Inappropriate Rate Research Articles

The use of artificial intelligence and deep learning methods in subcutaneous implantable cardioverter defibrillator screening to optimise selection in special patient populations

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Dr.Mohamed ElRefai is receiving an unrestricted grant from Boston Scientific. Introduction Adult congenital heart disease (ACHD) and hypertrophic cardiomyopathy (HCM) patients who require defibrillator therapy are often relatively young and may require several generator replacements in their lifetime. The increased risk of complications associated with transvenous ICDs make the subcutaneous (S-ICD) a valuable alternative. However, higher S-ICD ineligibility rates (20-40% in ACHD and 7-38% in HCM) and higher inappropriate shock rates (10.5% in ACHD and 12.5% in HCM) are observed in these populations. Unfavourable T:R ratios and dynamic changes in the R and T wave amplitudes are the primarily factors behind ineligibility and inappropriate shocks, which are most commonly caused by T wave over-sensing. Purpose We report a novel application of deep learning methods used to autonomously screen patients for S-ICD eligibility over a longer period than conventional screening. We hypothesise that this screening approach might achieve better patient selection and optimise S-ICD vector selection in challenging patient cohorts. Methods Adult patients with ACHD or HCM and a control group of normal subjects were fitted with a 24-hour ambulatory ECG with the leads placed to record their S-ICD vectors. T: R ratio throughout the recordings was analysed utilising phase space reconstruction matrices to convert the ECG signal into compressed pixel images. Whilst a convolutional neural network model was trained to provide an in-depth description of the T: R variation plot for each vector T: R variation was compared statistically using a one-way ANOVA test. Results 20 patients (age 44.1 ±11.68, 60% male, 7 HCM, 6 ACHD and 7 control subjects) were enrolled. A significant difference was observed in the mean and median T: R values between the three groups (p<0.001). There was no difference observed in the standard deviation of T: R between the control subjects and HCM group. However, there was a statistically significant difference in the standard deviation of T: R between the control subjects and the ACHD group (p= 0.01). [see Figure]. Conclusions T:R ratio, a main determinant for S-ICD eligibility, is significantly higher in ACHD and HCM when compared to normal hearts and it also has more tendency to fluctuate in ACHD patients when compared to HCM and normal hearts populations. We hypothesise that our novel model could be used to select S-ICD eligible patients by better characterisation of T:R ratio reducing the risk of T wave oversensing and inappropriate shocks particularly in the ACHD patients’ cohort.

Three-year chronic follow-up from the pilot study of a substernal extravascular implantable cardioverter defibrillator

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Medtronic Background The investigational Extravascular Implantable Cardioverter-Defibrillator (EV ICD) uses a substernal lead and delivers defibrillation and pacing therapies, including antitachycardia pacing (ATP). Objective To characterize EV ICD system performance through 3 years. Methods The prospective, first-in-human EV ICD Pilot study was conducted at 4 sites in Australia and New Zealand. ICD-indicated patients were enrolled July-December of 2018. Defibrillation testing was conducted for all patients at implant, and chronically per physician discretion. Electrical testing was conducted at pre-hospital discharge, 2 weeks, 4-6 weeks and 3 months post-implant, and every 6 months thereafter. Posture effects on pacing and sensing were evaluated through 3 months. Results Of 26 patients enrolled, 21 underwent the EV ICD implant procedure. There were no intraprocedural complications. After successful implantation and testing, 17 of 21 patients entered chronic follow-up. 14 patients continue follow up, representing 523 patient-months. Eight elective chronic defibrillation tests converted 7 of 7 patients with ≤ 40 J (maximum energy). Five episodes of spontaneous ventricular tachycardia (VT) were detected in 1 patient and either self-terminated or successfully defibrillated with appropriate shock. Over the total course of follow-up, 3 patients received an inappropriate shock due to; lead tip displacement with subsequent P-wave oversensing; Electromagnetic interference (EMI) in a ungrounded hot-tub; and EMI while doing plumbing work on unearthed electrical pipes, resulting in an annualized inappropriate shock rate of 6.9%. Pacing capture thresholds remained stable across time (5.1 ± 2.0 V at implant and 5.5 ± 2.7 V at 3 years); similarly, R-wave amplitudes were stable across time (3.4 ±2.0 mV at implant and 4.2 ± 2.7 mV at 3 years). Pacing thresholds tended to be lowest with the patient lying on the right side and pacing threshold often increased relative to supine position for left-side, prone or bending postures. R-wave amplitude tended to be greater when bending forward. There were 10 system or procedure-related adverse events in 8 patients through 3 years, including 3 elective system removals for: a single inappropriate shock (1), chronic defibrillation testing showing no safety margin in a patient with arrhythmogenic right ventricular dysplasia (1), intolerance to ATP (1 - high pacing threshold and frequent VT). Other than the lead tip displacement within the first 3 months, no additional clinically significant lead displacements have been observed through 3 years. Conclusion The EV ICD is a novel platform for delivering high-voltage therapy. There were no procedure and system related complications observed after the first year post-implant. Lead position and chronic system performance have generally remained stable through 3 years with a low rate of adverse events.

