Low-hanging Fruit Research Articles

Buprenorphine Prior Authorization Removal: Low Hanging Fruit in the Opioid Overdose Crisis

The overdose crisis in the United States is not abating. The number of overdose mortalities has never been higher, and synthetic opioid mortalities increased 45% from 2016 to 2017 (Scholl, et al., 2019). The scope is daunting, but there is “low-hanging fruit” yet to be addressed. Though seldom mentioned in public debate, effective treatment is available, yet access to it is mired in red tape.

Heterogeneous biochars from agriculture residues and coal fly ash for the removal of heavy metals from coking wastewater.

While we have started down the path towards a global transition to a green economy, as with most things we began with the “low-hanging fruit,” such that increasingly difficult material and chemical conversions remain. Coking is one such example; it is unlikely that steel production will transition away from using coking coal anytime in the near future, such that coking wastewater remains a global environmental challenge. However, we can develop greener methods and materials to treat such waste. The present work demonstrates how wheat straw, an abundant agricultural residue, can be co-pyrolyzed and co-activated with coal fly ash to produce a high surface area biochar. Coal fly ash has previously been shown to promote devolatilization and deoxygenation of pyrolyzed biofuels. This work shows how coal fly ash increases microporosity as well as aromaticity of the surface functional groups, while decreasing carbonyl but preserving or only slightly decreasing ketones and carboxylic acids. CO2-activation of 5 and 10 wt% fly ash with wheat straw blends yields heterogeneous biochars with adsorption capacities upwards of 170 mgmetal gchar−1, with 5 wt% blends showing higher capacity and adsorption uptake rates than the 0 or 10 wt% blends. The adsorption of the four heavy metals ions (Ni2+, Co2+, Zn2+, and Mn2+) was chemical in nature, with cobalt preferentially adsorbing to the char surface. The overall adsorption rate is limited by an initial rapid uptake to fill available surface adsorption sites.

The CDM low-hanging fruits problem under ex-ante and ex-post baselines

The CDM low-hanging fruits problem under ex-ante and ex-post baselines

The Case against Carbon Prices

Professor Dr. Anthony Patt is head of the Climate Policy Group in the Department of Environmental Systems Science at ETH Zurich, Switzerland. His research focus is on technological pathways and public policies for climate change mitigation and adaptation. He is a Coordinating Lead Author in Working Group III of the Intergovernmental Panel on Climate Change. He obtained his PhD at Harvard University's Kennedy School of Government. He is the author of “Transforming Energy: Solving Climate Change with Technology Policy” (Cambridge University Press, 2015). Download : Download high-res image (204KB) Download : Download full-size image Professor Dr. Johan Lilliestam is head of the Renewable Energy Policy Group in the Department of Environmental Systems Science at ETH Zurich, Switzerland. His research focus is policies and strategies for a transition to a completely renewable energy system, including the effects of interactions between different energy policies. He obtained his PhD at the Central European University in Budapest, Hungary. Before joining the ETH, he worked at the Potsdam Institute for Climate Impact Research (PIK) in Potsdam, Germany, and the International Institute for Applied Systems Analysis (IIASA) in Laxenburg, Austria. He currently holds a grant from the European Research Council for his work on policy interactions. Download : Download high-res image (202KB) Download : Download full-size image

A Pharmacogenomics Clinical Decision Support Service Based on FHIR and CDS Hooks.

Pharmacogenomics (PGx) is often considered a low-hanging fruit for genomics-electronic health record (EHR) integrations, and many have expressed the notion that drug-gene interaction checking might one day become as much a commodity in EHRs as drug-drug and drug-allergy checking. In addition, the U.S. Office of the National Coordinator has recognized the trend toward storing complete sequencing data outside the EHR in a Genomic Archiving and Communication System (GACS) and has emphasized the need for "pilots that test Fast Healthcare Interoperability Resources (FHIR) Genomics for GACS integration with EHRs." We sought to develop a PGx clinical decision support (CDS) service, leveraging the emerging FHIR and CDS Hooks standards, and based on an assumption that pharmacogene sequencing data would be stored alongside the EHR in a GACS. We developed a PGx CDS service as a functional prototype. The service is triggered by a medication order in the EHR. When evoked, the service looks for relevant genetic data in a GACS and returns corresponding recommendations back to the ordering clinician. Where the patient has no genetic data on file, the service can recommend pretreatment genetic testing where applicable. Overall, we were able to meet our objectives and deploy a functional prototype, interfaced with a commercial EHR. We identified several areas where FHIR or CDS Hooks lacked necessary semantics or have implementation ambiguity. Primary FHIR challenges included multiple ways to say the same thing, which exacerbated the complexity of variant to allele conversion and lack of representation of deoxyribonucleic acid region(s) studied. Primary CDS Hooks challenges included the complexity of executing an authenticated query against one system (GACS) upon being triggered by a different system (the EHR), and limitations in the types of actionable recommendations that can be returned to the EHR. In conclusion, we have found that PGx CDS based on FHIR and CDS Hooks appears to represent a promising means of genomics-EHR integration. More real-world testing along with a set of use-case driven GACS interface requirements will push us closer to the U.S. National Human Genome Research Institute vision of a plug-in PGx app.

