Inappropriate Rate Research Articles

Remote monitoring of implantable cardioverter defibrillators: a systematic review and meta-analysis of randomised controlled trials

Abstract Background Remote monitoring (RM) of implantable cardioverter defibrillators (ICD) has been widely adopted as the standard follow-up strategy [1]. Observational data [2,3] has suggested morbidity and mortality reduction associated with RM compared to traditional in-person ICD follow-up, however, randomised controlled trials (RCTs) demonstrate heterogeneous results. Purpose To assess the impact of RM of ICDs on morbidity and mortality through a systematic review and meta-analysis of RCTs comparing RM versus in-person follow-up. Methods PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) and reference lists were searched for RCTs evaluating RM compared to in-person follow-up of patients with ICDs or cardiac resynchronisation therapy with defibrillator (CRT-D) devices. Meta-analyses of all-cause mortality, cardiovascular (CVD) hospitalisation and inappropriate ICD shock rates were performed. Results Literature search identified 1011 relevant publications, out of which 15 RCTs [4-18] involving a total of 7579 patients (13 RCTs reporting mortality rate, 7 RCTs reporting CVD hospitalisation rate, 6 RCTs reporting inappropriate ICD shock rate) met the inclusion criteria. Pooled analyses demonstrated that RM is not associated with a significant reduction in all-cause mortality (OR 0.95; 95% CI 0.78-1.16; p=0.60)(Figure 1, panel a) or odds of CVD hospitalisation (OR 0.95; 95% CI 0.72-1.25; p=0.70) (Figure 1, panel b). RM was, however, shown to be associated with significantly lower odds of receiving an inappropriate ICD shock compared to the control group (OR 0.63; 95% CI 0.46-0.88; p=0.006) (Figure 1, panel c). The IN-TIME study (the only RCT that independently reached statistical significance in terms of RM effect on mortality) enrolled patients exclusively with a Biotronik ICD or CRT-D; this raised the question as to whether the choice of vendor had an impact on mortality. Our subgroup analysis of the Biotronik device studies demonstrated that there was no significant all-cause mortality benefit (OR 0.87, 95% CI 0.59-1.27; p=0.46). Conclusions This meta-analysis of 15 RCTs including 7579 patients suggests that RM of ICDs is associated with a reduction in inappropriate ICD shocks, without a significant reduction in mortality or CVD hospitalisation when compared to in-person follow-up. Further studies comparing different RM processing and alert response models are warranted.

Performance and Safety of the Extravascular Implantable Cardioverter-Defibrillator Through Long-Term Follow-Up: Final Results From the Pivotal Study.

Substernal lead placement of the extravascular implantable cardioverter-defibrillator (EV ICD) permits both defibrillation at thresholds similar to those seen with transvenous ICDs and effective antitachycardia pacing (ATP), while avoiding the vasculature and associated complications. The global Pivotal study has shown the EV ICD system to be safe and effective through 6 months, but long-term experience has yet to be published. We aim to report the performance and safety of the EV ICD system throughout the study. The EV ICD Pivotal study was a prospective, global, single-arm, pre-market clinical study. Individuals with a class I or IIa indication for a single-chamber ICD per guidelines were enrolled. Freedom from major system- or procedure-related complications, as well as appropriate and inappropriate therapy rates, were assessed through 3 years using the Kaplan-Meier method. Anti-tachycardia pacing success was calculated using simple proportions. An implant was attempted in 316 patients [25.3% female, 53.8±13.1 years old, 81.6% primary prevention, LVEF 38.9%±15.4%]. Of 299 patients with a successful implant, 24 experienced 82 spontaneous arrhythmic episodes that were appropriately treated with either ATP only (38, 46.3%), shock only (34, 41.5%), or both (10, 12.2%) for a Kaplan-Meier-estimated rate of first any appropriate therapy of 9.2% at 3 years. Antitachycardia pacing was successful in 77.1% (37/48) of episodes, and ATP usage significantly increased from discharge to last follow-up visit (P<0.0001). Shock therapy was successful in 100% (27/27) of discrete, spontaneous ventricular arrhythmias. The inappropriate shock rates at 1 and 3 years were 9.8% and 17.5%, respectively, with P-wave oversensing the predominant cause. No major intraprocedural complications were reported and the estimated freedom from system- or procedure-related major complications was 91.9% at 1 year and 89.0% at 3 years. The most common major complications were lead dislodgement (10 events; n=9 patients, 2.8%), postoperative wound or device pocket infection (n=8, 2.5%), and device inappropriate shock delivery (n=4, 1.3%). Twenty-four system revisions were performed as a result of major complications related to the EV ICD system or procedure. From implant to study completion, the EV ICD Pivotal study demonstrated that a single integrated system with an extravascular lead placed in the substernal space maintains high ATP success, effective defibrillation, and a consistent safety profile.

