Affairs Medical Center Research Articles

Modernizing Surgical Quality: A Novel Approach to Improving Detection of Surgical Site Infections in the Veteran Population.

Introduction: Surgical site infections (SSIs) are an important quality measure. Identifying SSIs often relies upon a time-intensive manual review of a sample of common surgical cases. In this study, we sought to develop a predictive model for SSI identification using antibiotic pharmacy data extracted from the electronic medical record (EMR). Methods: A retrospective analysis was performed on all surgeries at a Veteran Affair's Medical Center between January 9, 2020 and January 9, 2022. Patients receiving outpatient antibiotics within 30 days of their surgery were identified, and chart review was performed to detect instances of SSI as defined by VA Surgery Quality Improvement Program criteria. Binomial logistic regression was used to select variables to include in the model, which was trained using k-fold cross validation. Results: Of the 8,253 surgeries performed during the study period, patients in 793 (9.6%) cases were prescribed outpatient antibiotics within 30 days of their procedure; SSI was diagnosed in 128 (1.6%) patients. Logistic regression identified time from surgery to antibiotic prescription, ordering location of the prescription, length of prescription, type of antibiotic, and operating service as important variables to include in the model. On testing, the final model demonstrated good predictive value with c-statistic of 0.81 (confidence interval: 0.71-0.90). Hosmer-Lemeshow testing demonstrated good fit of the model with p value of 0.97. Conclusion: We propose a model that uses readily attainable data from the EMR to identify SSI occurrences. In conjunction with local case-by-case reporting, this tool can improve the accuracy and efficiency of SSI identification.

Concurrent Hospice Healthcare Utilization in the Hematology/Oncology Veteran's Affairs Patient Population.

Objectives: Concurrent care is a unique care delivery system that allows patients to receive disease modifying treatments and other supportive interventions while also receiving the traditional benefits of hospice care. The objectives of our observational study were to examine health care utilization, use of cancer-directed therapies and palliative interventions, and location of death in patients enrolled in concurrent care. Methods: 72 hematology-oncology patients at the Hines Veteran's Affairs Medical Center (VAMC) who enrolled in concurrent care from 12/2018-4/2021 were reviewed. Data were summarized with descriptive statistics including medians and percentages. Results: A minority of patients received cytotoxic chemotherapy (27.8%), immunotherapy (20.8%), palliative radiation (20.9%), blood products (11.1%), or invasive pain procedures (4.2%). Patients also used fewer cancer-directed treatments as they approached end of life (24.4% within 30 days of death compared to 13.3% within 14 days of death). Most patients died at home (62.9%) or in inpatient hospice (12.9%) as opposed to the hospital (2.9%). Conclusions: A minority of concurrent care patients received cancer-directed therapies or additional types of health care interventions despite the option to do so. Cancer-directed treatment utilization also decreased as patients approached end of life. Patients enrolled in concurrent care were able to appreciate its benefits for longer, as the average length of stay on concurrent care was nearly 3months.

Long-Term Follow-Up of Colonoscopy Quality Monitoring.

High-quality colonoscopy is paramount for colorectal cancer prevention. Since 2009, endoscopists at our institution have received quarterly report cards summarizing individual colonoscopy quality indicators. We have previously shown that implementing this intervention was associated with short-term improvement in adenoma detection rate (ADR). However, the long-term effect of continued monitoring on colonoscopy quality is unclear. We conducted a retrospective study of prospectively administered quarterly colonoscopy quality report cards at the Roudebush Veteran's Affairs Medical Center between April 1, 2012, and August 31, 2019. The anonymized reports included individual endoscopists' ADRs, cecal intubation rates, and withdrawal times. Analyses were performed to determine slopes over time for each quality metric by physician and assess for differences based on whether ADRs were calculated quarterly or yearly. Data from the report cards of 17 endoscopists who had performed 24,361 colonoscopies were included. The mean quarterly ADR (±SD) was 51.7% (±11.7%) and mean yearly ADR was 47.2% (±13.8%). There was a small increase in overall ADR based on quarterly and yearly measurements (slope + 0.6%, P = 0.02; and slope +2.7%, P < 0.001, respectively), but no significant change in individual ADRs, cecal intubation rates, or withdrawal times. Analysis of SD of ADRs showed no significant difference between yearly and quarterly measurements ( P = 0.064). Individual endoscopists' ADR SD differences between yearly and quarterly measurements ranged from -4.7% to +6.8%. Long-term colonoscopy quality monitoring paralleled stable improvements in overall ADR. For endoscopists with baseline high ADR, frequent monitoring and reporting of colonoscopy quality metrics may not be necessary.

