Criteria For Appropriate Use Research Articles

Analysis of European Association of Urology Guidelines 2023 and its adherence to GRADE methodology

AbstractIntroductionThe European Association of Urology (EAU) has reported the use of a modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach for developing guideline recommendations since 2018; however, the full adoption of GRADE remains a work in progress.MethodsTwo members of the research team identified and independently abstracted all individual recommendations and summary of evidence statements available from all EAU guidelines published in 2023. We evaluated the current adherence to established criteria for appropriate GRADE use, the proportion of strong and weak recommendations, the underlying strength of evidence, and criteria for appropriate use of GRADE.ResultsWe included a total of 20 guideline documents with a total number of 1985 recommendations. The median number of strong recommendations was 46 (interquartile range: 32–87), representing 62.6% of all recommendations. The surgical thromboprophylaxis guideline had the lowest percentage of strong recommendations (18.2%; 30/165), and the neuro‐urology guideline had the highest percentage (95.5%; 42/44). EAU guidelines provided 2580 summaries of evidence statements, of which 1608 reported a level of evidence. The reported levels of evidence were I, II, III and IV/V at 31.8%, 28.5%, 32.4% and 7.3%, respectively. Of the six criteria for the appropriate use of GRADE, criterion 6, which reports the framing of recommendations as strong or weak, was met consistently; all other criteria were met only by a single guideline on thromboprophylaxis.ConclusionsThe EAU guidelines adoption of GRADE has been largely limited to the framing of recommendations as strong or weak. In all but one guideline, published guidelines did not meet any of the other criteria for appropriate GRADE use. Increased efforts to fully adopt GRADE, similar to its implementation in the thromboprophylaxis guideline in future editions, may enhance trust and uptake of EAU guidelines, thereby assisting policymakers and improving patient care.

ASSESSMENT OF THE SPATIAL APPROPRIATENESS OF THE FUTURE URBANIZATION OF THE CITY OF (AIN BEIDA, ALGERIA) USING GEOGRAPHIC INFORMATION SYSTEMS, THE ANALYTICAL HIERARCHY PROCESS, AND THE DELPHI METHOD

Spatial adequacy evaluation is a valuable tool for planning land use strategies. It provides planners with data and outcomes that can help them make informed decisions to ensure effective and secure utilization of land in future urbanization processes. The objective of this study is to analyze the urbanization patterns in the city of Ain El Beida to determine the most appropriate areas for urban development. The aim is to create self-sustaining growth centers that effectively support the city, while also helping decision-makers address current expansions and protect agricultural lands. The study utilized spatial analysis methodology to evaluate and map the suitability of expanding the city's future space. It proposed an integration strategy that combined modern methods and techniques of the Delphi methodology to establish criteria for appropriate land use. The influence of these criteria will be analyzed spatially by administering a questionnaire to a sample of specialists in urban planning and city geography, followed by the application of spatial analyst techniques. The user's text is straightforward and precise. within the GIS framework, integrated via the analytic hierarchy approach. The user's text is straightforward and precise. To evaluate the suitability of the spatial location, to determine the significance of the factors influencing the expansion process based on their relative importance, to ensure that the desired goals are achieved in a way that reflects the priority of the decision-making criteria, and to identify the most favorable options for urban development in the study area. The findings indicated that the optimal locations for the urban growth of Ein El-Baida were determined to be 239.57 hectares, which accounts for 26.31 per cent of the entire land area under investigation. These areas are situated on the northern side of the city along National Road 80 (Ain Beida Presh) and on the western side along National Road 10 (Oum el-Bouaghi Ain Beida). These locations have been identified as the most suitable areas for spatial expansion due to their numerous incentives for urban attraction. Firstly, there is a considerable distance from the fertile and generously compensated agricultural areas, which offer unoccupied and level terrain, as well as its proximity to the central area of the pristine city of Ein. The study also determined that integrating GIS with hierarchy is crucial for constructing spatial models that accurately represent physical reality through mathematical means. This integration aids planners in selecting the most appropriate alternatives for urbanization and achieving comprehensive development of the city.

