Computerized Patient Record System Research Articles

Acetabular fracture in India: An epidemiological study

IntroductionAcetabular fractures, resulting from high-energy trauma, present significant orthopaedic challenges. Despite their rarity, the incidence of these fractures is rising, necessitating a comprehensive understanding of their epidemiological characteristics, especially in diverse populations like India. MethodsThis retrospective study analyzed data from 3643 patients across four level-1 trauma centers in India (North 1, North 2, West, and South) from January 2001 to December 2019. Prior ethical approval was obtained from the respective institutions. Data were collected using the computerized patient record system (CPRS) and included patients with complete clinical and radiological records. Only patients with full radiological data were included, comprising standard anteroposterior radiograph, Judet views on radiographs, and computed tomography scan of the pelvis. The study evaluated the demographic characteristics, fracture patterns and surgical approaches. ResultsThe majority of patients were males (84.05 %) and the fractures were mostly seen in young individuals between 19 and 40 years’ age group (44.9 %), followed by 41–60 years (42.3 %). Associated bony or other system injuries were seen in 53.42 % of patients, with pelvic injuries being the most common (9.8 %). Posterior wall fractures were the most frequent (20.7 %), while anterior wall fractures were the least common (0.8 %). Operative management was employed in 82 % of cases, with the Kocher-Langenbeck approach being the most commonly employed (42.5 %). ConclusionHigh-velocity trauma remains the commonest cause of acetabular trauma in India, primarily affecting young male individuals. Pelvic fractures are the most commonly associated injuries. Posterior wall fractures are the commonest type of acetabular fracture, and the Kocher-Langenbeck approach is the commonly adopted surgical approach.

Enterococcal Bacteremia outbreaks during SARS-COV-2 in Intensive Care Unit (ICU): The role of Strain Identification

Background: An unprecedented burden of morbidity and mortality has been reported in patients admitted to healthcare facilities with SARS-COV-2 infection globally since March 2020. A higher incidence of ICU-acquired bloodstream infection has been described with the cumulative risk increased with the length of ICU stay, use of steroids, anti-inflammatory agents, and indwelling catheters. Additionally, SARS-COV-2 infection may increase the risk of bacteremia from gastrointestinal flora such as Enterococcus species by disrupting the gastrointestinal barrier and microbiome. Methods: We aimed to investigate the outbreaks of Enterococcus bacteremia in patients with SARS-COV-2 infection and included patients aged>18 years admitted to the ICU at the Oklahoma City Veterans Affairs Medical Center who were infected with SARS-COV-2 and were identified as having positive blood cultures for Enterococcus faecalis, Enterococcus faecium including vancomycin-resistant species and other bacterial or candida species between March 1, 2020, to March 9, 2022. We collected the following data: duration of hospitalization including ICU stay, unit and room location during the hospital stay, blood culture collection date and results, duration, and site of central line placement, duration of ventilation, administration of antimicrobials and COVID-19 directed therapeutics using computerized patient record system (CPRS). We sent 10 E. faecalis and 12 E. Faecium isolates for genetic analysis. DNA was sequestered from each isolate and multi-locus sequence typing (MLST) was performed by amplifying 7 regions of the E. faecalis genome and 7 regions of the E. faecium genome by polymerase chain reaction (PCR). Resulting amplicons were sequenced and allele type for each gene region and overall sequence type was determined using MLST database (http://pubmlst.org). Results: There were 22 episodes of enterococcal bacteremia in a 3-month duration in the ICU in 20 patients of which 17 were associated with another episode with the same strain (Figure-1-2). Central line placement was noted in 18/22 episodes. Genetic analysis by multi-locus sequence typing of enterococcal bacterial strains was performed by the Public Health Reference Laboratory, Palo Alto. Similar strains were localized to patients in the same geographical region in the ICU (Figure 3). The isolates from 2 other patients who presented with the same strain of Enterococcus but were never hospitalized at the same time during the COVID-19 pandemic were localized to another hospital where both had received care at different times. Conclusion: Higher rates of enterococcal bacteremia were reported during the SARS-COV-2 pandemic. Geographical proximity with strained infection control measures accounted for ICU outbreaks seen in our tertiary care setup.

An evaluation of antimicrobial prophylaxis for transrectal prostate biopsies: A potential stewardship target

Transrectal prostate biopsy (TRPB) is a common procedure used to obtain a prostate biopsy. Although generally safe, complications may occur including infection. Preprocedural antimicrobial prophylaxis is recommended to minimize risk of subsequent infection. This study is a retrospective chart review via the computerized patient record system from January 1, 2018 to February 28, 2022. The study included patients who underwent a TRPB at the Western New York, Syracuse, or Albany Stratton Veterans Affairs Healthcare Systems. This study included a total of 932 patients who underwent TRPB. Postoperative infection occurred in 3.2% (n=30) of patients within 14days of the TRPB. Of the 30 patients who developed an infection, 30% (n=9) resulted in bacteremia. For the 932 patients evaluated, 24 different antibiotic regimens were used, none of which followed guideline recommendations. None of the regimens were found to have an impact on rates of subsequent infection. The results of this study suggest a need for guideline adherence. There was no benefit to using the guideline-discordant regimens as they were not associated with a decreased risk of infection, and in many cases exposed patients to unnecessarily broad and prolonged antibiotic regimens.

