scholarly journals 1632. Non-Visit-Based and Non-Infection-Related Ambulatory Antibiotic Prescribing

2018 ◽  
Vol 5 (suppl_1) ◽  
pp. S43-S43 ◽  
Author(s):  
Jeffrey A Linder ◽  
Tiffany Brown ◽  
Ji Young Lee ◽  
Kao-Ping Chua ◽  
Michael A Fischer
Keyword(s):  
Nurse Practitioners ◽  
Physician Assistants ◽  
Antibiotic Prescribing ◽  
Face To Face ◽  
Health Delivery ◽  
Online Portal ◽  
Diagnosis Codes ◽  
Icd 10 ◽  
Primary Care Clinicians ◽  
Attending Physicians

Abstract Background Many studies have examined or intervened on ambulatory antibiotic prescribing based on infection-related diagnosis codes. However, clinicians may prescribe antibiotics without seeing patients face-to-face or without documenting an infection-related diagnosis. Methods We measured the prevalence of non-visit-based and non-infection-related oral, antibacterial–antibiotic prescribing between November 2015 and October 2017 using the EHR of an integrated health delivery system. We examined the visit type (in-person vs. other) and classified prescriptions into 3 mutually exclusive groups based on same-day diagnosis codes: (1) infection-related for prescriptions associated with at least one of 21,730 ICD-10 codes that may signify infection; (2) non-infection-related for prescriptions only associated with the 72,519 ICD-10 codes that do not signify infections; and (3) associated with no diagnosis. Results There were 509,534 antibiotic prescriptions made to 279,169 unique patients by 2,413 clinicians in 514 clinics. Patients had a mean age of 43 years old, were 60% women, and 75% white. Clinicians were 54% women; were 63% attending physicians, 18% residents/fellows, 10% nurse practitioners, and 7% physician assistants; and were 41% medical specialists, 21% primary care clinicians, and 7% surgical specialists. The most common antibiotic classes were penicillins (30%), macrolides (23%), cephalosporins (14%), fluoroquinolones (11%), tetracyclines (10%), and sulfonamides (6%). Clinicians prescribed 20% of antibiotics outside of an in-person visit; prescription encounters were in-person (80%), telephone (10%), order-only (4%), refill (4%), and online portal (1%). Clinicians prescribed 46% of antibiotics without an infection-related diagnosis: 54% of antibiotic prescriptions were infection-related, 29% were non-infection-related, and 17% were associated with no diagnosis. Various look-back and look-forward durations for diagnosis codes changed the results only slightly. Conclusion Clinicians prescribed 20% of antibiotics outside of in-person visits and 46% of antibiotics without an infection-related diagnosis. Interventions that target visit-based, diagnosis-specific prescriptions miss a large share of antibiotic prescribing. Disclosures All authors: No reported disclosures.

scholarly journals 1123. Specificity of Diagnosis Codes and Adequacy of Supportive Documentation for Common Acute Pediatric Infections: Implications for Ambulatory Stewardship

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S399-S399
Author(s):  
Zachary Willis ◽  
Elizabeth Walters
Keyword(s):  
Acute Otitis Media ◽  
Antibiotic Prescribing ◽  
National Guidelines ◽  
Laboratory Findings ◽  
Healthcare Settings ◽  
Diagnosis Codes ◽  
Icd 10 ◽  
Pediatric Infections ◽  
Data Elements ◽  
Physical Findings