Implementing diagnostic stewardship to improve diagnosis of urinary tract infections across three medical centers: A qualitative assessment.

Urine-culture diagnostic stewardship aims to decrease misdiagnosis of urinary tract infections (UTIs); however, these interventions are not widely adopted. We examined UTI diagnosis and management practices to identify barriers to and facilitators of diagnostic stewardship implementation. Using a qualitative descriptive design, we conducted semistructured interviews at 3 Veterans' Affairs medical centers. Interviews were conducted between November 2021 and May 2022 via Zoom videoconferencing using an interview guide and visual prototypes of proposed interventions. Interviewees were asked about current practices and thoughts on proposed interventions for urine-culture ordering, processing, and reporting. We used a rapid analysis matrix approach to summarize key interview findings and compare practices and perceptions across sites. We interviewed 31 stakeholders and end users. All sites had an antimicrobial stewardship program but limited initiatives targeting appropriate diagnosis and management of UTIs. The majority of those interviewed identified the importance of diagnostic stewardship. Perceptions of specific interventions ranged widely by site. For urine-culture ordering, all 3 sites agreed that documentation of symptomology would improve culturing practices but did not want it to interrupt workflow. Representatives at 2 sites expressed interest in conditional urine-culture processing and 1 was opposed. All sites had similar mechanisms to report culture results but varied in perceptions of the proposed interventions. Feedback from end users was used to develop a general diagnostic stewardship implementation checklist. Interviewees thought diagnostic stewardship was important. Qualitative assessment involving key stakeholders in the UTI diagnostic process improved understanding of site-specific beliefs and practices to better implement interventions for urine-culture ordering, processing, and reporting.

Immune checkpoint inhibitor-related adverse events: Real-world experience from a single veterans' affairs medical center.

Immune checkpoint inhibitors (ICIs) are antineoplastic agents associated with a multitude of immune-related adverse events (irAEs). Available data from clinical trials include highly selective patient populations which may limit their applicability to real-world clinical practice. We present a retrospective cohort study of cancer patients treated with ICI therapy at the Zablocki VA Medical Center between 2014 and 2021. Information on demographics, cancer diagnosis, type of therapy, treatment duration, comorbidities, irAE type, and overall survival were collected. We identified 187 patients who received at least one dose of ICI. About half the patients experienced at least one irAE, the most common categories being fatigue, pulmonary, and endocrine irAEs. Approximately half of the irAEs were diagnosed within the first three months of starting ICI therapy, and 60.38% of those who experienced irAEs discontinued ICI therapy. Patients who experienced endocrine or intestinal irAEs had a significantly longer overall survival. Immune-related complications due to ICI therapy are common and can frequently lead to treatment discontinuation in the real-world setting. Endocrine and intestinal irAEs may correlate with improved survival. The ICI-treated patients who received palliative radiation therapy to the bone had less irAEs, possibly due to immunogenic cell death.

Risk Factors and Cardiovascular Events in Orthotopic Liver Transplantation

Patients undergoing liver transplantation often have significant cardiovascular risk factors and may experience cardiac-related morbidity and mortality. The aim of this study was to assess the frequency of cardiovascular risk factors and outcomes in this population, and to identify factors predictive of post-transplant cardiac morbidity and mortality. We studied 261 patients who underwent liver transplantation at a single Veterans' Affairs Medical center between 1997 and 2015 to evaluate new cardiovascular events post-transplantation. The cohort consisted of 261 patients (253 men and 8 women) with a mean age of 58.3 (± 6.5 years), mean model for end-stage liver disease score of 18.0 (±7.2), and mean Framingham risk score of 8.1 (± 4.9). After a median follow-up of 82 months a total of 75 (28.7%) patients died, with 13 deaths (17.3%) attributed to a primary cardiovascular event and 9 (12%) deaths due to a coronary-specific event. Coronary events and/ or the need for revascularization post-transplant occurred in 24 (9.2%) patients. The strongest pre-transplant predictors of mortality were age (p=0.01), Framingham risk score (p=0.01), preexisting coronary artery disease (p=0.01), and preexisting dyslipidemia (p=0.01). The strongest post-transplant predictors of mortality were new-onset hypertension (p=0.01) and new-onset diabetes mellitus (p=0.03) post-transplant. In this cohort of veterans, coronary artery disease was significantly associated with mortality in the post liver transplantation population; however, the majority of deaths after transplant were attributable to other causes.

Antimicrobial physician and pharmacist experience and perception of an antimicrobial Self-Stewardship Time-Out Program (SSTOP) intervention at eight Veterans' Affairs medical centers.