Cold Instruments, Warm Outcomes: A Decade of Supraglottoplasty in Managing Children with Moderate and Severe Laryngomalacia

Objective: The study aims to review the clinical outcomes of supraglottoplasty in moderate and severe laryngomalacia. Methods: This is a retrospective study. Demographic and clinical data of children diagnosed with moderate and severe laryngomalacia who underwent supraglottoplasty between 2012 and 2021 were retrieved from the computerized patient record system of Hospital Sultanah Bahiyah. The surgical procedure of supraglottoplasty was mainly performed with cold instrument, with occasional assistance from a microdebrider. Study outcome includes complete stridor resolution, weaning from tube feeding, and weaning from respiratory support post supraglottoplasty. Results: 124 children were included in the study. Complete stridor resolution was achieved in 64.51% (n=80) 1-month post-surgery and 86.29% (n=107) 3-months post-surgery. Half of the children with tube feeding pre-operatively could be weaned off to oral feeding within 1-month post-surgery. All the children with oral feeding maintained oral feeding post-surgery. All the children with no or low respiratory support (nasal prong oxygen) pre-operatively were able to be weaned down to room air within 1-month post-surgery. Within the group of children with high respiratory support (high-flow nasal cannula, non-invasive ventilation, and endotracheal intubation) pre-operatively, half were weaned down to room air within 1-month post-surgery. None of the children with isolated laryngomalacia required tracheostomy after supraglottoplasty. All laryngomalacia patients who required tracheostomy after supraglottoplasty were associated with either synchronous airway lesions or medical comorbidities. Only 3 cases (2.42%) required revision supraglottoplasty with a maximum of one revision. Conclusions: We conclude that supraglottoplasty contributes to substantial clinical improvement in moderate and severe laryngomalacia. Supraglottoplasty facilitated weaning down of respiratory support and tube feeding in laryngomalacia with respiratory difficulty and feeding intolerance.

Assessing the discordance rate of HER2 expression by immunohistochemistry between primary and secondary prostate cancer biopsies.

e17014 Background: Preliminary evidence suggests that human epidermal growth factor receptor 2 (HER2) expression may play a role in tumor cell proliferation in prostate cancer. Minner et al ( Clin Cancer Res, 2010) identified a prevalence of ~ 20% HER2 expression in prostate cancer. The aim of the study is to assess the prevalence and discordance rate of HER2 expression in prostate cancer patients with multiple prostate biopsies using immunohistochemistry (IHC) at a Veterans Affairs hospital. Methods: A single-center, retrospective chart review of at least 30 patients with prostate cancer that had two prostate biopsies based on data collected from the Computerized Patient Record System (CPRS) and Veterans Information Systems and Technology Architecture (VISTA). Demographic and laboratory data including age, race, Gleason score, and stage of cancer were collected under IRB-approved waivers for consent and HIPAA authorization. Formalin-fixed paraffin embedded (FFPE) prostate tumors were evaluated for IHC analysis by the Washington DC Pathology Department. HER2 expression was assessed using the VENTANA anti-HER2/neu (4B5) rabbit monoclonal primary antibody and scored as 0, 1+, 2+, and 3+. HER2 scores of 0 and 1+ to 3+ were categorized as HER2-negative and HER2-positive, respectively. The primary endpoints are the prevalence and discordance rate of HER2 expression in paired prostate samples. Results: In our predominately African American (94%) cohort of 32 patients with a mean age of 60 years, overall HER2 prevalence was 25% (n = 8) and 56% (n = 18) in the primary and secondary biopsies, respectively. The mean time between biopsies was 41 weeks and overall HER2 discordance was 56% (n = 18). Discordance from HER2-negative to HER2-positive was 38% (n = 12), while discordance from HER2-positive to HER2-negative was 6% (n = 2). The remaining discordance were from HER2-low to HER2-positive or vice-versa. The most common variance between primary and secondary biopsies was observed as +1 HER2 scoring category (n = 11). No significant associations were found between HER2 discordance and Gleason score or stage of cancer . Conclusions: In our cohort of patients with prostate cancer, HER2 expression was observed in 25% of initial biopsies and over 50% of secondary biopsies. Discordance of HER2 expression was found in over 50% of patients. A few patients had initial HER2-positive biopsies and subsequent HER2-negative biopsies. The majority of HER2 discordance involved patients who had initial HER2-negative biopsies and secondary HER2-positive biopsies with most showing +1 difference in IHC scores. This study could lead to the consideration of utilizing multiple prostate cancer biopsies to determine the eligibility for anti-HER2 therapy in future trials.

