Guideline Concordance Research Articles

Association Between Online Information-Seeking and Adherence to Guidelines for Breast and Prostate Cancer Screening

IntroductionFrom 2012 through 2014, the US Preventive Services Task Force (USPSTF) recommended biennial mammography for women aged 50 to 75 and recommended against the prostate specific antigen (PSA) test for men of any age, emphasizing informed decision making for patients. Because of time constraints and other patient health priorities, health care providers often do not discuss benefits and risks associated with cancer screening. We analyzed the association between seeking information online about breast and prostate cancer and undergoing mammography and PSA screening.MethodsWe assessed guideline concordance in mammogram and PSA screening, according to USPSTF guidelines for those at average risk for disease. We used data on 4,537 survey respondents from the National Cancer Institute’s Health Information National Trends Survey (HINTS) for 2012 through 2014 to assess online information-seeking, defined as whether people searched for cancer-related information online in the past 12 months. We used HINTS data to construct multivariable logistic regression models to isolate the effect of exposure to online information on the incidence of cancer screening.ResultsAfter controlling for available covariates, we found no significant association between online information-seeking and guideline-concordant screening for breast or prostate cancer. Significant covariate values suggest that factors related to access to care were significantly associated with conformance to mammography guidelines for women recommended for screening and that physician discussion was significantly associated with nonconformance to guidelines for prostate-specific antigen screening (ie, having a PSA test in spite of the recommendation not to have it). Decomposition of differences between those who sought online information and those who did not indicated that uncontrolled confounders probably had little effect on findings.ConclusionWe found little evidence that online information-seeking significantly affected screening for breast or prostate cancer in accordance with USPSTF guidelines among people at average risk.

Adequacy of Depression Treatment in Spouses of Cancer Survivors: Findings From a Nationally Representative US Survey.

Recent research suggests that mental health problems in spouses of cancer survivors are associated with worse mental health in the survivors themselves. Adequately treating spousal mental health problems therefore represents an opportunity to improve outcomes for both cancer survivors and their co-surviving family members. Using nationally representative data, this study sought to determine how depression treatment differs between spouses of cancer survivors with depression compared to the general married population and assess rural/urban disparities in treatment. The design of the study is cross sectional. Data are from the Medical Expenditures Panel Survey, a household-based survey of US adults; we concatenated data from 2004 to 2013. We identified spouses of cancer survivors (n= 225) and a comparison group of married adults (n= 3678). Key measures included depression, guideline concordance of depression treatment (at least four prescriptions related to depression treatment, or at least eight psychotherapy or counseling visits), and sociodemographic characteristics. Logistic regressions evaluated the association between whether their spouse had cancer and receipt of guideline-concordant treatment, controlling for sociodemographic characteristics; secondary analyses included rurality as a moderator. Analyses were weighted to account for the complex sampling design. Spouses of cancer survivors were 33% less likely to receive guideline-concordant depression treatment than comparison spouses (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.45-0.99), controlling for covariates. Rural-urban disparities were observed: rural spouses of cancer survivors were 72% less likely to receive guideline-concordant treatment (OR 0.28, 95% CI 0.11-0.68) than rural comparison spouses. Spouses of cancer survivors and comparison spouses were no different in their receipt of any treatment versus no treatment. Spouses of cancer survivors with depression may be at increased risk of non-guideline-concordant depression treatment, particularly in rural areas. The findings have implications for identifying and educating individuals with depression in primary care and other clinical areas.

P152 PATIENT EXPERIENCES WITH COLORECTAL CANCER SURVEILLANCE (CRC) IN INFLAMMATORY BOWEL DISEASE (IBD): A QUALITATIVE STUDY