192. More Low-hanging Fruit: Antibiotic Chelation Drug Interactions

BackgroundAttainable, low-resource antimicrobial stewardship (AMS) interventions, “low-hanging fruit” can be facilitated by electronic medical record (EMR) enhancements. Oral (PO) fluoroquinolone (FQ) or tetracycline (TCN) coadministration with di- and tri-valent cations reduces antibiotic absorption by up to 75%, is common, and may represent low-hanging fruit. We evaluated concomitant administration and outcomes in a five hospital system before and after an EMR medication safety improvement.MethodsIRB approved quasi-experiment, emergency (ED) visits and hospital admissions September 2016–February 2017 and September 2017–February 2018. Standard of Care: cations were scheduled 0900 and 2100; FQ and TCN administration instructions stated: “Administer at least 2 hours before or 6 hours after (cations).” Intervention: April 2017 EMR change in the default timing of FQ and TCN to 0630 and 1530 with pharmacy and nurse education. Primary endpoint: coadministration, defined as administration of PO product containing calcium, magnesium, iron, or phosphate binder 2 hours before or 6 hours after PO doxycycline, ciprofloxacin, or moxifloxacin.ResultsA total of 4,414 and 5,231 patients, representing 4,887 and 5,781 encounters, received PO FQ or TCN pre- and post-intervention, respectively. Average age (years) pre: 62.1, post: 61.3. Respiratory infection most common (25% pre, 27% post) followed by genitourinary (13% pre, 12% post). Concomitant administration: 3629/17,702, 20.5% pre vs. 2,184/20,524, 10.6% post (P < 0.001), see Table 1. Median hospital length of stay: 3 (0.3, 6) pre, 2.9 (0.3, 5.8) post. Thirty-day all-cause readmission: 28% pre and 27.2% post.ConclusionA system-based change to the EMR was effective to reduce the frequency of FQ and TCN chelation interactions by half and represents a low-hanging fruit strategy for AMS programs. Our institution has subsequently employed this strategy to reduce chelation interactions with HIV integrase inhibitors.Table 1: Coadministration by AntibioticPre-groupPost-groupDrugNo. of AdministrationsNo. (%) of CoadministrationsNo. of AdministrationsNo. (%) of CoadministrationsCiprofloxacin6,2091,394 (22.5%)6,721787 (11.7%)Moxifloxacin1,689392 (23.2%)1,378168 (12.2%)Doxycycline9,8041,843 (18.8%)12,4251,229 (9.9%)Disclosures S. L. Davis, Achaogen: Scientific Advisor, Consulting fee. Allergan: Scientific Advisor, Consulting fee. Melinta: Scientific Advisor, Consulting fee. Nabriva: Scientific Advisor, Consulting fee. Zavante: Scientific Advisor, Consulting fee.

