Agency For Healthcare Research & Quality Research Articles

What interventions keep older people out of nursing homes? A systematic review and meta-analysis.

Nursing home admission remains a central outcome in many healthcare systems and community-based programs. The objective of this meta-analysis was to determine the efficacy of pharmacological and nonpharmacological interventions in preventing nursing home admission for adults aged 65 years or older. MEDLINE, EMBASE, PsycInfo, CINAHL, and the Cochrane Library were all last searched in March 2022 to identify up-to-date eligible studies for the meta-analysis. Two reviewers screened each abstract independently. In instances where reviewers disagreed as to inclusion, all reviewers convened to review the Abstract to come to a consensus decision regarding inclusion. Two reviewers independently collected data from each report. Disagreements were resolved using group consensus. The first author reviewed the narrative descriptions of intervention components to create a categorization scheme for the various interventions evaluated in selected studies. These categorizations were reviewed with the co-authors (second-fifth) and collapsed to create the final classification of intervention type. Study risk of bias was assessed using an instrument developed based on Agency for Healthcare Research & Quality (AHRQ) guidance. Differences between the percentages of participants in treatment versus control arms was the outcome of interest. Two-hundred and eighty-three studies with a total of 203,735 older persons were included in the meta-analysis. Specialty geriatrics care (OR = 0.77, 95% CI, 0.60-0.99), multicomponent interventions (OR = 0.82, 95% CI, 0.67-0.99), and cognitive stimulation (OR = 0.60, 95% CI, 0.38-0.96) were associated with less frequent nursing home admission. Home-based and inpatient/discharge management interventions approached statistical significance but were not associated with reduced institutionalization. Even in the face of complex care needs, older adults wish to live at home. Effectively disseminating and implementing geriatric care principles across healthcare encounters could achieve a highly valued and preferred outcome in older adulthood: aging in place.

Do colorectal cancer patients with a postoperative stoma have sexual problems? A pooling up analysis of 2566 patients

This study aimed to evaluate the effect of the stoma on sexual function in colorectal cancer patients. Search strategy was conducted in four databases including PubMed, Embase, the Cochrane Library, and Medline on Nov 20, 2022. After that, the quality of eligible studies was assessed by the Newcastle Ottawa Scale (NOS) and the Agency for Healthcare Research Quality (AHRQ). In order to evaluate the sexual function between the stoma group and the non-stoma group, mean values and standard deviation were pooled for scores in questionnaires, and odds ratio and 95% confidence intervals were pooled for self-designed problems. Results were shown in forest plots; Egger's test and the trim and fill analysis were used for assessing the publication bias. All the data analyses above were performed by STATA 16.0 software. Six cohort studies and three cross-sectional studies were included for this pooling up analysis. As for the European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ-C38), male patients with stomas had more sexual problems (mean differences = 0.32, 95% confidence intervals = 0.01 to 0.63, I2 = 67.80%, P = 0.05); however, other indicators including sexual functioning, sexual enjoyment, and female sexual problems had little difference between the two groups. As for other questionnaires and problems, stoma did not have an impact on sexual function. The stoma after surgery was not significantly associated with the sexual function of female patients with colorectal cancer and was associated with worse scores on only sexual problems for males.

Success of Patient and Family Advisory Councils: The Importance of Metrics.

Hospital Patient and Family Advisory Councils have been around for over 40 years. Yet, their adoption is waning with only slightly more than 50% of hospitals fielding Councils, which are composed of patient and family volunteers, who provide feedback to hospital staff. Demonstrating the value of Councils is critically important to their success and sustainability. Hospitals can ensure Council success by adopting these initiatives: (1) Highlight the importance of measuring program impacts to Council liaisons and members, (2) Educate members and staff about the three types of impacts defined by the Agency for Healthcare Research Quality, (3) Describe the steps to ensure that the value of the Council is well documented, and (4) Provide tools and training for the Council and staff to conduct robust measurements and analysis. When Councils measure their impact, their value to hospitals and leadership will increase.

Accuracy of the electronic health record's problem list in describing multimorbidity in patients with heart failure in the emergency department.

