South Texas Veterans Health Care Research Articles

Impact of a pharmacist-led oral chemotherapy monitoring clinic at the South Texas Veterans Health Care System.

As cancer treatments shift from traditional intravenous chemotherapy to inclusion of oral oncolytics, there is a critical need for structured oral chemotherapy monitoring and follow-up programs. To provide continuous care and minimize clinical gaps to Veterans receiving oral chemotherapy, the hematology/oncology clinical pharmacy practitioners designed and initiated a pilot, pharmacist-driven, Oral Chemotherapy Monitoring Clinic at the South Texas Veterans Health Care System supported by an oral chemotherapy certified pharmacy technician. A retrospective evaluation of patients receiving oral chemotherapy at the South Texas Veterans Health Care System was performed before (Phase I) and after (Phase II) pilot implementation to assess the impact of an Oral Chemotherapy Monitoring Clinic on compliance with drug-specific lab and symptom monitoring. Complete monitoring was defined as 100% of recommended labs and symptoms assessed per cycle, partial monitoring was <100%, but >0%, and incomplete monitoring was defined as 0%. The primary outcome assessed the proportion of patients receiving complete monitoring in Phase II compared to Phase I. Most patients were male (94%), with a median age of 72 years. The most common oncolytic was abiraterone acetate. Overall, drug-specific baseline and follow-up laboratory and symptom monitoring was complete at a statistically significantly higher rate in Phase II compared with Phase I (p-value < 0.01). A significantly higher portion of patients in the Phase II cohort had a clinical pharmacy practitioner intervention (44% vs. 90%; p < 0.01). Monitoring for Veterans receiving oral chemotherapy was optimized with clinical pharmacy practitioner and certified pharmacy technician involvement while simultaneously alleviating Oncologist and nurse oral chemotherapy workload.

The effect of level of injury on diabetes incidence and mortality after spinal cord injury - a longitudinal cohort study.

Retrospective longitudinal cohort study of veterans with SCI. Spinal cord injury (SCI) is associated with an increased risk of developing diabetes mellitus (DM), likely due to body composition alterations and autonomic nervous system dysfunction. These factors are more pronounced in persons with tetraplegia (TP) versus paraplegia (PP). However, the effect of level of injury (LOI) on DM incidence is largely unknown. Therefore, the objective is to examine the effect of LOI on DM incidence in persons with SCI. South Texas Veterans Health Care System. We obtained electronic record data on age, sex, race/ethnicity, LOI and HbA1c concentration from January 1st 2001 through December 31st 2021. Cox proportional hazard regression analyses were used to assess the association between LOI, DM and all-cause mortality. Among 728 non-diabetic veterans with SCI (350 TP/ 378 PP, 52 ± 15 years, 690 male/38 female) 243 developed DM, of which 116 with TP and 127 with PP. Despite chronological variations between TP and PP, DM risk over the entire follow-up did not differ between the groups (hazard ratio (HR): 1.06, 95% CI: 0.82-1.38). Mortality was higher in TP versus PP (HR: 1.40, 95% CI: 1.09-1.78). However, developing DM did not increase the risk of death, regardless of LOI (HR: 1.07, 95% CI: 0.83-1.37). Despite chronological variations between both groups, the level of injury had minimal effect on long-term DM development in this cohort of veterans with SCI. Sponsorship NIH (DK105379; MS), RR&D SPiRE (I21RX003724-01A1; MT and SH).

Ethnic disparity in hospitalization among veterans with COVID-19 and cancer.