We explored experiences and perceptions surrounding the Self-Stewardship Time-Out Program (SSTOP) intervention across implementation sites to improve antimicrobial use. Semistructured qualitative interviews were conducted with Antibiotic Stewardship physicians and pharmacists, from which 5 key themes emerged. SSTOP may serve to achieve sustainable promotion of antibiotic use improvements.

Antecedents to COVID-19 vaccine uptake among patients and employees in the Veterans Health Administration.

The present study sought to understand the antecedents to COVID-19 vaccination among those reporting a change in vaccine intention in order to improve COVID-19 vaccine uptake in the United States. We employed semi-structured interviews and one focus group discussion with vaccinated and unvaccinated Veterans Health Administration (VHA) employees and Veterans at three Veterans' Affairs medical centers between January and June 2021. A subset of these participants (n=21) self-reported a change in COVID-19 vaccine intention and were selected for additional analysis. We combined thematic analysis using the 5C scale (confidence, collective responsibility, complacency, calculation, constraints) as our theoretical framework with a constant comparative method from codes based on the SAGE Working Group on Vaccine Hesitancy. We generated 13 themes distributed across the 5C constructs that appeared to be associated with a change in COVID-19 vaccine intention. Themes included a trusted family member, friend or colleague in a healthcare field, a trusted healthcare professional, distrust of government or politics (confidence); duty to family and protection of others (collective responsibility); perceived health status and normative beliefs (complacency); perceived vaccine safety, perceived risk-benefit, and orientation towards deliberation (calculation); and ease of process (constraints). Key factors in promoting vaccine uptake included a desire to protect family; and conversations with as key factors in promoting vaccine uptake. Constructs from the 5C scale are useful in understanding intrapersonal changes in vaccine intentions over time, which may help public health practitioners improve future vaccine uptake.

Improving the breast MRI process: A longitudinal QI project at the Houston VA.

371 Background: The number of female veterans is increasing by more than 18,000 per year, and 700 veterans enrolled in VA healthcare are diagnosed with breast cancer each year. The American Cancer Society recommends screening MRI in women with 20-25% or greater lifetime risk of breast cancer, and primary care physicians and oncologists order breast MRIs regularly. The Michael E. DeBakey Veteran’s Affairs Medical Center (MEDVAMC) performs mammograms and ultrasounds on site, but breast MRI is not currently available. Care in the Community arranges for veterans to obtain these studies at outside facilities. This is a complex process, requiring coordination among multiple departments at the MEDVAMC, outside MRI facilities, and patients. Methods: We created a comprehensive process map for the current breast MRI ordering process to determine areas for improvement. We reviewed all breast MRI orders from 1/2019 to 5/2021 at the MEDVAMC and determined the cancellation rate and the rate of benign (BIRADS 1-2) vs non benign (BIRADS 0, 3-5) screening outcomes. We created a Pareto analysis of cancellation reasons. Our process measures were percentage of placed breast MRI orders that were cancelled and delay from MRI order to MRI performed. Our outcome measures were percentage of order cancellations due to incorrect or incomplete orders and delay from MRI order placement to results uploaded. Results: Of the 434 orders that were placed for breast MRIs, 64% were cancelled. Only 117 of the 167 patients that had MRIs ordered ultimately received one. Of the 104 patients without known malignancy who competed an MRI, 45% had non-benign findings requiring follow-up. Our pareto analysis showed that the top cancellation reason was incorrect orders, usually contrast or side verbiage. In June 2021, the CITC order set for MRI was changed from a free text box to discrete, clickable options for side and contrast. In December 2021, we held educational interventions on how to avoid delay or cancellation. Our p-chart of percentage of cancellations due to incorrect ordering shows an extremely promising decrease, with the last seven consecutive subgroups of 15 patients below the mean. The order cancellation percentage is also decreasing. The average delay pre-intervention from MRI order placement to results uploaded was 67 days. In January 2022, we implemented a breast MRI nurse navigator to help acquire results and expedite scheduling. Post-intervention, the average delay has decreased to 38.5 days. Using XmR and S charts, we have also shown an increase in precision. Conclusions: Providing discrete, clickable options within the MRI order set reduced the number of cancellations due to incorrect verbiage. Early data suggests that the educational intervention improved the cancellation rate. Instituting a nurse navigator decreased both the delay and variability for the time from order placement to results received, which will reduce the delay to follow-up of non-benign findings.