Patients with heart failure (HF) often suffer from multimorbidity. Rapid assessment of multimorbidity is important for minimizing the risk of harmful drug-disease and drug-drug interactions. We assessed the accuracy of using the electronic health record (EHR) problem list to identify comorbid conditions among patients with chronic HF in the emergency department (ED). A retrospective chart review study was performed on a random sample of 200 patients age ≥65 years with a diagnosis of HF presenting to an academic ED in 2019. We assessed participant chronic conditions using: (1) structured chart review (gold standard) and (2) an EHR-based algorithm using the problem list. Chronic conditions were classified into 37 disease domains using the Agency for Healthcare Research Quality's Elixhauser Comorbidity Software. For each disease domain, we report the sensitivity, specificity, positive predictive value, and negative predictive of using an EHR-based algorithm. We calculated the intra-class correlation coefficient (ICC) to assess overall agreement on Elixhauser domain count between chart review and problem list. Patients with HF had a mean of 5.4 chronic conditions (SD 2.1) in the chart review and a mean of 4.1 chronic conditions (SD 2.1) in the EHR-based problem list. The five most prevalent domains were uncomplicated hypertension (90%), obesity (42%), chronic pulmonary disease (38%), deficiency anemias (33%), and diabetes with chronic complications (30.5%). The positive predictive value and negative predictive value of using the EHR-based problem list was greater than 90% for 24/37 and 32/37 disease domains, respectively. The EHR-based problem list correctly identified 3.7 domains per patient and misclassified 2.0 domains per patient. Overall, the ICC in comparing Elixhauser domain count was 0.77 (95% CI: 0.71-0.82). The EHR-based problem list captures multimorbidity with moderate-to-good accuracy in patient with HF in the ED.

P.209 Prevalence of healthcare conditions and services used by patients with myotonic dystrophy (DM) pre- and post-diagnosis: A real-world data analysis

DM types 1 and 2 are dominantly inherited multisystem disorders that cause progressive weakness and myotonia along with variable cardiopulmonary, gastrointestinal, endocrine, and neurological manifestations that adversely affect quality of life. Literature describing the DM patient journey is limited. To describe the changes in outcomes (healthcare conditions, services, costs, and care days) we analyzed PharMetrics deidentified-US-claims (Jan-2010—Mar-2021) for patients with DM compared with matched controls (MCs) two years post-pre diagnosis. DM-patients had ≥2 DM claims ≥30 days apart (index date=first diagnosis date). Cohorts were matched (5-MC:1-DM) on index date, age, region, gender, plan, and payer types. Outcomes were compared two-years post-diagnosis minus two-years pre-diagnosis (Post-PreDx) using US agency for healthcare research & quality (AHRQ) categories. Data reported is per-member-per-year. All reported findings were significant (p<0.05). We identified 519 DM-patients and 2595 MCs. Most outcomes demonstrated higher care utilization in DM-patients than MCs. Post-PreDx care days increased at all service settings except lab for both cohorts (↑9.9 DM vs ↑1.5 MCs). Post-preDx DM-patients' AHRQ-prevalence changed in 58 (↑57↓1) categories led by "other nervous system disorders" (37.6% DM vs 3.2% MCs), "cardiac dysrhythmias" (17.3% DM vs 2.3% MCs) and "other lower respiratory disease" (16.0% DM vs 2.7% MCs). DM-patients' mean number of services increased post-preDx (21.3 vs 2.9 MCs). Post-preDx DM-patients' utilization increased in 21 AHRQ-service and 7 AHRQ-cost categories. Total medical and drug costs increased for DM-patients' (↑$6,889 to $25,594) vs MCs (↑$1,044 to $6,684). Health care utilization increased significantly in DM patients following diagnosis and was overall both higher and in different categories than MCs. This likely reflects the need to evaluate and manage previously unsuspected manifestations of DM following formal diagnosis.

Abstract P176: Reliability Of The Electronic Health Record’s Problem List In Describing Multimorbidity In Patients With Heart Failure In The Emergency Department