Cautionary tales in the use of magnets for the treatment of long gap esophageal atresia

BackgroundThe use of magnets for the treatment of long gap esophageal atresia or “magnamosis” is associated with increased incidence of anastomotic strictures; however, little has been reported on other complications that may provide insight into refining selection criteria for appropriate use. MethodsA single institution, retrospective review identified three cases referred for treatment after attempted magnamosis with significant complications. Their presentation, imaging, management, and outcomes were reviewed. ResultsAll three patients had prior cervical or thoracic surgery to close a tracheoesophageal fistula prior to magnamosis, creating scar tissue that can prevent magnet induced esophageal movement, leading to either magnets not attracting enough or erosion into surrounding structures. Two patients had a reported four centimeter esophageal gap prior to attempted magnamosis, both failing to achieve esophageal anastomosis, suggesting that these gaps were either measured on tension with variability in gap measurement technique, or that the esophageal segments were fixed in position from scar tissue and unable to elongate. One patient had severe tracheobronchomalacia requiring tracheostomy, with improvement in his airway after eventual tracheobronchopexies, highlighting that magnamosis does not address comorbidities often associated with this patient population. ConclusionsWe propose the following inclusion criteria and considerations for magnamosis: an esophageal gap truly less than four centimeters off tension with standardized measurement across centers, cautious use with a history of prior thoracic or cervical esophageal surgery, no associated tracheobronchomalacia or great vessel anomaly that would benefit from concurrent repair, and ideally to be used in centers equipped to manage potential complications. Level of evidenceLevel IV treatment study.

Reducing High-flow Nasal Cannula Overutilization in Viral Bronchiolitis.

Heated high-flow nasal cannula (HHFNC) therapy for bronchiolitis has become increasingly prevalent without evidence that this therapy impacts patient outcomes. Lack of criteria for appropriate use may lead to overutilization, resulting in increased costs without patient benefit. Our primary aim was to decrease use of HHFNC in patients with bronchiolitis over one season. Patients with Bronchiolitis younger than 2 years of age admitted to the Hospital Medicine Service were included in this study. Using the model for improvement framework, we identified key drivers for HHFNC overuse and revised our bronchiolitis protocol to include low-flow nasal cannula trials before HHFNC initiation. We compared preintervention HHFNC utilization (December 2018-April 2019) with postintervention HFNC utilization (December 2019-March 2020). One hundred ninety patients met inclusion criteria, 98 of them in the preintervention cohort and 92 in the postintervention cohort. Overall, the median age was 9 months and 65% of patients were male. Our HHFNC utilization rate decreased from 62% (61/98) to 43% (40/92) in the postintervention period. Our SPC analysis suggested special cause variation based on 7 points below the preintervention mean. This QI intervention implementing a specified low-flow nasal cannula trial before the initiation of HHFNC shows promise in reducing overall HHFNC use. Future studies should focus on clear initiation and discontinuation criteria for HHFNC use in bronchiolitis.

Development of an Electronic Algorithm to Identify Inappropriate Antibiotic Prescribing for Pediatric Pharyngitis

Background: Antibiotic overuse contributes to antibiotic resistance and unnecessary adverse drug effects. Antibiotic stewardship interventions have primarily focused on acute-care settings. Most antibiotic use, however, occurs in outpatients with acute respiratory tract infections such as pharyngitis. The electronic health record (EHR) might provide an effective and efficient tool for outpatient antibiotic stewardship. We aimed to develop and validate an electronic algorithm to identify inappropriate antibiotic use for pediatric outpatients with pharyngitis. Methods: This study was conducted within the Children’s Hospital of Philadelphia (CHOP) Care Network, including 31 pediatric primary care practices and 3 urgent care centers with a shared EHR serving >250,000 children. We used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify encounters for pharyngitis at any CHOP practice from March 15, 2017, to March 14, 2018, excluding those with concurrent infections (eg, otitis media, sinusitis), immunocompromising conditions, or other comorbidities that might influence the need for antibiotics. We randomly selected 450 features for detailed chart abstraction assessing patient demographics as well as practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for evaluating the electronic algorithm. Criteria for appropriate use included streptococcal testing, use of penicillin or amoxicillin (absent β-lactam allergy), and a 10-day duration of therapy. Results: In 450 patients, the median age was 8.4 years (IQR, 5.5–9.0) and 54% were women. On chart review, 149 patients (33%) received an antibiotic, of whom 126 had a positive rapid strep result. Thus, based on chart review, 23 subjects (5%) diagnosed with pharyngitis received antibiotics inappropriately. Amoxicillin or penicillin was prescribed for 100 of the 126 children (79%) with a positive rapid strep test. Of the 126 children with a positive test, 114 (90%) received the correct antibiotic: amoxicillin, penicillin, or an appropriate alternative antibiotic due to b-lactam allergy. Duration of treatment was correct for all 126 children. Using the electronic algorithm, the proportion of inappropriate prescribing was 28 of 450 (6%). The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were sensitivity (99%, 422 of 427); specificity (100%, 23 of 23); positive predictive value (82%, 23 of 28); and negative predictive value (100%, 422 of 422). Conclusions: For children with pharyngitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. Future work should validate this approach in other settings and develop and evaluate the impact of an audit and feedback intervention based on this tool.Funding: NoneDisclosures: None