1796. Inappropriate Aztreonam Usage Identified as an Opportunity to Reduce Pharmaceutical Expenditures

BackgroundTargeting “low-hanging fruit” is a pillar of antimicrobial stewardship (AMS). Β-lactam allergies (BLA) frequently restrict clinical decision-making and lead to utilization of alternative, less preferred antimicrobials making them an ideal AMS target. Prior studies have demonstrated that BLA are grossly over reported by patients. This study aimed to calculate the excess pharmaceutical expenditures incurred by utilization of aztreonam in patients who had previously (or subsequently) tolerated a β lactam (BL).MethodsRetrospective chart review was performed on inpatients >18 years old at our institution who received at least one dose of aztreonam during the 2017 calendar year. Data collected included: BLA, both prior and subsequent BL classes tolerated, number of doses and days of aztreonam administered. Patients were excluded from the analysis if they did not have a documented BLA or if they received aztreonam as targeted/de-escalation therapy. Cost of aztreonam therapy was then compared with the cost of alterative BL agents based on prior and subsequently tolerated classes of BLs. Comparator agents included: pipericillin/tazobactam (penicillin), cefepime (cephalosporin) and meropenem (carbapenem). Wholesale acquisition costs were used for each agent and comparator regimens were based on our health system-wide dosing guidelines adjusted for renal function.ResultsOne hundered thirty-two patients met inclusion criteria. Of those patients, 88/132 (66.7%) had demonstrated tolerance of a BL agent. Specifically 69/132 (52.3%) previously and 19/132 (14.4%) subsequently tolerated a β-lactam. Across the study, $40,768.84 was spent on aztreonam for patients with prior/subsequent BL tolerance. Cost for alternative therapy was estimated at $13,143.25 total; with an estimated cost difference of $27,625.59. Estimated cost difference for prior tolerance was $21,987.87 and subsequent tolerance $5,637.72.ConclusionAztreonam is an uncommon but costly antimicrobial. This study demonstrated that reduction in aztreonam utilization based on prior tolerance of β-lactam agents could lead to a meaningful reduction in pharmaceutical expenditures and serve as low-hanging fruit for an antimicrobial stewardship program.Disclosures All authors: No reported disclosures.

1847. Impact of Antimicrobial Stewardship Commitment Posters on Antibiotic Prescribing for Upper Respiratory Tract Infections in a Rural Outpatient Setting

BackgroundThe Centers for Disease Control and Prevention advocates for the display of commitment posters in outpatient clinics for healthcare providers to pledge to only prescribe antibiotics when a bacterial infection is suspected. However, their impact on antibiotic prescribing in the outpatient setting has largely been part of multi-faceted interventions in academic medical centers or urban cities rather than in rural settings.MethodsThe objective of this study was to determine the impact of commitment posters as a single-intervention in rural outpatient clinics on antibiotic prescribing for upper respiratory tract infections (URIs). This was a quasi-experimental study performed at The Guthrie Clinic, a network of outpatient clinics located in rural New York and Pennsylvania. Commitment posters were displayed in examination and waiting rooms of outpatient clinics (n = 19) between April and June 2017 (intervention period). Patients with a URI visit diagnosis code during the period of July 1, 2016–December 31, 2016 (pre-intervention) and July 1, 2017–December 31, 2017 (post-intervention) were included. Demographic, provider, clinic, and antibiotic prescription data were collected.ResultsA total of 4,422 and 3,830 URI cases were diagnosed, and antibiotics were prescribed for 2,406 and 1,969 cases in the pre- and post-intervention periods, respectively. Fewer antibiotics were prescribed for URI cases in the post-intervention period compared with pre-intervention (54.6% vs. 51.6%, P = 0.013). The most commonly prescribed antibiotics in both cohorts were amoxicillin, amoxicillin–clavulanate, and azithromycin. Male gender (P = 0.0045), older age (P < 0.001), and patients who were seen by a provider other than their primary care provider (P = 0.001), were associated with a higher proportion of antibiotics prescribed per URI diagnosis. There was no statistically significant difference in antibiotics prescribed for patients with and without certain comorbidities such as diabetes or chronic obstructive pulmonary disease.ConclusionAntibiotic stewardship commitment posters were associated with a decrease in the number of antibiotics prescribed for URIs in rural clinics and represent a low-hanging fruit intervention for outpatient antibiotic stewardship programs, particularly in rural settings.Disclosures All authors: No reported disclosures.

"The low-hanging fruit has already been harvested"

"The low-hanging fruit has already been harvested"

Technology Update: Optimizing Well Productivity: Horizontal Logs Unlock Critical Geologic Knowledge

Technology Update With drilling on the rise, US oil production is expected to continue to increase. However, many industry professionals are concerned that the “brute force” model, which has seen a massive influx of capital flow into completion and hydraulic fracturing operations, is not an economically sustainable business model. There is a growing belief that better understanding of the effectiveness of completion designs and hydraulic fracturing strategies will require far greater subsurface geological understanding. Moreover, continued well productivity improvements will only be realized through improved reservoir characterization, and by applying formation petro-physical and geomechanical information to optimize methods of drilling, completing, and stimulating wells. There has been considerable media attention focused on how the industry is drilling wells longer and more quickly, as well as applying higher-intensity fractures. Until recently, however, there has been less emphasis on constructing productive wells with less capital. Traditional vertical well tool conveyance methods effectively addressed industry logging requirements for almost a century, but in today’s “horizontal” world, conventional methodologies are either not applicable or expensive and risky. Essentially, the multibillion-dollar logging market has not quite been turned upside down, but has toppled onto its side. Using available industry data, the low-hanging fruit in the growing “big data” boom, geosciences departments have labored to build accurate high-resolution geological models. Given the nonhomogeneous nature of the geology in unconventional reservoirs, applying vertical offset well logs and interpolating field reservoir models is generally accepted as a good start, but hardly the complete solution. To develop an accurate reservoir model, the heterogeneous nature of shale plays requires far greater data resolution than most operators appreciate. If operators are going to efficiently exploit every stage of their wellbore, they need accurate, measured formation insights along every foot of the horizontal wellbore. Geometric completions and fracturing strategies are not practical or effective in these unpredictable heterogenous environments. Along the wellbore, operators are encountering highly variable rock properties that affect fracturing efficiencies, and result in poor or unexpected well production results. This trend is forcing producers to evaluate stage-by-stage production contributions. They are finding that large portions of their wells are not contributing. There is a growing realization that improved well results that are repeatable and predictable are only going to come about by enhancing production at every stage in the wellbore. This requires engineered completions programs and tailored fracturing strategies that account for the considerable rock heterogeneity along the lateral.