Introduction: Patients with heart failure (HF) often suffer from multimorbidity, the co-occurrence of two or more chronic conditions. Electronic health records (EHRs) store data on chronic conditions within the problem list, which can be readily extracted for research purposes. Objective: To assess the reliability in using the EHR-based problem list to identify comorbid conditions among patients with HF in the emergency department. Methods: A retrospective chart review study was performed on a random sample of 200 patients age &gt;65 years with a diagnosis of HF who presented to an academic emergency department (ED) in 2019 (mean age 78.3 years old, 52.5% women). Manual chart review was performed by a trained medical student (BK) as the gold standard in identifying additional chronic conditions in patients with HF. All diagnoses were mapped to International Classification of Diseases, Tenth Revision, Clinical Modification diagnostic codes and classified into 38 domains using the Agency for Healthcare Research Quality’s Elixhauser Comorbidity Software. We computed sensitivity, specificity, positive predictive value, and negative predictive value of using the EHR’s problem list to capture each domain. We calculated the intra-class correlation coefficient (ICC) to estimate reliability in the total number of domains captured by each method. Results: Our chart review found that patients with HF had a mean of 5.4 chronic conditions (SD 2.1). In comparison, the EHR's problem list identified a mean of 4.0 chronic conditions (SD 2.0). The five most prevalent domains were hypertension, diabetes, obesity, chronic pulmonary disease, and renal failure. Specificities for the five most prevalent domains were at least 97% whereas sensitivities were considerably lower and varied widely (28.6%-80.7%; Table 1). The ICC comparing chart review to the problem list was 0.77 (95% CI: 0.68-0.80). Conclusion: Multimorbidity in patients with HF in the ED was captured with good reliability using the EHR problem list.

Advances in Stroke: Stroke in Women.

Advances in Stroke: Stroke in Women.

Association Between Homocysteine and Type 2 Diabetes Mellitus: a Systematic Review and Meta-analysis

Several studies have been performed to assess the relationship between hyperhomocysteinemia and type 2 diabetes mellitus (T2DM). However, inconsistent results have been obtained. Therefore, we performed this meta-analysis to address this knowledge gap. We searched PubMed, Cochrane library, and EMBASE database for studies that evaluated the relationship between blood homocysteine (HCY) level and T2DM from inception to Jun 2019. The quality of all included studies was assessed by the Newcastle Ottawa Scale (NOS) and the Agency for Healthcare Research Quality (AHRQ). RevMan5.3 and Stata12.0 were used for data analyses. Twenty-five studies (including 1881 cases and 2868 controls) on blood HCY level in T2DM were pooled in our meta-analysis. The blood HCY level in the T2DM patients was significantly higher than in the healthy individuals (SMD = 0.63, 95% CI = 0.43–0.84, and p < 0.001, I2 = 89%, p < 0.001), ignores the effects of age, sex, cardiovascular and cerebrovascular disease conditions, and other comorbidity. Additionally, in T2DM patients with nephropathy or retinopathy, blood HCY level was also significantly higher than in those with only T2DM (SMD = 1.17, 95% CI = 0.76–1.58, p < 0.001; I2 = 90%, p < 0.001 and SMD = 0.91, 95% CI = 0.39–1.44, p <0.001; I2 = 82%, p <0.001, respectively). Our meta-analysis revealed the HCY level in the blood of T2DM patients was significantly higher than those of the health subjects, especially in patients with diabetic nephropathy (DN) and diabetic retinopathy (DR).

Association between homocysteine and obesity: A meta-analysis.

According to previous studies of obesity, we found that the association between homocysteine concentrations and obesity was reported controversially. Thus, we carried out this meta-analysis to investigate this association. We searched PubMed, The Cochrane library, and EMBASE database for studies that evaluate the relationship between homocysteine concentrations and obesity from inception to March, 2019. The quality of all included studies was assessed by the Newcastle Ottawa Scale (NOS) and the Agency for Healthcare Research Quality (AHRQ). The RevMan5.3 software and Stata12.0 software were used for conducting all data analyses. Standardized mean differences (SMD) with the corresponding 95% confidence intervals (95% CIs) were used as a measure of effect size to assess the relationship betweenhomocysteine concentrations and obesity through a meta-analysis. The level of significance was set at P<.05. A total of 14 studies were ultimately included in our meta-analysis. Meta-analysis of the 14 studies found remarkable lower homocysteine concentrations in controls than in obese patients (SMD=0.76, 95% CI=0.25-1.27, P<.01; I2 =94% and P<.01 for heterogeneity), regardless of nutritional status, dietary habit, insulin resistance (IR) status, special disease history, history of medicine taken, genetic background, and so on. Homocysteine concentrations in nonobese patients with polycystic ovarian syndrome (PCOS) were lower than obese patients with PCOS (SMD=0.48, 95% CI=0.20-0.77, P<.01; I2 =39% and P=.18 for heterogeneity). The result of our meta-analysis showed that homocysteine concentrations were significantly elevated among obese patients.