Abstract Background Assessing the appropriateness of antibiotic prescribing in ambulatory care generally relies on the accuracy of diagnosis codes, which is uncertain. It is also uncertain if documented history and physical findings support antibiotic indications (AI). We completed a retrospective study of pediatric primary care (PPC) encounters to determine: A) if documented findings supported documented AI; and B) whether diagnosis codes captured documented AI (figure). Methods We conducted point-prevalence audits of the 9 PPC clinics in our healthcare system, randomly selecting one weekday per month to review all visits between 9/2017 and 4/2018. We included only encounters with antibiotic prescribing. We reviewed clinician notes, orders, laboratory results, and ICD-10 diagnosis codes. We recorded demographics; visit date/location; AI as documented in notes; history, examination, and laboratory findings; and diagnosis codes. We used national guidelines to determine whether documentation supported AI. We calculated the sensitivity of diagnosis codes using documented AI as the gold standard. Results The sample included 452 encounters. The most common AI were acute otitis media (AOM), pharyngitis, and sinusitis. For AOM, 163 of 168 encounters (97.0%) had an appropriate diagnosis code; for pharyngitis, 127 of 138 (92.0%); and for sinusitis, 68 of 75 (90.7%). For AOM, 160 of 168 encounters (95.2%) had adequate documentation of supportive findings. For sinusitis, 44 of 75 encounters had adequate supporting history and/or examination findings (58.7%). For pharyngitis, while 135 of 139 (97.1%) had a positive streptococcal test, 104 of 139 (74.8%) had history and examination findings to support testing. Conclusion By chart review, we identified each AI and evaluated whether findings supported those AI. The sensitivity of diagnosis codes for AI ranged from 90.7–97.0% for common conditions; this result can inform the design of ambulatory stewardship programs. Only 74.8% of children treated for pharyngitis and 58.7% of children treated for sinusitis had sufficient supporting documentation. Use of discrete data elements alone (Figure 1) may result in overestimates of the proportion of children for whom antibiotics are appropriate. Further research is needed across healthcare settings. Disclosures All authors: No reported disclosures

scholarly journals Appropriateness of outpatient antibiotic prescribing among privately insured US patients: ICD-10-CM based cross sectional study

BMJ ◽  
2019 ◽  
pp. k5092 ◽  
Author(s):  
Kao-Ping Chua ◽  
Michael A Fischer ◽  
Jeffrey A Linder
Keyword(s):  
Classification Scheme ◽  
Antibiotic Prescription ◽  
Antibiotic Prescribing ◽  
Diagnosis Code ◽  
Diagnosis Codes ◽  
The Us ◽  
Look Back ◽  
Icd 10 ◽  
Recent Diagnosis ◽  
Privately Insured

Abstract Objective To assess the appropriateness of outpatient antibiotic prescribing for privately insured children and non-elderly adults in the US using a comprehensive classification scheme of diagnosis codes in ICD-10-CM (international classification of diseases-clinical modification, 10th revision), which replaced ICD-9-CM in the US on 1 October 2015. Design Cross sectional study. Setting MarketScan Commercial Claims and Encounters database, 2016. Participants 19.2 million enrollees aged 0-64 years. Main outcome measures A classification scheme was developed that determined whether each of the 91 738 ICD-10-CM diagnosis codes “always,” “sometimes,” or “never” justified antibiotics. For each antibiotic prescription fill, this scheme was used to classify all diagnosis codes in claims during a look back period that began three days before antibiotic prescription fills and ended on the day fills occurred. The main outcome was the proportion of fills in each of four mutually exclusive categories: “appropriate” (associated with at least one “always” code during the look back period, “potentially appropriate” (associated with at least one “sometimes” but no “always” codes), “inappropriate” (associated only with “never” codes), and “not associated with a recent diagnosis code” (no codes during the look back period). Results The cohort (n=19 203 264) comprised 14 571 944 (75.9%) adult and 9 935 791 (51.7%) female enrollees. Among 15 455 834 outpatient antibiotic prescription fills by the cohort, the most common antibiotics were azithromycin (2 931 242, 19.0%), amoxicillin (2 818 939, 18.2%), and amoxicillin-clavulanate (1 784 921, 11.6%). Among these 15 455 834 fills, 1 973 873 (12.8%) were appropriate, 5 487 003 (35.5%) were potentially appropriate, 3 592 183 (23.2%) were inappropriate, and 4 402 775 (28.5%) were not associated with a recent diagnosis code. Among the 3 592 183 inappropriate fills, 2 541 125 (70.7%) were written in office based settings, 222 804 (6.2%) in urgent care centers, and 168 396 (4.7%) in emergency departments. In 2016, 2 697 918 (14.1%) of the 19 203 264 enrollees filled at least one inappropriate antibiotic prescription, including 490 475 out of 4 631 320 children (10.6%) and 2 207 173 out of 14 571 944 adults (15.2%). Conclusions Among all outpatient antibiotic prescription fills by 19 203 264 privately insured US children and non-elderly adults in 2016, 23.2% were inappropriate, 35.5% were potentially appropriate, and 28.5% were not associated with a recent diagnosis code. Approximately 1 in 7 enrollees filled at least one inappropriate antibiotic prescription in 2016. The classification scheme could facilitate future efforts to comprehensively measure outpatient antibiotic appropriateness in the US, and it could be adapted for use in other countries that use ICD-10 codes.