Multidisciplinary Tool Kit for Febrile Neutropenia: Stewardship Guidelines, Staphylococcus aureus Epidemiology, and Antibiotic Use Ratios.

Inappropriate vancomycin for febrile neutropenia (FN) is an ideal antimicrobial stewardship target. To improve vancomycin prescribing, we instituted a multifaceted intervention, including an educational guideline with audit for compliance; an antibiotic use audit; and an assessment of local burden of methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection. We conducted a quasi-experimental pre-post intervention review of vancomycin initiation for FN on a 32-bed hematology/oncology unit. A retrospective chart review was conducted from November 2015 to May 2016 (preintervention period). In January 2017, we implemented an institutional FN guideline emphasizing criteria for appropriate use. Vancomycin audit was conducted from February 2017 to October 2017 (postintervention period). The primary outcome was appropriateness of vancomycin initiation. We then compared average antibiotic use (days of therapy per 1,000 patient days) for vancomycin and cefepime before and after intervention. Finally, unit-wide MRSA screening cultures were obtained upon admission and bimonthly for 6 weeks (October 2, 2017, to November 9, 2017). Screened patients were followed for 12 months for clinical MRSA infection. Forty-three (49%) of 88 preintervention patients were started on empiric vancomycin appropriately, compared with 59 (66%) of 90 postintervention patients (P = .02). There was a significant decrease in vancomycin use after intervention. Six (7.1%) of 85 patients screened positive for MRSA colonization. During the 12-month follow-up, no colonized patients developed clinical MRSA infections (positive predictive value, 0.0%). Of the 79 noncolonized patients, 2 developed a clinically significant infection (negative predictive value, 97.5%). Guideline-focused education can improve vancomycin appropriateness in FN and should be bundled with education and feedback about local MRSA epidemiology and antibiotic use rates for maximal stewardship impact.

The cost-effectiveness of guideline-driven use of drug-eluting stents: propensity-score matched analysis of a seven-year multicentre experience

Background: In routine clinical practice, the implantation of a drug-eluting stent (DES) versus a bare metal stent (BMS) for percutaneous coronary intervention (PCI) has been guided by criteria for appropriate use. The cost-effectiveness (CE) of adopting these guidelines, however, is not clear, and was investigated from the perspective of the Australian healthcare payer.Methods and results: Baseline and 12-month follow-up data of 12,710 PCI patients enrolled in the Melbourne Interventional Group (MIG) registry between 2004 and 2011 were analysed. Costs inputs were derived from a clinical costing database and published sources. Propensity-score-matching was performed for DES and BMS groups within sub-groups. Incremental cost-effectiveness ratios (ICERs) were evaluated for all patients, and sub-groups of patients with ‘0’, 1, 2, or ≥3 indications for a DES. The incremental cost per target vessel revascularization avoided for the overall population was $24,683, and for patients with 0, 1, and 2 indications for a DES was $44,635, $33,335, and $23,788, respectively. However, for those with >3 indications, DES compared with BMS was associated with cost savings. At willingness to pay thresholds of $45,000–$75,000, the probability of cost-effectiveness of DES for the overall cohort was 71–91%, ‘0’ indications, 49–67%, 1 indication, 56–82%, 2 indications, 70–90%, and ≥3 indications, 97–99%.Conclusions: The cost-effectiveness of DES compared with BMS increased with increasing risk profile of patients from those who had 1, 2, to ≥3 indications for a DES. When compared with BMS, DES was least cost effective among patients with ‘0’ indications for a DES. Based on these results, selective use of DES implantation is supported. These findings may be useful for evidence-based clinical decision-making.