Where Is the "Low-Hanging Fruit" in Diagnostic Quality and Safety?

Where Is the "Low-Hanging Fruit" in Diagnostic Quality and Safety?

Micah

Micah

“Low-Hanging Fruit”: Enhancing Culinary Medicine Curricula by Building Intuitive Community Partnerships

Culinary medicine courses blend culinary arts and social science with biomedical nutrition science to increase student capacity to coach patients towards healthier eating. Our experiences suggest that building diverse community partnerships into such curricula can further broaden students’ nutritional knowledge and support professional identity formation. We describe how others involved in culinary medicine courses might integrate such intuitive partnerships into curricular development.

Why do we not pick the low-hanging fruit? Governing adaptation to climate change and resilience in Tyrolean mountain agriculture

Impacts of climate change have become more and more evident and can be observed in ecosystems, societies and economies worldwide. Mountain agriculture is especially vulnerable to climate change, and adaptation seems crucial. Thus, certain adaptation activities, such as installing irrigation technology, switching to drought-resistant crop varieties or shifting planting dates, can already be observed. Despite these efforts, the barriers for climate change adaptation are still manifold and lead to adaptation gaps. One problem is that many approaches ignore non-climatic drivers, such as economic conditions or cultural aspects, which have a strong influence on farmers´ decisions. In the literature, the focus is mostly on planned, “top-down” induced adaptations, where climate change is considered the most important driver. Within this study, we focus on local, “bottom-up” adaptation actions in Tyrolean mountain agriculture that may be triggered by climatic as well as by non-climatic drivers. We identify 27 adaptation practices and cluster them into six types of climate change adaptation: ´Resilience-raising products and production´, ´Hidden actions by farmer organizations´, ´CC motivated agronomic actions´, ´CCA scientific knowledge production´, ´Risk-driven adaptations´ and ´Hidden governmental actions´. These types are helpful to show the broad range of local practices contributing to climate change adaptation. Several adaptation actions from practice are not motivated by climate change and thus are termed “hidden” adaptations, as they do not fit into common adaptation concepts. Hidden climate change adaptation practices, although not considered to date in official CCA policy documents, constitute “low-hanging fruit” for decision makers as they have already proved their feasibility and gained legitimacy by actors on the ground. We argue that additional support for such hidden adaptation practices can help to overcome present adaptation barriers and adaptation gaps.

Incentives for Public Experimentation

A group of agents exert effort to generate random increments in a public flow of benefits. As benefits increase, net returns to effort decrease. We show that, in the unique symmetric Markov equilibrium with benefits as the state variable, effort drops as benefits increase and this may cause a welfare loss. Moreover, the same is true in the most efficient equilibrium if strategies condition on time and on the history of benefits. As a result, short-term productivity increases may reduce effort and welfare. In the context of an R&D partnership in which improvements in the collective technology raise the incentive to shift resources towards private activities, the appearance of a ‘low-hanging fruit’ may slow down progress.