Combined treatment with sacubitril/valsartan plus dapagliflozin in patients affected by heart failure with reduced ejection fraction.

Data about real-world effects of combined therapy with sacubitril/valsartan plus dapagliflozin in patients affected by heart failure (HF) with reduced ejection fraction (HFrEF) has not been widely reported. In this article, the benefits of dapagliflozin and sacubitril/valsartan respect to improvements of cardiac function in patients with HFrEF would be investigated. HF patients prescribed sacubitril/valsartan between January 2020 and January 2022 in a tertiary teaching hospital were selected using the Computerized Patient Record System. Patients were divided into two groups according to whether they were taking dapagliflozin. Clinical parameters at baseline and during follow-up were retrospectively collected and analyzed. Total of 136 consecutive patients were recruited for this study. 72 patients treated with sacubitril/valsartan and dapagliflozin were assigned to Group A, and another 64 patients receiving sacubitril/valsartan monotherapy were assigned to Group B. After treatment with sacubitril/valsartan plus dapagliflozin for a median follow-up period of 189 days (IQR, 180-276), significant improvements of cardiac function were achieved in Group A. Median N-terminal pro-B-type natriuretic peptide (NT-proBNP) level was significantly decreased from 2585 pg/ml (1014-3702.5) to 1260.5 pg/ml (439.8-2214.3) (P < 0.001). Mean left ventricular ejection fraction (LVEF) improved from 34.7 ± 4.6% to 39.2 ± 7.5% (P < 0.001). Mean daily dose of loop diuretics decreased from 37.1 ± 17.3 mg/day to 25.9 ± 18.5 mg/day (P < 0.001). Regarding safety, both systolic blood pressure (P = 0.002) and diastolic blood pressure (P = 0.002) significantly decreased. For patients in Group B, significant improvements in mean LVEF (P < 0.001), decreases in mean daily dose of loop diuretics (P = 0.001) and reductions in diastolic blood pressure (P = 0.023) were observed. Strikingly, both median Δ NT-proBNP (P = 0.04) and median Δ LAD (P = 0.006) in Group A were more pronounced in comparison with those seen in Group B. The combined use of sacubitril/valsartan and dapagliflozin was associated with improved cardiac function in patents with HFrEF, and led to greater reductions in LAD and NT-proBNP levels compared to sacubitril/valsartan monotherapy. These findings suggest that the combination therapy may offer more potent cardiovascular benefits.

PTSD is associated with self-perceived hearing handicap: An evaluation of comorbidities in Veterans with normal audiometric thresholds.

Background Cases of self-reported hearing difficulty despite normal audiometric results have risen with the return of Veterans from recent conflicts in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. Auditory outcomes improved despite low compliance among those receiving treatment. Medical chart data appeared more comprehensive for Veterans with, rather than without, auditory complaints. One possibility is that self-reported hearing problems are associated with a subset of these comorbidities, the treatment of which improved auditory outcomes. Purpose This study examined the relationships between Veterans' self-reported auditory problems and other diagnosed medical conditions. Research Design A retrospective chart review was used. Study Sample Participants were 286 Veterans, aged 21 - 52 with normal hearing. Veterans were dichotomized into a group with either self-reported hearing complaints (n = 143) or an aged-matched control group with no auditory complaints (n = 143). Data Collection and Analysis A query of the Computerized Patient Record System was performed with the date range restricted to 2009 to 2018. Metrics of self-perceived hearing handicap, APD testing, and hearing aid use were collected. All diagnoses and related symptoms were recorded. A best subsets regression with principled model selection was performed to investigate the role of these comorbidities on self-perceived hearing loss. Results The Self-Report group had 16 comorbidities that were classified as prevalent, having occurred in ≥33.3% of the group, compared to the age-matched control group, which had 2 comorbidities. The number of diagnosed medical conditions was associated with self-perceived hearing impairment. Specifically, posttraumatic stress disorder (PTSD) and related symptom clusters constituted the largest group of comorbidities that were significantly associated with self-reported hearing problems. Conclusions The significant association between PTSD and self-perceived hearing impairment warrants investigations on whether treatment of PTSD would reduce perceived hearing handicap severity. Further, PTSD assessments could be useful for audiologists to identify potential candidates for auditory complaints with normal audiometric thresholds. Keywords: Auditory processing disorder, hidden hearing loss, comorbidities, Veterans, posttraumatic stress disorder, traumatic brain injury Abbreviations: APD, auditory processing disorder; CAP, central auditory processing; HHIA, Hearing Handicap Inventory for Adults; mTBI, mild traumatic brain injury; PTSD, posttraumatic stress disorder; TBI, traumatic brain injury; U.S., United States.