A Predictive Model for Pediatric Postoperative Respiratory Failure: A National Inpatient Sample Study.

To identify risk factors for pediatric postoperative respiratory failure and develop a predictive model. This retrospective case-control study utilized the US National Inpatient Sample (NIS) from 2012 to 2014. Significant predictors were selected, and the predicted probability of pediatric postoperative respiratory failure was calculated. Sensitivity, specificity, and accuracy were then calculated, and receiver-operator curves were drawn. National Inpatient Sample data sets from years 2012, 2013, and 2014 were used. Patients aged 17 and younger in the 2012, 2013, and 2014 NIS data sets. Candidate predictors included demographic variables, type of surgical procedure, a modified pediatric comorbidity score, presence of substance abuse diagnosis, and presence/absence of kyphoscoliosis. The primary outcome measure was the pediatric quality indicator (PDI 09), which is defined by the Agency for Healthcare Research Quality, and identifies pediatric patients with postoperative respiratory failure. The incidence of pediatric postoperative respiratory failure in each year's data set varied from 1.31% in 2012 to 1.41% in 2014. Significant risk factors for the development of postoperative respiratory failure included abdominal surgery ([OR] = 1.92 in 2012 data set, 1.79 in 2013 data set), spine surgery (OR = 7.10 in 2012 data set, 6.41 in 2013 data set), and an elevated pediatric comorbidity score (score of 3 or greater: OR = 32.58 in 2012 data set, 22.74 in 2013 data set). A predictive model utilizing these risk factors achieved a C statistic of 0.82. Risk factors associated with postoperative respiratory failure in pediatric patients undergoing noncardiac surgery include type of surgery (abdominal and spine) and higher pediatric comorbidity scores. A prediction model based on the identified factors had good predictive ability.

Abstract PD10-09: Impact of insurance and socioeconomic status on clinical outcomes in therapeutic clinical trials for breast cancer

Abstract Background: Studies have shown an association between insurance status, socioeconomic status (SES) and disparities in clinical outcomes among breast cancer patients. The objective of this study was to evaluate insurance status and SES with respect to protocol treatment completion and survival among participants in two large randomized adjuvant breast cancer clinical trials. Methods: The data sources for this study were the ECOG-ACRIN (EA) clinical trials E1199 and E5103. An Agency for Healthcare Research Quality (AHRQ) SES index was calculated using zip codes from the trial patients’ residence and were linked to county level data on occupation, income, poverty, wealth, education and crowding. Insurance status at randomization was categorized into private, government (Medicaid, Medicare, and other government insurance), and self-pay. Logistic regression models and Cox proportional hazard models were used to estimate odds ratios [OR] and hazard ratios [HR] for the association between insurance type (government relative to private and self-pay relative to private) with protocol treatment completion (yes vs. no) and with overall survival respectively. The estimates reported here were adjusted for SES, race, age, tumor size, nodal status, hormone receptor status, and primary surgery at randomization. Preliminary analyses of individual government insurance types with outcome showed no difference in results versus using one combined ‘government’ insurance type category. Results: The study sample included 4954 patients from E1199 and 4836 patients from E5103. The majority of patients in E1199 and E5103 had private insurance 83.8% (4154/4954) and 82% (3987/4836) respectively. The median(range) SES index was 53.8 (41.8-66.8) for E1199 and 54.1(44.5-66.1) for E5013. Patients with government type insurance were less likely to complete treatment per protocol (OR (.95CI): E1199 0.73 (0.57-0.94), E5103 0.76 (0.64-0.91)) and had increased association with death (HR (.95CI):E1199 1.44 (1.22-1.70), E5103 1.29 (1.06-1.58)) compared to those patients with private insurance. Conversely, there was no association in completing treatment per protocol (E1199 1.03(1.01-1.06), E5103 1.14 (0.67-1.95)) or survival (E1199 1.00 (0.98-1.01), E5013 1.17(0.63-2.20)) between those patients who self-paid for care relative to those who were privately insured. There was no association between SES index and completing treatment per protocol (E1199 1.03(1.01-1.06), E5103 1.01 (0.99-1.03)) or survival (E1199 1.00(0.98-1.01), E5103 0.98(0.96-1.00)). Conclusions: In these two clinical trials, patients with government type insurance appeared to face barriers in trial treatment completion and had a lower survival compared to their privately insured counterparts. Future studies are encouraged to focus on patient and institution related variables that might be contributing to these insurance-based disparities in outcomes. Citation Format: Samilia Obeng-Gyasi, Anne O'Neil, Fengmin Zhao, Sheetal M Kircher, Timsina R Lava, Lynne I Wagner, Kathy D Miller, Joseph A Sparano, George W Sledge, Ruth C Carlos. Impact of insurance and socioeconomic status on clinical outcomes in therapeutic clinical trials for breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr PD10-09.