Eligibility for subcutaneous implantable cardiac defibrillator utilising artificial intelligence and deep learning methods for prolonged screening: where is the cut-off?

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Main author is receiving an unrestricted grant by Boston Scientific Background S-ICD eligibility is determined by a single surface ECG analysis in which the suitability of an individual’s ECG vector morphology is assessed. A major predictor of eligibility is the T:R ratio. Current screening tools proposes T: R of 1:3 as a cut-off for eligibility. Inappropriate shocks due to T-wave oversensing (TWO) remains an issue despite screening. EFFORTLESS and PRAETORIAN trials reported inappropriate shock rates of 11.4% and 9.7% respectively, most frequently caused by cardiac oversensing. Purpose The cut-off T: R of 1:3 currently used incorporates a safety margin to accommodate for ECG signal amplitudes fluctuations without affecting S-ICD sensing. Prolonged screening using our tool accurately measures the T: R fluctuations. However, utilising a T: R of 1:3 for prolonged screening can unnecessarily exclude appropriate S-ICD candidates. The purpose of our study is to provide groundwork for future trials to find the optimal ratio that identifies patients at risk of TWO and inappropriate shocks while not excluding true S-ICD candidates after prolonged screening. Methods Patients were fitted with 24-hour Holter monitors with leads placed to correspond to the vectors of an S-ICD. We used our tool to assess T: R over the recordings utilising Phase Space Reconstruction matrices - to convert the ECG signal into compressed pixel images. A Convolutional Neural Network (CNN) model was trained to accurately predict the T: R from these images resulting in a T: R variation plot for each vector. We then applied multiple T:R ratio cut-offs on the recordings to identify patients at risk of inappropriate shocks due to TWO at each proposed value. A vector with a T: R above the cut-off for 20 consecutive seconds was deemed to have failed screening, the time determined by the current detection, charge, and redetection time of the current S-ICD system. A patient has to have at least one suitable vector to pass the screening at the selected threshold. Results 37 patients (mean age 54.5 years,64.8% male) were included. 14 had Heart failure, 7 Hypertrophic cardiomyopathy, 7 normal hearts, 6 Adult congenital heart disease and 3 patients who received inappropriate S-ICD shocks due to TWO. Overall, 20 (54%) of patients passed prolonged screening using a 1:3 ratio. All of the patients passed screening with a T: R of 1:1. The only subgroup to wholly pass the screening for all the proposed ratios are the normal hearts group. Conclusion We propose adopting prolonged screening to select S-ICD eligible patients with low probability of TWO and inappropriate shocks. However, utilising T: R of 1:3 can unnecessarily exclude otherwise S-ICD eligible patients. The appropriate ratio likely lies between 1:3 - 1:1. Further studies are needed to identify the optimal screening thresholds, particularly in patients that have had inappropriate shocks due to TWO.

Influence of user-centered clinical decision support on pediatric blood product ordering errors.