Guideline-Directed Medical Therapy in Hospitalized Heart Failure Patients: Still Underprescribed Despite Updated Guidelines and Over 20 Years of Evidence

Background Heart failure (HF) is a progressive condition and repeated hospitalizations are associated with worse outcomes. Guideline-directed medical therapy (GDMT) is proven to reduce morbidity and mortality however previous literature has demonstrated low rates of prescribing. In April 2017, the ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guidelines for the Management of Heart Failure provided a clarified recommendation supporting the clinical strategy of renin-angiotensin system inhibition through angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs) or angiotensin receptor-neprilysin inhibitors (ARNIs) in conjunction with evidence-based beta blockers and aldosterone antagonists in select heart failure with reduced ejection fraction (HFrEF) patients. We aimed to evaluate prescriber adherence rates to GDMT in patients hospitalized with acute decompensated heart failure (ADHF) at time of discharge after the publication of the guideline update. Methods A retrospective chart review of HF admissions at a large urban academic health system was conducted between October 1, 2017 and December 31, 2017. Patients 18 years or older with a left ventricular ejection fraction of 40 percent or less were included. Patients were excluded if they had a left ventricular assist device, heart transplant, end-stage renal disease on hemodialysis or were dependent on inotropes. Criteria for appropriate GDMT use were developed to guide data collection based off the 2017 ACC/AHA/HFSA Focused Update. The primary outcome was prescriber adherence to GDMT determined by prescriptions written at the time of discharge or documented on the discharge summary. Secondary outcomes included 30-day all-cause readmission rate and guideline adherence by provider service. Results Of the 50 patients reviewed only 32% (n=16) were discharged on appropriate GDMT. Table 1 depicts the percent of eligible patients receiving therapy upon discharge by drug class. Guideline adherence among the internal medicine service was 33.3% (12/36) compared to 28.5% (4/14) among the cardiology service. The 30-day readmission rate was lower among those discharged on appropriate therapy versus inappropriate therapy (25% vs. 46%). Conclusion Despite over 20 years of evidence and recently published guideline updates our results demonstrate poor prescriber adherence to GDMT with an alarmingly low number of eligible patients receiving aldosterone antagonists and appropriate combination therapy. Health systems must recognize and address barriers to guideline adherence in order to improve outcomes for HF patients.

Revision arthroplasty for periprosthetic joint infections: When to consider one-stage versus two-stage protocols?

For chronic periprosthetic joint infection, two-stage exchange arthroplasty has long remained the gold-standard treatment, but has come under scrutiny of late. Recent studies have shown increased costs, unacceptably high rates of recurrence for resistant organisms, and lower than expected rates of eventual reimplantation for subjects treated in a two-stage fashion. While the appeal of single-stage exchange arthroplasty has grown, rigorous data is lacking for universal application for all infections. Improvements in patient selection with set criteria for appropriate use will better define a treatment algorithm for optimum periprosthetic joint infection management moving forward.

The siren call of probability: Dangers associated with using probability for consideration of the future

Many tools for thinking about the future employ probability. For example, Delphi studies often ask expert participants to assign probabilities to particular future outcomes. Similarly, while some scenario planners reject probability, others insist that assigning probabilities to scenarios is required to make them meaningful. Formal modelling and forecasting methods often also employ probability in one way or another. The paper questions this widespread use of probability as a device for considering the future, firstly showing that objective probability, based on empirically-observed frequencies, has some well-known drawbacks when used for this purpose. However, what is less-widely acknowledged is that this is also true of the subjective probability used in, for example, Delphi. Subjective probability is less distinct from objective probability than proponents of its use might imply, meaning it therefore suffers from similar problems. The paper draws on the foundations of probability theory as set out by Kolmogorov, as-well-as the work of Keynes, Shackle, Aumann, Tversky and Kahneman, and others, to reassert the essential distinction between risk and uncertainty, and to warn about the dangers of inappropriate use of probability for considering the future. The paper sets out some criteria for appropriate use.