Gender and Patient Satisfaction in a Veterans Health Administration Outpatient Chemotherapy Unit.

Our objective was to explore whether differences in patient satisfaction based on gender exist at the Veterans Affairs Portland Health Care System (VAPHCS) outpatient chemotherapy infusion unit. Veterans who received outpatient infusion treatments at the VAPHCS outpatient chemotherapy infusion unit from 2018 to 2020 were invited to take an anonymous survey. Response differences were analyzed using Fisher exact and Welch t tests. Male and female patient lists were first generated based on Computerized Patient Record System designation, then defined and results reported based on gender self-identification from survey responses. The survey was conducted over a 2-week period during January and February of 2021. In total, 69 veterans were contacted: 21 (70%) of 30 female and 20 (51%) of 39 male veterans completed the survey. Most (62%) female patients were aged < 65 years, and 52% were treated for breast cancer. Most (90%) male patients were aged ≥ 65 years, and most commonly treated for prostate cancer (20%) or a hematologic malignancy (20%). Using our survey, patient satisfaction (SD) was 8.7 (2.2) on a 10-point scale among women, and 9.6 (0.6) among men (P = .11). History of sexual abuse or harassment was reported by 86% of women compared with 10% of men (P < .001). Women reported feeling uncomfortable around other patients in the infusion unit compared with men (29% vs 0%; P = .02) and discomfort in relaying uncomfortable feelings to a clinician (29% vs 0%; P = .02). Gender seems to be related to how veterans with cancer perceive their ambulatory cancer care. This may be due to the combination of a high history of sexual abuse and/or harassment among women who represent a minority of the total infusion unit population, the majority of whom receive treatment for a primarily gender-specific breast malignancy. Analysis was limited by the small sample size of women, many with advanced malignancy.

The Value of Neutrophil-To-Lymphocyte Ratio for Evaluating Blood Stream Infection Caused by Carbapenem-Resistant Klebsiella pneumoniae: A Retrospective Cohort Study.

BackgroundThe neutrophil-to-lymphocyte ratio (NLR) is a useful marker of inflammation. However, the prognostic function of the NLR in patients with carbapenem-resistant Klebsiella pneumoniae (CRKP) blood stream infection (BSI) remains largely unknown. The aim of this study was to explore the potential relationship between the NLR and mortality in these patients.MethodsWe performed a retrospective cohort study based on data retrieved from the computerized patient record system in a tertiary hospital from 1 January 2017 to 31 October, 2020. A total of 134 inpatients with CRKP BSI were enrolled in this study, including 54 fatal cases and 80 survival cases, 28 days after the onset of CRKP BSI. A logistic analysis was performed to assess the association between the NLR on the 4th day and 28-day mortality. Multivariate analyses were used to control for the confounders.ResultsThe overall 28-day mortality rate of patients with a CRKP BSI episode was 40.3% (54/134). We conducted a multivariate analysis of the data of 134 patients and found that the NLR on the 4th day [odds ratio (OR) 1.148, 95% confidence interval (CI) 1.076–1.225, p < 0.001] and antibiotic exposure before BSI onset (OR 3.847, 95% CI 1.322–11.196, p = 0.013) were independent risk factors for 28-day mortality of patients with CRKP BSI, while appropriate initial therapy (AIT, OR 0.073, 95% CI 0.017–0.307, p < 0.001) was an independent protective factor. Among patients treated with AITs, the Cox proportional hazards regression analysis revealed a significant difference in prognosis (p = 0.006) between the ceftazidime/avibactam contained (CAZ) group and non CAZ-AVI groups. After dividing the non CAZ-AVI group into the tigecycline (TGC), colistin (COL), and TGC + COL groups, there were no differences between the CAZ-AVI group and the TGC group (p = 0.093), but CAZ-AVI group showed lower 28-day mortality than COL (p = 0.002) and TGC + COL (p = 0.002) groups. Meanwhile, there was no difference in NLR on the 1st day (p = 0.958) of patients in different groups but significant difference in NLR on the 4th day (p = 0.047).ConclusionsThe NLR on the 4th day is a readily available and independent prognostic biomarker for patients with CRKP BSI. This marker may have the potential for use in evaluating the efficacy of different anti-infection therapy strategies at an early stage.

Utilization of a neurology specialty service by primary care providers for headache management at a tertiary care hospital.