Antimicrobial prescription pattern and appropriateness for respiratory tract infection in outpatients: a systematic review and meta-analysis

BackgroundMillions of people die every year as a result of antimicrobial resistance worldwide. An inappropriate prescription of antimicrobials (e.g., overuse, inadequate use, or a choice that diverges from established guidelines) can lead to a heightened risk of antimicrobial resistance. This study aimed to determine the rate and appropriateness of antimicrobial prescriptions for respiratory tract infections.MethodsThis review was conducted in accordance with the PRISMA guidelines. Web of Science, PubMed, ProQuest Health and Medicine, and Scopus were searched between October 1, 2023, and December 15, 2023, with no time constraints. Studies were independently screened by the first author and the co-authors. We included original studies reporting antimicrobial prescription patterns and appropriateness for respiratory tract infections. The quality of included studies’ was assessed via the Joanna Briggs Institute’s Critical Appraisal Checklists for Cross-Sectional Studies. The assessment of publication bias was conducted using a funnel plot and Egger’s regression test. A random effect model was employed to estimate the pooled antibiotic prescribing and inappropriate rates. Subgroup analysis was conducted by country, study period, data source, and age group.ResultsOf the total 1220 identified studies, 36 studies were included in the review. The antimicrobial prescribing rate ranged from 25% (95% CI 0.24–0.26) to 90% (95% CI 0.89–0.91). The pooled antimicrobial prescription rate was 66% (95% CI 0.57 to 0.73). Subgroup analysis by region revealed that the antimicrobial prescription rate was highest in Africa (79%, 95% CI 0.48–0.94) and lowest in Europe (47%, 95% CI 0.32–0.62). Amoxicillin and amoxicillin-clavulanate antimicrobials from the Access group, along with azithromycin and erythromycin from the Watch group, were the most frequently used antimicrobial agents. This study revealed that the major reasons for antimicrobial prescription were acute bronchitis, pharyngitis, sinusitis, and the common cold. The pooled inappropriate antimicrobial prescription rate was 45% (95% CI 0.38–0.52). Twenty-eight of the included studies reported that prescribing antimicrobials without proper indications was the main cause of inappropriate antimicrobial prescriptions. Additionally, subgroup analysis by region showed a higher inappropriate antimicrobial prescription rate in Asia at 49% (95% CI 0.38–0.60). The result of the funnel plot and Egger’s tests revealed no substantial publication bias (Egger’s test: p = 0.268).ConclusionThe prescribing rate and inappropriate use of antimicrobials remain high and vary among countries. Further studies should be conducted to generate information about factors contributing to unnecessary antimicrobial prescriptions in outpatients.Systematic review registrationSystematic review registration: CRD42023468353.

Cautionary Tales on Heating-rate Prescriptions in Kilonovae

A major ingredient for kilonova lightcurves is the radioactive heating rate and its dependence on the electron fraction and velocity of the ejecta and, in principle, on the nuclear mass formula. Heating-rate formulae commonly used as the basis for kilonova models previously employed in the literature produce substantially different outputs for high electron fractions (Y e ≳ 0.3) and at late times (t ≳ 1 day) compared to newer prescriptions. Here, we employ standard semianalytical models for kilonovae with better heating rate prescriptions valid for the full parameter space of kilonova velocities and electron fractions to explore the impact of the heating rate on kilonova lightcurves. We show the dangers of using inappropriate heating rate estimates by simulating realistic observations and inferring the kilonova parameters via a misspecified heating-rate prescription. While providing great fits to the photometry, an incorrect heating-rate prescription fails to recover the input ejecta masses with a bias significantly larger than the typical statistical uncertainty. This bias from an incorrect prescription has significant consequences for interpreting kilonovae, their use as additional components in gamma-ray burst afterglows, and understanding their role in cosmic chemical evolution or for multimessenger constraints on the nuclear equation of state. We showcase a framework and tool to better determine the impact of different modeling assumptions and uncertainties on inferences into kilonova properties.

Implantable cardioverter defibrillator therapy in paediatric patients for primary vs. secondary prevention.