Understanding how IBD patients’ experiences with colonoscopy influence their acceptance and participation in CRC surveillance colonoscopy may facilitate design and implementation of CRC surveillance strategies. The aim of this study was to define IBD patients’ experiences with colonoscopy and their decision-making process regarding CRC surveillance with colonoscopy. We performed a qualitative study of patients with IBD who had at least 1 colonoscopy for IBD using in-depth interviews. Trained investigators conducted in-depth interviews in-person or via telephone using open-ended questions to elicit data regarding perceptions of barriers and motivators of surveillance colonoscopy and expected outcomes related to CRC surveillance. We interviewed 30 IBD patients (14 CD and 16 UC); 7 were male, and 23 were female, with an age range of 18–74 years. We identified patient-reported motivators and barriers to CRC surveillance colonoscopy (Table 1) and created a patient decision-making model. Patients reported high concern for CRC, yet they often perceived the indication of colonoscopy was for IBD disease management, not for CRC prevention or detection. We identified several novel factors having a negative impact on acceptance of surveillance, including discrepancy in colonoscopy interval recommendations between providers, patient awareness of lack of guideline concordance, and communication with other IBD patients with differing colonoscopy intervals. This study identified motivators and barriers influencing patient decision-making for IBD-related CRC surveillance colonoscopy. We used these factors to develop a model of IBD patient decision-making for CRC surveillance, which may be used to inform development of a multi-component intervention for patient-centered IBD-related CRC surveillance and prevention.

Variation in guideline-concordant care for elderly patients with metastatic breast cancer in the United States.

Prior studies have identified shortcomings in the quality of care for early-stage breast cancer. Guidelines recommend systemic therapy for metastatic breast cancer (MBC), but few studies have examined guideline concordance for these patients. We used Surveillance, Epidemiology, and End Results (SEER)-Medicare data to identify patients aged ≥66 diagnosed in 2010-2011 with de novo MBC who were continuously enrolled in fee-for-service Medicare. We described initial care (within 6months of diagnosis) for hormone receptor (HR)-positive/human epidermal receptor-2 (HER2)-negative, HER2-positive, and triple-negative (TN) tumors. We identified factors independently associated with receiving no initial systemic therapy, and compared hospice and hospital utilization for treated versus untreated patients. Among 446 patients, 65% were HR-positive, 21% were HER2-positive, and 14% were TN. Most patients (76.9%) received initial systemic treatment. Among treated HR-positive patients, 15% received chemotherapy as initial treatment; among treated HER2-positive patients, 34% did not receive HER2-targeted initial therapy. Factors independently associated with receiving no initial systemic therapy included older age (ORage continuous/year=1.08, 95% CI 1.04-1.11), being not married (ORnot married vs. married=2.87, 95% CI 1.42-5.81), and subtype (ORTN vs. HR+=4.95, 95% CI 2.53-9.71). Of patients who did not receive initial systemic therapy, 41.1% did not receive hospice services. In this population-based MBC cohort, almost one quarter did not receive initial systemic therapy and a substantial proportion of treated patients did not receive guideline-concordant first-line therapy. Further research should explore underuse of chemotherapy and HER2-targeted therapies, investigate whether patterns of care are consistent with patient preferences, and identify opportunities to optimize hospice utilization for patients not receiving treatment.

Hepatitis Transmission Risk in Kidney Transplantation (the HINT study): A Cross-Sectional Survey of Transplant Clinicians in Australia and New Zealand.

Interpreting hepatitis serology and virus transmission risk in transplantation can be challenging. Decisions must balance opportunity to transplant against potential infection transmission. We aimed to survey understanding among the Australian and New Zealand medical transplant workforce of hepatitis risk in kidney donors and recipients. An anonymous, self-completed, cross-sectional survey was distributed via electronic mailing lists to Australian and New Zealand clinicians involved in kidney transplantation (2014-2015). We compared interpretation of clinical scenarios with paired donor and recipient hepatitis B virus and hepatitis C virus serology to recommendations in clinical practice guidelines. We used logistic regression modeling to investigate characteristics associated with decisions on transplant suitability in scenarios with poor (<50%) guideline concordance (odds ratios [OR]). One hundred ten respondents had representative workforce demographics: most were male (63%) nephrologists (74%) aged 40 to 49 years. Although donor and recipient hepatitis status was largely well understood, transplant suitability responses varied among respondents. For a hepatitis B virus surface antigen-positive donor and vaccinated recipient, 44% suggested this was unsuitable for transplant (guideline concordant) but 35% suggested this was suitable with prophylaxis (guideline divergent). In 4 scenarios with transplant suitability guideline concordance less than 50%, acute transplant care involvement predicted guideline concordant responses (OR, 1.69; P = 0.04). Guideline concordant responses were chosen less by hepatologists, intensive care doctors (OR, 0.23, 0.35, respectively; P = 0.01), and New Zealanders (guideline concordant responses OR, 0.17; P < 0.01; alternative responses OR, 4.31; P < 0.01). Despite broadly consistent interpretations of hepatitis serology, transplant suitability decisions varied and often diverged from guidelines. Improved decision support may reduce clinician variability.