Children are at increased risk from transfusion-related medical errors. Clinical decision support (CDS) can enhance pediatric providers' decision-making regarding transfusion practices including indications, volume, rate, and special processing instructions. Our objective was to use CDS in a pediatric health system to reduce:blood product-related safety events from ordering errors;special processing ordering errors for patients with T-cell dysfunction, sickle cell disease (SCD), or thalassemia;transfusions administered faster than 5 mL/kg/h. In this single-center before and after quality improvement study, we evaluated how user-centered design of pediatric blood product orders influenced pediatric transfusion practices and outcomes. Safety events were identified through active and passive surveillance. Other clinically relevant outcomes were identified through electronic health record queries. Blood product-related safety events from ordering errors did not change significantly from the baseline period (6 events, 0.4 per month, from 1/1/2018-3/27/2019) to the intervention period (1 event, 0.1 per month, from 3/28/2019-12/31/2019; rate ratio: 0.27 [0.01-2.25]). Packed red blood cell (PRBC) and platelet orders for patients with T-cell dysfunction that did not specify irradiation decreased significantly from 488/12,359 (3.9%) to 204/6,711 (3.0%, risk ratio: 0.77 [0.66-0.90]). PRBC orders for patients with SCD or thalassemia that did not specify phenotypically similar units fell from 386/2,876 (13.4%) to 57/1,755 (3.2%, risk ratio: 0.24 [0.18-0.32]). Transfusions administered faster than 5 mL/kg/h decreased from 4,112/14,641 (28.1%) to 2,125/9,263 (22.9%, risk ratio: 0.82 [0.78-0.85]). User-centered design of CDS for pediatric blood product orders significantly reduced special processing ordering errors and inappropriate transfusion rates. Larger studies are needed to evaluate the impact on safety events.

Analysis of inappropriate repeated laboratory testing

Abstract Objectives Laboratory services are an important part of the healthcare system. However many requested tests may be considered inappropriate or unnecessary. We evaluated laboratory use in a period of 3 years in terms of the inappropriate test repeats. Methods We analyzed inappropriate repeat rate (IRR) of hemoglobin A1c (HbA1c), 25-OH vitamin D [25(OH)D], thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), free thyroxine (FT4), anti-thyroid peroxidase antibody (anti-TPO), vitamin B12, folate, iron, ferritin and total cholesterol in the light of clinical guidelines. Results IRR of 3 year was found to be 10% on average (4.2–15.5%). In TSH, FT3, and FT4 parameters, IRR was between 4.2 and 5.3%, while it was between 12.9 and 15.5% for 25(OH)D, iron, ferritin, and total cholesterol. In all tests (except anti-TPO), IRRs were found to be higher in inpatients for each of the 3 years. Inappropriate repetition of total cholesterol, iron, and ferritin parameters were more frequent in men. Inappropriate repeats were performed in all parameters (except HbA1c) after a result that had been in the reference range. Conclusions Examined test repetitions were mostly inappropriate. To reduce the inappropriate laboratory test requests, it is important to analyze the causes and to ensure cooperation between laboratory specialists and clinicians.

MO801: Use of the Anemia Control Model is Associated With Improved Hemoglobin Target Achievement, as Well as Lower Rates of Inappropriate ESA USE And Severe Anemia Among Dialysis Patients

