Care Veterans Affairs Medical Center Research Articles

2257. Cost-Benefit Analysis of Fidaxomicin (FDX) as First Line Treatment for Initial Episode of Clostridioides difficile Infection (CDI) during the COVID-19 Pandemic: A Quality Control/Improvement (QC/QI) Project at a Tertiary Care Veterans Affairs Medical Center (VAMC) over a 4-year period

Abstract Background In 2021, Clostridioides difficile infection treatment guidelines were updated to recommend fidaxomicin over oral vancomycin as first-line therapy for initial and recurrent episodes of CDI. The aim of this analysis is to evaluate the cost benefit advantage of using fidaxomicin as first line therapy for the first episode of CDI. Methods A retrospective review of outpatient oral vancomycin and fidaxomicin use at the VAMC in Detroit, Michigan was conducted by evaluating total prescription fills per 1000 unique patients from 2019 to 2022. This study was done during the COVID-19 pandemic when there was an increased use of antibiotics for respiratory infections, and after the updated IDSA guidelines recommending fidaxomicin as first line therapy for initial and first recurrence of CDI. Diagnosis of CDI was based on clinical presentation and a positive stool C diff PCR test. Despite substantial cost of FDX, the expectation was that there would be a significant reduction in recurrent CDI, hospitalizations, length of stay, all of which would offer a cost-benefit advantage. Results There was a 5-fold increase in the use of fidaxomicin in 2021-2022 compared to 2018-2019. Its use was directly proportional to the increased use of respiratory quinolones and Beta lactam antibiotics for respiratory infections during the COVID-19 pandemic in 2020. Insurance co-pays were high and the FDX company support programs failed to cover veterans with Medicaid/Medicare coverage. Veterans were unable to complete the 10-day course of FDX as it was unaffordable. They had to be transitioned to oral vancomycin to complete the 10-day course for CDI. Conclusion Reduction of recurrent CDI may not offset the higher up-front cost of fidaxomicin ($2,400/10 days), compared to oral vancomycin ($30/10 days). This QC/QI analysis over a 4-year period revealed that increased use of fidaxomicin as first-line treatment for CDI did not translate into a cost advantage through decreases in CDI recurrence, given the high cost of fidaxomicin. Reduction in cost of fidaxomicin to < $1,200 may be needed to achieve the expected cost benefit. Based on our data, starting November 2022, FDX has been restricted in our institution. Prescription for FDX requires ID approval, and is reserved for recurrent CDI and not for the first episode of CDI. Disclosures All Authors: No reported disclosures

2230. Consumption of Quinolones, Macrolides, and Beta-Lactam Antibiotics at a Tertiary Care Veterans Affairs Medical Center (VAMC) during COVID-19 Pre-pandemic and Pandemic periods: A 4-year Analysis and Implications for Antimicrobial Stewardship

Abstract Background During the coronavirus disease 2019 (COVID-19) pandemic, antimicrobial use increased tremendously. Evidence suggests that the pandemic has resulted in an increased rate of AMR due to inadvertent antibiotic use. This likely reflects difficulties in distinguishing COVID-19 from community-acquired pneumonia when patients first arrive at a hospital. Strengthening antimicrobial stewardship (AMS) efforts by formulating policies for the use of antibiotics is crucial to prevent emergence of AMR. Methods A retrospective analysis to assess changes in antibiotic use during the pandemic and pre-pandemic patterns was done. Results : In the inpatient setting, there was an overall decrease in antibiotic use (all units that follow are in DOT/1000 BDOC) from an average of 380 to 300, vancomycin from 90 to 62, cefazolin from 30 to 17, Linezolid from 5 to 2, Zosyn from 57 to 30 from pre-pandemic period (Jan 2019) to pandemic period (Dec 2022). Antimicrobials that showed an increase during the pandemic included ceftriaxone from 70 to 82, Cefepime from 5 to 8, Levofloxacin from 2 to 5, and fluconazole from 4 to 10 compared to pre-pandemic use. In the outpatient settings (units are in fills/1000 unique patients), levofloxacin use doubled from 3 to 6, cefuroxime use increased from 0.5 to 2 and Azithromycin use dropped from 80 to < 20, with concomitant increase in doxycycline use from 45 to 60. Outpatient antibiotic prescriptions were high for levofloxacin, doxycycline and cefuroxime and increases corresponded to peaks in cases of COVID-19. Conclusion Our analysis demonstrates that COVID-19 had shifted the antibiotic consumption curve towards treatment of pneumonia and invasive fungal infections (in seriously ill patients) which has key implications for AMS. Implementation of stringent AMS and mandatory Infectious disease consultation for all COVID 19 infections helped keep our antibiotic consumption well below the national average and curtail AMR. Disclosures All Authors: No reported disclosures

Antimicrobial stewardship in solid organ transplantation: Perspective from a Veterans Affairs Medical Center.

