Inpatient Prescription Research Articles

Influence of the adequacy of data collection, during two years, in the management of community acquired pneumonia in emergency departments

Objective. The aim of this study was to analyze whether structured data collec-tion of patients with community-acquired pneumonia (CAP) in the Emergency De-partment (ED) improves compliance with clinical guidelines regarding inpatient and outpatient treatment and prescription of antibiotics at discharge. Material and methods. We performed a quasi experimental, multicenter, pre/post-intervention study. The intervention con-sisted of basic training for the participat-ing physicians and the incorporation of a data collection sheet in the clinical history chart, including the information neces-sary for adequate decision making re-garding patient admission and treatment, in the case of discharge. We analyzed the adequacy of the final destination of pa-tients classified as Fine I-II and antibiotic treatment in patients receiving outpatient treatment, with each participating physi-cian including 8 consecutive patients (4 pre-intervention and 4 post-intervention). Results. A total of 738 patients were in-cluded: 378 pre-intervention and 360 post-intervention. In the pre-intervention group, Fine V was more frequent and pa-tients were older, had more ischemic heart disease, active neoplasms and fewer risk factors for atypical pneumonia. Of the patients with Fine I-II, 23.7% were in-adequately admitted and 19.6% of those discharged received treatment not rec-ommended by guidelines. No differences were observed in the target variables be-tween the two groups. Conclusion. The adequacy of the decision to admit patients with Fine I-II CAP and outpatient antibiotic treatment can be im-proved in the ED. Structured data collec-tion does not improve patient outcome.&nbsp

A Hospitalist-Led Initiative to Promote Antibiotic Citizenship on Internal Medicine Teaching Services

BackgroundHospitalists are critical partners in antimicrobial stewardship program (ASP) efforts to improve antimicrobial use, but limited data exists on the effectiveness of ASP-hospitalist collaboration. We performed a hospitalist-led quality improvement project with pharmacy collaboration to improve antimicrobial prescribing practices on general internal medicine teaching services at an urban academic medical center.MethodsWe conducted a 3-arm intervention study on internal medicine teaching services from September-December 2016. Three services received an educational (Ed) intervention consisting of an antibiotic rationale checklist, a templated progress note to promote trainee critical thinking about antibiotic management, and a pocket card with institutional guidelines. In addition, 1 team received twice weekly stewardship rounds with an infectious disease clinical pharmacist (Ed+ID-PharmDx2) while another team received 5x week stewardship rounds with a generalist clinical pharmacist (Ed+PharmDx5). The primary outcome was broad-spectrum antibiotic use calculated as days of therapy (DOT) per 1000 patient days compared with historical data from the corresponding months. Secondary outcomes included duration of inpatient therapy, antibiotic costs, length of stay, 30-day readmission, ICU transfer and in-hospital mortality.ResultsBroad-spectrum antibiotic use significantly decreased by 26% (415 vs. 306 DOT/1000 patient days) and 32% (425 vs. 287 DOT per 1000 patient days) on the Ed and Ed+PharmDx5 teams, respectively (P <0.01). Broad-spectrum use on the ED+ID-PharmDx2 team decreased by 9% but was not statistically significant. There was a significant improvement in median length of stay among patients receiving antibiotics for Ed only (-1.5 days; P < 0.001) and Ed+PharmDx5 (-1 day; P < 0.001) and no significant change in 30 day readmissions, ICU transfer and in-hospital mortality for any team. Direct antibiotic costs were reduced by $80,000 during the study period.ConclusionA hospitalist-led initiative to improve inpatient antimicrobial prescribing led to reductions in broad-spectrum antimicrobial use and reduced length of stay. ASPs should target hospitalists and pharmacists as partners in programmatic efforts to improve inpatient antimicrobial prescribing.Disclosures All authors: No reported disclosures.