Abstract BACKGROUND AND AIMS Renal anemia management remains challenging for the nephrologist. Chronic inflammation, EPO resistance, uremia, malnutrition, iron deficiency, dialysis modalities, bleeding, infections, hydration status all interfere with erythropoiesis and erythrocytes half-life. Since 2013, >100 clinics in the FMC Nephrocare network have been using the Anemia Control Model (ACM), an artificial-intelligence based, certified medical device, decision support tool, to assist nephrologists in optimizing the monthly ESA and iron dose based on the specific characteristics of the patient and the amount of ESA dose already taken in the last 90 days. Based on this widespread experience, we sought to evaluate the real-world effectiveness of the use of ACM to facilitate hemoglobin target achievement among dialysis patients. METHOD In this historical cohort study, we analyzed electronic health records (EHR) of adult patients receiving in-center hemodialysis therapy in Fresenius Medical Care European dialysis clinics between 1 January 2015 and 31 December 2018 registered in the European Clinical Database (EuCliD®). We compared the rate of target achievement between patients treated with the ESA dose, suggested by ACM, against three control groups of patients treated in clinics without ACM and stratified by different target achievement rates for hemoglobin (Hb in the range of 10–12 g/dL or > 12 g/dL without ESA administration) (Fig. 1). To decrease indication bias, we matched patients belonging to the four comparison groups by a propensity-score assessing the likelihood of receiving the same dose suggested by ACM based on patients’ characteristics (i.e. demographic, comorbidities, anemia-related biomarkers and dialysis vintage). Centers where Hb target achievement < 70% were classified as Tier 1 centers; centers where Hb target achievement was between 70% and 80% were classified as Tier 2 centers, and centers where Hb target achievement was >80% were classified as Tier 3 centers. Performance was evaluated in the month before the index date for all the patients in any given clinic. For each matched group, the index date corresponds to the date of dose suggestion (ACM group) or to the last Hb assessment date (for all matched patients belonging to other three control groups). The study endpoints were Hb target achievement, inappropriate ESA administration (ESA administration despite Hb > 12 g/dL) and severe anemia (Hb < 9 g/dL). All endpoints have been evaluated in the month following the index date. RESULTS After matching, we obtained four groups accounting for 8 5512 patient-months each. There were negligible differences in patients’ characteristics across the four matched groups (Table 1). In the ACM group, the Hb target achievement rate was 87.52/100 patient-months 95% confidence interval (95% CI): 86.89–88.15], inappropriate ESA use rate was 4.13/100 patient-months (95% CI: 3.99–4.27) and the incidence of severe anemia was 2.14/100 patient-months (95% CI: 2.04–2.24); the Hb target achievement rate ratio (95% CI) was 1.18 (1.17–1.2), 1.08 (1.07–1.09), 1.01 (1–1.02) for ACM versus Tier 1 centers, ACM versus Tier 2 centers and ACM versus Tier 3 centers, respectively. Rate ratio for inappropriate ESA administration were 0.37 (0.36–0.39), 0.49 (0.47–0.51), 0.66 (0.64–0.69) for ACM versus Tier 1 centers, ACM versus Tier 2 centers and ACM versus Tier 3 centers, respectively. The risk ratios for severe anemia were 0.43 (0.41–0.46), 0.65 (0.62–0.7), 0.95 (0.89–1.02) for ACM versus Tier 1 centers, ACM versus Tier 2 centers and ACM versus Tier 3 centers, respectively. CONCLUSION In this matched historical cohort study, we observed an increased hemoglobin target achievement rate, decreased inappropriate ESA usage and a decreased incidence of severe anemia among patients treated according to ACM suggestions. Target achievement rate among patients treated according to ACM suggestions was 87%. The magnitude of the effect in favor of ACM was larger in centers with a lower target achievement rate.

A multimodal intervention to decrease inappropriate outpatient antibiotic prescribing for upper respiratory tract infections in a large integrated healthcare system.

To evaluate the effectiveness of Carolinas Healthcare Outpatient Antimicrobial Stewardship Empowerment Network (CHOSEN), a multicomponent outpatient stewardship program to reduce inappropriate antibiotic prescribing for upper respiratory infections by 20% over 2 years. Before-and-after interrupted time series of antibiotics prescribed between 2 periods: April 2016-October 2017 and May 2018-March 2020. The study included 162 primary-care practices within a large healthcare system in the greater Charlotte, North Carolina region. Adult and pediatric patients with encounters for upper respiratory infections for which an antibiotic is inappropriate. Patient and provider educational materials, along with a web-based provider prescribing dashboard aimed at reducing inappropriate antibiotic prescribing were developed and distributed. Monthly antibiotic prescribing rates were calculated as the number of eligible encounters with an antibiotic prescribed divided by the total number of eligible encounters. A segmented regression analysis compared monthly antibiotic prescribing rates before versus after CHOSEN implementation, while also accounting for practice type and seasonal trends in prescribing. Overall, 286,580 antibiotics were prescribed during 704,248 preintervention encounters and 277,177 during 832,200 intervention encounters. Significant reductions in inappropriate prescribing rates were observed in all outpatient specialties: family medicine (relative difference before and after the intervention, -20.4%), internal medicine (-19.5%), pediatric medicine (-17.2%), and urgent care (-16.6%). A robust multimodal intervention that combined a provider prescribing dashboard with a targeted education campaign demonstrated significant decreases in inappropriate outpatient antibiotic prescribing for upper respiratory tract infections in a large integrated ambulatory network.