BackgroundRecent data indicate that the three-month prevalence of severe headaches or migraines in the US general population is close to 25%. Participation of primary care providers will therefore be critical in providing care to affected individuals.ObjectiveTo determine the number of headache disorder consult requests to a neurology outpatient service in a tertiary medical center, the appropriateness of the consult requests, and the effectiveness of a lecture series on headache diagnosis and management in preventing inappropriate consult requests from non-neurology providers.MethodsClinical data on US Veterans is captured and documented in the Veterans Health Information Systems and Technology Architecture (VISTA). The Computerized Patient Record System (CPRS) electronic medical record (EMR) was used for data entry and retrieval. All consult requests for the study period within the VA North Texas Health Care System were identified in VISTA, and the clinical information reviewed in CPRS. Based on a defined algorithm, headache consult request were categorized as appropriate or inappropriate. A board-certified neurologist provided four in-person/virtual lectures to ambulatory care providers, primary care providers, internal medicine residents, and emergency room providers within the VA North Texas Health Care System on the diagnosis and management of headaches. Prior and post the lecture series, the total number of headache consults per day was assessed over 45-day periods.ResultsThe number of daily headache consult requests in the 45-day period prior to the lecture series was 3.6 per day (standard deviation 2.7), and 6.0 per day after the lecture series (standard deviation 2.1). The difference was not statistically significant. There were as many inappropriate headache consult requests after the lecture series as appropriate ones (50% each).ConclusionWe found that a short-term educational initiative that instructed primary care providers on the diagnosis and management of common headache disorders did not reduce the number of consultation requests and, surprisingly, it did not improve the appropriateness of the consults. Given the prevalence of headaches in the general population, better training of all primary care providers in headache management should be pursued.

Use of a Deprescribing Tool in an Interdisciplinary Primary-Care Patient-Aligned Care Team.

Objective: To pilot the VIONE approach in a single Primary Care Patient Aligned Care Team (PACT). The authors aim for the Clinical Pharmacy Specialist (CPS) to perform 20 comprehensive medication reviews (CMRs) and the pilot PACT physician (PCP) to complete 200 VIONE discontinuations. Cost avoidance and CPS recommendations will also be analyzed. Polypharmacy is associated with increased risk of adverse drug events, falls, hospitalizations, and death. VIONE is a deprescribing tool that assists providers in identifying inappropriate medications. Design: Quality Improvement Setting: Single VA Health Care System (VAHCS) Participants: High-risk veterans in pilot PACT Interventions: The CPS educated the PCP regarding VIONE methodology and assisted with CMRs. When deprescribing was warranted, VIONE discontinuation reasons were selected in the Computerized Patient Record System (CPRS). Data were electronically stored in a national dashboard. Results: The authors identified 231 veterans at risk for polypharmacy-related adverse events. The PCP and CPS were able to reach 99 veterans and make 136 medication discontinuations between September 1, 2019, and March 1, 2020. The CPS performed 20 CMRs, resulting in 90 deprescribing recommendations. Thirty-eight CPS recommendations were accepted and contributed $18,835.95 to the sum annualized cost avoidance of $21,904.80. Conclusion: The VIONE methodology was successfully implemented in the pilot PACT. The utilization of the CPS was associated with an increased average number of medication discontinuations per veteran and contributed to cost avoidance.

223. The Value of Neutrophil to Lymphocyte Count Ratio for Predicting the Clinical Outcomes of Patients with Carbapenem-resistant Klebsiella pneumonia Blood Stream Infection

BackgroundThe neutrophil to lymphocyte count ratio (NLR) has been recognized as a useful marker of inflammation. But, the prognostic function of NLR in patients with Carbapenem-resistant Klebsiella pneumonia (CRKP) blood stream infection is still largely unknown. The aim of this study was to explore the relationship between postoperative NLR and mortality in those patients.MethodsWe performed a retrospective study based on the database from Computerized Patient Record System in Sir Run Run Shaw Hospital from 1/1/2017 to 31/10/2020. Logistic analysis was performed to assess the associations between NLR and 28-day mortality. Multivariate analyses were used to control for confounders.ResultsA total of 134 CRKP blood stream infection inpatients were included in this study, including 54 fatal cases and 80 survival cases on the 28-day after the onset of CRKP BSI, the overall 28-day mortality rate of patients with a CRKP BSI episode was 40.3% (54/134). We conducted a multivariate analysis on these 134 patients and found that APACHE II score on the 4th day (OR 1.379 95% CI 1.065- 1.785, p = 0.015), NLR on the 4th day (OR 1.134 95% CI 1.054- 1.221, p = 0.001) were significant risk factors for the 28-day mortality of CRKP BSI patientsConclusionElevated NLR was significantly associated with increased 28-day mortality as well as APACHE II score on the 4th day after first positive culture.NLR is promising to be a readily available and independent prognostic biomarker for patients with CRKP blood stream infection.Disclosures All Authors: No reported disclosures