Exploratory Compatibility Regularity of Chinese Medicinal Prescription in Treating Osteoarthritis

Background: Traditional Chinese medicine (TCM) is increasingly widely used as a complementary approach for the treatment of osteoarthritis. In this paper, we examined the implicit prescription patterns behind the Chinese medicinal formulae by using association rules mining and clustering analysis, so as to explore the compatibility regularity of Chinese medicinal prescription in the treatment or control of osteoarthritis. Methods: This study was based on a participant survey conducted in First Affiliated Hospital of Anhui University of Chinese Medicine. The Chinese medicinal prescriptions of inpatients with osteoarthritis were from June 2012 to June 2016. TCM was listed according to the selected medicinal formulae and the added information was organized to establish a database. The association rules and clustering are conducted on SPSS Modeler 14.2. An initial statistical analysis was carried out to categorize the herbs according to their medicinal types, dosage, natures, flavors, channel tropism, and functions. Based on the categorization, the frequencies of occurrences were computed. At the same time, the relationship between TCM and immune and inflammatory markers was analyzed. Results: The main features from the formulae data are: (1) Warm or cold herbs in the Five Properties category are the most frequently prescribed in the 3609 medicinal formulae. Sweet or bitter herbs in the Five Flavors category in which affinity to the Spleen meridian also are the most frequently prescribed in the 3609 medicinal formulae. (2) Herbs with blood-activating and stasis-resolving, tonifying and replenishing medicinal, water-disinhibiting damppercolating, heat-clearing and detoxicating or expelling wind-damp functions that are frequently prescribed; (3) Association rule analysis extracted three frequently used pairs of herbs, which are Red flower and Tao Ren, Pu Gong Ying and Bai Hua She She Cao, Fu Ling and Ze Xie. (4) Association rule between TCM and Immunoinflammation Index showed that Du Huo and Chen Pi was associated with increased super oxide dismutase enzyme. Mai Ya and Dan Shen was associated with decreased high-sensitivity C-reactive protein, erythrocyte sedimentation rate, complement C3, complement C4, and Ig(A). Mai Ya and Fu Ling were associated with decreased IgM. Conclusions: The results indicate that there is a close relationship between osteoarthritis and spleen dysfunctions. These prescriptions focus on herbs that replenishing qi and fortifying the spleen and blood-activating and stasis-resolving. It can also dry dampness to fortify the spleen and clear heat and detoxicating. Meanwhile, he use of tonifying and replenishing herbs and spleen-strengthening herbs also forms a basic pattern of the prescriptions.

Association of Perioperative Statin Use With Mortality and Morbidity After Major Noncardiac Surgery

The efficacy of statins in reducing perioperative cardiovascular and other organ system complications in patients undergoing noncardiac surgery remains controversial. Owing to a paucity of randomized clinical trials, analyses of large databases may facilitate informed hypothesis generation and more efficient trial design. To evaluate associations of early perioperative statin use with outcomes in a national cohort of veterans undergoing noncardiac surgery. This retrospective, observational cohort analysis included 180 478 veterans undergoing elective or emergent noncardiac surgery (including vascular, general, neurosurgery, orthopedic, thoracic, urologic, and otolaryngologic) who were admitted within 7 days of surgery and sampled by the Veterans Affairs Surgical Quality Improvement Program (VASQIP). Patients were admitted to Department of Veterans Affairs hospitals and underwent 30-day postoperative follow-up. Data were collected from October 1, 2005, to September 30, 2010, and analyzed from November 28, 2013, to October 31, 2016. Statin use on the day of or the day after surgery. All-cause 30-day mortality (primary outcome) and standardized 30-day cardiovascular and noncardiovascular outcomes captured by VASQIP. Use of statins and other perioperative cardiovascular medications was ascertained from the Veterans Affairs Pharmacy Benefits Management research database. A total of 180 478 eligible patients (95.6% men and 4.4% women; mean [SD] age, 63.8 [11.6] years) underwent analysis, and 96 486 were included in the propensity score-matched cohort (96.3% men; 3.7% women; mean [SD] age, 65.9 [10.6] years). At the time of hospital admission, 37.8% of patients had an active outpatient prescription for a statin, of whom 80.8% were prescribed simvastatin and 59.5% used moderate-intensity dosing. Exposure to a statin on the day of or the day after surgery based on an inpatient prescription was noted in 31.5% of the cohort. Among 48 243 propensity score-matched pairs of early perioperative statin-exposed and nonexposed patients, 30-day all-cause mortality was significantly reduced in exposed patients (relative risk, 0.82; 95% CI, 0.75-0.89; P < .001; number needed to treat, 244; 95% CI, 170-432). Of the secondary outcomes, a significant association with reduced risk of any complication was noted (relative risk, 0.82; 95% CI, 0.79-0.86; P < .001; number needed to treat, 67; 95% CI, 55-87); all were significant except for the central nervous system and thrombosis categories, with the greatest risk reduction (relative risk, 0.73; 95% CI, 0.64-0.83) for cardiac complications. Early perioperative exposure to a statin was associated with a significant reduction in all-cause perioperative mortality and several cardiovascular and noncardiovascular complications. However, the potential for selection biases in these results must be considered.