Effect of the water exchange rate in a recirculation aquaculture system on growth, glucose and cortisol levels in Oreochromis niloticus

In recirculating aquaculture systems (RAS), the water exchange rate influences the removal of waste compounds. However, the inappropriate exchange rate favors the presence of stress factors, causing alterations in the cultured organisms. Therefore, the aim was to determine the effect of the water exchange rate in the different productive stages (fingerling, juvenile, and adult) of Nile tilapia (Oreochromis niloticus). Three exchange rates were used: rates of 1.2 (T1), 2.8 (T2), and 5.3 (T3) tank volume h-1. The following were established as response variables: growth rate (GR), survival rate (SR), feed conversion rate, protein efficiency, and condition factor. Likewise, cortisol and glucose concentrations were established as explanatory variables. The results suggest that in the fingerling stage, the T2 treatment contributes most to the productive performance (GR = 40.24 g and SR = 95%), keeping low levels of cortisol and glucose (6.76 ng mL-1 and 33.73 mg dL-1). In the juvenile stage, T3 treatment shows the best result both in productive performance (GR = 117.69 g and SR = 90%) and in cortisol and glucose concentrations (35.13 ng mL-1 and 70.67 mg dL-1). Finally, all treatments present cortisol and glucose levels above the normal range in the adult stage, T1, where the highest productive performance is presented (GR = 90.06 g and SR = 95%). The information leads us to consider the variation in the exchange rate in a RAS through the different stages of the Nile tilapia to maintain the favorable conditions that lead to the highest performance.

Improving the Bioactivity of Hydroxyapatite Through Strontium Substitution and Forming a Composite with Graphitic Carbon Nitride

To overcome the limitations of hydroxyapatite, such as low mechanical strength, inappropriate degradation rate, and poor biological response with respect to bone apatite and growing interest on Sr doped hydroxyapatite, due to the advanced bone recovery and improved bioactivity of Sr and the non-toxic, graphitic carbon nitride (GCN) towards the biomedical applications, the present work focuses on synthesis of HAP/GCN and Sr-HAP/GCN composites by chemical precipitation followed by the hydrothermal treatment. The characteristic properties of these composites were evaluated using scanning electron microscopy, X-ray diffraction measurements, and Fourier transform infrared spectroscopy. The bioactivity of HAP/GCN and Sr-HAP/GCN composites was evaluated by immersing them in simulated body fluid (SBF) at 37 ± 1°C for 14 days and the extent of formation of apatite on their surface is observed using optical microscope. When compared to HAP, HAP/GCN, and Sr-HAP/GCN, exhibit better bioactivity and among them Sr-HAP/GCN is promising for biomedical applications.

Impact of a Clinical Decision Support System on Inappropriate Prescription of Glucose-lowering Agents for Patients With Renal Insufficiency in an Ambulatory Care Setting

Inappropriate dosing of glucose-lowering drugs in patients with renal insufficiency can cause severe harm. This study evaluated the short- and long-term effects of clinical decision support systems (CDSS) on inappropriate prescriptions of glucose-lowering agents for patients with renal insufficiency in an ambulatory care setting. This retrospective longitudinal observational study was conducted by using an electronic medical record database and the CDSS log data at Taipei Veterans General Hospital between January 1, 2015, and December 31, 2018. Outpatients who received 7 target glucose-lowering medications and had an estimated glomerular filtration rate <50 mL/min/1.73 m2 were included. Inappropriate prescriptions were defined as a dose, frequency, or daily dose of target drugs that exceeded the dosing recommendations based on renal function. Inappropriate monthly rates were calculated, and the interrupted time series analysis method was used to explore the 1- and 3-year post-implementation effects of CDSS. The major outcome measurements were the level changes and the inappropriate prescription rate trend changes after renal CDSS implementation. The acceptance rates of alerts were also analyzed. A total of 141,037 drug prescriptions were obtained during the study period. In the short-term analysis, the baseline inappropriate rate for overall medications was estimated to range from 30.54% in the first month to 27.06% in month 12. The predicted inappropriate rate 12 months after implementation was 19.35%, corresponding to an estimated 28.49% [(27.06 - 19.35)/27.06] decrease in inappropriate rate. However, after long-term analysis, the predicted inappropriate rate at the end of the study (36 months after implementation) was 18.02%. A total of 27,189 alerts were generated and 628 were accepted during the study period. Thus, after short- and long-term analysis, the overall acceptance rate was 3.06% and 2.31%, respectively. Implementing a CDSS for renal dosing adjustment could significantly decrease the inappropriate prescription rate of glucose-lowing agents among patients with renal insufficiency in an ambulatory setting in the short term, while the long-term effect of a CDSS is limited.