e18613 Background: COVID19 results in severe disease and resource utilization, particularly among patients with cancer. Hospitalization rates among COVID19 outpatient US veterans with cancer vary according to race (white vs non-Hispanic black). Less is known about ethnic (Hispanic vs non-Hispanic) disparities in hospitalization rates. We aimed to identify ethnic disparities in all-cause hospitalization rates among COVID19 outpatient US veterans with cancer. Methods: We conducted a retrospective cohort study of veterans with cancer and an index diagnosis of COVID19 (ICD10 U07) between 1/1/2020 and 3/31/2022 managed at the South Texas Veterans Health Care System. We included patients for whom ethnicity data (Hispanic or non-Hispanic white) were available. Our primary outcome was all-cause hospitalization rates at 30 days and 60 days following an index diagnosis of COVID19 among Hispanic and non-Hispanic white patients with cancer. We analyzed continuous variables using unpaired t test and categorical variables using Chi-square analysis for statistical significance (p &lt; 0.05). Results: Of 968 outpatient veterans with a history of cancer and a COVID19 diagnosis between 1/1/2020 and 3/31/2022, 762 met our inclusion criteria. Of these, 300 (39.4%) identified as Hispanic (94% male, p &lt; 0.05) and 462 (60.6%) identified as non-Hispanic white (90% male). At baseline Hispanic patients were younger and were more likely to have underlying comorbidities (T2DM, mild liver disease, AIDS; p &lt; 0.05). Hispanic patients with cancer demonstrated hospitalization rates after the index COVID19 diagnosis comparable to those of non-Hispanic white patients at 30d (34% vs 28.8%) and 60d (35.7% vs 32%). Conclusions: Although Hispanic patients with cancer demonstrated a trend of higher hospitalization rates at 30d and 60d following a COVID19 diagnosis, this difference was not statistically significant. Further studies with a larger sample size and generalizability to assess ethnic disparities in other clinical settings are warranted.

Clinical utility of methicillin-resistant Staphylococcus aureus nasal PCR to streamline antimicrobial use in treatment of diabetic foot infection with or without osteomyelitis

BackgroundDiabetic Foot Infection (DFI) guidelines recommend empiric methicillin-resistant Staphylococcus aureus (MRSA)-targeted therapy in settings where there is high prevalence of MRSA infections or in cases of severe infection; however, they do not provide recommendations for de-escalation. This approach has the potential to increase unnecessary use of broad-spectrum antibiotics; therefore, additional strategies are needed to optimize appropriate antibiotic use. This study evaluates the effect of MRSA nasal PCR testing on MRSA-targeted antibiotic use and clinical outcomes in patients with DFI.MethodsThis was a retrospective quasi-experimental study of patients admitted to South Texas Veterans Health Care System for DFI, with or without osteomyelitis (OM), who had an MRSA nasal PCR and culture data. Eligible patients were identified from the Corporate Data Warehouse and reviewed via electronic health record. Patients were allocated into two groups: PRE (5/1/2019-4/30/2020) and POST (12/1/2020-11/30/2021) protocol implementation for de-escalation or avoidance of MRSA-targeted antibiotics. The primary outcome was median (interquartile range [IQR]) hours of empiric inpatient MRSA-targeted antibiotic therapy. A Wilcoxon Rank Sum test was used to assess the difference between the groups for the primary outcome. Secondary outcomes included the proportion of patients needing MRSA coverage added back for MRSA after de-escalation, hospital readmission, length of hospital stay (LOS), patient mortality, and acute kidney injury.ResultsA total of 151 patients were included (83 PRE; 68 POST). Most patients were male (98% PRE; 97% POST) with a median age of 64 (IQR, 56–72) years. Incidence of MRSA in DFI in the cohort was 14.7% overall (12% PRE and 17.6% POST). MRSA was detected via nasal PCR in 12% of patients 15.7% PRE and 7.4% POST). After protocol implementation, there was a significant decrease in empiric MRSA-targeted antibiotic therapy use, from a median of 72 (IQR, 27–120) hours in the PRE group, to 24 (IQR, 12–72) hours in the POST group (p < 0.01). No significant differences were found for other secondary outcomes.ConclusionThis study of patients presenting to a Veterans Affairs (VA) hospital with DFI identified a statistically significant decrease in median duration of MRSA-targeted antibiotic use post-protocol implementation. This suggests a favorable effect of MRSA nasal PCR for de-escalation or avoidance of MRSA-targeted antibiotics in DFI.

Outcomes in Patients With Curative Malignancies Receiving Filgrastim as Primary Prophylaxis.

