%–25.2%), and 23.9% (95% CI, 22.7%–25.3%) of antibiotic use, respectively. Only 9.2% (95% CI, 8.3%–10.1%) of all antibiotics were administered in critical care units. Antibiotics with a broad spectrum of gram-negative activity accounted for 30.4% (95% CI, 29.0%–31.9%) of antibiotics. Infections of the respiratory tract were the leading indication for antibiotics. Conclusions In an integrated healthcare system, more than half of antibiotic use occurred in the emergency department/urgent care centers and outpatient clinics. Antibiotics with a broad spectrum of gram-negative activity accounted for a large portion of antibiotic use. Analysis of antibiotic utilization across the spectrum of inpatient and ambulatory care is useful to prioritize antibiotic stewardship efforts.

scholarly journals 1007. A novel approach to evaluate antibiotic utilization across the spectrum of inpatient and ambulatory care and implications for prioritization of antibiotic stewardship efforts

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S354-S354
Author(s):  
Holly M Frost ◽  
Bryan C Knepper ◽  
Katherine C Shihadeh ◽  
Timothy C Jenkins
Keyword(s):  
Ambulatory Care ◽  
Healthcare System ◽  
Antibiotic Stewardship ◽  
Antibacterial Agent ◽  
Antibiotic Use ◽  
Urgent Care ◽  
Outpatient Clinics ◽  
Integrated Healthcare ◽  
Adult Outpatient ◽  
Systemic Antibacterial

Abstract Background Antibiotic overuse remains a significant problem in inpatient and outpatient settings. The objective of this study was to develop a methodology to evaluate antibiotic use across inpatient and ambulatory care sites in an integrated healthcare system in order to prioritize antibiotic stewardship efforts. Methods We conducted an epidemiologic study of antibiotic use across an integrated healthcare system on 12 randomly-selected days between October 1, 2017 and September 30, 2018. Inpatients and perioperative patients were recorded as having received an antibiotic if they were administered ≥1 dose of a systemic antibacterial agent. Outpatients were recorded as having received an antibiotic if they were prescribed ≥1 systemic antibacterial agent. Results On the study days, 10.9% (95% CI 10.6–11.3%) of patients received an antibiotic. Of all antibiotics administered or prescribed, 54.1% were from ambulatory care (95% CI 52.6–55.7%), 38.0% were from the hospital, (95% CI 36.6–39.5%), and 7.8% (95% CI 7.1–7.8%) were perioperative. The emergency department/urgent care centers, adult outpatient clinics, and adult noncritical care inpatient wards accounted for 26.4% (95% CI: 25.0–27.7%), 23.8% (95% CI: 22.6–25.2), and 23.9% (95% CI 22.7–25.3) of antibiotic use, respectively. Only 9.2% (95% CI: 8.3–10.1%) of all antibiotics were administered in critical care units. Antibiotics with a broad spectrum of Gram-negative activity accounted for 30.4% (95% CI: 29.0–31.9%) of all antibiotics prescribed. Infections of the respiratory tract were the leading indication for antibiotic use. Conclusion In an integrated healthcare system, nearly three-quarters of antibiotic use occurred in the emergency department/urgent care centers, adult outpatient clinics, and adult noncritical care inpatient wards. Antibiotics with a broad spectrum of Gram-negative activity accounted for a large portion of antibiotic use. Analysis of antibiotic utilization across the spectrum of inpatient and ambulatory care is useful to prioritize antibiotic stewardship efforts. Disclosures All authors: No reported disclosures.

scholarly journals 115. Variable Use of Diagnostic Codes for Acute Respiratory Infections Across Emergency Departments and Urgent Care Clinics in an Integrated Healthcare System: Implications for Accuracy of Antibiotic Stewardship Metrics

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S171-S172
Author(s):  
Daniel J Livorsi ◽  
Rajeshwari Nair ◽  
Michihiko Goto ◽  
Eli N Perencevich
Keyword(s):  
Healthcare System ◽  
Antibiotic Stewardship ◽  
Respiratory Infections ◽  
Urgent Care ◽  
Diagnostic Code ◽  
Acute Respiratory Infections ◽  
Integrated Healthcare ◽  
Diagnostic Codes ◽  
Facility Level ◽  
Tract Infections