How equitable is access to treatment for lung cancer patients? A population-based review of treatment practices in Ontario.

Aim:Guideline concordance is one of the metrics used by the Cancer Quality Council of Ontario and Cancer Care Ontario to assess the quality of cancer care and to drive quality improvement.Materials & Methods:The rates for lung cancer surgical resection and concordance with the Cancer Care Ontario postoperative adjuvant chemotherapy (AC) guideline were assessed by health region during two time periods (2010–2011 and 2012–2013) according to five equity measures (age, sex, neighborhood income, location of residence and size of immigrant population).Results:Of the patients with stage I/II NSCLC, 52.2% to 63.0% underwent surgical resection in the province of Ontario, Canada; for patients with stage IIIA disease, the rate was 26.4%. The probability of a surgical resection decreased substantially with age; only 26.9% of those with potentially resectable (stage I–IIIA) disease over 80 years underwent surgery. The use of postoperative AC increased modestly over the time of the study but the rate of use varied widely by health region (34.6 to 84.6%). Patients in rural areas were as likely to receive AC as urban dwellers; however, older aged patients (≥65 years) and those from the lowest income neighborhoods were significantly less likely to receive AC.Conclusion:Surgical rates and the use of AC vary by health region in Ontario and by age and level of neighborhood income despite universal access in a publicly funded health care system. The reasons for this variance are unclear but warrant further study.Presented in part at the 15th World Conference on Lung Cancer, Sydney, Australia, 27–30 October 2013

Perioperative management of new oral anticoagulants in patients undergoing elective surgery at a tertiary hospital.

Increasing numbers of patients receiving new oral anticoagulants (NOAC) are undergoing elective surgery. The extent to which perioperative interruption of NOAC therapy and use of bridging heparin are concordant with best evidence is uncertain. To determine: (i) concordance of NOAC and bridging heparin use with guidelines; and (ii) associations between guideline concordance and patient characteristics, surgical factors and perioperative adverse events. Retrospective study of consecutive adult patients undergoing elective surgery at a tertiary hospital between 1 January 2014 and 30 June 2015 and were receiving NOAC for at least 3 months prior to surgery. Concordance of perioperative anticoagulation management with hospital guidelines was rated by two independent researchers according to explicit thrombosis and bleeding risk tables. One hundred and fifty patients of mean (±SD) age 72.0 (±11.6) years were studied; 75% had atrial fibrillation as NOAC indication. Decision to interrupt anticoagulation in 142 patients was rated guideline-concordant in 59 (41.5%) based on low bleeding risk in all cases and high thrombotic risk in one-third. Concordant decisions were associated with past myocardial infarction (P = 0.009), chronic kidney disease (P = 0.05), use of dabigatran (P = 0.06) and major surgery (P < 0.001). Bridging heparin was prescribed in 51 (35.9%) patients and not prescribed in 91 (64.1%), with 64 (45.1%) decisions rated guideline-discordant comprising 27 decisions to prescribe and 37 not to prescribe. Guideline concordant bridging was associated with chronic kidney disease (P = 0.02); discordant bridging with use of dabigatran (P = 0.04), high thrombotic risk (P = 0.004), past ischaemic stroke (P = 0.07). At 30 days, only one adverse event (major bleed) was noted. Considerable discordance exists between guideline recommendations and perioperative NOAC management. Assistive tools are required that better align decision-making with current best practice.

Risk of cancer death by comorbidity severity and use of adjuvant chemotherapy among women with locoregional breast cancer.