Factors Associated With the Prophylactic Prescription of a Bowel Regimen to Prevent Opioid-Induced Constipation.

Identify factors associated with the prophylactic prescription of a bowel regimen with an inpatient opioid prescription. This was a retrospective cohort study from June 1, 2013, to October 31, 2014 of pediatric inpatients prescribed an oral or intravenous opioid on the general medical/surgical floors. We identified patients with or without a prophylactic prescription of a bowel regimen. We obtained patient demographics, prescriber training level and service and used multivariate logistic regression to analyze the factors associated with prophylactic bowel regimen and opioid prescription. Of the 6682 encounters that met study criteria, only 966 (14.5%) encounters had prophylactic prescriptions. Patient factors associated with prophylactic prescription include increasing age (per year; odds ratio [OR] = 1.06, 95% confidence interval [CI] 1.05-1.07) and sickle cell diagnosis (OR = 3.19, 95% CI 2.08-4.91). Medication factors associated with prophylactic prescription include a scheduled opioid prescription (OR = 1.75, 95% CI 1.46-2.1) and a prescription for oxycodone (OR = 3.59, 95% CI 2.57-5.00) or morphine (OR = 1.84, 95% CI 1.39-2.44), compared with acetaminophen-hydrocodone. Compared with medical providers, surgeons were less likely (OR = 0.43, 95% CI 0.35-0.53) and pain service providers were more likely to prescribe a prophylactic bowel regimen (OR = 4.12, 95% CI 3.13-5.43). More than 85% of inpatient opioid prescriptions did not receive a prophylactic bowel regimen. Future research should examine factors (eg, clinical decision support tools) to increase prophylactic prescription of bowel regimens with opioids for populations found to have lower rates.

A Quality Improvement Initiative: Improving the Frequency of Inpatient Electronic Prescribing.

To improve the frequency of electronic prescribing (e-prescribing) of discharge prescriptions at a children's hospital via a bundle of quality improvement interventions. Surveys and focus groups were conducted with patient families and pediatric residents to identify barriers and propose solutions to e-prescribing. These data were used to generate a series of interventions, including the following: (1) provider education; (2) changes in patient registration workflow; and (3) electronic health record changes to improve the frequency of e-prescribing on the pediatric hospital medicine (PHM) service. The primary outcome measure was the e-prescribing frequency, with a balance measure of e-prescribing errors. From July 2014 through June 2015, e-prescribing frequency on the PHM service improved from a median of 7.4% to 48.9% (P < .001) and was sustained for an additional 6 months (July 2015-December 2015), surpassing meaningful use targets with associated US News and World Report hospital ranking points. The frequency of PHM prescription errors remained unchanged, and in comparison, the resident outpatient clinic revealed no statistically significant change in e-prescribing frequency during this time period. Engaging front-line providers in hospital-wide initiatives and quality improvement interventions can directly affect hospital metrics in programs such as meaningful use and US News and World Report, as shown through successful improvement in PHM e-prescribing frequency. Future studies are necessary to determine whether increased e-prescribing frequency affects patient outcomes and compliance.