1417. Fosfomycin Use in the Treatment of Complicated Urinary Tract Infections at a Veterans Affairs Medical Center

BackgroundThe prevalence of multidrug resistant gram-negative urinary tract infections (UTIs) is increasing, often requiring intravenous antimicrobial therapy. Oral fosfomycin is a recommended alternative agent for the treatment of cystitis caused by extended spectrum beta-lactamase (ESBL)-producing Escherichia coli (E. coli). The primary objective of this study is to evaluate the efficacy of fosfomycin in the treatment of UTIs at the Veterans Affairs Long Beach Healthcare System. The secondary objective is to assess the incidence of adverse drug reactions associated with fosfomycin. MethodsThis is a retrospective, single-center, cohort study. Patients who received fosfomycin between June 1st, 2015 – June 30th, 2020 were included. Data collection was completed by chart review through the Computerized Patient Record System (CPRS). Descriptive analysis was used to evaluate data. Treatment outcomes were analyzed using a composite of clinical and microbiological cure. Clinical cure was defined as resolution of UTI symptoms. Microbiological cure was defined as urine sterilization within 1 month after completing treatment course with fosfomycin.ResultsA total of 62 unique patients were evaluated in this study. The mean age was 71.9 years. 56 patients (90.3%) were male, 31 patients (50.0%) had an indwelling catheter present at the time of treatment, and 48 patients (77.4%) had the presence of genitourinary tract pathology that may increase the risk of developing UTIs. Majority of patients (50%) had a urine culture result positive for E. coli prior to treatment, of which 43.5% were ESBL-producing. 60 patients (96.8%) received more than 1 dose of Fosfomycin. Out of 29 patients who were eligible to be evaluated for clinical outcomes, 20 patients (68.9%) met a positive composite outcome of either microbiological cure, clinical cure, or both. 4 patients (6.5%) experienced an adverse drug reaction of diarrhea that was self-limited. ConclusionFosfomycin is an effective and well-tolerated antimicrobial agent that may be considered for treatment of complicated UTIs without evidence of pyelonephritis or bacteremia caused by multi-drug resistant organisms in the veteran population.Disclosures All Authors: No reported disclosures

Development and Evaluation of a Rules-based Algorithm for Primary Open-Angle Glaucoma in the VA Million Veteran Program

ABSTRACT The availability of electronic health record (EHR)-linked biobank data for research presents opportunities to better understand complex ocular diseases. Developing accurate computable phenotypes for ocular diseases for which gold standard diagnosis includes imaging remains inaccessible in most biobank-linked EHRs. The objective of this study was to develop and validate a computable phenotype to identify primary open-angle glaucoma (POAG) through accessing the Department of Veterans Affairs (VA) Computerized Patient Record System (CPRS) and Million Veteran Program (MVP) biobank. Accessing CPRS clinical ophthalmology data from VA Medical Center Eye Clinic (VAMCEC) patients, we developed and iteratively refined POAG case and control algorithms based on clinical, prescription, and structured diagnosis data (ICD-CM codes). Refinement was performed via detailed chart review, initially at a single VAMCEC (n = 200) and validated at two additional VAMCECs (n = 100 each). Positive and negative predictive values (PPV, NPV) were computed as the proportion of CPRS patients correctly classified with POAG or without POAG, respectively, by the algorithms, validated by ophthalmologists and optometrists with access to gold-standard clinical diagnosis data. The final algorithms performed better than previously reported approaches in assuring the accuracy and reproducibility of POAG classification (PPV >83% and NPV >97%) with consistent performance in Black or African American and in White Veterans. Applied to the MVP to identify cases and controls, genetic analysis of a known POAG-associated locus further validated the algorithms. We conclude that ours is a viable approach to use combined EHR-genetic data to study patients with complex diseases that require imaging confirmation.

Improving Unadjusted and Adjusted Mortality With an Early Warning Sepsis System in the Emergency Department and Inpatient Wards

Mortality reduction has been a major focus of improvement for health care systems. Although several studies have noted improved sepsis-related mortality with the use of electronic health record (EHR) systems, there are no known published early warning sepsis systems using the Veterans Health Administration (VHA) EHR system. The Malcom Randall Veterans Affairs Medical Center (MRVAMC), a large academic 1a VHA facility within the North Florida/South Georgia Veterans Health System (NF/SGVHS), was identified as having opportunities for improvement related to inpatient mortality outcomes. Sepsis was discovered as the primary contributor to inpatient mortality for MRVAMC's acute level of care (LOC). Education along with implementation of an early warning sepsis system (EWSS) was subsequently integrated in the VHA EHR known as the Veterans Information Systems and Technology Architecture/ Computerized Patient Record System (VistA/CPRS) at NF/SGVHS, which applied a combination of informatics solutions within a Lean Six Sigma quality improvement framework. At MRVAMC, there was an observed decrease in the number of inpatient deaths for the acute LOC from a high of 48 in fiscal year (FY) 2017, quarter 3 to a low of 27 in FY 2019, quarter 4. This resulted in as large of an improvement as a 44% reduction in unadjusted mortality with education and implementation of an EWSS from FYs 2017 to 2019. Additionally, the MRVAMC acute LOC risk-adjusted mortality (standardized mortality ratio) improved from > 1.0 to < 1.0, demonstrating fewer inpatient mortalities than predicted from FYs 2017 to 2019. Education along with the possible implementation of an EWSS within the VHA EHR was associated with improvement in unadjusted and adjusted inpatient mortality at MRVAMC. This may be an effective approach for patients with sepsis.