The decisions about placing an ICD in a child are more difficult than in an adult due to longer expected lifespan and the complication risk. Young patients gain the most years from ICDs, despite higher risk of device-related complications. The secondary prevention ICD indication is clear, and device is implanted regardless of potential complications. For primary prevention, risk of sudden cardiac death and complications need to be evaluated. We aimed to compare outcomes for primary and secondary prevention ICDs. Retrospective nationwide cohort study including paediatric patients identified from the Danish ICD registry with ICD implanted at an age ≤ 15 from 1982-21. Demographics, complications (composite of device-related infections or lead-failure requiring re-operation, mortality because of arrhythmia, or unknown cause), and mortality were retrieved from medical charts. Endpoint was appropriate therapy (shock or anti-tachycardia pacing for ventricular tachycardia or fibrillation). Of 72 receiving an ICD, the majority had channelopathies (n = 34) or structural heart diseases (n = 28). ICDs were implanted in 23 patients for primary prevention and 49 for secondary prevention, at median ages of 13.8 and 11.6 years (P-value 0.01), respectively. Median follow-up was 9.0 (interquartile ranges: 4.7-13.5) years. The 10-year cumulative incidence of first appropriate therapy was 70%, with complication and inappropriate therapy rates at 41% and 15%, respectively. No difference was observed between prevention groups for all outcomes. Six patients died during follow-up. In children, two-thirds are secondary prevention ICDs. Children have higher appropriate therapy and complication rates than adults, while the inappropriate therapy rate was low.

Reduction of inappropriate shock rate through signal filtering (smart-pass) in patients with implantable subcutaneous cardioverter-defibrillator: a systematic review and meta-analysis.

Subcutaneous implantable cardioverter-defibrillators (S-ICD) are effective in protecting patients against sudden death but expose them to a higher risk of inappropriate shock (IAS). We performed a systematic search of studies published between January 2010 and December 2019 assessing IAS due to cardiac oversensing by the selection process (PRISMA) and identified 17 eligible articles. Fifteen studies were observational, and two studies were retrospective. For the meta-analysis, the final population included 6111 patients: 3356 without SMART pass (SP) filter (group 1) and 2755 with SP filter (group 2). 1614 shocks (appropriate shocks plus IAS) were registered (1245 in group 1 and 369 in group 2). The random effects meta-analysis estimated an overall IAS rate of 7.78% (95% confidence interval: 4.93-10.64) with substantial variability between studies (I square=96.05%, p<0.001). The IAS rate was 10.75% (95% confidence interval: 8.49-13.02) for group 1 and 3.61% (95% confidence interval: 1.36-5.86) for group 2 (p<0.001). Third-generation S-ICD technology with SP filters reduced the risk of cardiac signal-related IAS.

Appropriateness of colonoscopies in a Tunisian endoscopy center: factors and EPAGE-I/II criteria comparison

BackgroundThere is a growing demand for colonoscopy, worldwide, resulting in increased rate of inappropriate referrals. This “overuse” of colonoscopies has become a major burden for health care.Objectivesto assess the appropriateness of colonoscopies performed at the endoscopy unit of the university hospital of Sousse and to compare these results of appropriateness according to the European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE) I and EPAGE II criteria.Patients and methodsthis cross-sectional study included all consecutive patients referred for a diagnostic colonoscopy, between January 2017 and December 2018. Patients referred for exclusively therapeutic indications, those with incomplete colonoscopies were not included. Patients with poor bowel preparation or missing data were also excluded. Indications were assessed using the EPAGE I and EPAGE II criteria.ResultsFrom 1972 consecutive patients, 1307 were included. Overall, 986 (75.4%) of all referrals were for out-patients. The majority of patients were referred by gastroenterologists (n = 1026 patients; 78.5%), followed by general surgeons (n = 85; 6.5%). The commonest indications were lower abdominal symptoms (275; 21%) followed by uncomplicated diarrhea (152; 11.6%). Relevant findings were present in 363 patients (27.7%). Neoplastic lesions were the dominant finding in 221 patients (16.9%). EPAGE I and EPAGE II criteria were applicable for 1237 (88.8%) and 1276 (97.7%) patients respectively. Hematochezia and abdominal pain recorded the highest inappropriate rates with both sets of criteria. Appropriate colonoscopies increased to 76.4% when EPAGE II criteria were applied; whereas uncertain and inappropriate procedures decreased to 10.3% and 10.9% respectively Appropriateness of indication was significantly higher in hospitalized patients. For the EPAGE II criteria, the specialty of the referring physician was also significantly associated to the appropriate use. The agreement between EPAGE I and EPAGE II criteria was slight using the weighted version of k (k = 0.153).ConclusionsThe updated and improved EPAGE II guidelines are a simple and valid tool for assessing the appropriateness of colonoscopies. They decreased the inappropriate rate and the possibility of missing potentially severe diagnoses.