An Antimicrobial Stewardship Initiative within a for-profit hospital: Impact of Criteria for Appropriate Use on Utilization

BackgroundAntimicrobial Stewardship Programs (ASP) have shown improved patient outcomes, reduced adverse events, improved antibiotic susceptibilities, and optimized resource utilization. With the re-introduction of a formal ASP at our for-profit, non-teaching, community hospital in early 2016 in response to both legislative and corporate requirements, we sought to evaluate the impact of one of our ASP initiatives, Criteria for Appropriate Use, on utilization of three specific antimicrobial agents: Daptomycin (DAP), Tigecycline (TIG) and Ertapenem (ERT). The results of this investigation will help characterize various shifts in prescribing practices facilitated by an ASP initiative as well as quantify resultant trends in utilization.MethodsThis single-center, retrospective cohort study included patients who received DAP, TIG, or ERT in matched time periods: July – Sept 2015 (pre-ASP) and July – Sept 2016 (post-ASP). Patients were analyzed based on demographics, antibiotic use, days of therapy (DOT), indication (criteria for use), prescriber, infection type, and antibiotic course. Cost data and adjusted patient-days (APD) were extracted from hospital records.Results644 cases were included. There were 555 pre-ASP cases per 31,884 APD: 128 (DAP), 368 (ERT), and 59 (TIG). In the post-ASP group, there were 89 cases per 30,960 APD: 40 (DAP), 39 (ERT), and 10 (TIG). Significant decreases were realized in the post-ASP period in: restricted antibiotic utilization (17.4 vs.. 2.9 cases/1000 APD, P < 0.0001), duration (58.2 vs. 14.3 DOT/1000 APD, P < 0.0001), off-criteria use (3.6 vs. 0.65 cases/1000 APD, P < 0.0001), and cost ($12.92 vs. $2.88/APD, P < 0.0001).ConclusionThe results of this study show that introduction of ASP, specifically Criteria for Appropriate Use implementation, was associated with not only significant decreases in utilization rates and antimicrobial cost, but significant shifts in prescriber behavior.Disclosures All authors: No reported disclosures.

Inappropriate Use of Proton Pump Inhibitor (PPI) Infusion in Upper Gastrointestinal Bleeding (UGIB) Patients and the Impact of Proper Physician Education on Outcome: An Experience in Two Community Hospitals

Introduction: UGIB remains a major health care burden in the United States. Recent ACG guidelines for ulcer bleeding supports no improvement in clinical outcome with pre-endoscopic PPI treatment in UGIB patients. However, if endoscopy is delayed or can't be performed or patient is hemodynamically unstable, IV PPI is recommended to reduce further bleeding. In addition to that, patients with suspected variceal bleeding might be benefited with pre-endoscopic PPI infusion along with vasopressin/octreotide infusion. Aim: To identify the prevalence of inappropriate use of pre-endoscopic PPI infusion in UGIB patients. To educate physicians about appropriate use of pre-endoscopic PPI infusion in UGIB and evaluate the change in clinical outcomes following education. Methods: A retrospective study was conducted in patients admitted with UGIB from July 2015 to May 2016. Physicians were educated via emails & posters about the appropriate use of pre-endoscopic PPI infusion in UGIB patients in January 2016. PPI infusion use was defined appropriate prior to endoscopy if patients were hemodynamically unstable, or EGD was delayed or could not be performed or in patients with history of cirrhosis in which variceal bleeding was suspected. Patients who did not meet the criteria for appropriate use of PPI infusion received PPI intermittent bolus. Patients were divided in two groups: Pre-education cohort and post-education cohort. Data was collected in each group to assess patients' demographics, laboratory values at the time of presentation, length of stay, cost, blood transfusion, complications and death. Results: Of 419 patients admitted with UGIB, 73 patients (17.4%) received PPI infusion prior to endoscopy. Inappropriate use of PPI infusion was reduced in post-education group compared to pre-education group. (35% vs 71%, p value 0.0069) (Table 1). Pre-education group was associated with higher length of stay and higher cost compared to post-education group. There was no difference in mortality, re-bleeding rate, and requirement of blood transfusion between two groups. (table 2).Table 1: Effect of education on inappropriate use of PPI infusion in UGIB patientsConclusion: Inappropriate use of pre-endoscopic PPI infusion in UGIB patients is very prevalent in our hospitals. Proper physician education leads to decrease in the inappropriate use of PPI infusion and was associated with reduce length of stay and hospital cost, without change in mortality, re-bleeding rate and requirement of blood transfusion. Further studies are warranted to support our data.Table 2