The importance of antimicrobial stewardship (AMS) activities specifically focused on solid organ transplant (SOT) recipients is increasingly recognized. In 2014, the Veterans Health Administration (VHA) created national guidance and committed resources to establish AMS programs at Veterans Affairs (VA) medical centers across the country. However, the AMS implementation is at the discretion of individual VA centers. We undertook an environmental scan of AMS activities in a tertiary care VA medical center. We describe AMS activities focused on SOT recipients. Strategies based on local epidemiology that leverage the electronic medical record together with engagement by transplant infectious diseases personnel are likely to be beneficial. AMS in SOT recipients is challenging yet impactful. Strategies described here may be useful for AMS activities focused on the SOT population.

Coordinated-Transitional Care for Veterans with Heart Failure and Chronic Lung Disease.

Patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) account for most 30-day hospital readmissions nationwide. The Coordinated-Transitional Care (C-TraC) program is a telephone-based, nurse-driven intervention shown to decrease readmissions in Veterans Affairs (VA) and non-VA hospitals. The goal of this project was to assess the feasibility and efficacy of adapting C-TraC to meet the needs of complex patients with CHF and COPD in a large urban tertiary care VA medical center. We used the Replicating Effective Programs model to guide the implementation. The C-TraC nurse received intensive training in cardiology and pulmonology and worked closely with both inpatient and outpatient providers to coordinate care. Eligible patients were admitted with CHF or COPD and had at least one additional risk for readmission. The nurse met patients in the hospital, participated in their discharge planning, and then provided intensive case management for up to 4 weeks. Over its initial 14 months, the program successfully enrolled 299 veterans with good fidelity to the protocol. A total of 43 (15.8%) C-TraC participants were rehospitalized within 30 days compared with 172 (21.0%) of historical controls matched 3:1 on age, risk of 90-day hospital admission, and discharge diagnosis. Participants were 54% less likely to be rehospitalized (odds ratio = .46; 95% CI = .24-.89). The program was financially sustainable. The total cost of care in the 30-day postdischarge period was $1842.52 less per C-TraC patient than per controls, leading the medical center to sustain and expand the program.

1882. Resistance (R) Trends in Gram-Negative Bacilli (GNB) to Fluoroquinolones (FQ), [Ciprofloxacin (CIP), Levofloxacin (LEV), Moxifloxacin (MOX)], Trimethoprim–Sulfamethoxazole (TMP/SMX) and Nitrofurantoin (NFT) over a 7-Year Period: Pre- and Post-Implementation of FQ Restriction at a Tertiary Care Veterans Affairs Medical Center (VAMC)