Improving the process of obtaining screening and diagnostic breast MRI: A quality improvement project at an urban VA hospital.

e18641 Background: There are two million female veterans across the United States, a number increasing by more than 18,000 per year. 1 in 8 women will be diagnosed with breast cancer in their lifetime, and studies have shown that servicewomen are 40% more likely to get breast cancer than civilians. The American Cancer Society (ACS) recommends screening MRI in women with 20-25% or greater lifetime risk of breast cancer, and both primary care physicians and oncologists are now ordering these more frequently. The Michael E. DeBakey Veteran’s Affairs Medical Center (MEDVAMC) performs screening mammograms and ultrasounds, but breast MRI is not currently available at the facility. Care in the Community arranges for veterans to obtain these studies at outside facilities. This is a complex process, requiring coordination among multiple departments, the outside MRI facility, and the patient. There are a significant number of MRI order cancellations per month, which can lead to delays in diagnosis or treatment. Methods: We created a comprehensive process map for the current breast MRI ordering process to determine areas for improvement. We looked at all breast MRI orders starting in 12/2020 at the MEDVAMC and determined the rate of cancellation and the rate of benign (BIRADS 1-2) vs non benign (BIRADS 0, 3-5) screening outcomes. We created a Pareto analysis to determine the most common cancellation reasons and p-charts of the percent of cancelled MRI orders per month and a run chart of the percent due to incorrect verbiage. Results: Of the 243 orders placed for MRI for 124 patients from 12/2020 to 1/2022, 64.2% were cancelled. Of the 57% of patients (71/124) with complete MRIs, 35.2% had non-benign findings requiring follow up, excluding known malignancies. Our Pareto analysis showed that most cancellations were due to incorrect verbiage in the order. An intervention in 6/2021 changed the MRI order from a free text box to clickable options, followed by an educational intervention in 12/2021. Cancellations due to incorrect verbiage decreased overall after June, however it has not yet reached significance. It is too early to determine if the educational intervention caused a significant change, however the cancellation rate has decreased. Conclusions: Providing discrete, clickable options within the MRI order has reduced the number of cancellations due to incorrect verbiage, though we have not yet reached significance. Early data suggests that the educational intervention has improved the cancellation rate. Fewer cancellations will lead to more timely studies, which will in turn lead to faster follow up of non-benign findings. Further directions include using a nurse navigator to reduce confusion and delays, further simplifying the ordering process, checking patient phone numbers in clinic, and sending patients home with information on the importance of screening MRI to reduce veteran cancellation.

127-OR: Diabetic Foot Ulcers in Remission: Cyclical-Pressure Topical Wound Oxygen Therapy Significantly Reduces DFU Related Hospitalizations and Amputations over a 12-Month Period

Purpose: The purpose of this real-world evidence (RWE) cohort study was to evaluate whether utilization of Cyclical-Pressure Topical Wound Oxygen (TWO2) therapy had any impact on the incidence of Diabetic Foot Ulcer (DFU) related hospitalizations and amputations over a 12-month period in patients with hard to heal Diabetic Foot Ulcers (DFU) Methods: An IRB approved retrospective review of deidentified DFU patient medical records was conducted at 2 US Veterans Affairs Medical Centers in Illinois and Virginia, which included demographic information on wound characteristics, clinical characteristics, neuropathy, cardiovascular disease (CVD) , peripheral vascular disease (PVD) , pain level and kidney disease etc. Results: Within the unmatched cohorts of 202 DFU patients (91 TWO2, 1NO TWO2) there was an 88% reduction in hospitalizations and 71% reduction in amputations over the 12-month period for the patients treated with TWO2 therapy compared to those that did not receive TWO2 therapy. After propensity score matching was conducted, which minimizes the effects of confounding by achieving more balanced covariates in the absence of a randomized study, resulting in matched cohorts of 140 DFU patients (70 TWO2, 70 NO TWO2) , 82% fewer TWO2 patients were hospitalized) and 73% fewer TWO2 patients had amputations, compared to those who did not receive TWO2 therapy (p &amp;lt; 0.0001, p = 0.00 respectively) . Conclusions: This large RWE study demonstrates that TWO2 therapy positively impacts patient’s quality-of-life and the costs associated with treating their DFU by forcing them into remission, resulting in significantly reduced rates of amputations and hospitalizations. Disclosure M.G.Garoufalis: None.