To examine the associations of comorbidity and chemotherapy with breast cancer- and non-breast cancer-related death. Included were women with invasive locoregional breast cancer diagnosed in 2004 from seven population-based cancer registries. Data were abstracted from medical records and verified with treating physicians when there were inconsistencies and missing information on cancer treatment. Comorbidity severity was quantified using the Adult Comorbidity Evaluation 27. Treatment guideline concordance was determined by comparing treatment received with the National Comprehensive Cancer Network guidelines. Kaplan-Meier method and multivariable Cox proportional hazards regressions were employed for statistical analyses. Of 5852 patients, 76% were under 70years old and 69% received guideline concordant adjuvant chemotherapy. Comorbidity was more prevalent in women age 70 and older (79% vs. 51%; p<0.001). After adjusting for tumor characteristics and treatment, severe comorbidity burden was associated with significantly higher cancer-related mortality in older patients (Hazard Ratio [HR]=2.38, 95% CI 1.08-5.24), but not in younger patients (HR=1.78, 95% CI 0.87-3.64). Among patients receiving guideline adjuvant chemotherapy, cancer-related mortality was significantly higher in older patients (HR=2.35, 95% CI 1.52-3.62), and those with severe comorbidity (HR=3.79, 95% CI 1.72-8.33). Findings suggest that, compared to women with no comorbidity, patients with breast cancer age 70 and older with severe comorbidity are at increased risk of dying from breast cancer, even after adjustment for adjuvant chemotherapy and other tumor and treatment differences. This information adds to risk-benefit discussions and emphasizes the need for further study of the role for adjuvant chemotherapy in these patient groups.

Abstract 20920: Does Provider Gender Matter? Guideline Concordance in Post-Cardiac Arrest Care

Introduction: Recent studies have suggested that female physicians are more likely to adhere to clinical practice guidelines in medical care. When clinical guidelines for post-cardiac arrest care are adhered to patients have better outcomes. Hypothesis: We hypothesize that gender of the attending provider may affect guideline concordance in post-cardiac arrest care. Methods: We identified 139 out-of-hospital cardiac arrest patients treated at an academic tertiary care facility between 12/2013 and12/2016. Patients were over 18 years of age, suffered a medical cardiac arrest and were comatose at hospital admission. Demographic data and arrest characteristics were collected. The gender of the admitting provider and the provider who lead the first documented family meeting were abstracted. To assess for evidence based practice, we utilized 4 previously cited guidelines that are associated with improved survival; a.) was coronary angiography completed within 24 hours of admission, b.) was targeted temperature management initiated, c.) was target temperature achieved, and d.) did withdrawal of life sustaining therapy occur before 72 hours from return of spontaneous circulation? Results: Of the total cohort, 61.9% were male, mean age was 57.5 ±16.2 years, 36.6% had an initial shockable rhythm and 41.7% received bystander CPR. Fifty-six (40.3%) individuals survived to hospital discharge. Approximately 28.8% of the cohort was admitted to the hospital by a female attending physician. Guideline adherence by provider gender is described in the Table. No statistically significant differences were appreciated when examining the frequency of guideline concordant care and attending physician gender. Conclusions: In this small cohort of post-cardiac arrest patients, provider gender does not appear to affect post-arrest care guideline adherence. Further study in a large, multi-center cohort may yield different findings.

Treatment of Atrial Fibrillation and Concordance With the American Heart Association/American College of Cardiology/Heart Rhythm Society Guidelines: Findings From ORBIT-AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation).

It is unclear how frequently patients with atrial fibrillation receive guideline-concordant (GC) care and whether guideline concordance is associated with improved outcomes. Using data from ORBIT-AF (Outcomes Registry for Better Informed Treatment of Atrial Fibrillation), we determined how frequently patients received care that was concordant with 11 recommendations from the 2014 American Heart Association/American College of Cardiology/Heart Rhythm Society atrial fibrillation guidelines pertaining to antithrombotic therapy, rate control, and antiarrhythmic medications. We also analyzed the association between GC care and clinical outcomes at both the patient level and center level. A total of 9570 patients were included. The median age was 75 years (interquartile range, 67-82), and the median CHA2DS2-VASc score was 4 (interquartile range, 3-5). A total of 5977 patients (62.5%) received care that was concordant with all guideline recommendations for which they were eligible. Rates of GC care were higher in patients treated by providers with greater specialization in arrhythmias (60.0%, 62.4%, and 67.0% for primary care physicians, cardiologists, and electrophysiologists, respectively; P<0.001). During a median of 30 months of follow-up, patients treated with GC care had a higher risk of bleeding hospitalization (hazard ratio=1.21; P=0.021) but a similar risk of death, stroke, major bleeding, and all-cause hospitalization. Over a third of patients with atrial fibrillation in this large outpatient registry received care that differed in some respect from guideline recommendations. There was no apparent association between GC care and improved risk-adjusted outcomes.