Evaluation of Meropenem Use Among Septic Patients at Hua Hin Hospital, Thailand

Antimicrobial-resistant bacteria are an important medical concern. This problem might be resulted from an inappropriate use of antibiotics. The review of antibiotic drug use could help understanding the cause of drug resistance and eventually resolve the problem. Our retrospective cohort study aimed to review meropenem use at Hua-hin hospital, Prachuap Khiri Khan, including therapeutic indications, dosage regimens and duration of sepsis treatment. Data were gathered from patients admitted in the hospital during January to December 2013. The sources of data included patient medical records, patient database from computer program and in-house form of meropenem evaluation. A total of thirty-six cases were evaluated, 17 cases (47.2%) were male, and the average age was 58.3 (±19.9) years. There were 22 cases (61.1%) and 14 cases (38.9%) receiving meropenem as empirical and definitive therapy, respectively. According to meropenem use evaluation, there were 29 (80.6%), 33 (91.7%) and 24 (85.7%) cases that met the criteria for indication, dosage regimen, and treatment duration, respectively. Only 17 cases (60.7%; n=28) met all three criteria for appropriate meropenem use. Thus, with our finding, the role of healthcare professionals in reducing the inappropriate use of antibiotics for the entire course of treatment should be encouraged.

Abstract 126: Cardiac Stress Testing: Optimizing Outcomes Through Dual Physician-Patient Education

Background: Even though cardiovascular (CV) tests, which are used to assess coronary arterial disease (CAD) are included in medical guidelines, cardiologists have limited ability to adequately perform appropriate testing modalities. In parallel, many patients have concerns or anxiety related to CV testing, and are not proactively educated on how to prepare for their procedure. Goals: To determine if an online parallel physician-patient education interventions could improve performance of cardiologists related to CV stress testing, and patient knowledge about the procedure. Methods: An online CME activity was developed as a 25-minute roundtable discussion with 3 leading experts on criteria for appropriate use of stress testing and preparing physicians to communicate the risks and benefits of testing modalities to their patients. The activity included a transcript of the discussion and a downloadable slide deck to reinforce key recommendations. Participant responses to questions were collected after the education (post-assessment) and compared with each user’s baseline data (pre-assessment) using a 2-tailed paired T-test to provide P values for assessing the impact of education. The CME activity also included a link to a patient/caregiver education module, developed in parallel to educate patients and their caregivers about cardiac stress testing. Patient/caregiver responses post-education compared to pre-education were also assessed to measure improvement in knowledge. Results: A total of 312 of cardiologists who participated in the CME activity and answered all pre- and post-assessment questions were included in the analysis. In addition, 3458 patients preparing for a stress test, 640 family members, 116 caregivers, and 3299 other participants interested in the topic of CV testing who completed the patient/caregiver education module and the pre- and post-education questions were included in the assessment. Post-education, significant improvements were observed (Table). Conclusion: This study demonstrated that both knowledge/competence of cardiologists on evidence-based practices as well as the understanding of patient/caregivers on CV testing can be improved using a dual approach to education.

Criteria for Appropriate PICC Use in Hospital Patients

According to this study: * Criteria developed by a multispecialty panel for the appropriate use of peripherally inserted central catheters can be used to improve the quality and safety of patient care and to inform quality improvement efforts. * These criteria are the first to provide guidance to clinicians who are responsible for the decision to place venous catheters.

Perspectives of Canadian Stakeholders on Criteria for Appropriateness for Total Joint Arthroplasty in Patients With Hip and Knee Osteoarthritis.

