Influence of Autoimmune Antibody Testing on the Use of Immunotherapy on an Inpatient Neurology Service

Objective: To determine the frequency of autoimmune antibody testing in an inpatient neurology setting and its influence on immunotherapy use on an inpatient neurology service. Methods: A retrospective descriptive cohort study of patients admitted to the neurology inpatient service at a large tertiary academic medical center who had autoimmune and/or paraneoplastic antibody testing performed between 10/1/2017 and 10/1/2018. Characteristics of patients’ initial clinical presentation, antibody testing results, test timing in relation to initiating immunotherapy, and final diagnosis using consensus criteria were extracted and analyzed. Case reports of patients with positive antibody panels are presented. Results: Of 1,604 patients, 50 patients (3.1%) had an antibody panel sent. Tests resulted after an average of 17 days (range 7-27). The most common clinical presenting symptom in those with a panel sent was encephalopathy. There were 5 (10%) positive serum panels and no positive CSF panels. Only one of these 5 patients had autoimmune encephalitis and was treated with immunotherapy. Of those with negative serum and CSF panels, 15 were treated acutely with empiric immunotherapy and the remainder with supportive care. Of those treated with immunotherapy, 14/15 (93%) were treated before the panel tests resulted. Four patients who had negative panels but were empirically treated met consensus criteria for an autoimmune-mediated neurologic process. Conclusion: Our study suggests that the results of antibody testing did not influence inpatient neurologists’ decision to treat with immunotherapy as most treatments began prior to final results being available.

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Clinical Ordering Practices of the SARS-CoV-2 Antibody Test at a Large Academic Medical Center

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa406 ◽

2020 ◽

Vol 7 (10) ◽

Author(s):

Joesph R Wiencek ◽

Carter L Head ◽

Costi D Sifri ◽

Andrew S Parsons

Keyword(s):

United States ◽

Medical Center ◽

Academic Medical Center ◽

Antibody Test ◽

The United States ◽

Molecular Testing ◽

Antibody Testing ◽

Academic Medical ◽

Public Health Epidemiology ◽

Testing Costs

Abstract Background The novel severe acute respiratory coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) originated in December 2019 and has now infected almost 5 million people in the United States. In the spring of 2020, private laboratories and some hospitals began antibody testing despite limited evidence-based guidance. Methods We conducted a retrospective chart review of patients who received SARS-CoV-2 antibody testing from May 14, 2020, to June 15, 2020, at a large academic medical center, 1 of the first in the United States to provide antibody testing capability to individual clinicians in order to identify clinician-described indications for antibody testing compared with current expert-based guidance from the Infectious Diseases Society of America (IDSA) and the Centers for Disease Control and Prevention (CDC). Results Of 444 individual antibody test results, the 2 most commonly described testing indications, apart from public health epidemiology studies (n = 223), were for patients with a now resolved COVID-19-compatible illness (n = 105) with no previous molecular testing and for asymptomatic patients believed to have had a past exposure to a person with COVID-19-compatible illness (n = 60). The rate of positive SARS-CoV-2 antibody testing among those indications consistent with current IDSA and CDC guidance was 17% compared with 5% (P < .0001) among those indications inconsistent with such guidance. Testing inconsistent with current expert-based guidance accounted for almost half of testing costs. Conclusions Our findings demonstrate a dissociation between clinician-described indications for testing and expert-based guidance and a significantly different rate of positive testing between these 2 groups. Clinical curiosity and patient preference appear to have played a significant role in testing decisions and substantially contributed to testing costs.

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Family Medicine Patients Have Shorter Length of Stay When Cared for on a Family Medicine Inpatient Service

Journal of Primary Care & Community Health ◽

10.1177/2150132719840517 ◽

2019 ◽

Vol 10 ◽

pp. 215013271984051 ◽

Cited By ~ 1

Author(s):

Gregory M. Garrison ◽

Rachel L. Keuseman ◽

Christopher L. Boswell ◽

Jennifer L. Horn ◽

Nathaniel T. Nielsen ◽

...

Keyword(s):

Primary Care ◽

Family Medicine ◽

Length Of Stay ◽

Medical Center ◽

Academic Medical Center ◽

General Medicine ◽

Inpatient Service ◽

Academic Medical ◽

The Family ◽

Hospital To Home

Introduction: Hospitalists have been shown to have shorter lengths of stays than physicians with concurrent outpatient practices. However, hospitalists at academic medical centers may be less aware of local resources that can support the hospital to home transition for local primary care patients. We hypothesized that local family medicine patients admitted to a family medicine inpatient service have shorter length of stay than those admitted to general hospitalist services which also care for tertiary patients at an academic medical center. Methods: A retrospective cohort study was conducted at an academic medical center with a department of family medicine providing primary care to over 80 000 local patients. A total of 3100 consecutive family medicine patients admitted to either the family medicine inpatient service or a general medicine inpatient service over 3 years were studied. The primary outcome was length of stay, which was adjusted using multivariate linear regression for demographics, prior utilization, diagnosis, and disease severity. Results: Adjusted length of stay was 33% longer (95% CI 24%-44%) for local family medicine patients admitted to general medicine inpatient services as compared with the family medicine inpatient service. Readmission rates within 30 days were not different (19% vs 16%, P = .14). Conclusions: Local primary care patients were safely discharged from the hospital sooner on the family medicine inpatient service than on general medicine inpatient services. This is likely because the family physicians staffing their inpatient service are more familiar with outpatient resources that can be effectively marshaled to help local patients with the transition from hospital to home.