Granulocyte colony-stimulating factor prophylaxis has been shown to reduce the risk and duration of chemotherapy-induced neutropenia and febrile neutropenia and is recommended for at-risk patients receiving chemotherapy. Within the South Texas Veterans Health Care System, daily filgrastim injections remain the preferred formulation of granulocyte colony-stimulating factor for primary prophylaxis of febrile neutropenia. This retrospective, single-center cohort study included 59 patients who received daily filgrastim as primary prophylaxis with a curative cancer diagnosis and a chemotherapy regimen at the South Texas Veterans Health Care System from September 1, 2015 to September 24, 2020. Patients had either a high risk for febrile neutropenia or a chemotherapy regimen with an intermediate risk for febrile neutropenia and additional risk factors. The primary outcome was the incidence of neutropenia/febrile neutropenia leading to treatment delays. Secondary outcomes included chemotherapy dose decreases or discontinuations, hospitalizations, days of hospitalization, infections, extended duration of filgrastim, and transitions to pegfilgrastim due to neutropenia/febrile neutropenia. Patients received a median (IQR) of 7 (5-10) doses of filgrastim for primary prophylaxis. Overall, 10 patients (17%) experienced treatment delays due to neutropenia/febrile neutropenia. Fifteen patients (25%) were hospitalized with a median (IQR) length of stay of 5 (4-7) days, 9 patients (15%) had documented infections, and 2 patients (3%) required a chemotherapy dose reduction. Additionally, 9 patients (15%) required an additional median (IQR) of 2 (2-5) doses of filgrastim, and 9 (15%) patients were transitioned to pegfilgrastim. These results suggest that additional measures such as tracking postnadir absolute neutrophil counts should be performed to ensure patients receive an appropriate number of filgrastim doses to prevent complications associated with neutropenia/febrile neutropenia.