PHP72 - Utilization And Cost Of Antimicrobials Used In Medicine And Surgery Departments Of A Tertiary Care Teaching Hospital

Irrational use of antimicrobials has led to grave consequences of antimicrobial resistance and economic burden on the health care system. This study was conducted in find out the pattern and extent of antimicrobial usage in inpatients and outpatients of Medicine and Surgery department and also to determine the economic impact of antimicrobials against their usage. The study was conducted over a period of 14 months in both outpatients and inpatients departments of two units of Medicine and Surgery. Prescriptions of inpatients and outpatients were analyzed using International Classification Code of Diseases for diagnosis and Anatomical Therapeutic Chemical Classification (ATC) and Defined Daily Doses (DDDs) for the antimicrobials used. A total of 2128 outpatient prescriptions and 400 inpatients case sheets from Medicine and Surgery were included in the study. In the outpatient department, the average number of medicines prescribed per patient was more in Medicine (3.0) than in Surgery (2.3). The most commonly used antimicrobial in both departments was amoxicillin+clavulanate. The use of antimicrobials in inpatient departments of both Medicine and Surgery was high, as 73.1% of the admitted patients were prescribed antimicrobials. The average antimicrobial prescribed per patient was 2.7. The most commonly used antimicrobials in the Medcine and Surgery inpatients were ceftriaxone, metronidazole and flouroquinolones. A total of 84 samples were sent for microbiological examination of which 39% were positive. Antimicrobial prescription for prophylactic conditions was greater in Surgery than in Medicine. The total DDDs/100 patient days in Medicine and Surgery were 3369 and 2247, respectively. Overall, the expenditure on the antimicrobials was 33% of the total cost of drug treatment. The average cost of antimicrobial per patient was INR 1501. We propose routine practice of batcerial culture and sensitivity testing, formulation of an antibiotic policy, and antimicrobial stewardship program to improve usage and clnical outcome.

215 Confirmation of Racial/Ethnic Disparities in the Management of Severe Bronchiolitis

Bronchiolitis is the #1 cause of hospitalization among infants in the U.S. and is associated with an increased risk of asthma. In an earlier multicenter study (Santiago et al. J Hosp Med 2014; 9: 565-572), we reported three racial/ethnic differences in the management of severe bronchiolitis: 1) ED/clinic albuterol use, 2) inpatient diagnostic imaging, and 3) prescription of inhaled corticosteroids at discharge. In the current study, we examine if racial/ethnic differences persist in a new multicenter severe bronchiolitis cohort. We enrolled infants (age <1y) with severe bronchiolitis between 2011 and 2014 at 17 teaching hospitals across 13 states in the 35th Multicenter Airway Research Collaboration (MARC-35) study. In total, 1016 infants had a structured interview and chart review during their bronchiolitis hospitalization. Race/ethnicity was assigned based on the guardian’s response to U.S. Census questions: Hispanic (y/n) and Race (eg, white, black, Asian - mark all that apply). Infants were categorized into three groups: non-Hispanic white (NHW), non-Hispanic black (NHB), or Hispanic. For analytical reasons, we excluded 39 infants who could not be categorized into these groups. This resulted in a total of 977 (96%) infants in our analytical dataset. Multivariable logistic regression was used to examine the independent association between race/ethnicity and diagnostic imaging, ED/clinic and inpatient treatment (albuterol, corticosteroids), management (intensive care interventions and length-of-stay), discharge on corticosteroids, and bronchiolitis relapse within three weeks. Among 977 infants, 430 (44%) were NHW, 239 (24%) were NHB, and 308 (32%) were Hispanic. The median age at enrollment was 3.2 months; 60% were male and 60% had public health insurance. Most infants tested positive for RSV (81%) and did not have a breathing problem before enrollment (80%); the median hospital length-of-stay was 2 days. In multivariable analyses, with NHW infants as reference group, we focused on three previously reported differences (Figure). We did not confirm the previously reported difference for ED/clinic albuterol across the three groups. We did confirm the other two findings, with NHB infants less likely to receive chest x-rays during hospitalization (OR: 0.64; 95% CI: 0.45-0.93), and Hispanic infants more likely to be discharged on corticosteroids (OR: 1.91; 95% CI: 1.05-3.48). We again found no significant racial/ethnic differences for all other outcomes: inpatient corticosteroid use, hospital length of stay, intensive care interventions, or worsening of bronchiolitis requiring medical treatment after discharge. We confirmed racial/ethnic differences for two practices (inpatient diagnostic imaging and prescription of corticosteroids at discharge); neither is recommended by the 2014 American Academy of Pediatrics guidelines for treatment of bronchiolitis. The causes of these management differences remain unclear, but they support implementation of care pathways for severe bronchiolitis to reduce disparities in care.