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A Nonresident Cardiovascular Inpatient Service Improves Residents’ Experiences in an Academic Medical Center: A New Model to Meet the Challenges of the New Millennium

Academic Medicine ◽

10.1097/00001888-200405000-00011 ◽

2004 ◽

Vol 79 (5) ◽

pp. 426-431 ◽

Cited By ~ 16

Author(s):

Rick A. Nishimura ◽

Jane A. Linderbaum ◽

James M. Naessens ◽

Barbara Spurrier ◽

Mark B. Koch ◽

...

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Inpatient Service ◽

New Model ◽

Academic Medical ◽

New Millennium

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Accuracy of and prescriber perceptions related to documenting antibiotic indications during order entry at an academic medical center

American Journal of Health-System Pharmacy ◽

10.1093/ajhp/zxz318 ◽

2020 ◽

Vol 77 (4) ◽

pp. 282-287

Author(s):

James Beardsley ◽

Mark Vestal ◽

Norbert Rosario ◽

Kalyn Meosky ◽

James Johnson ◽

...

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Final Diagnosis ◽

Antibiotic Prescribing ◽

Order Entry ◽

Empiric Antibiotics ◽

Academic Medical ◽

Progress Notes ◽

Secondary Endpoints ◽

A Minor

Abstract Purpose To assess the accuracy of antibiotic indication documentation provided during order entry and prescriber perceptions of the requirement to specify indications. Methods Patients who received 1 of 6 selected antibiotics from May 1 through June 30, 2017, were identified. Records of 30 randomly selected patients who received each study antibiotic were retrospectively reviewed. The primary endpoint was indication accuracy, defined as agreement of the indication entered during order entry with that documented in progress notes at the time of order entry. Secondary endpoints included correlation of entered indication and final diagnosis for empiric antibiotics. A brief survey was emailed to prescribers to assess the burden and perceptions of requiring an indication during order entry. Results Four thousand five hundred twenty-four patients received 1 or more doses of a study antibiotic. For the 180 patients selected for evaluation, 89.4% of indications were accurate. Indications for antibiotics ordered for prophylaxis were more likely to be inaccurate than those for empiric or definitive antibiotics (accuracy rates of 46%, 94%, and 92%, respectively, p < 0.05). For empiric antibiotics, 78.5% of indications documented at order entry matched the final diagnosis. Two hundred fifty-four of 863 prescribers (29%) responded to the survey request. Most respondents felt that documenting the indication took no more than 20 seconds, was a “minor nuisance” or “occasionally burdensome,” and had no impact on their consideration of antibiotic appropriateness. Conclusion With the exception of prophylaxis, the indications documented during order entry were sufficiently accurate to assist antimicrobial stewardship efforts. Although indication documentation was perceived as a minor burden, surveyed prescribers indicated it had only a minimal beneficial effect on antibiotic prescribing.

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Clinical Ordering Practices of the SARS-CoV-2 Antibody Test at a Large Academic Medical Center

10.1101/2020.07.12.20152165 ◽

2020 ◽

Author(s):

Joesph R Wiencek ◽

Carter L Head ◽

Costi D Sifri ◽

Andrew S Parsons

Keyword(s):

Antibody Response ◽

Medical Center ◽

Academic Medical Center ◽

Antibody Test ◽

The United States ◽

Molecular Testing ◽

Antibody Testing ◽

Academic Medical ◽

Cost Implications ◽

Public Health Epidemiology

Background: The novel severe acute respiratory coronavirus 2 (SARS-CoV-2) that causes COVID-19 originated in December 2019 and has now infected over 3 million people in the United States. In Spring of 2020, private laboratories and some hospitals began antibody testing despite lacking evidence-based guidance. Objective: To describe clinician-described indications for SARS-CoV-2 antibody testing, including cost implications, immediately following testing availability. Design: Retrospective chart review of patients who received antibody testing from May 14, 2020 to June 15, 2020. Setting: A large academic medical center, one of the first in the US to provide antibody testing capability to individual clinicians. Patients: 447 consecutive patients who received SARS-CoV-2 antibody testing. Measurements: Clinician-described indications for SARS-CoV-2 antibody testing, cost implications, and comparison with current expert-based guidance from the IDSA and CDC. Results: Of 444 individual antibody test results meeting inclusion criteria, the two most commonly described indications for ordering the antibody test, apart from public health epidemiology studies (n=223), were for patients with a now resolved COVID-19 compatible illness (n=105) with no previous molecular testing and in asymptomatic patients believed to have had a past exposure or contact with a person with COVID-19 compatible illness (n=60). The rate of positive SARS-CoV-2 antibody testing among those indications consistent with current IDSA and CDC guidance was 17% compared with 5% (p<0.0001) among those indications inconsistent with current IDSA and CDC guidance. Total cost estimates ranged from $57,720 to $97,680, of which 42% was for testing inconsistent with current expert-based guidance. Limitations: The duration of antibody response following infection is unclear and asymptomatic individuals may not develop a positive antibody response. Conclusions: Our findings demonstrate a dissociation between clinician described indications for testing and expert-based guidance and a significantly different rate of positive testing between these two groups. Clinical curiosity and patient preference appear to have played a significant role in testing decisions and substantially contributed to testing costs.