National Quality Assurance &amp; Improvement System (NQAIS) – Medicine

Introduction: Length of stay varies by hospital, admission type, diagnosis and clinical team, while waiting lists, emergency department throughput and delayed discharges generate frustration for patients and health professionals. The National Acute Medical Programme (NAMP) was established in 2010 by the Royal College of Physicians of Ireland and the Health Service Executive (HSE) to enable: - Swifter access to senior decision makers - Swifter access to investigations and interventions - Reduced overnight admissions - Shorter average length of stay (AvLOS) - Optimal use of Acute Medical Assessment Unit (AMAU) NQAIS Medicine: NQAIS Medicine supports NAMP and hospitals to re-engineer care delivery based on interdisciplinary co-operation using timely and relevant data. The system was developed by Health Intelligence, Health & Wellbeing, Health Service Executive, in collaboration with NAMP and OpenApp. It is deployed under the governance framework of the Joint NQAIS (Surgery & Medicine) Steering Group. NQAIS Medicine is a web-enabled, role-based quality assurance and improvement system providing an evidence base to inform decisions. Innovative “diamond” plots (simplified box and whisker) and trend plots in easily understood “ribbons” are displayed by hospital (or group), admission category, diagnosis and clinical team. Patient profiles (age, co-morbidity, admission day/time etc.) can be flexibly explored. Selected records can be identified for chart review. The predictive impact of meeting targets are summarised by the novel computation of the potential “number of beds freed per day” which could be made available for other patients. The Clinical Classification System (CCS) - Agency for Healthcare Research & Quality (AHRQ) - converts the principal (admission) diagnosis into clinically meaningful groups. The Charlson Index is used to convert secondary diagnoses into a “complexity” score. AvLOS and readmission rates are dynamically analysed in the context of data-driven targets: AvLOS per CCS diagnosis as achieved by top quartile (Irish) teams; 50%+ all acute medical admissions should be routed via the AMAU of whom 25% should be discharged home. AvLOS is computed for each CCS nationally in the context of its trim point - national 75%ile + 3 X (25% – 75%ile). If the target AvLOS is achieved and AMAU usage optimised, the potential impact is translated into simple summary metrics - beds used within, close to and off target. These metrics identify and prioritise processes in hospital most likely to reveal potential learning and reengineering opportunities for using beds for other patients. Implementation: A train-the-trainers approach within hospital groups, guided by a national training team, supports the national deployment of the system. NQAIS Medicine combines science and art to provide detailed but very understandable feedback to unequivocally identify areas for review. Modest meeting of targets would transform a system struggling to cope with increasing demands. The successful implementation of NAMP, using NQAIS Medicine as a continuous improvement enabler, requires sustained focus and commitment from clinicians and management alike. The system is currently being deployed to all acute hospital in Ireland, and is being extended to encompass surgery and other domains within a single system referred to as NQAIS Clinical.

An Event-Based Approach to Design a Teamwork Training Scenario and Assessment Tool in Surgery