As rates of total joint arthroplasty (TJA) for osteoarthritis (OA) rise, there is a need to ensure appropriate use. We undertook this study to develop criteria for appropriate use of TJA. In prior work, we used qualitative methods to separately assess OA patients' and arthroplasty surgeons' perceptions regarding appropriateness of patient candidates for TJA. The current study reviewed the appropriateness themes that emerged from each group, and a series of statements were developed to reflect each unique theme or criterion. A group of arthroplasty surgeons then indicated their level of agreement with each statement using electronic voting. Where ≤70% agreed or disagreed, the criterion was discussed and revised, and revoting occurred. In standardized telephone interviews, OA patient focus group participants indicated their level of agreement with each revised criterion. Qualitative research in 58 OA patients and 14 arthroplasty surgeons identified 11 appropriateness criteria. Member-checking in 15 surgeons (including 5 who had participated in the qualitative study) resulted in agreement on 6 revised criteria. These included evidence of arthritis on joint examination, patient-reported symptoms negatively impacting quality of life, an adequate trial of appropriate nonsurgical treatment, realistic patient expectations of surgery, mental and physical readiness of patient for surgery, and patient-surgeon agreement that potential benefits exceed risks. Thirty-six of the original 58 OA patient focus group participants (62.1%) participated in the member-check interviews and endorsed all 6 criteria. Patients and surgeons jointly endorsed 6 criteria for assessment of TJA appropriateness in OA patients. Prospective validation of these criteria (assessed preoperatively) as predictive of postoperative patient-reported outcomes is under way and will inform development of a surgeon-patient decision-support tool for assessment of TJA appropriateness.

Trauma Patients Over‐Triaged to Helicopter Transport in an Established Midwestern State Trauma System

To characterize helicopter transport use in a mature Midwestern trauma system located in a low population density state, examine characteristics of patients over-triaged to helicopter transport, and determine predictors of over-triage to helicopter transport. A retrospective observational study conducted using State Trauma Registry data for years 2008-2009. Study sample included patients with medical helicopter transportation. Bivariate analyses compared patients defined and not defined as over-triaged to helicopter transport. Multivariate regression was used to determine predictors of over-triage. Of the 2,084 helicopter-transported study patients, 552 (26%) were defined as over-triaged. Differences in patients based on over-triaged status included race, age, injury mechanism, injury type, and injury intent (P < .05). Multivariate-based significant predictors of over-triage were transfer status, patient age, and injury mechanism (P= .0223; <.0001; and .0007, respectively). Patients transported from scene had a greater odds (OR: 1.29; 95% confidence interval: 1.04, 1.60) of being over-triaged to helicopter transport than interfacility transfers. Younger patients were also more likely to be over-triaged. Interactions between patient age and injury mechanism demonstrated varied likelihoods for over-triage. Younger patients injured in falls were more likely over-triaged than younger patients injured in a motor vehicle crash or by other non-fall causes. Study data showed over-triage to helicopter transport was substantial in a mature trauma system. It is recommended that trauma systems develop and monitor compliance with criteria for appropriate use of air medical transport. These actions can assist in refinements to prehospital and interfacility transfer protocols.

The Power and Peril of Administrative Databases

Archives of Internal Medicine Implantable Cardiac Device Procedures in Older Patients: Use and In-Hospital Outcomes Jason P. Swindle, MPH; Michael W. Rich, MD; Patrick McCann, MD; Thomas E. Burroughs, PhD; Paul J. Hauptman, MD Background: Although the effectiveness of implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) alone or in combination is well established, limited data are available on device use and short-term outcomes in older patients. We sought to characterize age-specific practices and outcomes among patients with heart failure undergoing device implantation using a large nationally representative administrative database. Methods: The cohort comprised patients older than 18 years with a diagnosis of heart failure who underwent implantation of an ICD or CRT between January 1, 2004, and December 31, 2005. Data included patient demographics, comorbidities, type of device, procedural complications, length of stay, total cost of hospitalization, and hospital characteristics. Multivariate stepwise logistic regression analysis was used to identify risk factors for in-hospital mortality. Results: We identified 26 887 patients who received an implantable device. The median age was 70.0 years (17.5% were ≥80 years), 72.6% were male, and 31.3% were of nonwhite race/ethnicity. Compared with younger patients, those 80 years or older were more likely to receive CRT alone. In-hospital mortality increased from 0.7% among patients younger than 80 years to 2.2% among those aged 80 to 85 years and 2.2% among those older than 85 years ( P Conclusions: Despite the fact that most device trials have excluded patients 80 years or older, more than one-fifth of ICD and CRT devices are implanted in this age group. Advanced age is an independent predictor of in-hospital mortality following device implantation, suggesting that additional study is needed to define criteria for appropriate device use in older patients.