scholarly journals Outpatient Antibiotic Prescribing Among United States Nurse Practitioners and Physician Assistants

2016 ◽  
Vol 3 (3) ◽  
Author(s):  
Guillermo V. Sanchez ◽  
Adam L. Hersh ◽  
Daniel J. Shapiro ◽  
James F. Cawley ◽  
Lauri A. Hicks
Keyword(s):  
United States ◽  
Respiratory Infection ◽  
Nurse Practitioners ◽  
Nurse Practitioner ◽  
Antibiotic Stewardship ◽  
Acute Respiratory Infection ◽  
Physician Assistant ◽  
Physician Assistants ◽  
Antibiotic Prescribing

Abstract We examined US nurse practitioner (NP) and physician assistant (PA) outpatient antibiotic prescribing. Antibiotics were more frequently prescribed during visits involving NP/PA visits compared with physician-only visits, including overall visits (17% vs 12%, P < .0001) and acute respiratory infection visits (61% vs 54%, P < .001). Antibiotic stewardship interventions should target NPs and PAs.

scholarly journals Uses of Mobile Device Digital Photography of Dermatologic Conditions in Primary Care (Preprint)

2017 ◽  
Author(s):  
Jennifer L Pecina ◽  
Kirk D Wyatt ◽  
Nneka I Comfere ◽  
Matthew E Bernard ◽  
Frederick North
Keyword(s):  
Primary Care ◽  
Nurse Practitioners ◽  
Physician Assistants ◽  
Mobile App ◽  
Usage Patterns ◽  
Primary Care Patients ◽  
Primary Care Clinicians ◽  
Curbside Consultation ◽  
Record Review ◽  
And Training

BACKGROUND PhotoExam is a mobile app that incorporates digital photographs into the electronic health record (EHR) using iPhone operating system (iOS, Apple Inc)–based mobile devices. OBJECTIVE The aim of this study was to describe usage patterns of PhotoExam in primary care and to assess clinician-level factors that influence the use of the PhotoExam app for teledermatology (TD) purposes. METHODS Retrospective record review of primary care patients who had one or more photos taken with the PhotoExam app between February 16, 2015 to February 29, 2016 were reviewed for 30-day outcomes for rates of dermatology consult request, mode of dermatology consultation (curbside phone consult, eConsult, and in-person consult), specialty and training level of clinician using the app, performance of skin biopsy, and final pathological diagnosis (benign vs malignant). RESULTS During the study period, there were 1139 photo sessions on 1059 unique patients. Of the 1139 sessions, 395 (34.68%) sessions documented dermatologist input in the EHR via dermatology curbside consultation, eConsult, and in-person dermatology consult. Clinicians utilized curbside phone consults preferentially over eConsults for TD. By clinician type, nurse practitioners (NPs) and physician assistants (PAs) were more likely to utilize the PhotoExam for TD as compared with physicians. By specialty type, pediatric clinicians were more likely to utilize the PhotoExam for TD as compared with family medicine and internal medicine clinicians. A total of 108 (9.5%) photo sessions had a biopsy performed of the photographed site. Of these, 46 biopsies (42.6%) were performed by a primary care clinician, and 27 (25.0%) biopsies were interpreted as a malignancy. Of the 27 biopsies that revealed malignant findings, 6 (22%) had a TD consultation before biopsy, and 10 (37%) of these biopsies were obtained by primary care clinicians. CONCLUSIONS Clinicians primarily used the PhotoExam for non-TD purposes. Nurse practitioners and PAs utilized the app for TD purposes more than physicians. Primary care clinicians requested curbside dermatology consults more frequently than dermatology eConsults.