BackgroundUnrestricted use of FQ has been associated with emergence of drug resistance in GNB. Active surveillance measures are essential components of antibiotic stewardship practice. The aim of this study was to evaluate antibiotic utilization, assess the impact of FQ restriction on resistance to FQ, TMP/SMX, and NFT, and identify quality improvement measures to prevent emergence of resistance in GNB.MethodsA retrospective records review and comparison of antimicrobial susceptibility data for GNB isolated at the Detroit VAMC over a 7-year period, pre- and post-FQ restriction, implemented in 2013. Susceptibility testing was performed by reference broth micro-dilution methods in a central laboratory. Antibiotic usage data were obtained from pharmacy computer records from 2011 to 2017. Antibiotic use in inpatients was expressed as days of therapy/1,000 patient-days (DOT/PD) and as number of prescriptions filled for outpatients. Data were analyzed using Pearson correlation coefficient score.ResultsIn 2016–2017, the most common GNB isolated in our institution were E. coli (n = 303), Klebsiella pneumoniae (n = 100), and P. aeruginosa (n = 70). Inpatient: During 2011–2012, DOT/1,000 PD for CIP, LEV and MOX were 34, 10, and 5 respectively, that dropped to 14, 5, and 3 during 2014–2017, post-FQ restriction initiated in 2013. Outpatient: During 2013–2017, outpatient CIP and MOX prescriptions decreased from 1936 to 781 and from 478 to 86, respectively; however, prescriptions for LEV, TMP/SMX, and NFT increased from 33 to 128, 680 to 1,074, and 95 to 322, respectively. Overall: resistance to CIP, LEV, and MOX had increased by 8% in E. coli (14–22%) and by 7% in P. aeruginosa (10–17%) during 2015–2017; FQ-R in K. pneumonia and NFT-R in E. coli stayed low at 7% and 2%, respectively. Also, isolates of TMP/SMX-resistant E. coli and NFT-resistant K. pneumonia increased from 20% to 27% and 40% to 51%, respectively.ConclusionUse of FQ among outpatients was still high (781 scripts in 2017) despite a 4-year restriction, resulting in high FQ-R in E. coli and P. aeruginosa; a concomitant increase in TMP/SMX and NFT resistance was noted, attributed to a compensatory increased use of these agents during the study period (P < 0.05). Reversal of resistance trends may take a few years. Antimicrobial stewardship activities need to be enhanced in both ambulatory and inpatient settings in order to achieve optimal results.Disclosures All authors: No reported disclosures.

Effect of Lean Processes on Surgical Wait Times and Efficiency in a Tertiary Care Veterans Affairs Medical Center

There are an increasing number of veterans in the United States, and the current delay and wait times prevent Veterans Affairs institutions from fully meeting the needs of current and former service members. Concrete strategies to improve throughput at these facilities have been sparse. To identify whether lean processes can be used to improve wait times for surgical procedures in Veterans Affairs hospitals. Databases in the Veterans Integrated Service Network 11 Data Warehouse, Veterans Health Administration Support Service Center, and Veterans Information Systems and Technology Architecture/Dynamic Host Configuration Protocol were queried to assess changes in wait times for elective general surgical procedures and clinical volume before, during, and after implementation of lean processes over 3 fiscal years (FYs) at a tertiary care Veterans Affairs medical center. All patients evaluated by the general surgery department through outpatient clinics, clinical video teleconferencing, and e-consultations from October 2011 through September 2014 were included. Patients evaluated through the emergency department or as inpatient consults were excluded. The surgery service and systems redesign service held a value stream analysis in FY 2013, culminating in multiple rapid process improvement workshops. Multidisciplinary teams identified systemic inefficiencies and strategies to improve interdepartmental and patient communication to reduce canceled consultations and cases, diagnostic rework, and no-shows. High-priority triage with enhanced operating room flexibility was instituted to reduce scheduling wait times. General surgery department pilot projects were then implemented mid-FY 2013. Planned outcome measures included wait time, clinic and telehealth volume, number of no-shows, and operative volume. Paired t tests were used to identify differences in outcome measures after the institution of reforms. Following rapid process improvement workshop project rollouts, mean (SD) patient wait times for elective general surgical procedures decreased from 33.4 (8.3) days in FY 2012 to 26.0 (9.5) days in FY 2013 (P = .02). In FY 2014, mean (SD) wait times were half the value of the previous FY at 12.0 (2.1) days (P = .07). This was a 3-fold decrease from wait times in FY 2012 (P = .02). Operative volume increased from 931 patients in FY 2012 to 1090 in FY 2013 and 1072 in FY 2014. Combined clinic, telehealth, and e-consultation encounters increased from 3131 in FY 2012 to 3460 in FY 2013 and 3517 in FY 2014, while the number of no-shows decreased from 366 in FY 2012 to 227 in FY 2014 (P = .02). Improvement in the overall surgical patient experience can stem from multidisciplinary collaboration among systems redesign personnel, clinicians, and surgical staff to reduce systemic inefficiencies. Monitoring and follow-up of system efficiency measures and the employment of lean practices and process improvements can have positive short- and long-term effects on wait times, clinical throughput, and patient care and satisfaction.