Simulation is a technique recommended for teaching and measuring teamwork, but few published methodologies are available on how best to design simulation for teamwork training in surgery and health care in general. The purpose of this article is to describe a general methodology, called event-based approach to training (EBAT), to guide the design of simulation for teamwork training and discuss its application to surgery. The EBAT methodology draws on the science of training by systematically introducing training exercise events that are linked to training requirements (i.e., competencies being trained and learning objectives) and performance assessment. The EBAT process involves: Of the 4 teamwork competencies endorsed by the Agency for Healthcare Research Quality and Department of Defense, "communication" was chosen to be the focus of our training efforts. A total of 5 learning objectives were defined based on 5 validated teamwork and communication techniques. Diagnostic laparoscopy was chosen as the clinical context to frame the training scenario, and 29 KSAs were defined based on review of published literature on patient safety and input from subject matter experts. Critical events included those that correspond to a specific phase in the normal flow of a surgical procedure as well as clinical events that may occur when performing the operation. Similar to the targeted KSAs, targeted responses to the critical events were developed based on existing literature and gathering input from content experts. Finally, a 29-item EBAT-derived checklist was created to assess communication performance. Like any instructional tool, simulation is only effective if it is designed and implemented appropriately. It is recognized that the effectiveness of simulation depends on whether (1) it is built upon a theoretical framework, (2) it uses preplanned structured exercises or events to allow learners the opportunity to exhibit the targeted KSAs, (3) it assesses performance, and (4) it provides formative and constructive feedback to bridge the gap between the learners' KSAs and the targeted KSAs. The EBAT methodology guides the design of simulation that incorporates these 4 features and, thus, enhances training effectiveness with simulation.

PC-FACS

PC-FACS

An Interdisciplinary Approach to Creating a Culture of Safety

Poster Presentation Purpose for the Program At New York Presbyterian Weill Cornell Medical Center, potentially unsafe behaviors or conditions have been observed on the labor and delivery unit. We demonstrate the successful implementation of an innovative program to improve the culture of safety within the obstetric unit with a goal to improve outcomes. Proposed Change To use TeamSTEPPS as a basis and transform a less safe working environment into a safer, more collaborative, working environment. Implementation, Outcomes, and Evaluation A formalized plan for a culture of safety was gradually introduced to the obstetric department. Before the initial culture of safety roll out, an Agency for Healthcare Research & Quality (AHRQ) survey was completed by staff members. Formalized TeamSTEPPS training set the framework for communication tools and modalities that would be the expectation in all obstetric areas. Eighty‐five percent (450 members) of the obstetric team completed TeamSTEPPS training by September 2014. Once staff had an understanding of the plan, leadership from nursing, obstetrics, and anesthesia were able to promote the use of tools, including multidisciplinary briefs, huddles, and debriefs, which created a general, nonpunitive, transparent department. This is demonstrated by a 45% increase in medical event reporting across all specialties from January 2013 to August 2014. Evaluation Metrics: Over a 2‐year interval, increases were noted in the following domains of a Culture of Safety survey: (a) When patient safety issues or events were identified and reported to leadership, staff response indicated a 6% increase in feeling that their issues were heard; (b) When patient safety issues or events were identified and reported to leadership, staff response indicates a 14% increase in feeling that action was taken to address the event; (c) When patient safety issues or events were identified and reported to leadership, staff response indicated a 13% increase in feeling the action taken/planned in response prevented future harm or similar events from occurring; (d) When patient safety issues or events were identified and reported to leadership, staff response indicated a 17% increase in feeling that feedback and communication are given about the event. Implications for Nursing Practice Adapting a transparent environment grants nurses the ability to discuss obstetric events and near misses rather than fear retaliation from reporting. The integration of a formal culture of safety program laid the roadmap for everyone to follow, set expectations, and generally changed the way members of the department interacted with one another.

The Reliability of AHRQ Common Format Harm Scales in Rating Patient Safety Events

A study was conducted to determine the reliability of Agency for Healthcare Research & Quality (AHRQ) Common Format Harm Scale versions 1.1 and 1.2 in rating patient safety events among users of the UHC Patient Safety Net, a Web-based incident reporting tool. To test interrater agreement, UHC developed a survey tool consisting of patient event scenarios. In 2011, a survey evaluating Harm Scale v.1.1 was distributed to 921 quality, risk, and safety (QRS) managers at 89 organizations; in 2012, a second survey evaluating Harm Scale v.1.2 was sent to 13,280 managers at 102 organizations. Regardless of the version used, in 3 of 9 scenarios, fewer than 60% of respondents agreed on a single score. Interrater agreement increased for certain event scenarios with v.1.2 but decreased for other scenarios. Interrater reliability was moderate for both v.1.1 (k = 0.51) and v.1.2 (k = 0.47). Interrater agreement improved in v.1.2 when results were limited to more experienced raters but still remained in the moderate range (k = 0.58). AHRQ Common Format Harm Scale v.1.1 and v.1.2 both had moderate interrater reliability. Using Harm Scale v.1.1, respondents had difficulty distinguishing "injury limited to additional treatment" from "temporary harm," whereas, using Harm Scale v.1.2, respondents had difficulty distinguishing moderate harm from one of the adjacent levels-mild or severe harm. This study provides valuable data that can inform harm scale revision to improve the quality of aggregate safety data used to define and direct safety efforts.