MORTALITY AMONG HISPANICS AND NON-HISPANICS WITH COMPARABLE COMORBIDITY BURDEN HOSPITALIZED FOR COVID-19

SESSION TITLE: Impact of Health Disparities and DifferencesSESSION TYPE: Rapid Fire Original InvPRESENTED ON: 10/19/2022 11:15 am - 12:15 pmPURPOSE: The COVID-19 pandemic resulted in an unexpected increase in mortality primarily among patients with preexisting comorbidities. San Antonio Texas and the surrounding areas are home to a proportionally larger Hispanic population relative to the remainder of the state and country. It has been well documented that patients with pre-existing comorbidities have increased mortality when admitted for COVID-19, but limited data are available regarding the Hispanic minority ethnic group. We determined whether Hispanic ethnicity contributed to 30-day mortality when compared to non-Hispanics among hospitalized COVID-19 patients with similar comorbidity burden.METHODS: We performed an observational cohort study among hospitalized patients that were enrolled at the South Texas Veterans Health Care System (STVHCS) from April 1, 2020 until December 31, 2021 and diagnosed with COVID-19 disease. The index data was defined as the day of COVID-19 diagnosis according to the ICD-10 code U07.1. Our independent variable was stratified according to the Hispanic ethnic group. We included COVID-19 patients with similar comorbidity burden, defined by a Charlson Comorbidity Index (CCI) of greater than or equal to 1. A priori adjustment was performed for variables that influence clinical outcome such as age, gender, and CCI, respectively. The primary outcome was 30-day all-cause mortality. Descriptive and multivariate analysis were performed using the IBM SPSS statistics software.RESULTS: Of the 1257 hospitalized patients during the study period, 1038 met inclusion criteria. There were 372 (35.8%) Hispanics and 666 (64.2%) non-Hispanics. Hispanic patients had similar demographic characteristics to non-Hispanic patients, regarding median age in years (68 [56-73] vs. 68 [58-74], male gender (n=354 [95.2%] vs. n=610 [91.6%]) and median CCI (4.0 [2.0-6.8] vs. 4.0 [2.0-7.0]), respectively. The 30-day all-cause mortality was 13.8% (n=50) in the Hispanic group compared to 14.0% (n=93) in the non-Hispanic group (p=0.81). After adjusting for age, gender and CCI, Hispanics had a similar 30-day all-cause mortality to the non-Hispanic group of COVID-19 hospitalized (AOR 0.98, 95% CI 0.66-1.43, p=0.97).CONCLUSIONS: Hispanic ethnicity was not associated with an increased 30-day all-cause mortality in a population of hospitalized COVID-19 patients with similar comorbidity burden.CLINICAL IMPLICATIONS: Hispanic ethnicity does not appear to be an independent risk factor for increased mortality related to COVID-19DISCLOSURES: No relevant relationships by Liwayway AndradeNo relevant relationships by Nicholas HodgemanNo relevant relationships by Marcos Restrepo SESSION TITLE: Impact of Health Disparities and Differences SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: The COVID-19 pandemic resulted in an unexpected increase in mortality primarily among patients with preexisting comorbidities. San Antonio Texas and the surrounding areas are home to a proportionally larger Hispanic population relative to the remainder of the state and country. It has been well documented that patients with pre-existing comorbidities have increased mortality when admitted for COVID-19, but limited data are available regarding the Hispanic minority ethnic group. We determined whether Hispanic ethnicity contributed to 30-day mortality when compared to non-Hispanics among hospitalized COVID-19 patients with similar comorbidity burden. METHODS: We performed an observational cohort study among hospitalized patients that were enrolled at the South Texas Veterans Health Care System (STVHCS) from April 1, 2020 until December 31, 2021 and diagnosed with COVID-19 disease. The index data was defined as the day of COVID-19 diagnosis according to the ICD-10 code U07.1. Our independent variable was stratified according to the Hispanic ethnic group. We included COVID-19 patients with similar comorbidity burden, defined by a Charlson Comorbidity Index (CCI) of greater than or equal to 1. A priori adjustment was performed for variables that influence clinical outcome such as age, gender, and CCI, respectively. The primary outcome was 30-day all-cause mortality. Descriptive and multivariate analysis were performed using the IBM SPSS statistics software. RESULTS: Of the 1257 hospitalized patients during the study period, 1038 met inclusion criteria. There were 372 (35.8%) Hispanics and 666 (64.2%) non-Hispanics. Hispanic patients had similar demographic characteristics to non-Hispanic patients, regarding median age in years (68 [56-73] vs. 68 [58-74], male gender (n=354 [95.2%] vs. n=610 [91.6%]) and median CCI (4.0 [2.0-6.8] vs. 4.0 [2.0-7.0]), respectively. The 30-day all-cause mortality was 13.8% (n=50) in the Hispanic group compared to 14.0% (n=93) in the non-Hispanic group (p=0.81). After adjusting for age, gender and CCI, Hispanics had a similar 30-day all-cause mortality to the non-Hispanic group of COVID-19 hospitalized (AOR 0.98, 95% CI 0.66-1.43, p=0.97). CONCLUSIONS: Hispanic ethnicity was not associated with an increased 30-day all-cause mortality in a population of hospitalized COVID-19 patients with similar comorbidity burden. CLINICAL IMPLICATIONS: Hispanic ethnicity does not appear to be an independent risk factor for increased mortality related to COVID-19 DISCLOSURES: No relevant relationships by Liwayway Andrade No relevant relationships by Nicholas Hodgeman No relevant relationships by Marcos Restrepo

LONG-TERM MORTALITY IN HOSPITALIZED PATIENTS WITH COVID-19 AND PREEXISTING ASTHMA

LONG-TERM MORTALITY IN HOSPITALIZED PATIENTS WITH COVID-19 AND PREEXISTING ASTHMA

Early Documentation of Life-Sustaining Treatment Orders Prior to Diagnosis of COVID-19 in Nursing Home Residents