Appropriateness of Antibiotic Prescriptions in Emergency Departments in the United States, 2016-2021

Background: Inappropriate antibiotic prescribing contributes to antimicrobial resistance, a global health threat. Prior studies have used ICD-9-CM codes to estimate inappropriate prescribing rates in ambulatory settings, including emergency departments (EDs), though the last national estimates date back to 2010-2015 (Hersh et al, CID 2021). Using the most recent publicly available data, we estimated inappropriate antibiotic prescribing rates in EDs across all conditions. For further characterization, we estimated rates of inappropriate antibiotic prescribing with and without codes that could be plausible indications for which antibiotics are prescribed. Methods: We analyzed 2016-2021 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative survey of EDs, subsetting to visits with ≥1 oral antibiotic prescription. Using ICD-10-CM codes (Chua et al, BMJ 2019), we calculated proportions of visits with inappropriate antibiotic prescribing; inappropriate antibiotic prescribing and ≥1 plausible antibiotic-inappropriate indication (e.g., viral infection); and inappropriate prescribing without plausible antibiotic-inappropriate indications. Among visits with plausible antibiotic-inappropriate indications, we subcategorized these further (e.g. viral infection, ophthalmologic conditions). Among visits without plausible antibiotic-inappropriate indications, we determined the most common diagnosis codes. We conducted analyses overall and separately among children (0-17 years), adults (18-64 years), and older adults (≥65 years). Results: Demographic characteristics by age group are shown in Table 1. Antibiotic prescription rates overall and for children, adults, and older adults were 18.6%, 17.8%, 19.1%, and 18.0%, respectively. Inappropriate prescription rates were 27.6%, 23.7%, 29.8%, and 24.6%, respectively. Inappropriate antibiotic prescription rates with plausible indications were 14.9%, 16.7%, 15.0%, and 12.6%, while inappropriate antibiotic prescription rates without plausible indications were 12.7%, 7.0%, 14.9%, and 12.0%, respectively (Figure 1). Rates of subcategories of inappropriate prescribing with plausible antibiotic indications overall and by age group are shown in Figure 2, with the most common diagnoses for potential signs and symptoms of infection in Table 2. The most common diagnoses for inappropriate prescribing without plausible indications are in Table 3. Conclusions: Inappropriate antibiotic prescriptions in EDs are common with a substantial proportion without plausible conditions. Most inappropriate prescriptions with plausible antibiotic-inappropriate indications are associated with potential signs and symptoms of infection without a more definitive diagnosis code, suggesting either diagnostic uncertainty or poor coding quality. Future work should distinguish between these two possibilities to determine whether stewardship efforts should focus on educational strategies to avoid unnecessary empiric antibiotic prescribing in the setting of diagnostic uncertainty, improving coding quality, or both.

The Effectiveness of Palliative Care Interventions in Long-Term Care Facilities: A Systematic Review.

The increasing elderly population is driving higher utilization rates of long-term care facilities, where residents often have multiple chronic diseases, making them potential candidates for palliative care. Timely palliative care interventions can improve their quality of life and medical autonomy. This study systematically reviews the effectiveness of palliative care programs in long-term care facilities. Databases such as PubMed, EMBASE, Cochrane Library, and Airiti Library were searched up to 31 December 2023, using PICO criteria and the following keywords: 'care home', 'nursing home', 'residential aged care facility', and 'long-term care facility' for patients; and 'Gold Standard Framework in Care Homes', 'integrated care pathway', 'care home project', and 'palliative care program' for interventions. Seven articles were included. The results indicate that the Program of All-Inclusive Care for the Elderly (PACE) intervention did not significantly influence overall quality of life but did improve the quality of death. There were no statistical differences in comfort or quality of death between the dementia and non-dementia groups. However, PACE significantly reduced healthcare costs. The implementation of the Liverpool Care Pathway (LCP) notably enhanced the control of terminal symptoms, while the Gold Standard Framework in Care Homes (GSFCH) effectively improved end-of-life care rates, do-not-resuscitate (DNR) signing rates, advance care planning (ACP) completion rates, and reduced inappropriate readmission rates. While palliative care interventions are shown to improve the quality of end-of-life care, their practical application should be adapted to fit the implementation conditions and capabilities of domestic long-term care facilities.