Antibiotic stewardship in pediatrics: global heath priority

Multidisciplinary antibiotic stewardship (AS) programs targeting both inpatient and outpatient antibiotic prescription to children need to be urgently developed in every country and implemented to tackle this global antibiotic menace.

Concordance entre prescriptions hospitalières et recommandations dans le traitement de la manie

There are differences between recommendations and practice in the pharmacological treatment of acute mania. The objective was to assess conformity of the anti-manic prescription between national recommendations (Haute Autorité de santé [French health authority, HAS] and "résumé des caractéristiques du produit" [product characteristics, RCP]) and clinical practice. We observed the drug prescriptions of in-patients for a manic episode. The main outcome measure was the concordance rate with the recommendations of the drugs prescriptions at the 48th hour. The secondary outcome repeated the same process with the hospital discharge statement of switches, associations, the presence of symptomatic and antidepressant treatments. Sixty-six episodes were included, 40patients (60%) had a prescription complies with RCP recommendations H48 and 46patients (70%) to HAS. These rates fall at hospital discharge. Off-label prescriptions, drug combinations and choices of not listed molecules are the most common reasons for non-conformity.

Prevalence and risk factors for medication reconciliation errors during hospital admission in elderly patients.

Background Care transitions are risk points for medication discrepancies, especially in the elderly. Objective This study was undertaken to assess prevalence and describe medication reconciliation errors during admission in elderly patients and to analyze associated risk factors. We also evaluate the effect of these errors on the length of hospital stay. Setting General surgery, orthopedics, internal medicines and infectious diseases departments of a 1070-bed Spanish teaching hospital. Method This is a prospective observational study. Patients >65years and taking ≥5 medications were randomly selected from those admitted to hospital. The pharmacist obtained the best possible medication history based on medical records, medical notes from patients' previous admissions to hospital, "brown bag" review, community care prescriptions, and comprehensive patient interviews. It was compared to current inpatient prescription to detect unintentional discrepancies (discrepancy with no apparent clinical explanation), which were reported to the physician. When the physician accepted the discrepancy by changing the medication order, it was recorded as a medication reconciliation error and classified by type of error. Several variables were analyzed as possible risk/protective factors. Main outcome measure Is prevalence of medication reconciliation errors at admission. Results Reconciliation was performed on 206 patients. Medication reconciliation errors occurred in 49.5% (102/206) of patients. 1996 medications were recorded, and 359 had unintentional discrepancies (56.0% (201/359) medication reconciliation errors). The most common was omission (65.1%). Identified risk factors were as follows: physician experience, number of pre-admission prescribed medications, and previous surgeries. Computerized order entry system was a protective factor. Conclusion Medication reconciliation errors occur in almost half of the elderly patients at admission, especially omissions. Risk factors were a larger number of previous medications, less physician years of experience, and more previous surgeries. Having a computerized order entry system in the hospital protected against some errors.

AUDIT OF PARACETAMOL PRESCRIPTIONS IN PAEDIATRIC SURGICAL PATIENTS

AimLocal Guidelines for peri-operative pain management in children published in 2012 recommended that paracetamol dosing was calculated using ideal body weight (IBW) to prevent inadvertent overdosing in overweight and obese...

Risk management of in-hospital administration of anticancer drugs: impact of Raccomandazione 14 from the Italian Ministry of Health.