Prospective audit and feedback of Clostridioides difficile PCR at the time of ordering increases appropriateness of testing

Background: Over-testing for Clostridioides difficile infection outside acute diarrheal illness without a clear alternative cause can lead to inappropriate diagnosis and treatment with antibiotic therapy. Preanalytical interventions such as education, order restriction, and electronic order assistance are common but are limited in effectiveness. As an alternative approach, our antibiotic stewardship program (ASP) implemented prospective audit and feedback (PAF) on C. difficile PCR orders to reduce inappropriate testing.Methods: The study was conducted at a 399-bed, tertiary-care, Veterans’ Affairs Medical Center and included adult inpatients and outpatients for whom C. difficile PCR testing was ordered. In the preintervention period from June through September 2019, the ASP was alerted to C. difficile PCR tests and collected data but did not intervene. From October 2019 to January 2020, the ASP performed real-time PAF at the time of ordering. Appropriateness of testing was determined based on whether there was a negative result in the prior 7 days and a 3-step review of clinical factors (Fig. 1). When possible, a direct conversation took place with the ordering provider. If not possible, a general note delineating appropriate clinical criteria for testing was generated. No PAF was done outside standard hours. The ASP recommended cancelling tests deemed inappropriate. Monthly test rates during the pre- and postintervention periods were compared using the Student t test with α = .05, and test appropriateness was compared using the χ2 test. All analyses were conducted using Microsoft Excel software. Results: During the preintervention period, a total of 418 tests were ordered (104.5 per month). This number decreased to 276 (69 per month) during the intervention period. (p Conclusions: Direct PAF at the time of C. difficile PCR ordering may increase test appropriateness and is associated with a reduction in overall testing, primarily by reducing the number of tests that are considered not appropriate on clinical grounds. PAF is effective but requires significant time investment by ASP staff and may not be a sustainable intervention over time.Funding: NoneDisclosures: None

Performance of infectious diseases specialists, hospitalists, and other internal medicine physicians in antimicrobial case-based scenarios: Potential impact of antimicrobial stewardship programs at 16 Veterans' Affairs medical centers.

As part of a project to implement antimicrobial dashboards at select facilities, we assessed physician attitudes and knowledge regarding antibiotic prescribing. An online survey explored attitudes toward antimicrobial use and assessed respondents' management of four clinical scenarios: cellulitis, community-acquired pneumonia, non-catheter-associated asymptomatic bacteriuria, and catheter-associated asymptomatic bacteriuria. This study was conducted across 16 Veterans' Affairs (VA) medical centers in 2017. Physicians working in inpatient settings specializing in infectious diseases (ID), hospital medicine, and non-ID/hospitalist internal medicine. Scenario responses were scored by assigning +1 for answers most consistent with guidelines, 0 for less guideline-concordant but acceptable answers and -1 for guideline-discordant answers. Scores were normalized to 100% guideline concordant to 100% guideline discordant across all questions within a scenario, and mean scores were calculated across respondents by specialty. Differences in mean score per scenario were tested using analysis of variance (ANOVA). Overall, 139 physicians completed the survey (19 ID physicians, 62 hospitalists, and 58 other internists). Attitudes were similar across the 3 groups. We detected a significant difference in cellulitis scenario scores (concordance: ID physicians, 76%; hospitalists, 58%; other internists, 52%; P = .0087). Scores were numerically but not significantly different across groups for community-acquired pneumonia (concordance: ID physicians, 75%; hospitalists, 60%; other internists, 56%; P = .0914), for non-catheter-associated asymptomatic bacteriuria (concordance: ID physicians, 65%; hospitalists, 55%; other internists, 40%; P = .322), and for catheter-associated asymptomatic bacteriuria (concordance: ID physicians, 27% concordant; hospitalists, 8% discordant; other internists 13% discordant; P = .12). Significant differences in performance regarding management of cellulitis and low overall performance regarding asymptomatic bacteriuria point to these conditions as being potentially high-yield targets for stewardship interventions.

Outcomes of an advanced practice nurse (APN)-led cancer genetics service.