Optimized design and simulation study of liquid-cooled heat sink model for IGBT module based on TPMS structure

Abstract In this paper, we propose a liquid-cooled heat sink model utilizing a TPMS (triple periodic minimal surface) structure for IGBT modules. Using parametric modeling software nTopology, we establish three TPMS structures: Schwarz P, Gyroid, and Diamond. Thermal simulation analysis is conducted on the radiator model using ANSYS Fluent. The optimal structural parameters are determined to ensure effective heat dissipation while preventing excessive pump power consumption due to inappropriate inlet flow rates. Simulation results demonstrate that the liquid-cooled radiator with TPMS structure outperforms conventional radiators in heat transfer efficiency, albeit with higher inlet and outlet pressure drops. Among the TPMS-structured radiators, the Schwarz P configuration exhibits the lowest pressure drop, approximately 20% less than the remaining two, offering superior thermal management advantages.

Survey of antibiotic use on outpatient at Can Tho city Otorhinolaryngology Hospital in 2023

Background: The effective use of antibiotic plays an important role in improving health and enhancing the quality of life for patients. The goal of the survey is to describe the situation of antibiotic use and to find out factors related to inappropriate antibiotic use in prescriptions of outpatient at Can tho city Otorhinolaryngology Hospital. Materials and method: A cross-sectional survey on retrospective data from 350 prescriptions of outpatient in 2023. Results: Pathology related to the ear, nose, and throat accounting for 34.3; 54.3, and 36.3% of antibiotic prescriptions, respectively. The most prescribed antibiotics belong to beta-lactam group (98.6%). The number of drugs per prescription has a significant influence on the appropriateness of antibiotic use, with prescriptions containing more than five drugs are 2.3 times more likely to be inappropriate than prescriptions containing not more than five drugs. Patients with ear disease have an inappropriate rate that is more than 14.8 times higher than patients with other diseases. Conclusion: The survey showed that the rationality in antibiotic use was influenced by the number of medications per prescription and closely related to ear disease (p &lt; 0.05). Key words: Can Tho city otorhinolaryngolory hospital; outpatient; antibiotic.

The nature of inappropriate referrals to wellness services in primary care setting in Qatar: Outcome of multifaced interventions on rate and quality of referrals

ObjectivesThe objectives of this study were to explore the rate and types of inappropriate referrals to the wellness services and to assess the impact of multi-level interventions on the rate of inappropriate referrals at Rawdat Al-Khail health center in Qatar. MethodsThis study employed a retrospective analysis of all referrals data to Rawdat Al-Khail wellness services extracted from the Electronic Health Records (EHRs) between July 2022 and August 2023. The monthly rates and types of inappropriate referrals were calculated. In this study, pre-post analyses were performed to evaluate the impact of two sets of interventions on reducing inappropriate referral rates. The first set involved the development and distribution of e-referral pathways training manual in September 2022. The second set, implemented in April 2023, included close monitoring the rate and types of referrals, and the initiation of feedback communication between wellness services supervisors and referring physicians for advice and corrective actions. ResultsA total of 966 referrals were received during the study period, with 1:5 male-to-female ratio. Of all referrals, 34.9 % were classified as inappropriate, exhibiting considerable variations among different referring health centers. The most common reason for inappropriate referrals was due to the lack of “exercise wellness gym assessment form” (23.8 %). While interventions aimed at enhancing the referral process, they did not result in a significant overall reduction in inappropriate referral rates. However, there was a noteworthy reduction in the inappropriate referrals caused by the lack of “exercise wellness gym assessment form” observed from March to August 2023 (41 %–18 %). ConclusionThis study sheds light on the complexities of wellness services referrals, revealing a high rate of inappropriate referrals that require closer scrutiny. Despite interventions not significantly reducing the rate of these referrals, it emphasizes the need for ongoing improvement strategies. Structured, periodic interventions at higher levels are recommended to enhance referral appropriateness.