Abstract 5051: Retrospective analysis of direct inpatient charges and mortality of leukemia pediatric patients with Methicillin-resistant Staphylococcus aureus, Candida, or Aspergillus infections in the United States

Abstract Objective: The purpose of this study was to assess risk factors that are associated with inpatient charges and mortality rates with Methicilin-resistant Staphylococcus aureus (MRSA), Aspergillus, and Candida in children with leukemia. We hypothesize that MRSA and opportunistic fungal infections are associated with higher inpatient charges and worse outcomes relative to those without infections. Identifying the risk factors that affect mortality and inpatient charges of these infections should add to the current knowledge of treating and preventing these infections in immune compromised patients. Methods: Retrospective cohort study using the Agency for Healthcare Research Quality's Healthcare Cost and Utilization Project 2009 KIDS database. Overall, 33,020 individual hospital visits were analyzed for pediatric leukemia patients. Results: Predictors of increased mortality were: Age (OR=1.1, SE=0.02), MRSA (OR=7.2, SE=5.2), Aspergillus (OR=6.3, SE=2.1), Candida (OR=5.7, SE=1.3), and Deyo-Charlson comorbidity scores (OR=1.7, SE=0.13). Significant predictors of increased inpatient charges were: MRSA (OR=2.2, SE=0.35), Aspergillus (OR=2.7, SE=0.25), Candida (OR=2.3, SE=0.15), Female Sex (OR=1.1, SE=0.04), Deyo-Charlson comorbidity scores (OR=1.2, SE=0.04), Urban Hospitals (OR=1.9, SE=0.24), and the Southern Region (OR=0.84, SE=0.2=07). Significant predictors of increased length of stay were similar to predictors of inpatient charges. Conclusions: Although uncommon in leukemia cases involving pediatrics or young adults, risks of higher mortality, length of stay, and inpatient charges were noted in cases involving MRSA, Aspergillus, and Candida. The burden of these illnesses requires further attention in order to improve outcomes among patients with leukemia. Citation Format: Tomas Nuño, Grant H. Skrepnek. Retrospective analysis of direct inpatient charges and mortality of leukemia pediatric patients with Methicillin-resistant Staphylococcus aureus, Candida, or Aspergillus infections in the United States. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 5051. doi:10.1158/1538-7445.AM2014-5051

The use of surveillance and preventative measures for methicillin-resistant staphylococcus aureus infections in surgical patients.

The Agency for Healthcare Research & Quality (AHRQ) found that Methicillin-resistant Staphylococcus aureus (MRSA) is associated with up to 375,000 infections and 23,000 deaths in the United States. It is a major cause of surgical site infections, with a higher mortality and longer duration of care than Methicillin-sensitive Staphylococcus aureus. A multifactorial bundled approach is needed to control this epidemic, with single interventions unlikely to have a significant impact on attenuating MRSA infection rates.Active surveillance has been studied in a wide range of surgical patients, including surgical intensive care and non-intensive care units; cardiac, vascular, orthopedic, obstetric, head and neck cancer and gastrostomy patients. There is sufficient evidence demonstrating a beneficial effect of surveillance and eradication prior to surgery to recommend its use on an expanded basis.Studies on MRSA surveillance in surgical patients that were published over the last 10 years were reviewed. In at least five of these studies, the MRSA colonization status of patients was reported to be a factor in preoperative antibiotic selection, with the modification of treatment regiments including the switching to vancomycin or teicoplanin in MRSA positive preoperative patients. Several authors also used decolonization protocols on all preoperative patients but used surveillance to determine the duration of the decolonization.Universal decolonization of all patients, regardless of MRSA status has been advocated as an alternative prevention protocol in which surveillance is not utilized. Concern exists regarding antimicrobial stewardship. The daily and universal use of intranasal antibiotics and/or antiseptic washes may encourage the promotion of bacterial resistance and provide a competitive advantage to other more lethal organisms.Decolonization protocols which indiscriminately neutralize all bacteria may not be the best approach. If a patient's microbiome is markedly challenged with antimicrobials, rebuilding it with replacement commensal bacteria may become a future therapy.Preoperative MRSA surveillance allows the selection of appropriate prophylactic antibiotics, the use of extended decolonization protocols in positive patients, and provides needed data for epidemiological studies.