71 Background: In oncology practice, there are increasing numbers of patients for whom genetic testing is recommended by the National Cancer Care Network (NCCN), including all metastatic and high-risk localized prostate cancer patients. However, there is a critical shortage of genetics services providers. Acuity for these consults can be high, particularly in the context of a treatment related decision. We hypothesized that nurses, particularly advanced practice nurses (APNs), can provide a workforce within VA that can address genetic testing and genetic care needs of prostate cancer patients. Methods: We initiated a cancer genetics service staffed with an advanced practice nurse (APN) geneticist and evaluated the success of the program at a large urban, academic-affiliated Veteran’s Affairs Medical Center (VAMC). Results: In the one year prior to the initiation of the APN geneticist-run program (10/1/2019-9/30/2020), 61 unaffected patients with a family history of cancer and 85 patients with cancer (36 with prostate cancer) were referred to a VA centralized telegenetics service. An average of seven cancer patients (average three with prostate cancer) were referred to VA telegenetics per month. Genetic testing was completed in eleven (18%) of unaffected patients and 21 (25%) of cancer patients. Five (13%) of tested patients were found to have a pathogenic or likely pathogenic mutation or variant of uncertain significance (VUS). In the eight months after initiation of the APN geneticist-run consult service (10/1/2020 - 5/30/2021), 39 unaffected patients with a family history of cancer and 90 patients with cancer (38 with prostate cancer) were referred. An average of 11 cancer patients (average five with prostate cancer) per month were referred. This represents a 57% increase in all cancer patient and a 67% increase in prostate cancer patient referrals. For those patients referred to the APN geneticist-run consult service, genetic testing was completed in three (7%) of unaffected patients and 30 (33%) of cancer patients (including 15 prostate cancer patients). The genetic testing rate therefore improved from 1.7 oncology patients per month to 3.9 oncology patients per month, an 130% increase in genetic testing. For prostate cancer patients, the genetic testing rate improved from 0.8 to 1.9 patients tested per month, representing a 137% increase. Comparison of genetic testing outcomes at one year will be included in the final presentation. Conclusions: Inclusion of an APN geneticist-run consult service embedded in oncology clinics will likely improve access to genetics services and genetic testing rates in cancer patients.

Outpatient treatment and clinical outcomes of bacteriuria in veterans: A retrospective cohort analysis.

To conduct a contemporary detailed assessment of outpatient antibiotic prescribing and outcomes for positive urine cultures in a mixed-sex cohort. Multicenter retrospective cohort review. The study was conducted using data from 31 Veterans' Affairs medical centers. Outpatient adults with positive urine cultures. From 2016 to 2019, data were extracted through a nationwide database and manual chart review. Positive urine cultures were reviewed at the chart, clinician, and aggregate levels. Cases were classified as cystitis, pyelonephritis, or asymptomatic bacteriuria (ASB) based upon documented signs and symptoms. Preferred therapy definitions were applied for subdiagnoses: ASB (no antibiotics), cystitis (trimethoprim-sulfamethoxazole, nitrofurantoin, β-lactams), and pyelonephritis (trimethoprim-sulfamethoxazole, fluoroquinolone). Outcomes included 30-day clinical failure or hospitalization. Odds ratios for outcomes between treatments were estimated using logistic regression. Of 3,255 cases reviewed, ASB was identified in 1,628 cases (50%), cystitis was identified in 1,156 cases (36%), and pyelonephritis was identified in 471 cases (15%). Of all 2,831 cases, 1,298 (46%) received preferred therapy selection and duration for cases where it could be defined. The most common antibiotic class prescribed was a fluoroquinolone (34%). Patients prescribed preferred therapy had lower odds of clinical failure: preferred (8%) versus nonpreferred (10%) (unadjusted OR, 0.74; 95% confidence interval [CI], 0.58-0.95; P = .018). They also had lower odds of 30-day hospitalization: preferred therapy (3%) versus nonpreferred therapy (5%) (unadjusted OR, 0.55; 95% CI, 0.37-0.81; P = .002). Odds of clinical treatment failure or hospitalization was higher for β-lactams relative to ciprofloxacin (unadjusted OR, 1.89; 95% CI, 1.23-2.90; P = .002). Clinicians prescribed preferred therapy 46% of the time. Those prescribed preferred therapy had lower odds of clinical failure and of being hospitalized.

Increased carbapenemase testing following implementation of national VA guidelines for carbapenem-resistant Enterobacterales (CRE).

To describe national trends in testing and detection of carbapenemases produced by carbapenem-resistant Enterobacterales (CRE) and associate testing with culture and facility characteristics. Retrospective cohort study. Department of Veterans' Affairs medical centers (VAMCs). Patients seen at VAMCs between 2013 and 2018 with cultures positive for CRE, defined by national VA guidelines. Microbiology and clinical data were extracted from national VA data sets. Carbapenemase testing was summarized using descriptive statistics. Characteristics associated with carbapenemase testing were assessed with bivariate analyses. Of 5,778 standard cultures that grew CRE, 1,905 (33.0%) had evidence of molecular or phenotypic carbapenemase testing and 1,603 (84.1%) of these had carbapenemases detected. Among these cultures confirmed as carbapenemase-producing CRE, 1,053 (65.7%) had molecular testing for ≥1 gene. Almost all testing included KPC (n = 1,047, 99.4%), with KPC detected in 914 of 1,047 (87.3%) cultures. Testing and detection of other enzymes was less frequent. Carbapenemase testing increased over the study period from 23.5% of CRE cultures in 2013 to 58.9% in 2018. The South US Census region (38.6%) and the Northeast (37.2%) region had the highest proportion of CRE cultures with carbapenemase testing. High complexity (vs low) and urban (vs rural) facilities were significantly associated with carbapenemase testing (P < .0001). Between 2013 and 2018, carbapenemase testing and detection increased in the VA, largely reflecting increased testing and detection of KPC. Surveillance of other carbapenemases is important due to global spread and increasing antibiotic resistance. Efforts supporting the expansion of carbapenemase testing to low-complexity, rural healthcare facilities and standardization of reporting of carbapenemase testing are needed.