Personalized screening before subcutaneous cardioverter-defibrillator implantation: Usefulness and outcomes in clinical practice—the S-ICD screening SIS prospective study

BackgroundElectrocardiographic screening before subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation is unsuccessful in around 10% of cases. A personalized screening method, by slightly moving the electrodes, to obtain a better R/T ratio has been described to overcome traditional screening failure. ObjectiveThe objectives of the SIS study were to assess to what extent a personalized screening method improves eligibility for S-ICD implantation and to evaluate the inappropriate shock rate after such screening success. MethodsAll consecutive patients eligible for an S-ICD implantation were prospectively recruited across 20 French centers between December 2019 and January 2022. In case of traditional screening failure, patients received a second personalized screening. If at least 1 vector was positive, the personalized screening was considered successful, and the patient was eligible for implantation. ResultsThe study included 474 patients (mean age, 50.4 ± 14.1 years; 77.4% men). Traditional screening was successful in 456 (96.2%) cases. This figure rose to 98.3% (n = 466; P = .002) when personalized screening was performed. All patients implanted after successful personalized screening had correct signal detection on initial device interrogation. Nevertheless, after 1-year follow-up, 3 of the 7 patients (43%) implanted with personalized screening experienced inappropriate shock vs 18 of the 427 patients (4.2%) with traditional screening and S-ICD implantation (P = .003). ConclusionTraditional S-ICD screening was successful in our study in a high proportion of patients. Considering the small improvement in success of screening and a higher rate of inappropriate shock, a strategy of personalized screening cannot be routinely recommended.ClinicalTrials.gov identifier: NCT04101253

Evaluation of appropriateness of alerts overrides and physicians' responses of the medication-related clinical decision support system in China, a hospital-based study.

This study was designed to investigate the state quo of the appropriateness of alerts overrides of the medication-related clinical decision support system (MRCDSS) in China. The medication-related alerts in one hospital from Jan 2022 to Dec 2022 were acquired and sampled. Rates of alert overrides, appropriateness of alert generation and physicians' responses were observed. Total 14,612 medication-related alerts (≤ level 3) were recorded, of those, 12,659 (86.6%) alerts were overridden. The top 3 alert types were: drug and diagnosis contraindications (23.8%), drug and test value contraindications (23.3%), and compatibility issues (17.7%). Of all sampled 1,501 alerts, 80.2% of them were appropriately overridden by the physicians. The appropriate rate of alert generation was 57.9% and the inappropriate rate was 42.1%. The inappropriate rate of physicians' responses was 17.8%, and 2.0% physicians' responses were undetermined. A few medications accounted for over 10% of overrides, 88.3% of "overridden reasons" inputted by the physicians were meaningless characters or values, indicating an obvious "alert fatigue" in these physicians. Our results indicated that the overridden rate of MRCDSS in China was still high, and appropriateness of generation of alert was quite low. These data indicated that the MRCDSS currently using in China still needs constantly optimization and timely maintenance. Proper sensitivity to reduce triggering of useless alerts and generation of alert fatigue might play a vital role. We believed that these findings are helpful for better understanding the state quo of MRCDSS in China and providing useful insights for future developing and improving MRCDSS.

Inappropriate Peak Inspiratory Flow Rate in the Patients with Stable Chronic Obstructive Pulmonary Disease in Korea.

While inhalation therapy efficacy hinges on attaining proper peak inspiratory flow rate (PIFR), the prevalence of inappropriate PIFR among patients with chronic obstructive pulmonary disease (COPD) remains unstudied in Korea. This study aimed to assess the prevalence of inappropriate PIFR, its correlation with COPD assessment test (CAT) scores, and factors associated with suboptimal PIFR. We enrolled 108 patients with COPD who had been using the same inhaler for at least 1 year without exacerbations. PIFR was measured using an inspiratory flow meter (In-Check DIAL G16). Demographic, clinical, pulmonary function, and CAT score data were collected. Inappropriate was defined as PIFR &lt;60 L/min for dry power inhaler (DPI) users, and &gt;90 L/min for aerosol device users. The cohort comprised 87 (80.6%) men, mean age 71.0±8.5 years, with mean post-bronchodilator forced expiratory volume in 1 second of 69.1%±1.8% predicted. Twenty-nine (26.9%) used aerosol devices only, 76 (70.4%) used DPIs only, and three (2.8%) used both. Inappropriate PIFRs were found in 17.2% of aerosol device users, and 42.1% of DPI users. CAT scores were significantly higher in the inappropriate PIFR group than in the appropriate PIFR group (11.2±7.7 vs. 7.5±4.9, p=0.003). In DPI users, female, shorter height, lower body weight and maximal voluntary ventilation (MVV) were associated with inappropriate PIFR. The prevalence of inappropriate PIFR among patients with COPD is 17.2% for aerosol device users, and 42.1% for DPI users. Suboptimal PIFR correlates with female gender, shorter stature, lower weight and MVV in DPI users.

Evaluation of ChatGPT in providing appropriate fracture prevention recommendations and medical science question responses: A quantitative research.