Treatment Trends and Outcomes in Healthcare-Associated Pneumonia.

The American Thoracic Society and Infectious Diseases Society of America guidelines for management of healthcare-associated pneumonia (HCAP), first published in 2005, have been controversial regarding the selection of empiric broad-spectrum antibiotics, whether the criteria for HCAP predicts the likelihood of infection with multidrug resistant organisms, and whether HCAP patients have improved outcomes when treated with empiric broad-spectrum antibiotics. A retrospective cohort study at 488 US hospitals from July 2007 to November 2011. Patients who met criteria for HCAP were included. Guideline-concordant antibiotics were assessed based on guideline recommendations. We assessed changes in hospital rates of concordant antibiotic use over time and their correlation with outcomes. Among 149,963 patients with HCAP, 19.6% received fully guideline-concordant antibiotics, 21.7% received partially concordant antibiotics, and 58.9% received discordant antibiotics. Guideline concordance increased over time. Rates of fully or partially concordant antibiotics varied across hospitals (median 36.4%; interquartile range 25.8%-49.1%). Among patients who received discordant antibiotics, 81.5% were treated according to community-acquired pneumonia (CAP) guidelines. On average, the rate of guideline concordance increased by 2.2% per 6-month interval, while hospital level rates of mortality, excess length of stay, and progression to respiratory failure did not change. In this large, nationally representative cohort, only 1 in 5 patients with risk factors for HCAP received treatment that was fully in accordance with guidelines, and many received CAP therapy instead. At the hospital level, increases in the use of concordant antibiotics were not associated with declines in mortality, excess length of stay, or progression to respiratory failure.

Treatment, logistical, and cost burden of prior authorization in community practice.

164 Background: Prior authorization (PA) process is complicated and labor intensive and with limited resources available to community practices, significant opportunity to reduce the costs of therapy exists by transforming this decision support process while being compliant with guidelines Methods: We retrospectively evaluated 123 patients between November 2016 and June 2016 across our three rural oncology practices with no dedicated in-house pharmacy. An established PA workflow involved two physicians, 1 nursing staff and 2 clerical staff involved in the process to manage PA for high cost imaging (PET/CT/MRI) or after a high-risk/cost prescription was initiated by a medical provider to a local pharmacy, specialty or mail-order pharmacy. Two Physicians determined strength of concordance with National Comprehensive Cancer Network (NCCN) guidelines. We examined approval rates, method of communications, time to approval and whether these variables were associated treatment delay and insurance provider Results: Eight decision steps were necessary to obtain a PA. Forty-nine Medicare (39%), 21 managed Medicaid (17%), 29 commercial insurance (23.5%) and 14 commercial insurances (11%) required PA mostly for targeted therapy (29%), oral chemotherapy (28%), PET/CT (24%). Approval rate was 94.3% on first attempt with only 1.6% being denied after an appeal process. 89% concordance with NCCN guidelines was seen. Median time to start treatment was 4 working days (Mean 4.7; Range 0-18 days). PA requests were associated with greatest delay in approval time with managed Medicaid (7 v 1.51 days; p &lt; 0.0001) compared to Medicare, when specialty pharmacy was used (5.2 v 2.3 days p &lt; 0.03) and when fax was used versus online (4.1 v 2.3 days p &lt; 0.02). Conclusions: The impact of the PA process on care delivery and cost reduction are not clear. Current process is particularly burdensome on small practices especially given the high approval rates. Significant opportunity exists to reduce the inefficiency of this system using a computer algorithm-based PA using real-time online decision support system using NCCN guideline concordance

Integrating CHWs as Part of the Team Leading Diabetes Group Visits: A Randomized Controlled Feasibility Study.