Teleophthalmology-enabled and artificial intelligence-ready referral pathway for community optometry referrals of retinal disease (HERMES): a Cluster Randomised Superiority Trial with a linked Diagnostic Accuracy Study—HERMES study report 1—study protocol

IntroductionRecent years have witnessed an upsurge of demand in eye care services in the UK. With a large proportion of patients referred to Hospital Eye Services (HES) for diagnostics and...

Subcutaneous implantable cardioverter-defibrillators: long-term results of the EFFORTLESS study.

AimsTo report 5-year outcomes of EFFORTLESS registry patients with early generation subcutaneous implantable cardioverter-defibrillator (S-ICD) devices.Methods and resultsKaplan–Meier, trend and multivariable analyses were performed for mortality and late (years 2–5) complications, appropriate shock (AS) and inappropriate shock (IAS) rates. Nine hundred and eighty-four of 994 enrolled patients with diverse diagnoses (28% female, 48 ± 17 years, body mass index 27 ± 6 kg/m2, ejection fraction 43 ± 18%) underwent S-ICD implantation. Median follow-up was 5.1 years (interquartile range 4.7–5.5 years). All-cause mortality was 9.3% (95% confidence interval 7.2–11.3%) at 5 years; 703 patients remained in follow-up on study completion, 171 withdrew including 87 (8.8%) with device explanted, and 65 (6.6%) lost to follow-up. Of the explants, only 20 (2.0%) patients needed a transvenous device for pacing indications. First and final shock efficacy for discrete ventricular arrhythmias was consistent at 90% and 98%, respectively, with storm episode final shock efficacy at 95.2%. Time to therapy remained unaltered. Overall 1- and 5-year complication rates were 8.9% and 15.2%, respectively. Early complications did not predict later complications. There were no structural lead failures. Inappropriate shock rates at 1 and 5 years were 8.7% and 16.9%, respectively. Self-terminating inappropriately sensed episodes predicted late IAS. Predictors of late AS included self-terminating appropriately sensed episodes and earlier AS.ConclusionIn this diverse S-ICD registry population, spontaneous shock efficacy was consistently high over 5 years. Very few patients underwent S-ICD replacement with a transvenous device for pacing indications. Treated and self-terminating arrhythmic episodes predict future shock events, which should encourage more personalized device optimization.

Impact of a pharmacy department-wide transitions-of-care program on inappropriate oral antibiotic prescribing at hospital discharge.

To evaluate oral antibiotic prescribing for common infections at hospital discharge before and after implementation of a pharmacist-driven transitions-of-care (TOC) program. Single-center before-and-after study. Acute-care, academic, community hospital in Santa Barbara, California. Eligible adult patients prescribed oral antibiotics at hospital discharge for community-acquired pneumonia, skin and soft-tissue infections, and urinary tract infections between September 2019 and December 2019 (preimplementation period) and between March 2021 and May 2021 (postimplementation period). Antimicrobial stewardship-initiated, department-wide, TOC program requiring all clinical pharmacists to review discharge antibiotic prescriptions in real time. In total, 260 antibiotic prescriptions were assessed for appropriateness: 140 before implementation and 120 after implementation. After implementation, the number of prescriptions considered inappropriate significantly decreased by 18% (52% vs 34%; P = .005). Inappropriate rates decreased in all assessment categories: dosing (15% vs 2%; P < .001), treatment duration (42% vs 31%; P = .08), antibiotic selection based on infection type or microbiology (8% vs 4%; P = .33), and antibiotics not indicated (16% vs 10%; P = .18). Median total antibiotic days decreased by 1 day after implementation (10 days vs 9 days; P = .67), and 30-day readmission rates were similar between both phases. A real-time, pharmacist-driven, TOC program for oral antibiotic prescriptions had a significant impact in reducing inappropriate prescribing of antibiotics at hospital discharge for common infections. Incorporating discharge antibiotic prescription review into pharmacist daily workflow may be a sustainable approach to outpatient antimicrobial stewardship in a setting with limited resources.

Trauma transfers discharged from the emergency department-Is there a role for telemedicine?