Board 554 - Technology Innovations Abstract An Asynchronous Social, Web-Enabled Serious Game for Improving Physician-Nurse Communication (Submission #417)

Introduction/Background Ineffective interprofessional communication is a leading contributor to preventable patient harm. Despite recognized need to understand professional, cultural, and personal differences that impact interprofessional communication, traditional Methods for teaching communication skills and changing behaviors encounter logistical and engagement difficulties. “Serious” games utilize video game technology and constructs such as quests, rewards and 3-D environments in a compelling, but subject matter appropriate, way. Games allow healthcare providers to experience the impact of ineffective interprofessional communication, while experimenting with and learning more effective skills and behaviors through practice and feedback – offering new approaches for improvement. Based on these ideas, we developed a social, web-based serious game called GLIMPSE (A Game to Learn Important Communication Methods for Patient Safety Enhancement). GLIMPSE is guided by curriculum grounded in communication, cultural competency and perspective sharing theories. Through instant game feedback, physician and nurse players experience the impact of communication on patient safety and satisfaction, while practicing structured and team-based communication. GLIMPSE immerses players in perspective sharing, situational awareness, power-gradient traps and similar concepts. The game is playable on computers and iPad’s to maximize delivery flexibility. Importantly, the game can be played asynchronously to overcome logistical difficulties. GLIMPSE is sponsored by the Agency for Healthcare Research Quality (AHRQ). Methods GLIMPSE follows key curriculum education objectives on structured communication techniques, team-based communication/perspective sharing skills, and effects of communication on patient safety. The design takes inspiration from the success of social media games. GLIMPSE is developed in the Unity game engine to support web-browsers and computer, mobile and tablet platforms. Design features that support curriculum objectives include viral episodic content with prescriptive themes and virtual role playing to experience perspective sharing. The game design features asynchronous gameplay with colleagues, 13 short episodes which allow nurses and physicians to fit play into busy schedules, and the ability to virally message and share content among players. While each player is assigned to a team, game play is not dependent on team member coordination. However, scores are reported for individuals and the full team, creating an “implied” team setting. Team competition and in-game rewards for learning and practicing prescriptive themes facilitate engagement and player accomplishment. Gameplay occurs in a 3-D Virtual MedSurg Unit. Essential to gameplay are dialog interactions between players which are scored using interaction or “i” points. Players gain “i” points by following suggested communication strategies. They also lose “i” points by showing anger or excessive ego – behaviors often experienced as barriers for effective team communication. The game also allows players to gain points by making an effort to get a “glimpse” or insight into the source of a colleague’s behavior. Players also win badges depending on their gameplay and virtual “thank you’s” from teammates such as – notes, gifts such as chocolates, or even a cup of coffee. The web dashboard features points scored and team rankings - spurring competition and engagement. Data is collected throughout gameplay on player performance statistics such as elapsed time per episode and frequency that episodes are accessed. Player demographics are also collected. The final episode of the game is a survey that collects information on knowledge gained and reported attitude change. Results: Conclusion GLIMPSE features an innovative methodology to explore whether asynchronous social games can engage nurses and physicians to complete communication education with a flexible schedule, in a chunked episodic format. Should this technique and design be successful in a planned evaluation study, a new paradigm for combined physician/nurse and interprofessional education will be created. This technique potentially opens new educational windows in environments where healthcare professionals have limited time and need new motivations to gain insights into the importance of communication for patient safety. Disclosures LWW.

Response to Evidence for Upgrading the Ratings for Transcendental Meditation: Response to AHA Scientific Statement on Alternative Methods and BP

We thank Dr Schneider1 for his positive comments and for raising important issues on our recent scientific statement. We highlight that when our conclusions differ it is a result of variances in perspective and not from any bias against transcendental meditation (TM). The writing group had spirited discussions on the level of evidence (LOE) and class of recommendation for each modality. Reaching consensus is often not as simple as following the exact wording of the writing-group guidance table.2 We did indeed review 11 randomized controlled trials and 3 meta-analyses, while acknowledging some limitations of the AHRQ (Agency for Healthcare Research & Quality) report,3 before conferring on …