Purpose The purpose of the study was to evaluate the feasibility of integrating Community Health Workers (CHWs) as part of the team leading diabetes group visits. Methods This was a randomized controlled study that integrated CHWs as part of the team leading diabetes group visits for low-income Hispanic adults (n = 50). Group visits met for 3 hours each month for a 6-month duration. Main measures included baseline and 6-month clinical outcomes (ie, A1C, lipids), concordance with 8 standard of care guidelines (ie, screens for cervical, breast, and colon cancer) from the US Preventive Task Force and American Diabetes Association, and participant acceptability. Results Compared to control participants, the intervention group resulted in significantly better clinical outcomes or guideline concordance for the following areas: target A1C levels, retinal eye exams, diabetes foot exams, mammograms, and urine microalbumin. Significantly more individuals in the control group gained weight, whereas a greater number of participants in the intervention group lost weight. Intervention participants found the group visits highly acceptable. Conclusions Integrating CHWs as part a comprehensive diabetes group visit program is a feasible and effective system-level intervention to improve glycemic control and achieve guideline concordance.

Opioid Prescribing for Opioid-Naive Patients in Emergency Departments and Other Settings: Characteristics of Prescriptions and Association With Long-Term Use

We explore the emergency department (ED) contribution to prescription opioid use for opioid-naive patients by comparing the guideline concordance of ED prescriptions with those attributed to other settings and the risk of patients' continuing long-term opioid use. We used analysis of administrative claims data (OptumLabs Data Warehouse 2009 to 2015) of opioid-naive privately insured and Medicare Advantage (aged and disabled) beneficiaries to compare characteristics of opioid prescriptions attributed to the ED with those attributed to other settings. Concordance with Centers for Disease Control and Prevention (CDC) guidelines and rate of progression to long-term opioid use are reported. We identified 5.2 million opioid prescription fills that met inclusion criteria. Opioid prescriptions from the ED were more likely to adhere to CDC guidelines for dose, days' supply, and formulation than those attributed to non-ED settings. Disabled Medicare beneficiaries were the most likely to progress to long-term use, with 13.4% of their fills resulting in long-term use compared with 6.2% of aged Medicare and 1.8% of commercial beneficiaries' fills. Compared with patients in non-ED settings, commercial beneficiaries receiving opioid prescriptions in the ED were 46% less likely, aged Medicare patients 56% less likely, and disabled Medicare patients 58% less likely to progress to long-term opioid use. Compared with non-ED settings, opioid prescriptions provided to opioid-naive patients in the ED were more likely to align with CDC recommendations. They were shorter, written for lower daily doses, and less likely to be for long-acting formulations. Prescriptions from the ED are associated with a lower risk of progression to long-term use.

Assessing physician knowledge regarding indications for a primary prevention implantable defibrillator and potential barriers for referral.

Although there is clear evidence to demonstrate that primary prevention implantable defibrillators (ICDs) reduce mortality in high-risk patients, ICDs are underutilized. Limited data exist assessing referring physicians' knowledge about guideline indications and attitudes towards ICDs, which may influence decision for referral. The Arrhythmia Working Group from the Alberta Cardiovascular and Stroke Strategic Clinical Network developed a web-based survey consisting of case scenarios regarding primary prevention ICD indications and a list of barriers for referral to aid in the design of a complex device care pathway. We invited referring physicians to participate in the survey including internists and cardiologists and cardiology residents. The survey was completed by 109 of 799 (response rate=14%) of physicians. Of those, 55% were internists, 32% cardiologists, and 13% cardiology residents. The majority of physicians were male (62%), practicing in a university hospital (66%). Overall, complete guideline-concordant answers were provided by 34% of physicians. In multivariable analysis, predictors of complete guideline concordance were being a cardiologist (odd ratio [OR] 5.9, confidence interval [CI] 2.1-16.4, P=0.001) and cardiology resident (OR 6.7, CI 1.7-27.3, P=0.007). The most common barrier for referral for internists was lack of confidence in knowledge of guideline recommendations; while cardiologists reported concerns about cost-effectiveness and cardiology residents were most concerned with inappropriate shocks. Knowledge regarding indications for primary prevention ICD is limited and varies significantly among referring physicians. The barriers for referral differ among physician groups and addressing these identified barriers may help to improve appropriate ICD utilization.