Invited commentary

In light of the current enthusiasm for the expanded use of branched and fenestrated endovascular aneurysm repair (F/B-EVAR) of complex aortic aneurysms, we are fortunate that Dr Schanzer and his colleagues have given us some insight into the high reintervention rate of patients after F/B-EVAR. The 26% need for at least one re intervention is probably understated in this study, given the inclusion of a small number of iliac branched devices and the significant number of commercially available Cook Zenith fenestrated renal branch devices (arguably the low-hanging fruit of F/B-EVAR grafts). Furthermore, the authors can expect even further reinterventions, given the relatively short-term follow-up of 25 months and the fact that reintervention rates seem to increase rather than to decrease over time. Several points are worth emphasizing. First of all, it is reassuring to see that the great majority of problems requiring reintervention after F/B-EVAR can be successfully managed (most often through an endovascular approach). Second, these devices were placed under the auspices of a physician-sponsored investigational device exemption trial. As such, patients were carefully selected to ensure anatomic suitability for a successful repair. This senior author knows better than most the poor results that can result when the limits of anatomic acceptability are stretched to expand the application of endovascular technology.1Schanzer A. Greenberg R.K. Hevelone N. Robinson W.P. Eslami M.H. Goldberg R.J. et al.Predictors of abdominal aortic aneurysm sac enlargement after endovascular repair.Circulation. 2011; 123: 2848-2855Crossref PubMed Scopus (576) Google Scholar Analogous to the application of EVAR, we can anticipate even higher rates of failure, reintervention, and poor outcomes as this technology proliferates to less selective surgeons. Third, the authors demonstrate a significantly higher reintervention rate in physician-modified endografts (PMEGs) compared with company-manufactured devices (CMDs). They note that there is still a role for PMEGs in urgent cases. By inference, CMDs are preferred for elective cases. Given that CMDs are restricted to only a small number of centers nationwide, the implications for surgeons using PMEGs for elective repair are important. Finally, patients with complex aneurysms repaired with F/B-EVAR should be considered to have a chronic disease with vigilant continued follow-up and anticipated reinterventions. Reinterventions after fenestrated or branched endovascular aortic aneurysm repairJournal of Vascular SurgeryVol. 68Issue 3PreviewReinterventions after fenestrated or branched endovascular aneurysm repair (F/B-EVAR) are sometimes necessary to maintain aneurysm exclusion or endograft and target artery patency. These reinterventions are nontrivial, potentially associated with morbidity, mortality, and resource utilization. Whereas rates, types, and outcomes of reintervention after infrarenal EVAR have been well described, they have not been well described for F/B-EVAR. We sought to characterize the morbidity, mortality, and resource utilization due to reinterventions after F/B-EVAR. Full-Text PDF Open Archive

Michael Kleerekoper (August 18, 1944 to May 10, 2018): In Relentless Pursuit of a Better Way.

Michael Kleerekoper (August 18, 1944 to May 10, 2018): In Relentless Pursuit of a Better Way.

DEMOGRAPHIC FACTORS OF SMALL AND MEDIUM TOURISM ENTERPRISES IN AND AROUND MASVINGO, ZIMBABWE

Tourism is viewed as one of the largest and fastest growing industries at the global level. Developing countries often see it as a low-hanging fruit in terms of stimulating economic development. A variety of perspectives has been explored in the study of tourism. However, one of the least researched issues is that of the demographic characteristics of the sector. Hence, there is a need to explore it. This study focusing on Masvingo Urban (Zimbabwe) examines several demographic features of the tourism industry. They include: age, gender, education as well as designation, nature and type of organization and experience. The data collection exercise was conducted in May, 2018. It is recommended that more such studies should be conducted so as to achieve more holistic views on the subject. Since women in the industry are outnumbered by men, there is a need to employ more of them in order to balance up the numbers. Although this study only focuses on Masvingo, there is a need to explore the issues at both national and regional levels so that policies can be drawn with a view to improve the situation. Article visualizations:

Unintended consequences of quality improvement programs on the prevention of hospital-acquired conditions: Avoiding the temptation to bite into low-hanging fruit

Hospital-acquired conditions such as pressure injuries, falls, and infections are common, costly, and deadly. Addressing the simultaneous needs of evidence-based prevention guidelines for multiple conditions can be challenging for clinical teams. Current payment incentives created by The Centers for Medicare and Medicaid Services using the Agency for Healthcare Research and Quality Patient Safety Indicator 90 (PSI90) measure impact how clinical resources are allocated by prioritizing conditions that are simpler and less costly to prevent. Pressure injury prevention guidelines may be one of the more complex programs for hospitals to implement due to the financial investment in nursing time and technology. However, a quality improvement program focused around pressure injury prevention holds good value by tackling many of the tangential conditions caused by issues related to the decubitus patient and mobility, including fall injury, venous thromboembolism, catheter-associated urinary tract infection, and sepsis. Hospitals should reconsider their prioritization of different patient safety indicators, and The Centers for Medicare and Medicaid Services should create more focused payment incentives on harmful hospital-acquired conditions such as pressure injury that are independent of composite measures of harm, including PSI90.

Expert Panel Discusses the Importance of Systems Medicine

Expert Panel Discusses the Importance of Systems Medicine