As the only Level I trauma center in the state, our hospital has seen an increase in the number of traumas requiring transfer for a higher level of care, placing strain on an already strained health care system. Traumas that are transferred to our facility and subsequently discharged back home indicate a subset of patients who may not be appropriate to transfer. The aim of this study is to identify commonalities between patients who were transferred for a higher level of care but do not require inpatient status and to assess patients who may benefit from a telemedicine evaluation. A 2-year retrospective review of a prospective collected database of patients who were discharged from the ED following transfer to a Level I trauma center was conducted. Data included demographics, injuries, transferring facility, method of transport, activation criteria and level, additional imaging, consulting services, procedures, and disposition. A total of 2,350 patients were transferred. Of those, 27% (632/2,350) were discharged home directly from the trauma bay. Of those patients, 36% (230/632) required complex bedside intervention or subspecialty consultation prior to discharge including complex laceration repairs 53%, ophthalmology examination 24%, splinting 18%, and joint reduction 5%. Sixty-four percent (402/632) of patients did not require complex bedside procedures prior to discharge. One hundred twenty hospitals transferred patients to our center during this period. The top 10 transferring facilities accounted for 40% (948/2,350) of our transfer volume. Our study demonstrates that patients who are transferred to our facility and subsequently discharged have a common pattern of injuries; typically, isolated hand and face/ophthalmology. This is likely attributed to the lack of resources in rural facilities to evaluate and develop treatment plans for these injuries; however, only 36% of discharged patients required a bedside procedure. Excluding Level I traumas, head and spine injuries, and patients requiring complex bedside procedures, there was a 13% inappropriate rate of transfer (310/2,350). Development and implementation of a telemedicine system could potentially reduce the transfer and ED discharge rate, thereby improving efficiency and allowing for reallocation of resources as appropriate. Prognostic and Epidemiologic, Level III.

Inefficiency of public hospitals: a multistage data envelopment analysis in an Italian region

BackgroundThe objective of this study was to assess public hospital efficiency, including quality outputs, inefficiency determinants, and changes to efficiency over time, in an Italian region. To achieve this aim, the study used secondary data from the Veneto region for the years 2018 and 2019.MethodsA nonparametric approach—that is, multistage data envelopment analysis (DEA)—was applied to a sample of 43 hospitals. We identified three categories of input: capital investments (Beds), labor (FTE), operating expenses. We selected five efficiency outputs (outpatient visits, inpatients, outpatient visit revenue, inpatient revenue, bed occupancy rate) and two quality outputs (mortality rate and inappropriate admission rate). Efficiency scores were estimated and decomposed into two components. Slack analysis was then conducted. Further, DEA efficiency scores were regressed on internal and external variables using a Tobit model. Finally, the Malmquist Productivity Index was applied.ResultsOn average, the hospitals in the Veneto region operated at more than 95% efficiency. Technical and scale inefficiencies often occurred jointly, with 77% of inefficient hospitals needing a downsizing strategy to gain efficiency. The inputs identified as needing significant reductions were full-time employee (FTE) administrative staff and technicians. The size of the hospital in relation to the size of the population served and the length of patient stay were important factors for the efficiency score. The major cause of decreased efficiency over time was technical change (0.908) rather than efficiency change (0.974).ConclusionsThe study reveals improvements that should be made from both the policy and managerial perspectives. Hospital size is an important feature of inefficiency. On average, the results show that it is advisable for hospitals to reorganize nonmedical staff to enhance efficiency. Further, increasing technology investment could enable higher efficiency levels.

Inappropriate drug use rates of geriatric patients attending to a university hospital cardiology policlinic.

The interest in risks related to inappropriate drug use (IDU) and polypharmacy among the elderly has increased in recent years. We aimed to determine the frequency of IDU and multiple drug use in elderly patients in the cardiology outpatient clinic. : In this prospective, cross-sectional study, a total of 513 patients aged 65 years and above who were admitted to the Cardiology Policlinic between December 2017 and January 2018 were included. To determine the prevalence of IDU, we investigated the suitability of the drugs used by the patients (according to the criteria of Beers 2015 and Screening Tool of Older People's Prescriptions [STOPP] version 2), the number of violated criteria in both the guidelines and which criterion was violated by the inappropriate drugs. : The 513 patients (mean age: 73.18 ± 5.99) in this study included females (n = 235; 45.8%) and males (n = 278; 54.2%). A total of 2,910 drugs were used by the 513 patients (mean per patient: 5.67 ± 2.51); 52.8% of the patients were using more than five drugs. The Beers criteria revealed that 304 IDUs were detected among the drugs and showed that 38.6% (n = 198) of the patients had IDU. According to the STOPP criteria, 366 IDUs were identified among the drugs used, and 45.6% (n = 234) of the patients had IDU. IDU frequencies of the elderly patients are similar to the world literature in our study. As the number of chronic illnesses the patients had increases, the frequency of IDU increases according to Beers and STOPP criteria in our study.