Public health guidelines to prevent spreading COVID-19 place older adults at risk of loneliness and social isolation. Evidence suggests that participation protects older adults from such detrimental outcomes, therefore we aimed to identify the factors associated with participation in life roles among older adults living in the community during the COVID-19 pandemic. We conducted a telesurvey on a random sample of community-dwelling older adults living in Hamilton, Ontario, Canada, between May and July 2020. Outcome measures included participation in life roles, physical function, physical activity, mobility, mental health, nutrition, and demographics. We conducted two multivariate regression analyses with the Late Life Disability Instrument’s (LLDI) frequency and limitations scales as the dependent variables. Candidate factors were organized by International Classification of Functioning, Disability, and Health (ICF) framework domains; personal factors, body functions and structures, activities, and environmental factors. A total of 272 older adults completed the telesurvey (mean age 78 ±7.3 yrs, 70% female). Age, using walking aids, driving status, household income, education, mental health, nutrition, physical function, and dwelling type explained 47.1% (p<0.001) of the variance observed in LLDI frequency scores. Using walking aids, driving status, receiving health assistance, mental health, and physical function explained 33.9% (p<0.001) of the variance observed in LLDI limitation scores. These findings highlight factors from multiple ICF domains that are associated with participation limitation and frequency among older adults during the pandemic. Our findings have implications for developing public health initiatives to mitigate the effects of the pandemic on the participation of older adults.

1402. NTM Infections; A Rising Global Health Problem/Clinical Characteristics and Outcomes of Patients with Non-Tuberculous Mycobacterial Infections at Two Tertiary Academic Medical Centers

BackgroundNon-Tuberculous Mycobacteria (NTM) cause infections in immunocompetent as well as immunocompromised individuals affecting pulmonary and extra pulmonary sites. These pathogens are widely distributed globally and recent reports have shown their rise in many developed countries. Our study aimed to assess the disease magnitude, describe patient characteristics and risk factors, assess diagnostic and therapeutic measures and review outcomes furthering our understanding of the overall disease process. MethodsWe conducted a retrospective, multicenter review of patients with positive NTM cultures treated at University Hospital System and South Texas Veterans Health Care System (STVHCS) from 2011 to 2018. Infections were classified as pulmonary or extrapulmonary, and we recorded demographics, microbiological data, treatment regimens, duration, complications, follow-up and mortality. All categorical variables were described using percentages and compared between groups using the chi-square test. ResultsA total of 176 patients were included for analysis, of which 111 (63.1%) met criteria for NTM disease (2020 ATS/IDSA). The most common cultured mycobacterium was M. Avium Complex (MAC). M. abscessus-chelonae was more commonly associated with clinical disease and isolated from an extra pulmonary site whereas M. simiae complex had similar distribution between the infected and un-infected groups. Over 50% of patients received treatment (80% in the infected group). Cure was seen in 47.2%, all-cause mortality was 27% at last follow-up. Median duration of therapy was 10 months. 47% of patients experienced adverse effects which led to treatment discontinuation in one third of patients. Patients who were able to achieve a cure received a longer duration of therapy (12 vs 7 months; not statistically significant) and treatment was halted more commonly in the group that did not achieve eventual cure (42.6% vs. 16.7%, p=0.007). ConclusionNTM infections represent a therapeutic challenge with low cure rates and high mortality. An understanding of the risk factors, treatment options and outcomes is essential to guide appropriate management. Our study highlights high rates of adverse effects and discontinuation which precludes prolonged courses of therapy required to achieve cure.Disclosures All Authors: No reported disclosures

758. Increased Prevalence of Clostridioides difficile Infection During the COVID-19 Pandemic Among Hospitalized Veterans in South Texas, USA