Currently, there are limited studies assessing ChatGPT ability to provide appropriate responses to medical questions. Our study aims to evaluate ChatGPT adequacy in responding to questions regarding osteoporotic fracture prevention and medical science. We created a list of 25 questions based on the guidelines and our clinical experience. Additionally, we included 11 medical science questions from the journal Science. Three patients, 3 non-medical professionals, 3 specialist doctor and 3 scientists were involved to evaluate the accuracy and appropriateness of responses by ChatGPT3.5 on October 2, 2023. To simulate a consultation, an inquirer (either a patient or non-medical professional) would send their questions to a consultant (specialist doctor or scientist) via a website. The consultant would forward the questions to ChatGPT for answers, which would then be evaluated for accuracy and appropriateness by the consultant before being sent back to the inquirer via the website for further review. The primary outcome is the appropriate, inappropriate, and unreliable rate of ChatGPT responses as evaluated separately by the inquirer and consultant groups. Compared to orthopedic clinicians, the patients' rating on the appropriateness of ChatGPT responses to the questions about osteoporotic fracture prevention was slightly higher, although the difference was not statistically significant (88% vs 80%, P = .70). For medical science questions, non-medical professionals and medical scientists rated similarly. In addition, the experts' ratings on the appropriateness of ChatGPT responses to osteoporotic fracture prevention and to medical science questions were comparable. On the other hand, the patients perceived that the appropriateness of ChatGPT responses to osteoporotic fracture prevention questions was slightly higher than that to medical science questions (88% vs 72·7%, P = .34). ChatGPT is capable of providing comparable and appropriate responses to medical science questions, as well as to fracture prevention related issues. Both the inquirers seeking advice and the consultants providing advice recognize ChatGPT expertise in these areas.

The Use of Anemia Control Model Is Associated with Improved Hemoglobin Target Achievement, Lower Rates of Inappropriate Erythropoietin Stimulating Agents, and Severe Anemia among Dialysis Patients

Introduction: The Anemia Control Model (ACM) is a certified medical device suggesting the optimal ESA and iron dosage for patients on hemodialysis. We sought to assess the effectiveness and safety of ACM in a large cohort of hemodialysis patients. Methods: This is a retrospective study of dialysis patients treated in NephroCare centers between June 1, 2013 and December 31, 2019. We compared patients treated according to ACM suggestions and patients treated in clinics where ACM was not activated. We stratified patients belonging to the reference group by historical target achievement rates in their referral centers (tier 1: <70%; tier 2: 70–80%; tier 3: >80%). Groups were matched by propensity score. Results: After matching, we obtained four groups with 85,512 patient-months each. ACM had 18% higher target achievement rate, 63% smaller inappropriate ESA administration rate, and 59% smaller severe anemia risk compared to Tier 1 centers (all p < 0.01). The corresponding risk ratios for ACM compared to Tier 2 centers were 1.08 (95% CI: 1.08–1.09), 0.49 (95% CI: 0.47–0.51), and 0.64 (95% CI: 0.61–0.68); for ACM compared to Tier 3 centers, 1.01 (95% CI: 1.01–1.02), 0.66 (95% CI: 0.63–0.69), and 0.94 (95% CI: 0.88–1.00), respectively. ACM was associated with statistically significant reductions in ESA dose administration. Conclusion: ACM was associated with increased hemoglobin target achievement rate, decreased inappropriate ESA usage and a decreased incidence of severe anemia among patients treated according to ACM suggestion.

Feedback Intervention for the Control of Glucocorticoid Prescription in Primary Care Institutions: A Cluster Randomized Cross-Over Controlled Trial in Southwest China.

The purpose of this study is to assess the effect of glucocorticoid prescription feedback intervention in complex primary care institutions for regulating its inappropriate use. A six-month cluster randomized cross-over controlled trial was conducted in primary care institutions. A total of 347 physicians from 69 participating institutions were randomly allocated to either group A or group B. Both groups were given feedback interventions or serve as control. The feedback intervention comprised two components: a real-time pop-up warning of inappropriate glucocorticoid prescriptions based on the Hospital Information System and a high-proportion prescription feedback intervention warning system. The primary outcome measure was the 10-day inappropriate glucocorticoid prescription rate, while the 10-day glucocorticoid prescription rate served as secondary outcome measure. At baseline, the 10-day inappropriate glucocorticoid prescription rates were 66.63% and 66.57% in group A and group B, respectively, showing no significant difference (p = 0.140). Following the intervention, group A exhibited a significant reduction in 10-day inappropriate glucocorticoid prescription rate at the crossing point by 13.69% (p < 0.001). In contrast, group B, which served as the control group, experienced an increase of 5.93% (p = 0.037) at the same crossover point. After the crossover point, there was a decrease in 10-day inappropriate glucocorticoid prescription rate for both groups. Group B as the intervention group demonstrated a reduction of 28.22% compared to the crossing point (p < 0.001), whereas group A showed a decrease of 12.20% (p = 0.339). The characteristics of physicians did not significantly influence the inappropriate glucocorticoid prescription rate. The real-time pop-up warning of inappropriate glucocorticoid prescriptions based on the Hospital Information System and high-proportion prescription feedback intervention warning system can effectively regulate the inappropriate glucocorticoid prescribing behavior of physicians. ISRCTN11747547.