Social Isolation Among Older Military Veterans

Social isolation is an increasingly critical issue among older adults and has been found to affect several domains of well-being, including physical, psychological, and cognitive health. Research has found that military veterans often experience hardships in the transition back to civilian life including emotional trauma, depression, substance misuse and pain from combat-related injuries, which have been shown to persist well into older adulthood. As such, this study aimed to examine the prevalence of social isolation among older military veterans and determine which veterans are most at-risk of experiencing social isolation, using the Berkman-Syme Social Network Index as a framework. Data were derived from Round 1 of the National Health and Aging Trends Study (NHATS), an annual longitudinal panel survey of adults aged 65 and older living in the United States. Results showed that about 4.5% of veterans in the NHATS are severely socially isolated while another 20.9% are socially isolated. After controlling for other explanatory variables, being White, being 85 and older, having lower educational attainment, being unmarried/unpartnered and having lower income were associated with an increased risk of experiencing social isolation. Interventions aiming to improve the well-being of older veterans should consider employing both preventative and amendatory measures. These may include the creation and administration of a standardized social isolation scale during visits to veterans’ affairs (VA) medical centers and a general effort to address stressors from military service by destigmatizing and improving access to mental health services.

1432. Patient-Reported Urinary Tract Infection Symptoms Among Veterans with Neurogenic Bladder

BackgroundUrinary tract infections (UTIs) and asymptomatic bacteria (AB) are common in patients with neurogenic bladder (NB) but differentiating between the two is challenging because laboratory tests cannot distinguish AB from UTI. This diagnostic uncertainty can lead to antibiotic overuse. Characterization of patient-reported symptoms from large cohorts of patients with NB can inform interventions to improve appropriate UTI diagnosis and management.MethodsRetrospective cohort study of 1,797 adults with NB due to spinal cord injury/disorder (SCI/D), multiple sclerosis (MS), and/or Parkinson’s Disease (PD) accounted for 568 patients with UTI encounters (via ICD10) at 4 Veterans Affairs (VA) medical centers between 2017-2018. Demographic and clinical data were collected from national VA datasets. Medical record review was performed on a random sample of 198 encounters. Chi-square/Fisher’s exact test were used to compare symptoms by patient and encounter characteristics.ResultsAmong the 198 encounters (mean age=65 years), 33% of patients had SCI/D, 29% PD, 20% MS, and 17% had more than one diagnosis. Most encounters were for men (88%) in inpatient or long-term care settings (62%). 76% of patients used bladder catheters; most indwelling (n=92). Fever was the most frequent symptom (30%), followed by change in urine odor, color, and/or consistency (26%) and lethargy/malaise (21%). Only 38% of encounters had a urinary tract-specific symptom recorded (e.g., dysuria); 81% had non-specific symptoms (e.g., fever, lethargy). 64% of encounters were deemed an appropriate UTI diagnosis. Characteristics in red in Figure 1 were significantly associated with non-specific symptoms (p< 0.05). Patient and encounter characteristics found to be significantly associated with non-specific symptoms, p < 0.05.ConclusionSymptoms not specific to the urinary tract are the most frequently reported symptoms in patients with NB and encounters with a UTI diagnosis. Change in urine odor/color were reported often; however, guidelines recommend against using these for UTI diagnosis. Providers should ensure that alternate sources of non-specific symptoms are evaluated prior to attributing them to UTI. Antibiotic stewardship interventions targeted to physical medicine and rehabilitation (PM&R) and primary care providers in inpatient settings may improve UTI diagnosis in patients with NB. Disclosures Charlesnika T. Evans, PhD, MPH, BioK+ (Consultant)

112. Prescriber Perceptions on Utilization of the Antibiotic Self-Stewardship Time Out Program (SSTOP) at Veterans Affairs Medical Centers (VAMC): A Strategy for Improved Antibiotic Use