The different stages of antineoplastic agent management build up a complex process, from supply to prescription, preparation, and administration. All steps in this process must be carefully monitored in order to control/reduce the risk of errors that can impact on patient safety. This work overviews the prevention of medication errors in oncology, including regulatory and legislative frameworks with specific reference to the Raccomandazione 14 (Recommendation 14) issued by the Italian Ministry of Health. We searched the literature for types, causes, and contributing factors of medication errors during administration of antineoplastic agents. International guidelines and recommendations were examined, with specific focus on the Raccomandazione 14. Medication errors may occur along the entire therapeutic process, involving physicians, pharmacists, nurses, and other healthcare providers. A computerized prescribing system combined with a clinical decision support system helps physicians in minimizing prescribing errors. Hospital pharmacists play a crucial role in preventing inpatient prescription errors and in managing storage, dispensing, and compounding of the anticancer drugs. The Italian Ministry of Health issued the Raccomandazione 14 to provide the Italian health system with shared univocal procedures for anticancer drug supply, compounding, storage, prescription, and administration. Other themes addressed are patient and family involvement, humanization of cancer care, and training and accountability of the personnel involved. The most effective means of managing the risk of medication errors remains prevention, which lies on the systematic documentation of medication errors reporting systems. All professionals of the healthcare team involved in anticancer drug management and the institutional authorities are called upon to strive for any possible effort to prevent and eliminate medication errors.

The CareFirst Patient-Centered Medical Home Program: Cost and Utilization Effects in Its First Three Years.

BackgroundEnhanced primary care models have diffused slowly and shown uneven results. Because their structural features are costly and challenging for small practices to implement, they offer modest rewards for improved performance, and improvement takes time.ObjectiveTo test whether a patient-centered medical home (PCMH) model that significantly rewarded cost savings and accommodated small primary care practices was associated with lower spending, fewer hospital admissions, and fewer emergency room visits.DesignWe compared medical care expenditures and utilization among adults who participated in the PCMH program to adults who did not participate. We computed difference-in-difference estimates using two-part multivariate generalized linear models for expenditures and negative binomial models for utilization. Control variables included patient demographics, county, chronic condition indicators, and illness severity.ParticipantsA total of 1,433,297 adults aged 18–64 years, residing in Maryland, Virginia, and the District of Columbia, and insured by CareFirst for at least 3 consecutive months between 2010 and 2013.InterventionCareFirst implemented enhanced fee-for-service payments to the practices, offered a large retrospective bonus if annual cost and quality targets were exceeded, and provided information and care coordination support.MeasuresOutcomes were quarterly claims expenditures per member for all covered services, inpatient care, emergency care, and prescription drugs, and quarterly inpatient admissions and emergency room visits.ResultsBy the third intervention year, annual adjusted total claims payments were $109 per participating member (95 % CI: −$192, −$27), or 2.8 % lower than before the program and compared to those who did not participate. Forty-two percent of the overall decline in spending was explained by lower inpatient care, emergency care, and prescription drug spending. Much of the reduction in inpatient and emergency spending was explained by lower utilization of services.ConclusionsA PCMH model that does not require practices to make infrastructure investments and that rewards cost savings can reduce spending and utilization.Electronic supplementary materialThe online version of this article (doi:10.1007/s11606-016-3814-z) contains supplementary material, which is available to authorized users.

Number of Diverticulitis Episodes Before Resection and Factors Associated With Earlier Interventions.