scholarly journals P113 How has COVID-19 affected the treatment of osteoporosis? The answers from a global survey

Rheumatology ◽  
2021 ◽  
Vol 60 (Supplement_1) ◽  
Author(s):  
Nicholas R Fuggle ◽  
Andrea Singer ◽  
Nicholas Harvey ◽  
Jean-Yves Reginster ◽  
Cyrus Cooper ◽  
...  
Keyword(s):  
Nurse Practitioners ◽  
Physical Therapists ◽  
Physician Assistants ◽  
Asia Pacific ◽  
Mineral Density ◽  
Face To Face ◽  
Medication Delivery ◽  
Relative Neglect ◽  
The Impact ◽  
Intravenous Medication

Abstract Background/Aims  The COVID-19 pandemic has had profound effects on the health of the global population both directly, via the sequelae of the infection, and indirectly, including the relative neglect of chronic disease management. Together the International Osteoporosis Federation and National Osteoporosis Foundation sought to ascertain the impact on osteoporosis management. Methods  Questionnaires were electronically circulated to a sample of members of both learned bodies and included information regarding the location and specialty of respondents, current extent of face to face consultations, alterations in osteoporosis risk assessment, telemedicine experience, alterations to medication ascertainment and delivery, and electronic health record (EHR) utilisation. Responses were collected, quantitative data analysed, and qualitative data assessed for recurring themes. Results  Responses were received from 209 healthcare workers from 53 countries, including 28% from Europe, 24% from North America, 19% from the Asia Pacific region, 17% from the Middle East, and 12% from Latin America. Most respondents were physicians (85%) with physician assistants, physical therapists and nurses/nurse practitioners represented in the sample. The main three specialties represented included rheumatology (40%), endocrinology (22%) and orthopaedics (15%).In terms of the type of patient contact, 33% of respondents conducted telephone consultations and 21% video consultations. Bone mineral density assessment by dual-energy x-ray absorptiometry (DXA) usage was affected with only 29% able to obtain a scan as recommended. The majority of clinicians (60%) had systems in place to identify patients receiving subcutaneous or intravenous medication, and 43% of clinicians reported difficulty in arranging appropriate osteoporosis medications during the COVID-19 crisis. Conclusion  To conclude through surveying a global sample of osteoporosis healthcare professionals, we have observed an increase in telemedicine consultations, delays in DXA scanning, interrupted supply of medications and reductions in intravenous medication delivery. Disclosure  N.R. Fuggle: None. A. Singer: None. N. Harvey: None. J. Reginster: None. C. Cooper: None. S. Greenspan: None.

More than Means to an End: Assessing Surgical Provider Familiarity with Palliative Care

2021 ◽  
pp. 000313482110488
Author(s):  
Candace L. Ward ◽  
Austin B. Goetz ◽  
Samantha N. Olafson ◽  
Ryan B. Cohen ◽  
Mark J Kaplan ◽  
...  
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Nurse Practitioners ◽  
Palliative Medicine ◽  
Physician Assistants ◽  
Training And Development ◽  
Medicine Service ◽  
Poor Outcomes ◽  
Attending Physicians ◽  
Question Survey

Background As palliative medicine concepts emerge as essential surgical education, there has been a resulting spike in surgical palliative care research. Historic surgical dogma viewed mortality and comfort-focused care as a failure of the providers’ endurance, knowledge base, or technical skill. Therefore, many providers avoided consultation to a palliative medicine service until it became evident a patient could not survive or was actively dying. As the need for surgical palliative care grows, the identification of deficits in surgical providers’ understanding of the scope of palliative medicine is necessary to direct further training and development efforts. Method A ten-question survey was emailed to all residents, physician assistants, nurse practitioners, and attending physicians in the general surgery and subspecialty surgical departments within the Einstein Healthcare Network. Results 30 non-trainees (attending surgeons, nurse practitioners, and physician assistants) and 26 trainees (PGY-1 to PGY-5) completed the survey. Less than half of participants reported training in conversations regarding withdrawal of life-prolonging treatments in the setting of expected poor outcomes, 55% reported receiving training in pain management, and 64% reported receiving training in delivery of bad news. 54% report being involved in five or more end-of-life discussions in the last year with trainees reporting fewer end-of-life discussions than non-trainees; 67% of trainees reported zero to four discussions while 23% of non-trainees reported over twenty discussions ( P = .009). Conclusions Despite many participants training in intensive care settings, providers lack the training to carry out major discussions regarding life-limiting illness, goals of care, and end-of-life independently.