Abstract Background Antibiotic stewardship initiatives can leverage metrics that make peer-peer comparisons. A commonly used metric measures how frequently a clinician prescribes antibiotics for acute respiratory infections (ARIs), as defined by diagnostic codes. However, it is unclear if clinicians differ in their use of ARI diagnostic codes. In this study, we evaluated differences in how frequently clinicians code for ARIs and factors that are associated with the use of ARI diagnostic codes in Emergency Department (ED) and Urgent Care (UC) visits across an integrated healthcare system. Methods We analyzed a retrospective cohort of all ED and UC patient-visits across 129 Veterans Affairs medical centers during 2016-2018. ARI visits were identified using ICD-10 codes for acute bronchitis, influenza, pharyngitis, sinusitis, and upper respiratory tract infections for clinicians with 100 or more visits. A generalized linear mixed model with a link logit function that accounted for clustering at the clinician and facility-level was used to calculate median odds ratios (OR) and to identify factors associated with increased likelihood of entering an ARI code. Results There were 6,016,499 patient-visits, and 519,389 (8.6%) were coded as an ARI (Table 1). The mean rate of ARI diagnoses across all visits was 8.9% (SD 2.5%) at the facility-level and 7.4% (SD 4.5%) at the clinician-level (Table 2). The median OR was 2.19 (95% CI 2.18, 2.22), suggesting there was between-clinician variation in coding for ARI diagnoses. Visits were significantly more likely to be coded as ARIs if seen by an advanced practice provider (OR=2.36, 95% CI 2.19, 2.54), if a fever was recorded (OR=4.20, 95% CI 4.18, 4.29), and if the visit occurred between December-March (OR=1.97, 95% CI 1.96, 1.98). Approximately 2/5th of the variability (41.4%) in assigning an ARI diagnostic code was explained by differences across individual clinicians. Conclusion There was substantial variability in how frequently ED and UC clinicians coded a visit as an ARI, and a large proportion of the variability was explained by differences across clinicians. Unmeasured factors could include different approaches to using diagnostic codes. ARI metrics based on diagnostic codes may need to account for differences in clinicians’ coding behavior. Disclosures All Authors: No reported disclosures

scholarly journals 18. Durations of Antibiotic Therapy and Factors Associated with Longer Than Recommended Durations for Common Ambulatory Infections in an Integrated Healthcare System

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S10-S10
Author(s):  
Axel Vazquez Deida ◽  
Katherine C Shihadeh ◽  
Deborah Aragon ◽  
Bryan C Knepper ◽  
Timothy C Jenkins
Keyword(s):  
Family Medicine ◽  
Antibiotic Therapy ◽  
Ambulatory Care ◽  
Healthcare System ◽  
Group Analysis ◽  
Urgent Care ◽  
Integrated Healthcare ◽  
Factors Associated ◽  
Duration Of Therapy ◽  
Medicine Clinic

Abstract Background Duration of antibiotic therapy is an important focus for antibiotic stewardship, but the extent and drivers of excessive durations are not well understood. This project aimed to describe durations of therapy prescribed for common infections across the ambulatory care settings of an integrated healthcare system and identify factors associated with longer than recommended durations. Methods This was a retrospective, cross-sectional evaluation conducted from July 1, 2018 to June 30, 2019. We identified antibiotic prescriptions for adults age 18 years or older presenting to a Denver Health ambulatory care facility (urgent care, emergency department, family medicine clinic, or internal medicine clinic) for an infection with a recommended duration of therapy of 5 days or less based on institutional guidance. Infections included purulent and non-purulent cellulitis, uncomplicated subcutaneous abscess, acute bacterial sinusitis (ABS), acute otitis media (AOM), community acquired pneumonia, cystitis, and pyelonephritis treated with an indicated fluoroquinolone. Prescriptions for more than 5 days were classified as longer than recommended. We evaluated whether the following factors were associated with longer than recommended prescriptions: location of visit, type of infection, patients’ age, race/ethnicity, sex, infection type, and prescribing provider type Results 5331 prescriptions met inclusion criteria. Of those, the duration of therapy was longer than recommended for 2095 (39%) (Table 1). Durations varied significantly across locations (p< 0.0001). In the sub-group analysis family medicine clinics had the highest proportion of longer than recommended durations (46%). Durations also varied significantly by type of infection. For cellulitis, ABS, and AOM, the duration was longer than recommended in 50%, 54%, and 75% of cases, respectively. Other factors associated with longer than recommended durations included male sex (p< 0.0001) and prescriptions by advanced practice providers (p = 0.0008). Table 1: Antibiotic Duration of Therapy for Common Outpatient Infections Conclusion Care locations, infection types, and both patient and prescriber factors were associated with longer than recommended prescriptions suggesting specific opportunities to prevent excessive durations of therapy. Disclosures All Authors: No reported disclosures