Predictors of epinephrine dispensing and allergy follow-up after emergency department visit for anaphylaxis

BackgroundNational guidelines recommend that patients with anaphylaxis be prescribed an epinephrine auto-injector (EAI) and referred to an allergy/immunology (A/I) specialist. ObjectiveTo evaluate guideline concordance and identify predictors of EAI dispensing and A/I follow-up in patients with anaphylaxis treated in the emergency department (ED). MethodsWe identified patients seen in the ED for anaphylaxis from 2010 through 2014 from an administrative claims database using an expanded International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithm. ResultsOf 7,790 patients identified, 46.5% had an EAI dispensed and 28.8% had A/I follow-up within 1 year after discharge. On multivariable analysis, those 65 years or older (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.30–0.41) and with a medication trigger (OR 0.24, 95% CI 0.21–0.28) had a lower likelihood of EAI dispensing. Those younger than 5 years (OR 2.67, 95% CI 2.15–3.32) and with food (OR 1.40, 95% CI 1.24–1.59) or venom (OR 4.48, 95% CI 3.51–5.72) triggers had a higher likelihood of EAI dispensing. Similarly, for A/I follow-up, the likelihood was lower for age 65 years or older (OR 0.46, 95% CI 0.39–0.54) and medication trigger (OR 0.66, 95% CI 0.56–0.78) and higher for age younger than 5 years (OR 3.15, 95% CI 2.63–3.77) and food trigger (OR 1.39, 95% CI 1.22–1.58). ConclusionOverall, 46.5% of patients with anaphylaxis in the ED had EAI dispensing and 28.8% had A/I follow-up. Patient age and triggers were associated with likelihood of EAI dispensing and A/I follow-up. Post-ED visit anaphylaxis management can be improved, with the potential to decrease future morbidity and mortality risk.

Concordance With Prevention Guidelines and Subsequent Cancer, Cardiovascular Disease, and Mortality: A Longitudinal Study of Older Adults.

Reports on the associations between multiple clinical and behavioral health indicators and major health outcomes among older adults are scarce. We prospectively examined concordance with guidelines from the American Cancer Society and American Heart Association for disease prevention in relation to cancer, cardiovascular disease (CVD), and mortality among Cardiovascular Health Study enrollees aged 65-98 years who, at baseline assessment in 1989-1996 (n = 3,491), were free of CVD and cancer. Total and cause-specific mortality, as well as incidence of cancer and CVD, were lower with higher guideline concordance. Independent of body mass index, blood pressure, total cholesterol, and fasting plasma glucose, better health behaviors (diet, physical activity, and alcohol consumption) were associated with lower mortality (2-sided P < 0.0001). Among individuals with ideal levels for 3-4 of these 4 cardiometabolic biomarkers, those with poor concordance with health behavior recommendations had higher mortality compared with those who had the highest concordance with these behavioral recommendations (adjusted mortality hazard ratio = 1.82, 95% confidence interval: 1.25, 2.67). Older adults who are concordant with recommendations for cancer and CVD prevention have reduced rates of chronic disease and mortality. Interventions to achieve and maintain healthy lifestyle behaviors may offer benefits both in the presence and absence of adverse traditional clinical risk factors.

Decision support during electronic prescription to stem antibiotic overuse for acute respiratory infections: a long-term, quasi-experimental study

BackgroundInterventions to support decision-making can reduce inappropriate antibiotic use for acute respiratory infections (ARI), but they may not be sustainable. The objective of the study is to evaluate the long-term effectiveness of a clinical decision-support system (CDSS) interposed at the time of electronic (e-) prescriptions for selected antibiotics.MethodsThis is a retrospective, observational intervention study, conducted within a large, statewide Veterans Affairs health system. Participants are outpatients with an initial visit for ARI. A CDSS was deployed upon e-prescription of selected antibiotics during the study period. From 01/2004 to 05/2006 (pre-withdrawal period), the CDSS targeted azithromycin and the fluoroquinolone gatifloxacin. From 05/2006 to 12/2011 (post-withdrawal period), the CDSS was retained for azithromycin but withdrawn for the fluoroquinolone. A manual record review was conducted to determine concordance of antibiotic prescription with ARI treatment guidelines.ResultsOf 1131 included ARI visits, 380 (33.6%) were guideline-concordant. For azithromycin, concordance did not change between the pre- and post-withdrawal periods, and adjusted odds of concordance was 8.8 for the full study period, compared to unrestricted antibiotics. For fluoroquinolones, guideline concordance decreased from 88.6% (39 of 44 visits) to 51.3% (59 of 115 visits), pre- vs. post-withdrawal periods (p < 0.005). The adjusted odds of concordance compared to “All Other Antibiotics” visits decreased from 24.4 (95% CI 9.0–66.3) pre-withdrawal to 5.5 (95% CI 3.5–8.8) post-withdrawal (p = .008). Concordance did not change between those same time periods for antibiotics that were never subjected to the intervention (“All Other Antibiotics”).ConclusionsA CDSS interposed at the time of e-prescription of selected antibiotics can shift their use toward ARI treatment guidelines, and this effect can be maintained over the long term as long as the CDSS remains in place. Removal of the CDSS after 3.5 years of implementation resulted in a rise in guideline-discordant antibiotic use.