scholarly journals Analysis of Patient Handoff between Providers at a Tertiary Urban Medical Center

2021 ◽  
Vol 14 ◽  
pp. 192-196
Author(s):  
Candice Metzinger ◽  
Samer Antonios ◽  
K James Kallail ◽  
Hayrettin Okut ◽  
Rosey Zackula ◽  
...  
Keyword(s):  
Nurse Practitioners ◽  
Medical Center ◽  
Hospital Medicine ◽  
Physician Assistants ◽  
Categorical Variables ◽  
Inpatient Stay ◽  
Continuous Variables ◽  
Medical Patients ◽  
Provider Type ◽  
Attending Physicians

Introduction. Few studies have quantified the total number of attending and consulting physicians involved in inpatients’ care, and no other research quantifies the total number of all providers participating in inpatients’ care. The purpose of this study was to calculate the number of attending hand-offs, the attending encounter time, and the total number of providers participating in inpatients’ care for all admitted patients at a tertiary urban medical center. Methods. The study design was an observational retrospective cohort. Subjects included pediatric and adult patients who were admitted to and discharged from Ascension Via Christi St. Francis (AVCSF) in Wichita, Kansas between November 01, 2019 and January 31, 2020. Data were abstracted from the Cerner Electronic Medical Record. Variables included: patient demographics, admitting diagnosis, diagnosis related group (DRG), admission service, and duration of inpatient stay. Provider variables abstracted included provider type and provider specialty. Categorical variables were presented as frequencies and percentages, while continuous variables were presented as means ± standard deviation. Results. The sample included information from 200 patient charts. Patients’ ages ranged from 5 to 94 years, with a mean of 61 years. Approximately 52% were female and 74.9% were admitted to a surgical service. The length of all inpatients’ stays ranged from less than 1 day to 31 days, with a mean of 4 days. Seventy-six different DRGs were recorded. The most frequent attending specialties for medical patients were hospital medicine, internal medicine, general surgery, and interventional cardiology. Consulting physicians had more patient encounters than any other healthcare provider. For all inpatients, an average of two attending physicians participated in care over the duration of their stay with a range of one to six attending physicians. There was an average of one hand-off between attending physicians. Patients had an average of five consulting physicians, two resident physicians, two physician assistants, and two nurse practitioners during a stay. There was an average of 10 total providers, with a range of one to 46 total providers participating in care. Conclusions. Understanding the provider data surrounding an inpatient stay is a foundational step in assessing the quality of the provider-inpatient encounter and potential areas for improvement. In this study, the average number of attending physicians and handoffs was reasonable; however, the total number of providers involved in care was relatively high. Assessment of staffing and scheduling requirements by hospital administration could identify areas of improvement to reduce the potential for medical error caused by multiple providers being involved in patient care.   

scholarly journals Digital Care Providers Antibiotic Prescribing Compared to Traditional Primary Healthcare: A Retrospective Database Study of 332,987 Healthcare Visits in Sweden.