Implantable Cardiac Device Procedures in Older Patients

Although the effectiveness of implantable cardioverter defibrillators (ICDs) and cardiac resynchronization therapy (CRT) alone or in combination is well established, limited data are available on device use and short-term outcomes in older patients. We sought to characterize age-specific practices and outcomes among patients with heart failure undergoing device implantation using a large nationally representative administrative database. The cohort comprised patients older than 18 years with a diagnosis of heart failure who underwent implantation of an ICD or CRT between January 1, 2004, and December 31, 2005. Data included patient demographics, comorbidities, type of device, procedural complications, length of stay, total cost of hospitalization, and hospital characteristics. Multivariate stepwise logistic regression analysis was used to identify risk factors for in-hospital mortality. We identified 26 887 patients who received an implantable device. The median age was 70.0 years (17.5% were > or =80 years), 72.6% were male, and 31.3% were of nonwhite race/ethnicity. Compared with younger patients, those 80 years or older were more likely to receive CRT alone. In-hospital mortality increased from 0.7% among patients younger than 80 years to 1.2% among those aged 80 to 85 years and 2.2% among those older than 85 years (P < .001). Independent predictors of in-hospital mortality included age 80 years or older, elevated comorbidity score, inotrope use, and procedure-related complications. Despite the fact that most device trials have excluded patients 80 years or older, more than one-fifth of ICD and CRT devices are implanted in this age group. Advanced age is an independent predictor of in-hospital mortality following device implantation, suggesting that additional study is needed to define criteria for appropriate device use in older patients.

Association between previous health care use and initiation of inhaled corticosteroid and long-acting β 2-adrenergic agonist combination therapy among US patients with asthma

Background: Combination inhaled corticosteroid and long-acting β 2-adrenergic agonist (ICS/LABA) therapy is recommended for patients whose asthma is not adequately controlled by other maintenance therapies and for those with moderate to severe asthma. Objectives: This study examined the appropriateness of initiation of ICS/LABA combination therapy based on health care use criteria and the proportions of US patients filling prescriptions for either of 2 available therapies. Methods: This retrospective cohort study analyzed data from commercially insured asthma patients aged 12 to 64 years who initiated combination therapy with fluticasone propionate/salmeterol (FSC) or budesonide/ formoterol fumarate dihydrate (BFC) from July 1, 2007, to June 30, 2008. Continuously enrolled patients who had not received ICS/LABA therapy during a 12-month preindex period were assigned to the BFC or FSC cohort based on their initial ICS/LABA prescription (index date). Appropriate initiation of ICS/LABA combination therapy was determined based on the risks for asthma exacerbation, high impairment, and previous controller medication use. Specifically, initiation of ICS/LABA therapy was considered appropriate if patients had claims during the preindex period for an ICS or leukotriene receptor antagonist, an asthma-related emergency department visit or hospitalization, ≥2 courses of oral corticosteroid, or ≥6 canisters of a rescue short-acting β 2-adrenergic agonist (SABA). Factors associated with appropriate initiation of ICS/LABA therapy were assessed by multivariate logistic regression. Results: Of 16,205 patients initiated on ICS/LABA therapy, 39.2% met ≥1 criterion for appropriate use—788 of 1417 patients (55.6%) in the BFC group and 5572 of 14,788 patients (37.7%) in the FSC group ( P < 0.001). Significantly greater proportions of BFC than FSC users met the individual criteria for previous controller medication use (45.7% vs 26.1%, respectively) and high SABA use (9.7% vs 6.1%). BFC users had a significantly higher likelihood of meeting ≥1 appropriateness criterion compared with FSC users (odds ratio = 1.79; 95% CI, 1.60–2.00; P < 0.001). Also significantly associated with appropriate use were receipt of the initial ICS/LABA prescription from a pulmonologist or allergist rather than from a physician in family medicine/general practice ( P < 0.001), residence in the West relative to the Northeast ( P < 0.005), and presence of specific comorbidities (allergic rhinitis, sinusitis, gastroesophageal reflux disease, and acute respiratory infection; all, P < 0.001). Conclusions: Just under 40% of patients met the criteria for appropriate initiation of ICS/LABA therapy, with significantly greater proportions of BFC than FSC users meeting the overall and individual criteria for appropriate use. Patients with appropriate initiation of ICS/LABA therapy were significantly more likely to be treated by pulmonologists and allergists than by family medicine/general practitioners.