Cervical Cancer Screening in South Florida Veteran Population, 2014 to 2020: Cytology and High-Risk Human Papillomavirus Correlation and Epidemiology.

ObjectiveThis project aims to use our robust women's health patient data to analyze the correlation between cytology and high-risk human papillomavirus (Hr-HPV) testing, study the performance of Hr-HPV testing for detecting cytology lesions, and examine epidemiologic measures of human papillomavirus (HPV) infections in the women's veteran population.MethodsWe collected patient data from 2014 to 2020 from our computerized patient record system. We performed HPV assays using the cobas® 4800 system (Roche Diagnostics, Basel, Switzerland). The cobas HPV assay detects HPV 16, HPV 18, and 12 other HPV types (31, 33, 35, 39, 45, 51, 56, 58, 59, 66, and 68). We organized cytology results and Hr-HPV assays with Microsoft Access and Microsoft Excel (Microsoft Corporation, Washington, USA) for analysis.ResultsA total of 9437 cervical specimens were co-tested. High-grade cytology lesions - high-grade intraepithelial lesion (HSIL) or higher and atypical squamous cells, cannot exclude HSIL (ASC-H) - were overwhelmingly positive for Hr-HPV (94.1% and 87.2%, respectively). Low-grade cytology lesions - low-grade squamous intraepithelial lesion ((LSIL) and atypical squamous cells of undetermined significance (ASC-US) - were positive for Hr-HPV in lower percentages (72.6% and 54.9%, respectively). Hr-HPV testing had a sensitivity of 91.3%, a specificity of 93.1%, a positive predictive value of 16.4%, and a negative predictive value of 99.8% for detecting high-grade cytology lesions. Hr-HPV testing had a lower performance for detecting low-grade cytology lesions. Ten cases had high-grade cytology and negative Hr-HPV test. Out of 10 such patients, nine showed no dysplasia (six) or low-grade dysplasia (three) on subsequent biopsy. Overall, 14.4% of tests were positive for Hr-HPV. The highest positive Hr-HPV test rates were in the third and eighth decades of life, 25.1% and 22.0%, respectively. However, the eighth decade consisted of a small sample of only 50 women. In women over 30 years of age with Hr-HPV infections, HPV types 16 and 18 were present in 11.7% and 6.4% of tests, respectively. Other HPV types were present in 82.3% of tests.ConclusionsHr-HPV testing has a high performance in detecting high-grade cytology lesions and a lower performance for detecting low-grade cytology lesions. However, studies show that LSIL rarely progresses to cervical intraepithelial neoplasia grade 3 or higher (CIN3+), suggesting minimal to no impact on cervical cancer screening. We believe our findings are in accordance with recent studies and affirm the guidelines that recommend primary Hr-HPV testing as the preferred screening method. The percentage of positive Hr-HPV tests and rates for age and HPV types 16 and 18 in our women’s veteran population suggest similar HPV prevalence to that of the general US population.

Big Data in the Veterans Health Administration: A Nursing Informatics Perspective.

This article reviews the missions of the U.S. Department of Veterans Affairs (VA) and the evolution of its electronic health record (EHR), the Veterans Health Information Systems and Technology Architecture (VistA). This system, along with its clinical graphical user interface the Computerized Patient Record System, form a key link in VA health care. A Veteran who receives healthcare through the VA can have their EHR accessed by clinicians at any VA healthcare facility across the United States and its territories. Data aggregated daily at a corporate data warehouse supports VA quality improvement and research. Serving over 9 million Veterans, the VA is one of the largest integrated healthcare systems in the United States. It has been a leader in the development and use of healthcare informatics, EHR, and big data analytics for over 30 years. Nurses engaged in major roles in the evolution of these developments. With over 500 nurses as members, the Office of Nursing Informatics' Field Alliance demonstrates the VA's continuing commitment to fostering nursing informatics. The commitment includes investment by the VA to develop nursing informaticists from among its own staff. Exemplars of the impact of nursing informatics are shared. Future directions include an EHR that begins during military service and follows the Veteran into VA health care.

Proton Pump Inhibitor Utilization in Veteran Patients on Combined Antithrombotic Therapy and Validation of Simplified Bleeding Risk Score.