scholarly journals Development of an Electronic Algorithm to Identify Inappropriate Antibiotic Prescribing for Pediatric Pharyngitis

2020 ◽  
Vol 41 (S1) ◽  
pp. s188-s189
Author(s):  
Jeffrey Gerber ◽  
Robert Grundmeier ◽  
Keith Hamilton ◽  
Lauri Hicks ◽  
Melinda Neuhauser ◽  
...  
Keyword(s):  
Predictive Value ◽  
Gold Standard ◽  
Antibiotic Stewardship ◽  
Chart Review ◽  
Antibiotic Use ◽  
Audit And Feedback ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Tract Infections ◽  
The Impact

Background: Antibiotic overuse contributes to antibiotic resistance and unnecessary adverse drug effects. Antibiotic stewardship interventions have primarily focused on acute-care settings. Most antibiotic use, however, occurs in outpatients with acute respiratory tract infections such as pharyngitis. The electronic health record (EHR) might provide an effective and efficient tool for outpatient antibiotic stewardship. We aimed to develop and validate an electronic algorithm to identify inappropriate antibiotic use for pediatric outpatients with pharyngitis. Methods: This study was conducted within the Children’s Hospital of Philadelphia (CHOP) Care Network, including 31 pediatric primary care practices and 3 urgent care centers with a shared EHR serving >250,000 children. We used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify encounters for pharyngitis at any CHOP practice from March 15, 2017, to March 14, 2018, excluding those with concurrent infections (eg, otitis media, sinusitis), immunocompromising conditions, or other comorbidities that might influence the need for antibiotics. We randomly selected 450 features for detailed chart abstraction assessing patient demographics as well as practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for evaluating the electronic algorithm. Criteria for appropriate use included streptococcal testing, use of penicillin or amoxicillin (absent β-lactam allergy), and a 10-day duration of therapy. Results: In 450 patients, the median age was 8.4 years (IQR, 5.5–9.0) and 54% were women. On chart review, 149 patients (33%) received an antibiotic, of whom 126 had a positive rapid strep result. Thus, based on chart review, 23 subjects (5%) diagnosed with pharyngitis received antibiotics inappropriately. Amoxicillin or penicillin was prescribed for 100 of the 126 children (79%) with a positive rapid strep test. Of the 126 children with a positive test, 114 (90%) received the correct antibiotic: amoxicillin, penicillin, or an appropriate alternative antibiotic due to b-lactam allergy. Duration of treatment was correct for all 126 children. Using the electronic algorithm, the proportion of inappropriate prescribing was 28 of 450 (6%). The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were sensitivity (99%, 422 of 427); specificity (100%, 23 of 23); positive predictive value (82%, 23 of 28); and negative predictive value (100%, 422 of 422). Conclusions: For children with pharyngitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. Future work should validate this approach in other settings and develop and evaluate the impact of an audit and feedback intervention based on this tool.Funding: NoneDisclosures: None

scholarly journals 1181. Significant Reduction of Non-Ventilator Hospital-Acquired Pneumonia (HAP) with a Prevention Bundle and Clinical and Leadership Feedback in a Large Integrated Healthcare System

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S423-S423
Author(s):  
Sejal Naik ◽  
Cristine Lacerna ◽  
Yulia Kevorkova ◽  
Jessica Galin ◽  
Donna Patey ◽  
...  
Keyword(s):  
Healthcare System ◽  
Oral Care ◽  
Antibiotic Use ◽  
Altered Mental Status ◽  
Feeding Tube ◽  
Healthcare Associated Infection ◽  
Integrated Healthcare ◽  
Benzodiazepine Use ◽  
Hospital Acquired Pneumonia ◽  
Hospital Acquired