Despite professional recommendations to delay elective colon resection for patients with uncomplicated diverticulitis, early surgery (after <3 preceding episodes) appears to be common. Several factors have been suggested to contribute to early surgery, including increasing numbers of younger patients, a lower threshold to operate laparoscopically, and growing recognition of "smoldering" (or nonrecovering) diverticulitis episodes. However, the relevance of these factors in early surgery has not been well tested, and most prior studies have focused on hospitalizations, missing outpatient events and making it difficult to assess guideline adherence in earlier interventions. To describe patterns of episodes of diverticulitis before surgery and factors associated with earlier interventions using inpatient, outpatient, and antibiotic prescription claims. This investigation was a nationwide retrospective cohort study from January 1, 2009, to December 31, 2012. The dates of the analysis were July 2014 to May 2015. Participants were immunocompetent adult patients (age range, 18-64 years) with incident, uncomplicated diverticulitis. Elective colectomy for diverticulitis. Inpatient, outpatient, and antibiotic prescription claims for diverticulitis captured in the MarketScan (Truven Health Analytics) databases. Of 87 461 immunocompetent patients having at least 1 claim for diverticulitis, 6.4% (n = 5604) underwent a resection. The final study cohort comprised 3054 nonimmunocompromised patients who underwent elective resection for uncomplicated diverticulitis, of whom 55.6% (n = 1699) were male. Before elective surgery, they had a mean (SD) of 1.0 (0.9) inpatient claims, 1.5 (1.5) outpatient claims, and 0.5 (1.2) antibiotic prescription claims related to diverticulitis. Resection occurred after fewer than 3 episodes in 94.9% (2897 of 3054) of patients if counting inpatient claims only, in 80.5% (2459 of 3054) if counting inpatient and outpatient claims only, and in 56.3% (1720 of 3054) if counting all types of claims. Based on all types of claims, patients having surgery after fewer than 3 episodes were of similar mean age compared with patients having delayed surgery (both 47.7 years, P = .91), were less likely to undergo laparoscopy (65.1% [1120 of 1720] vs 70.8% [944 of 1334], P = .001), and had more time between the last 2 episodes preceding surgery (157 vs 96 days, P < .001). Patients with health maintenance organization or capitated insurance plans had lower rates of early surgery (50.1% [247 of 493] vs 57.4% [1429 of 2490], P = .01) than those with other insurance plan types. After considering all types of diverticulitis claims, 56.3% (1720 of 3054) of elective resections for uncomplicated diverticulitis occurred after fewer than 3 episodes. Earlier surgery was not explained by younger age, laparoscopy, time between the last 2 episodes preceding surgery, or financial risk-bearing for patients. In delivering value-added surgical care, factors driving early, elective resection for diverticulitis need to be determined.

Inpatient prescribing systems used in NHS Acute Trusts across England: a managerial perspective

ObjectiveThe individualised patient prescription chart, either paper or electronic, is an integral part of communication between healthcare professionals. The aim of this study is to ascertain the extent to which...

Factors Associated With Musculoskeletal Injuries in Children and Adolescents With Attention-Deficit/Hyperactivity Disorder.

Musculoskeletal injuries may be associated with attention-deficit/hyperactivity disorder (ADHD) symptom severity, comorbid psychiatric or medical conditions, and the prescribed psychostimulant. A population-based, retrospective cohort design was employed using South Carolina's Medicaid claims data set covering outpatient and inpatient medical services and medication prescriptions over an 11-year period (January 1, 1996, through December 31, 2006) for patients ≤ 17 years of age with ≥ 2 visits for ICD-9-CM diagnostic codes for ADHD. A cohort of 7,725 cases was identified and analyzed using logistic regression to compare risk factors for those who sustained focal musculoskeletal injuries and those who did not. The risk of sustaining sprains, arthropathy and connective tissue disorders, or muscle and joint disorders was significantly related to being diagnosed with comorbid hypertension (adjusted odds ratios [aORs] = 1.60, 2.09, and 1.46, respectively) and a substance use disorder (aORs = 1.58, 1.38, and 1.28). Having a substance use disorder was also related to incident fractures and dorso/spinal injuries (aORs = 1.42 and 1.21). Diagnosed hypertension was related to incident concussions (aOR = 2.00), a diagnosed thyroid disorder was related to an increased risk of sprain and concussion (aORs = 1.44 and 2.05), a diagnosed anxiety disorder was related to an increased risk of dorso/spinal disorders (aOR = 1.71), and diagnosed diabetes was related to incident bone and cartilage disorders (aOR = 1.61). Comorbid hypertension, substance use disorders, and thyroid disorders deserve increased clinical surveillance in children and adolescents with ADHD because they may be associated with an increased risk of more than one musculoskeletal injury.

Using Random Forest Models to Identify Correlates of a Diabetic Peripheral Neuropathy Diagnosis from Electronic Health Record Data.