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Executive Summary.

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Executive Summary.

Contribution of Selected Factors on Farmers’ Work Performance towards Fertilizer Application in Rice of Bangladesh

There is enormous possibility to increase rice yield in Bangladesh. Inefficient and often imbalanced fertilizer use impedes farmers from achieving expected yields. It is evident from past research that farmers have resorted to applying fertilizers at inappropriate rates that do not match well with the nutrient requirement of certain crops. Therefore, this study explores the contribution of selected factors that influence farmers’ work performance and determine the highest contributing factors on farmers’ work performance towards fertilizer application in rice. This research used a multistage simple random sampling method to select 355 farmers from twenty-one rice production areas of Bangladesh. Data, collected using a structured questionnaire, were subjected to multiple linear regression analysis to explore the contribution of selected factors and identify the highest contributing factors towards farmers’ work performance. Results revealed that all the factors explained 56.1% of the variance in farmers’ work performance. Motivation of farmers was found to be the highest contributing factor, followed by knowledge that influences farmers’ work performance. The study concludes that farmers need to be equipped with essential knowledge and motivation crucial to strengthening their work performance as this will subsequently increase rice production.

Significantly less inappropriate shocks in ischemic patients compared to non-ischemic patients: The S-ICD experience of a high volume single-center.

The subcutaneous cardioverter-defibrillator (S-ICD) continues to be preferentially used in relatively young patients, with less advanced heart disease. We, therefore, studied the short and long-term efficacy and safety of the S-ICD in subgroups of patients, which are underreported at present. A total of 218 patients between November 2010 and February 2019 undergoing S-ICD with a follow up of at least 6 months implantation were included in a prospective registry. Mean follow up was 38 months. The most common indication for S-ICD implantation was ischemic cardiomyopathy (n=106, 49%). Complication rate needing invasive intervention was 9% (n=21). Appropriate shock rate in patients with an S-ICD was 3.5%/year. A total of 30 inappropriate shocks (IAS) occurred in 19 patients (8.7%; 2.7%/year). The proportion of appropriate and inappropriate shock rates in patients with different cardiomyopathies shows remarkable variances. There were significant more IAS (3.6%/year vs. 1.7%/year, p=.048) in patients with non-ischemic cardiomyopathy versus patients with ischemic cardiomyopathy. Multivariate analysis identified, besides type of cardiomyopathy, atrial fibrillation (AF) as predictor for IAS. In this real-world prospective registry we analyzed S-ICD performance in the more traditional ICD patient. Patients with ischemic cardiomyopathy had significantly less inappropriate therapy compared to patients with non-ischemic cardiomyopathy and appear to be appropriate patients for this type of device.

Accelerating Employability through Social Safety Net in Rural Bangladesh: Employment Generation Programme for the Poorest

This article assesses the effectiveness of the employment generation programme for the poorest (EGPP) and its impact on ensuring employment opportunities and employability of targeted beneficiaries in rural areas in Bangladesh. In particular, it examines the appropriateness of targeted beneficiaries, selection, and the impact of the programme on changing their livelihood and economic indicators. Respondents were selected from 12 unions of four districts of the Chattogram division, and data were collected using the interview method and key informant interview. First, the findings suggest that accurately selecting beneficiaries and households was a challenging task owing to inappropriate wage rates, social context and political influences. Besides, misappropriation of the selection process of beneficiaries is one of the main concerns of this programme. Second, the EGPP has improved the income levels of a significant number of beneficiaries and made a positive impact on their certain basic needs and livelihood indicators. Despite drawbacks in the implementation, the study concludes that the provision of adequate measures of employment generation programmes based on equity and geographical demands will notably contribute to ensuring the employability of the unemployed and marginalised sections of the country.