Abstract Background Non-Ventilator Hospital-acquired Pneumonia (HAP) is a prevalent healthcare-associated infection with mortality of 21%. HAP prevention literature is scant. We developed a definition enabling accurate surveillance to support this effort and implemented a prevention bundle based on available literature and characteristics of our high-performing centers. Methods Kaiser Permanente Northern California is an integrated healthcare system providing care for 4.4 million patients at 21 medical centers. Discharge diagnoses of HAP cases were reviewed for accuracy and factors permitting programmatic confirmation. A natural language extraction program identified new and persisting imaging findings, providing specificity. No other surveillance factors added specificity. Surgery, altered mental status, sedation, albumin <3 g/dl and tube feedings were identified as predictive risks. Seven interventions became part of a new pneumonia prevention order set for automatically identified high-risk patients: aggressive mobilization, upright posture for meals, swallowing evaluation before feeding, sedation restriction, elevated head of bed, oral care and feeding tube care. The project was fully implemented in 2015. Results Results were reported by 1,000 admissions and by 100,000 members served, to address a rapidly growing population. HAP decreased from 5.92 to 1.79/1000 admissions and 24.57 to 6.49/100,000 members and HAP case mortality remained stable (18–19%) while overall HAP mortality decreased from 1.05 to 0.34/1000 admissions (4.37 to 1.24 /100,000 members) (Figure 1 and 2). Carbapenem, quinolone, aminoglycoside and vancomycin use all decreased significantly (Figure 3). Benzodiazepine use decreased from 10.4% of all inpatient-days in 2014 to 8.8% of inpatient-days in 2016. Conclusion HAP rates, mortality and broad-spectrum antibiotic use were all reduced significantly, despite the absence of clinical practice guidelines or strong supportive literature for guidance. Some interventions had limited support, but most augmented basic nursing care. None had risks of adverse consequences. This supports the need to examine practices to improve care despite absent literature and even more so supports a need to study these difficult nebulous areas of care. Disclosures All authors: No reported disclosures.

scholarly journals Outpatient Antibiotic Use for Common Infectious Diagnoses: Patterns in Telehealth During the Emergence of COVID-19

2021 ◽  
Vol 1 (S1) ◽  
pp. s35-s36
Author(s):  
Brigid Wilson ◽  
Taissa Bej ◽  
Sunah Song ◽  
Janet M Briggs ◽  
Richard Banks ◽  
...  
Keyword(s):  
Primary Care ◽  
Healthcare System ◽  
Acute Respiratory Infection ◽  
Antibiotic Prescription ◽  
Antibiotic Use ◽  
Outpatient Clinics ◽  
Administrative Databases ◽  
Community Based ◽  
Outpatient Visits ◽  
Outpatient Settings

Background: The influence of increased use of telehealth during the emergence of COVID-19 on antibiotic prescriptions in outpatient settings is unknown. The VA Northeast Ohio Healthcare System has 13 community-based outpatient clinics (CBOCs) that provide primary and preventive care. We assessed changes in antibiotic prescriptions that occurred as care shifted from in-person to telehealth visits. Methods: Using VHA administrative databases, we identified all primary care CBOC visits between January 1, 2019, and December 31, 2020, that included a diagnosis for an acute respiratory infection (ARI), a urinary tract infection (UTI), or a skin or soft-tissue infection (SSTI), excluding visits with >1 of these diagnoses or with additional infectious diagnoses (eg, pneumonia, influenza). We summarized the proportion of telehealth visits and the proportion of patients prescribed antibiotics at quarterly intervals. We specifically assessed outpatient visits from April to December 2019 compared to the same months in 2020 to account for seasonality while analyzing diagnosis and antibiotic trends in the emergence of the COVID-19 pandemic. Results: The patients receiving care in April–December 2019 compared to April–December 2020 were similar (Table 1). From April through December 2019, 90% of CBOC primary care visits with a diagnosis for ARI, UTI, or SSTI were in-person, and antibiotics were prescribed at 63%, 46%, and 65% of visits in either modality, respectively (Figure 1). From April through December 2020, only 33% of CBOC primary care visits for ARI, UTI, and SSTI were in person, and antibiotics were prescribed at 46%, 38%, and 47% of visits in either modality, respectively. Comparing April–December in 2019 and 2020, the number of CBOC visits for ARI fell by 76% (2,152 visits to 509 visits), with a more modest decline of 20% and 35% observed for UTI and SSTI visits. In-person visits for ARIs and SSTIs were more likely than telehealth visits to result in an antibiotic prescription (Figure 2). Conclusions: Among the CBOCs at our healthcare system, an increase in the proportion of telehealth visits and a reduction in ARI diagnoses occurred after the emergence of COVID-19. In this setting, we observed a reduction in the proportion of visits for ARIs, UTIs, and SSTIs that included an antibiotic prescription.Funding: MerckDisclosures: None