Physician practice migration and changes in practice style: An empirical analysis of inappropriate diagnostic imaging in primary care

Much interest exists in physicians’ ability and willingness to adapt their practice styles, as research demonstrates that many physicians practice in ways that are not aligned with the best available scientific evidence. We exploit migration patterns of primary care physicians in Massachusetts over a span of 8 years by tracking physician migrations to practice sites comprised of new peers who shared actual physical working space. We examined whether a patient's likelihood of receiving an inappropriate referral for diagnostic imaging, specifically a magnetic resonance imaging (MRI), was associated with a change in the work environment of the referring physician. Study results indicate that migrating physicians changed their practice style for imaging relatively soon after migration in conformance with the average practice style of their new peer group regardless of whether or not the practice style was aligned with evidence‐based standards for diagnostic imaging. To place our results in context, a 1 percentage point difference in average inappropriate MRI referral rates between a migrating physician's new and previous work environment was associated with approximately a 14% change in the probability that a patient received an inappropriate MRI referral. The effect diminished with greater variability in inappropriate MRI referral rates within the new peer group. The results show that physician practice style may deviate from evidence‐based standards and vary markedly among physicians within a work environment. At the same time, physician practice style is also malleable in either direction—more or less likely to deviate from evidence‐based standards in conformance with the average practice style of their new peer group. These results imply that healthcare managers can employ various institutional‐level interventions to influence physician behavior in the direction of evidence‐based practice by including strategies directed towards developing strong peer influence in physicians’ work environments.

1198. More is not Merrier: Mitigating Meropenem Misuse in the ICU at an Academic Medical Center

Abstract Background Inappropriate use of carbapenems is a major driver of antimicrobial resistance. The intensive care unit (ICU) at Mayo Clinic Arizona had a higher meropenem (MER) days of therapy (DOT) per 1000 patient days (PD) compared to other Mayo Clinic Enterprise sites, despite low rates of Pseudomonal resistance to narrower spectrum anti-pseudomonal beta-lactams. Methods A multidisciplinary team of infectious diseases (ID) and critical care medicine (CCM) physicians and pharmacists was created to reduce inappropriate use of MER in the ICU. The baseline rate of appropriateness was determined by evaluating all MER days in the ICU during Q4 2019 and Q4 2020. Each MER day was designated as appropriate or inappropriate based on pre-determined criteria after review by at least one ID and one CCM member. Discordant days were evaluated by the whole team to achieve consensus. The team provided education to the CCM department on the initiative, baseline data, and strategies to reduce inappropriate MER use. The active intervention included prospective audit and feedback of all patients on MER performed by the ID clinical pharmacists Mon-Fri 0700-1530 in Q4 2022. DOT/1000 PD was assessed for the pre-intervention and intervention periods. Results The baseline rate of inappropriate MER use in the ICU was 52% (442/846 days). The two most common reasons for inappropriate MER use in the baseline period were: susceptible organism for which a narrower agent could have been used (93/442, 21%), and infectious workup/cultures negative (89/442, 20%). During the intervention period, the inappropriate rate of MER use was reduced to 23%, below the pre-determined goal of 30%. The MER DOT/1000 PD in the baseline period were 103.9 (Q4 2019) and 151.5 (Q4 2020) versus 66.1 (Q4 2022) in the intervention period. There was no difference in ICU sepsis-related mortality in the pre-intervention vs intervention period (13.4 vs 0%, p=0.04). Conclusion A multidisciplinary team approach, including education and prospective audit and feedback, reduced inappropriate MER use in the ICU of an academic medical center from 52 to 23%. An associated decrease in MER DOT/1000 patient days was also observed. Disclosures All Authors: No reported disclosures