2021 ◽  
Author(s):  
Justyna Ivarsson ◽  
Thorne Wallman ◽  
Andy Wallman
Keyword(s):  
Primary Healthcare ◽  
Antibiotic Prescription ◽  
Personal Information ◽  
Antibiotic Prescribing ◽  
Care Providers ◽  
Place Of Residence ◽  
Diagnosis Codes ◽  
Icd 10 ◽  
Virtual Visits ◽  
Retrospective Database

Abstract ObjectivesThe aim of this study was to examine if there was a difference in antibiotic prescribing between private digital care providers, and traditional primary healthcare, and to investigate if the prescriptions differed regarding diagnosis between virtual visits and physical visits adjusted for age, sex, and place of residence for patients seeking care digitally and in person.MethodsAntibiotic prescribing based on ATC-codes during the period of two months in 2020 was studied. Prescriptions issued by online doctors and by physicians working within PHC Sörmland County, Sweden were considered. Information about healthcare provider, date of the visit, staff category that patient had contact with, ICD-10-diagnosis codes, ATC-codes of prescribed medicines and personal information such as: age, sex, and place of residence were used. Statistical analysis and logistic regression were performed.ResultsAltogether 332,987 healthcare visits were registered. Of all visits to physicians at PHC in Region Sörmland, antibiotics were prescribed in 5.9% of cases, and 3.9% of all visits to online doctors. The total number of visits that led to infection diagnosis was 112,354. Within physical visits at PHC 21.5% infection visits ended with antibiotic prescription, while within online visits the corresponding percentage was 10.1%. Additionally, the study focused on seventeen infection diagnoses.ConclusionThis study has shown that private digital care providers do not prescribe more antibiotics than doctors at PHC. Probability of receiving antibiotic prescription during digital visits was 4.88 times lower compared to physical visits.

scholarly journals Using a Human Factors Framework to Assess Clinician Perceptions of and Barriers to High Reliability in Hand Hygiene

2020 ◽  
Vol 41 (S1) ◽  
pp. s426-s426
Author(s):  
Ana Maria Vaughan ◽  
Thomas J. Sandora
Keyword(s):  
Patient Safety ◽  
Hand Hygiene ◽  
Human Factors ◽  
Nurse Practitioners ◽  
High Reliability ◽  
Physician Assistants ◽  
Healthcare Associated Infections ◽  
Medical Specialties ◽  
Healthcare Associated ◽  
Attending Physicians

Background: Hand hygiene is essential to prevent healthcare-associated infections, but adherence among clinicians remains low. Objective: We used a human factors framework to understand clinician perceptions of and barriers to achieving high reliability in hand hygiene. Methods: The Systems Engineering Initiative for Patient Safety 2.0 model was used to develop a 24-item electronic survey. Perceived barriers to hand hygiene were classified into several domains: technology and tools, person, organization, tasks, environment, and care processes. After pilot testing, the survey was distributed to a stratified random sample of attending physicians, nurse practitioners, and physician assistants in medical specialties and surgery-anesthesia at a quaternary-care pediatric hospital. Frequencies, percentages, and descriptive statistics were used to summarize responses. Results: Of 200 clinicians, 61 (31%) responded to the survey: 74% were attending physicians, 18% were nurse practitioners, and 7% were physician assistants. Moreover, 51% of respondents represented medical specialties, and 49% came from surgical disciplines or anesthesia. Respondents had served a median 12 years (IQR, 5–19 years) in their current role. Overall, 70% perceived hand hygiene to be “essential” among patient safety issues at the institution, and 84% agreed that leadership openly promotes hand hygiene. Additionally, 97% believed personal hand hygiene efforts were effective in preventing healthcare-associated infections. The availability of alcohol-based hand rub and being a good example for colleagues were perceived as “very effective” in permanently improving hand hygiene reliability by most respondents (87% and 67%, respectively). Furthermore, 77% of clinicians reported alcohol-based hand rub dispensers to be “sometimes” or “often” empty; 52% cited distractions in the workplace as hindrances to hand hygiene; and 21% reported that peers do not openly promote hand hygiene. One-quarter of the respondents indicated that the layout of patient care areas was not conducive to performing hand hygiene. Staffing shortages and the pace and demands of work precluded hand hygiene for 15% and 11% of respondents, respectively. Conclusions: Most clinicians view hand hygiene as essential to patient safety, but aspects of organizational culture, environment, tasks, and tools were identified as barriers to high performance reliability. These data can inform efforts to use human factors engineering principles to optimize systems and organizations to more effectively promote hand hygiene.Funding: NoneDisclosures: None

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