Dealing With No Shows: A Quality Improvement Initiative at a Tertiary Care Veterans Affairs Medical Center

Dealing With No Shows: A Quality Improvement Initiative at a Tertiary Care Veterans Affairs Medical Center

Management of Acute Contrast Media Reactions: Assessing Preparedness of a Tertiary Care Veterans Affairs Medical Center

THE PROBLEM: HOSPITAL READINESS FOR CONTRAST MEDIA REACTIONS Acute contrast media reactions can range in severity from mild discomfort to life-threatening anaphylaxis. Three percent of all patients receiving intravenous (IV) contrast will experience reactions, although most will not require treatment. Severe, potentially life-threatening reactions occur in about 1 in 2,500 patients [1]. Overall, contrast reactions remain rare, particularly because of the widespread use of nonionic, lowosmolar contrast media. Because of the rarity of adverse reactions to contrast, many radiologists and hospital staff members remain unfamiliar with optimal treatments, appropriate medications, and their respective doses. Additionally, reaction training for nonradiology staff members covering after hours is not well established. Potential errors that commonly occur in the management of contrast reactions are a failure to recognize a contrast reaction; uncertainty regarding how to treat a reaction; failure to administer oxygen promptly; incorrect dosing or administration of epinephrine, atropine, and antihistamines; and an overall lack of advanced preparedness for the possibility of reactions [2,3]. Because of this concern for a lack f preparedness, other radiology epartments have performed local udit studies or surveys, and often any of these management errors re identified [4,5]. In our quality mprovement initiative, we assessed he readiness of our department nd medical center both during and after hours in responding to acute contrast media reactions and identified areas for improvement to ensure proper and efficient treatment should a contrast reaction occur.

Is heart failure guideline adherence being underestimated? The impact of therapeutic contraindications

Several studies based on claims data have reported underutilization of evidence-based heart failure (HF) therapies. The degree to which these estimates fail to account for therapeutic contraindications is unclear. We identified patients with HF and left ventricular ejection fraction ≤45% seen between January 1, 2010, and July 1, 2010, at a tertiary care Veterans Affairs Medical Center. Medical records were abstracted to evaluate utilization of and contraindications to β-blocker, angiotensin-converting enzyme inhibitor, aldosterone antagonist, anticoagulation for atrial fibrillation, implantable cardioverter-defibrillator, and cardiac resynchronization therapies. Of the 178 patients with HF and an ejection fraction ≤45%, 78 (44%) received every guideline-recommended therapy. After accounting for medical contraindications, 77 (72%) of 107 patients received every guideline-recommended therapy. Adherence to recommendations for β-blocker (98%), angiotensin-converting enzyme inhibitor/angiotensin blocker (95%), and anticoagulation (97%) were better than adherence to implantable cardioverter-defibrillator (82%), cardiac resynchronization therapy (59%), or aldosterone antagonist (51%) recommendations. In adjusted analysis, lower New York Heart Association functional class and care by a cardiologist were associated with improved guideline adherence (P < .001). Many patients with HF have therapeutic contraindications, and a failure to account for these may lead to a large underestimation of the true guideline adherence rates.

Celiac Disease in an Urban VA Population with Iron Deficiency: The Case Against Routine Duodenal Biopsy

Celiac disease is considered an under-recognized cause of iron deficiency. Small intestinal biopsy is proposed to be part of routine evaluation for iron deficiency. To determine the prevalence of celiac disease in an urban, mostly male, mostly minority population with iron deficiency. Clinical, endoscopic, and pathologic records of veterans who had undergone esophagogastroduodenoscopy (EGD) and duodenal biopsy for iron deficiency at an urban, tertiary care Veterans Affairs Medical Center were reviewed. The yield of positive duodenal biopsies for celiac disease and pre-defined clinically important findings on EGD were calculated. Confounding factors were assessed in multivariate analysis. The main outcome measures were prevalence of celiac disease and prevalence of clinically important findings on upper gastrointestinal endoscopy. The records of 310 veterans were reviewed. Mean age was 63, range 32-91years old. Most were male (89%) and African-American (73%). Five of 306 small intestinal biopsies were consistent with celiac disease (type 1 lesions), but tissue transglutaminase obtained in four of the patients was normal, making the prevalence of potential celiac disease 0.33% (95% CI: 0.06-1.83%). Fifty of 310 EGDs demonstrated findings that were considered to have a moderate or high probability of producing iron deficiency (16.1, 95% CI: 12.5-20.6%). The prevalence of celiac disease is low in an urban, predominately male, African-American population with iron deficiency. Routine small intestinal biopsy for celiac disease in similar populations should not be done. EGD remains clinically important.