Concomitant use of anticoagulant and antiplatelet agents can increase the risk of gastrointestinal bleed (GIB). Use of proton pump inhibitors (PPIs) has been proposed to decrease the risk of GIB in patients on combined antithrombotic therapy (CAT). To describe the current utilization of PPIs in veteran patients on CAT and associated clinical predictors of GIB. This retrospective study included patients on CAT receiving PPIs, with at least one of the CAT agents initiated between January 1, 2018 and October 30, 2018. Data were extracted from the computerized patient record system. Primary end point included estimating proportion of patients on CAT receiving PPI co-therapy, describing patient characteristics, and identifying clinical predictors of GIB. Secondary outcomes included reporting GIB events and all-cause mortality. Additional outcome was to validate the five-factor risk score (FFRS) for GIB in patients on CAT and compare its overall predictive performance to HAS-BLED score. This study reports an overall rate of PPI co-therapy in patients on CAT of 40.9% (484/1181), with only 22.3% of patients on CAT receiving PPI for GIB prophylaxis. There was no difference in the mean follow up duration of PPI users and PPI co-therapy (264.01 vs 271.92days; p=0.3761). Current alcohol use (p=0.005), current smokers (p=0.022), chronic kidney disease (p=0.004), peptic ulcer disease (p<0.001), and non-steroidal anti-inflammatory drug use (p=0.048) were significant predictors of GIB in multivariate analyses of our study cohort. We further provide exploratory validation that use of a simplified FFRS to predict GIB showed a trend towards better overall predictive performance as compared to HAS-BLED score (C-statistic: 0.738; 95% CI 0.684-0.787 for FFRS vs C-statistic: 0.596; 95% CI 0.538-0.653 for HAS-BLED; p=0.0094). This study reports lower rate of PPI co-therapy in veteran patients on CAT per currently available guidance. Further we explore utilization of simplified FFRS model to predict GIB in patients on CAT with long-term PPI co-therapy.

Patient outcomes following state-mandated opioid dose reductions.

Maine Public Law Chapter 488 required that all opioid doses be reduced to below 100 morphine milligram equivalent (MME) by July 1, 2017, and VA Maine Healthcare System implemented policies consistent with the state law. The purpose of this study was to assess self-reported pain scores over 2 years and overall utilization of alternative healthcare services for veterans who were using opioid doses in excess of 100 MME prior to the implementation of policies consistent with Maine PL Chapter 488 in the VA Maine Healthcare System. In this retrospective chart review, veterans were selected for inclusion if they were receiving chronic opioid therapy at the VA Maine Healthcare System of at least 100 MME daily in March 2016 according to the opioid therapy risk report (OTRR). Self-reported pain scores and use of alternative healthcare services were evaluated using VA Computerized Patient Record System (CPRS) data. Of the 147 patients evaluated per protocol, 75 patients (51%) did not have a clinically significant change in self-reported pain scores, and the self-reported pain scores of 29 patients (20%) improved from March 2016 to March 2018 (P = 0.054). We found that mandatory dose reductions of chronic opioid medications did not result in a clinically or statistically significant worsening of self-reported pain scores. Our study suggests that opioid dose reductions may not negatively impact a patient's functioning and pain intensity and calls into question the use of long-term opioid therapy for pain given the safety implications.

When Patients Have Neuropathy: Frequency Of A Positive Immunofixation Electrophoresis (IFE) For Monoclonal Protein When The Serum Protein Electrophoresis (SPEP) Is Negative, The Veteran Affairs Medical Center (VAMC) Experience

Abstract Introduction/Objective Although serum protein electrophoresis (SPEP) is the backbone of testing to determine the presence of monoclonal proteins, immunofixation electrophoresis (IFE) is more sensitive with the ability to pick up fainter bands or bands comigrating with the normal beta protein peak. Given the costs of performing additional IFE and the known increased sensitivity, algorithms for reflex IFE published in the literature have stated that unexplained neuropathy would be an indication for reflex IFE even if the SPEP appears negative in a new patient. However, literature on exactly how many of these reflex IFE’s end up positive is sparse. Therefore, we present the Veteran Affairs Medical Center (VAMC) experience in a veteran population. Methods As part of a quality assurance/improvement project, retrospective Vista/Fileman search of all SPEPs with IFE performed from January 2017 to February 2019 was undertaken to identify all SPEPs/IFE with the standard comment language typically used in patients with neuropathy, namely a preliminary diagnosis of no monoclonal bands on SPEP with an IFE to confirm this diagnosis. All SPEPs and IFEs had undergone review by a pathologist prior to signout which includes a chart review in the computerized patient record system (CPRS) to rule out the documented presence of unexplained neuropathy in new patients who have not previously had IFE workup. Results There were 129 SPEP/IFE cases identified. Of these 129, the overwhelming majority or 123 specimens (95%) were negative on IFE. However, there were 6 specimens (5%) that demonstrated a band on IFE without a band being identified on the SPEP. These bands were in the beta region or very faintly located in the gamma region at or below the limit of detection of the SPEP Conclusion The performance of IFE for patients with unexplained neuropathy would, in the veteran population at the VAMC, identify a monoclonal band in about 1/20 cases. This provides support for the published algorithms advocating for performing IFE on negative SPEP specimens from patients with unexplained neuropathy, as this finding might be important and would otherwise have been missed if just the SPEP was performed alone.