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Evaluation of a Pharmacy-to-Dose Pneumococcal Vaccination Protocol at an Academic Medical Center

Annals of Pharmacotherapy ◽

10.1177/1060028018805439 ◽

2018 ◽

Vol 53 (4) ◽

pp. 364-370

Author(s):

Ashlee Baucom ◽

Christina Brizendine ◽

Ann Fugit ◽

Christopher Dennis

Keyword(s):

Medical Center ◽

Academic Medical Center ◽

Pneumococcal Vaccination ◽

Primary Objective ◽

Fisher Exact Test ◽

Inpatient Service ◽

Exact Test ◽

Vaccine Administration ◽

Vaccination Protocol ◽

Academic Medical

Background: In February 2016, a pharmacy-to-dose (PTD) pneumococcal vaccination protocol was implemented to aid in the appropriate selection of pneumococcal vaccines. Objective: The primary objective was to compare the rate of appropriate vaccine ordering with the PTD protocol. Secondary objectives were to assess vaccine administration rate and determine factors preventing patients from receiving the vaccine after appropriate selection. Methods: This was a single-center, retrospective cohort study of adult patients admitted to an inpatient service. Eligible patients were 19 years of age or older and had either a PTD pneumococcal vaccination order placed or an alert triggered indicating that the patient was a candidate for a vaccination. Patients were excluded if they had contraindications to receiving either pneumococcal vaccine. The Fisher exact test was used to evaluate the primary objective, and descriptive statistics were used to evaluate the secondary objectives. Results: A total of 327 patients were included in the analysis: 167 in the preprotocol cohort and 160 in the postprotocol cohort. The correct vaccine ordering rates were found to be 26.9% (45/167) and 83.1% (133/160) in the preprotocol and postprotocol cohorts, respectively ( P < 0.001). In the postprotocol cohort, 17.5% (28/160) of patients did not have a vaccine administered. Reasons for vaccine administration failure were identified as patient refusal, patient expired during admission, vaccine not dispensed by pharmacy, and vaccine dispensed by pharmacy but returned. Conclusions: The PTD pneumococcal vaccination protocol significantly improved correct vaccine ordering rates.

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Added Value of Chest CT in Suspected COVID-19: An Analysis of 239 Patients

10.20944/preprints202005.0193.v1 ◽

2020 ◽

Author(s):

Daniel A. Korevaar ◽

Ruud S. Kootte ◽

Loek P. Smits ◽

Joost G. van den Aardweg ◽

Peter I. Bonta ◽

...

Keyword(s):

Emergency Department ◽

Medical Center ◽

Academic Medical Center ◽

Final Diagnosis ◽

Chest Ct ◽

Added Value ◽

Rt Pcr ◽

Positive Serology ◽

Academic Medical

Introduction: Clinicians have been struggling with the optimal diagnostic approach of patients with suspected COVID-19. We evaluated the added value of chest CT over RT-PCR alone. Methods: Consecutive adult patients with suspected COVID-19 presenting to the emergency department (Academic Medical Center, Amsterdam University Medical Centers, the Netherlands) from March 16th to April 16th were retrospectively included if they required hospital admission and underwent chest CT and RT-PCR testing for SARS-CoV-2 infection. The CO-RADS classification was used to assess the radiological probability of COVID-19, where a score of 1-2 was considered as negative, 3 as indeterminate, and 4-5 as positive. CT results were stratified by initial RT-PCR results. For patients with a negative RT-PCR but a positive CT, serology or multidisciplinary discussion after clinical follow-up constituted the final diagnosis. Results: 258 patients with suspected COVID-19 were admitted, of which 239 were included because they had both CT and RT-PCR testing upon admission. Overall, 112 patients (46.9%) had a positive initial RT-PCR, and 14 (5.9%) had a positive repeat RT-PCR. Of 127 patients with a negative or indeterminate initial RT-PCR, 38 (29.9% [95%CI 21.3-39.3%]) had a positive CT. Of these, 13 had a positive RT-PCR upon repeat testing, and 5 had positive serology. The remaining 20 patients were assessed in a multidisciplinary consensus meeting, and for 13 it was concluded that COVID-19 was ‘very likely’. Of 112 patients with a positive initial RT-PCR result, CT was positive in 104 (92.9% [95%CI 89.3-97.5%]). Conclusion: In a high-prevalence emergency department setting, chest CT showed high probability of COVID-19 (CO-RADS 4-5) in 29.9% of patients with a negative or indeterminate initial RT-PCR result. As the majority of these patients had proven or ‘very likely’ COVID-19 after follow-up, we believe that CT helps in the identification of patients who should be admitted in isolation.

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