Risk factors for unplanned transfer to intensive care within 24 hours of admission from the emergency department in an integrated healthcare system

2012 ◽  
Vol 8 (1) ◽  
pp. 13-19 ◽  
Author(s):  
M. Kit Delgado ◽  
Vincent Liu ◽  
Jesse M. Pines ◽  
Patricia Kipnis ◽  
Marla N. Gardner ◽  
...  
Keyword(s):  
Risk Factors ◽  
Emergency Department ◽  
Intensive Care ◽  
Healthcare System ◽  
Integrated Healthcare

scholarly journals Characteristics of low-acuity paediatric emergency department consultations in two tertiary hospitals in Switzerland: a retrospective observational study

2021 ◽  
Vol 5 (1) ◽  
pp. e001267
Author(s):  
Manon Jaboyedoff ◽  
Carl Starvaggi ◽  
Joan-Carles Suris ◽  
Claudia E Kuehni ◽  
Mario Gehri ◽  
...  
Keyword(s):  
Emergency Department ◽  
Observational Study ◽  
Healthcare System ◽  
Tertiary Care ◽  
Urgent Care ◽  
Retrospective Observational Study ◽  
Paediatric Emergency Department ◽  
Paediatric Emergency ◽  
Care Services ◽  
French Speaking

BackgroundLow-acuity paediatric emergency department (PED) visits are common in high-income countries and are an increasing burden for the healthcare system and quality of care. Little is known about low-acuity PED visits in Switzerland. This study shows frequency and characteristics of such visits in two large PEDs in German-speaking and French-speaking regions of Switzerland.MethodsWe conducted a retrospective observational study in the PED of two Swiss tertiary care hospitals, Bern and Lausanne. We extracted standardised administrative and medical data from the clinic information system for all PED visits of children aged 0–17 years from January to December 2018. We defined low-acuity visits as those meeting all of the following criteria: (1) triage category 4 or 5 on the Australasian Triage Scale, (2) no imaging or laboratory test performed and (3) discharge home. We used a binary multiple logistic regression model to identify factors associated with low-acuity visits.ResultsWe analysed 53 089 PED visits. The proportion of low-acuity visits was 54% (95% CI 53% to 54%, 28 556 visits). Low-acuity visits were associated with age younger than 5 years (adjusted OR, aOR 1.87, 95% CI 1.81 to 1.94), living within a 5 km radius of PED (aOR 1.27, 95% CI 1.22 to 1.32), and after hour presentations (weekends: aOR 1.14, 95% CI 1.10 to 1.18, nights: aOR 1.10, 95% CI 1.23 to 1.36).ConclusionLow-acuity visits are frequent in our PEDs and associated with younger age and convenience factors (proximity of residency and after hour presentation), pointing to a high demand for paediatric urgent care services in Switzerland not currently covered by the primary healthcare system.

scholarly journals Factors Associated with Longer than Recommended Durations of Antibiotic Therapy for Uncomplicated Ambulatory Infections in an Integrated Healthcare System

2021 ◽  
Author(s):  
Axel A Vazquez Deida ◽  
Katherine C Shihadeh ◽  
Deborah Aragon ◽  
Bryan C Knepper ◽  
Timothy C Jenkins
Keyword(s):  
Logistic Regression ◽  
Antibiotic Therapy ◽  
Ambulatory Care ◽  
Healthcare System ◽  
Integrated Healthcare ◽  
Care Network ◽  
Factors Associated

Abstract Across the ambulatory care network of an integrated healthcare system, durations of antibiotic therapy prescribed for uncomplicated infections were longer than recommended in 39% of cases. By logistic regression, site of care, prescriber characteristics, and type of infection were independently associated with longer than recommended durations of therapy.

Sign in / Sign up

Export Citation Format

Share Document