Assessing guideline-concordant prescribing for community-acquired pneumonia.

Background Current reports of outpatient antimicrobial prescribing practices may overestimate guideline concordance since they address only drug selection. Appropriate stewardship should consider all prescribing criteria (i.e., dose, frequency, duration, and route of administration) to fully assess guideline concordance. Objective Using a community-acquired pneumonia (CAP) example, the aims of this pilot study were to estimate guideline concordance in adult patients 18years or older when all prescribing criteria are considered, and provide recommendations to optimize treatment. Specific objectives were to determine which medications were most commonly prescribed for high-and low-risk patients, respectively, and determine if prescription parameters typically meet guideline recommendations. Methods This historical (retrospective) chart review at a large, non-emergent, outpatient academic practice included adult cases of CAP identified by ICD-9 codes, 481.x-486.x, 480.x and 487.x, diagnosed between July 1, 2014 and June 30, 2015. Patients were stratified into low- or high-risk categories based on presence of comorbidities and recent antibiotic use. Descriptive statistics were used to profile the sample and estimate aggregate guideline appropriateness, based on Infectious Disease Society of America/American Thoracic Society guidelines. Cases that were not prescribed an antibiotic at the index visit were excluded from assessment of concordance. Results Of the 101 total episodes identified, 49% were treated with an antibiotic. Of the 45 cases that met low-risk criteria, seven of the 24 treated cases (29%) received an appropriate antibiotic. When considering all prescription elements, all seven cases were congruent, for a composite concordance rate of 29%. Of the 56 cases that met high-risk criteria, 13 of the 25 treated cases (52%) received an appropriate antibiotic, although two cases were prescribed a suboptimal dose, and one case was prescribed a suboptimal duration, dropping composite concordance to 40%. Overall, prescribing was concordant in 17 of the 49 treated cases (35%). Conclusion Concordance with current guidelines in this local sample is suboptimal. In the low-risk group, when the correct medication was chosen, dose, duration, and frequency were appropriate. Consideration of dose and duration of treatment decreased the rate of concordant prescribing in the high-risk group.

Poor Adherence to National Clinical Management Guidelines: A Population-Based, Cross-Sectional Study of the Surgical Management of Melanoma in New South Wales, Australia.

Standardization of the clinical management of melanoma through the formulation of national guidelines, based on interpretation of the existing evidence and consensus expert opinion, seeks to improve quality of care; however, adherence to national guidelines has not been well studied. A population-based, cross-sectional study of the clinical management of all patients with newly notified primary melanomas in the state of New South Wales, Australia, during 2006/2007 was conducted using cancer registry identification and questionnaires completed by treating physicians. Surgical margin guidelines were adhered to in 35% of cases; 45% were over treated and 21% were undertreated. Factors independently associated with non-concordance on multivariate analysis were lower Breslow thickness, lower socio-economic status of the physician's practice location, older physician age, lower physician caseload, and physicians who biopsied the lesion and then referred for definitive management. Complications were not related to over- or under-treatment on multivariate analysis (p=0.72). Sentinel lymph node biopsy was performed in 17% of patients with invasive melanoma, with the main determinant for selection being a Breslow thickness>0.75mm. The low level of concordance with national guidelines for surgical management of melanoma resulted in overtreatment of many patients. However, a fifth of patients were undertreated, which is likely to have resulted in increased locoregional recurrence rates. The better concordance achieved by physicians treating>30 melanomas per year suggests that a minimum caseload threshold for physicians treating melanoma patients would be desirable. High guideline concordance will ensure patients receive optimal care and minimize morbidity and health service costs.