Guideline concordant venous ulcer care predicts healing in a tertiary care Veterans Affairs Medical Center

This study describes the impact of 80% adherence to guideline concordant care for compression therapy, moist wound-healing environment, and debridement on venous ulcer outcomes. The retrospective cohort design included patients from a tertiary care Veterans Affairs Medical Center from October 2003 to September 2007. During this 5-year interval, 155 patients with 400 venous ulcers met study inclusion. A majority of ulcers (n=362) healed, with an average time to healing of 18.1 weeks (range 2-209 weeks, median 10.4 weeks). From the multivariate Poisson regression, the likelihood of ulcer healing increased when compression therapy was provided during at least 80% of visits (relative risk [RR], 1.93; 95% confidence interval [CI], 1.27-2.92) or when a moist wound-healing environment was provided during at least 80% of visits (RR, 1.63; 95% CI, 1.09-2.42). Debridement alone was not significantly associated with ulcer healing (RR, 1.0; 95% CI, 0.61-1.64). Patients who received all three treatments during at least 80% of their visits were more likely to heal than those who received < 80% treatment (RR, 2.52; 95% CI, 1.53-4.16). Guideline concordant venous ulcer care was significantly associated with venous ulcer healing, when provided at 80% or more of patient visits.

Concordance Between Self-Reported Race/Ethnicity and that Recorded in a Veteran Affairs Electronic Medical Record

Using information from electronic health records (EHRs) to examine racial/ethnic health disparities is increasingly common. This study examines the degree of concordance between administratively recorded race/ethnicity and the criterion standard of self-reported race/ethnicity at a tertiary care Veterans Affairs Medical Center (VAMC) in North Carolina. We compared self-reported race among 204 respondents to a cross-sectional mailed survey of patients with diabetes conducted in 2006-2007 to the race/ethnicity recorded in the EHR. Concordance was defined as the percent agreement between self-reported and administratively-reported race. The overall response rate to the survey was 68.9% (204 of 296). Of the 204 respondents, 32 (15.7%) reported a different race/ethnicity from the race/ethnicity reported in the EHR. Misclassification resulted from either the patient reporting a race/ethnicity and having the information missing in the EHR (9.3% of respondents) or the EHR having a different race/ethnicity listed than reported by the patient (6.3% of respondents). This study was conducted at one VAMC. While we found misclassification of race/ethnicity in the EHR, the level of discordance is smaller than previously reported in the Veterans Health Administration. Despite this, efforts still need to be made to ensure correct information is included in the EHR.

Infection and colonization with vancomycin-resistant Enterococcus faecium in an acute care Veterans Affairs Medical Center: A 2-year survey

Background: After our first known patient with vancomycin-resistant enterococci (VRE) infection was admitted in 1993, we observed a gradual increase in infections and colonization caused by this organism. Thus we initiated a prospective study to quantitate the incidence of VRE infection versus colonization, to identify risk factors for VRE, and to define the natural history of VRE colonization among our patients. Methods: Stool/rectal cultures were performed for patients admitted to the intensive care units at the time of admission and weekly thereafter. Patients found to be carrying VRE were followed with cultures every 2 weeks, and this protocol was continued after transfer to the medical-surgical wards. A surveillance form was initiated on each VRE patient and included demographics, underlying diseases, and risk factors. Environmental cultures in the intensive care units were randomly performed. Patients with positive cultures were isolated. Results: During a 27-month period, 210 patients were found to be colonized or infected with VRE. Ages ranged from 35 to 97 years; the mean age was 65 years. Fourteen percent (29 of 210) of the patients were VRE positive on admission. Nosocomial colonization or infection occurred at an average of 28 days after admission. Seventeen percent (25 of 216) of patients cleared VRE during their hospital stay; 19% (40 of 210) developed 47 infections. One third of infections involved the urinary tract. Liver transplantation, chemotherapy, and total parenteral nutrition were each associated with infection. Conclusion: Routine measures as advocated by the Centers for Disease Control and Prevention were not effective in controlling VRE in our patient population. (AJIC Am J Infect Control 1998;26:558-62)

Literature review of nonpharmacologic methods for the treatment of chronic pain

Associate Chief Nursing Service for Extended Care Veterans Affairs Medical Center Associate Chief Nursing Service for Education Veterans Affairs Medical Center Boise, Idaho