BackgroundEvidence is lacking on how to implement effective and sustainable antibiotic stewardship strategies. The Antibiotic Self-Stewardship Time Out Program (SSTOP) evaluated the implementation at VAMCs of an “Antibiotic Timeout” 3 days after the initiation of antibiotics to encourage providers to review continued use of broad-spectrum antibiotics. MethodsSites launched the SSTOP note templates in a rolling fashion from June 2019-March 2020. Clinical pharmacists largely drove the implementation. The vancomycin note template was implemented at 6 of 8 sites and the antipseudomonal note template across 4 of 8 sites. Two sites were unable to launch the note templates due to lack of resources, however they utilized SSTOP principles/guided tools. From Sept 2019-Nov 2020 we conducted post-launch qualitative interviews with Antibiotic Stewardship Program (ASP) champions involved in implementation across the 8 VAMCs. Interviews were transcribed and analyzed for thematic content.ResultsFeedback from ASP providers suggests prescribers had mixed reviews on the note template, but overall liked the process and deemed it to be straightforward. Many valued the algorithm, indicating it was helpful in both thinking about antibiotics prior to initiation, and identification of appropriate antibiotics. Barriers included staffing (e.g., rotating residents/turnover), surgery service, information technology (IT) support, COVID-19, and the need to remind providers to use the template. Facilitators consisted of strong stewardship, local champions (e.g., ID Fellow), medicine service, and SSTOP data feedback reports. Recommendations largely centered on improvements to the note template usability and to SSTOP feedback reports (e.g., inclusion of patient/provider-level data).ConclusionOverall, the SSTOP note templates were considered acceptable and straightforward. By guiding providers to prescribe more appropriate antibiotics, they act as influencers for practice change, and may strengthen provider/ASP relations. Plans for continued utilization of the note templates after the project concludes suggest SSTOP may serve as a way to achieve sustainable promotion of antibiotic use improvements. Disclosures Matthew B. Goetz, MD, Nothing to disclose

702. Risk Factors for Acute Gastroenteritis Among Patients Hospitalized in 5 Veterans Affairs Medical Centers, 2016–19

BackgroundIn the United States, an estimated 179 million acute gastroenteritis (AGE) episodes occur each year. Identifying factors contributing to AGE susceptibility and severity is important to address the high disease burden of AGE among adults. The primary objective of this analysis was to identify risk factors for all-cause AGE, norovirus-associated AGE and severe AGE among hospitalized adults. MethodsWe analyzed data from 1029 inpatient AGE cases and 624 non-AGE controls enrolled prospectively from December 1, 2016 – November 30, 2019 from 5 Veterans Affairs Medical Centers (Atlanta, Bronx, Houston, Los Angeles, Palo Alto). Standardized patient interviews and medical chart abstractions were conducted to collect demographics, exposure history, and underlying medical conditions. Stool samples from participants were tested for 22 pathogens using the BioFire Gastrointestinal Panel. Severity of AGE was determined using a 20-point modified Vesikari score (MVS) and severe AGE was defined as a MVS score of ≥ 11. Multivariate logistic regression was performed to assess associations between potential risk factors and outcomes. ResultsOf the total AGE cases, 551 (54%) had severe AGE; 44 (4%) were norovirus positive. Risk factors for all-cause AGE vs. non-AGE controls included household contact with a person with AGE in the past 7 days (aOR=2.9, 95% CI:1.3-6.7), severe renal disease (aOR=3.1, 95% CI:1.8-5.2), human immunodeficiency virus (HIV) (aOR=3.9, 95% CI:1.8-8.5), and immunosuppressive therapy (aOR=5.6, 95% CI:2.7-11.7). Factors associated with norovirus positivity by univariate analysis were contact with a person with AGE outside (OR=4.4, 95% CI:1.6-12.0) and within (OR=5.0, 95% CI:2.2-11.5) the household in the past 7 days. Detection of any viral pathogen (aOR=4.0, 95% CI:1.7-9.5) was a risk factor for severe AGE.ConclusionOur findings suggest that inpatients with HIV or severe renal disease, on immunosuppressive therapy, or in contact with a person with AGE within household are at higher risk for all-cause AGE. Patients with these medical conditions should be monitored for AGE related hospitalizations and may benefit from targeted AGE prevention messaging. Disclosures Vincent Marconi, MD, Bayer (Consultant, Scientific Research Study Investigator)Eli Lilly (Consultant, Scientific Research Study Investigator)Gilead Sciences (Consultant, Scientific Research Study Investigator)ViiV (Consultant, Scientific Research Study Investigator)