To identify variables correlated with a diagnosis of diabetic peripheral neuropathy (DPN) using random forest modeling applied to electronic health records. Retrospective analysis. Humedica de-identified electronic health records database. Subjects ≥ 18 years old with type 2 diabetes from January 1, 2008-September 30, 2013 having continuous data for 1 year pre- and postindex with DPN (n = 35,050) and without DPN (n = 288,328) were identified. Demographic, clinical, and health care resource utilization variables (e.g., inpatient and outpatient encounters, medications, and procedures) were input into a random forest model to identify the most important correlates of a DPN diagnosis. Random forest modeling is a computationally extensive, robust data mining technique that accommodates large sets of variables to identify associated factors using an ensemble of classifications trees. Accuracy of the model was evaluated using receiver operating characteristic curves (ROC). The final random forest model consisted of the following variables (importance) associated with a DPN diagnosis: Charlson Comorbidity Index score (100%), age (37.1%), number of pre-index procedures and services (29.7%), number of pre-index outpatient prescriptions (24.2%), number of pre-index outpatient visits (18.3%), number of pre-index laboratory visits (16.9%), number of pre-index outpatient office visits (12.1%), number of inpatient prescriptions (5.9%), and number of pain-related medication prescriptions (4.4%). ROC analysis confirmed model performance, with an area under the curve of 0.824 and accuracy of 89.6% (95% confidence interval 89.4%, 89.8%). Random forest modeling can determine likelihood of a DPN diagnosis. Further validation of the random forest model may help facilitate earlier diagnosis and enhance management strategies.

Safe medication management and use of narcotics in a Joint Commission International-accredited academic medical center hospital in the People's Republic of China.

Safe medication management and use of high-alert narcotics should arouse concern. Risk management experiences in this respect in a large-scale Joint Commission International (JCI)-accredited academic medical center hospital in the People’s Republic of China during 2011–2015, focusing on organizational, educational, motivational, and information technological measures in storage, prescribing, preparing, dispensing, administration, and monitoring of medication are summarized. The intensity of use of meperidine in hospitalized patients in 2015 was one-fourth that in 2011. A 100% implementation rate of standard storage of narcotics has been achieved in the hospital since December 2012. A “Plan, Do, Check, Act” cycle was efficient because the ratio of number of inappropriate narcotics prescriptions to total number of narcotics prescriptions for inpatients decreased from August 2014 to December 2014 (28.22% versus 2.96%, P=0.0000), and it was controlled below 6% from then on. During the journey to good pain management ward accreditation by the Ministry of Health, People’s Republic of China, (April 2012–October 2012), the medical oncology ward successfully demonstrated an increase in the pain screening rate at admission from 43.5% to 100%, cancer pain control rate from 85% to 96%, and degree of satisfaction toward pain nursing from 95.4% to 100% (all P-values <0.05). Oral morphine equivalent dosage in the good pain management ward increased from 2.3 mg/patient before June 2012 to 54.74 mg/patient in 2014. From 2011 to 2015, the oral morphine equivalent dose per discharged patient increased from 8.52 mg/person to 20.36 mg/person. A 100% implementation rate of independent double-check prior to narcotics dosing has been achieved since January 2013. From 2014 to 2015, the ratio of number of narcotics-related medication errors to number of discharged patients significantly decreased (6.95% versus 0.99%, P=0.0000). Taken together, continuous quality improvements have been achieved in safe medication management and use of narcotics by an integrated multidisciplinary collaboration during the journey to JCI accreditation and in the post-JCI accreditation era.

Bortezomib Inpatient Prescribing Practices in Free-Standing Children's Hospitals in the United States.

This study is a pharmacoepidemiologic description of pediatric bortezomib use. Exposure was identified through billing codes in patients admitted to US children’s hospitals that participated with the Pediatric Health Information System between 2004 and 2013. Associated information on underlying diseases, demographics, institutional use, mortality, and physician type was collected. Exposure to bortezomib was identified in 314 patients. Hematologist/Oncologists prescribed half of the bortezomib used. Use increased during the study period. Inpatient volume was positively correlated with bortezomib utilization. Bortezomib use in pediatrics is increasing for a variety of diseases. Variation in use exists across institutions. Further studies are needed to characterize bortezomib’s efficacy in pediatric diseases.