Background Clostridioides difficile infection (CDI) continues to be a major global public health concern, particularly during the ongoing SARS-CoV-2 coronavirus disease 2019 (COVID-19) pandemic. Despite new social distancing guidelines and enhanced infection control procedures (e.g., masking, hand hygiene) being implemented since the beginning of COVID-19, little evidence indicates whether these changes have influenced the prevalence of CDI hospitalizations. This study aims to measure CDI prevalence before and during the COVID-19 pandemic in a local cohort of U.S. Veterans. MethodsThis was a cross-sectional study of all Veterans presenting to the South Texas Veterans Health Care System in San Antonio, Texas from Jan 1, 2019 to Apr 30, 2021. Monthly laboratory confirmed CDI events were collected overall and categorized as the following: hospital-onset, healthcare facility-associated (HO-HCFA-CDI), community-onset, healthcare facility-associated CDI (CO-HCFA-CDI), and community-associated CDI (CA-CDI). Monthly confirmed COVID-19 cases were also collected. CDI prevalence was calculated as CDI events per 10,000 bed days of care (BDOC) and was compared between pre-pandemic (Jan 2019-Feb 2020) and pandemic (Mar 2020-Apr 2021) periods.ResultsA total of 285 CDI events, 920 COVID-19 cases, and 104,220 BDOC were included in this study. The overall CDI rate increased from 20.33 per 10,000 BDOC pre-pandemic to 34.51 per 10,000 during the pandemic (p< 0.0001). This was driven primarily by a rise in CO-HCFA-CDI rates (0.95 vs 2.52 per 10,000 BDOC; p< 0.0001) during the pandemic, followed by increases in CA-CDI (15.58 vs. 18.61 per 10,000 BDOC; p< 0.0001) and HO-HCFA-CDI (2.66 vs. 5.43 per 10,000 BDOC; p< 0.0001). Lastly, CDI rates have tripled since the start of the pandemic (March-Apr 2020) compared to the current year (March-Apr 2021) (14.69 vs. 43.76 per 10,000 BDOC). ConclusionOverall, CDI prevalence increased during the COVID-19 pandemic, driven mostly by an increase in CO-HCFA-CDI. As COVID-19 rates increased, CDI rates also increased, likely due to greater healthcare exposures and antibiotic use. Continued surveillance of COVID-19 and CDI is warranted to further decrease infection ratesDisclosures All Authors: No reported disclosures

Validation of Available Extended-Spectrum-Beta-Lactamase Clinical Scoring Models in Predicting Drug Resistance in Patients with Enteric Gram-Negative Bacteremia Treated at South Texas Veterans Health Care System.

Extended-spectrum-beta-lactamase (ESBL)-producing Enterobacteriaceae are increasingly common; however, predicting which patients are likely to be infected with an ESBL pathogen is challenging, leading to increased use of carbapenems. To date, five prediction models have been developed to distinguish between patients infected with ESBL pathogens. The aim of this study was to validate and compare each of these models to better inform antimicrobial stewardship. This was a retrospective cohort study of patients with Gram-negative bacteremia treated at the South Texas Veterans Health Care System over 3 months from 2018 to 2019. We evaluated isolate, clinical syndrome, and score variables for the five published prediction models/scores: Italian "Tumbarello," Duke, University of South Carolina (USC), Hopkins clinical decision tree, and modified Hopkins. Each model was assessed using the area under the receiver operating characteristic curve (AUROC) and Pearson correlation. One hundred forty-five patients were included for analysis, of which 20 (13.8%) were infected with an ESBL Escherichiacoli or Klebsiella spp. The most common sources of infection were genitourinary (55.8%) and gastrointestinal/intraabdominal (24.1%), and the most common pathogen was E. coli (75.2%). The prediction model with the strongest discriminatory ability (AUROC) was Tumbarello (0.7556). The correlation between prediction model score and percent ESBL was strongest with the modified Hopkins model (R2 = 0.74). In this veteran population, the modified Hopkins and Duke prediction models were most accurate in discriminating between Gram-negative bacteremia patients when considering both AUROC and correlation. However, given the moderate discriminatory ability, many patients with ESBL Enterobacteriaceae (at least 25%) may still be missed empirically.

A geriatrics walking clinic improves hemoglobin A1c and timed gait in older veterans with type 2 diabetes

Over one quarter of older adults in the U.S. has diabetes; and, physical activity is important for the promotion of healthy aging in this population. The purpose of this clinical demonstration project is to evaluate the effect of physical activity in the form of walking on glycemic control and timed gait in older Veterans with type 2 diabetes (T2D). Veterans aged ≥60 years were enrolled in the Geriatrics Walking Clinic (GWC), a clinical demonstration project, at South Texas Veterans Health Care System. GWC is a 6-week clinical program that promotes physical activity and is delivered by a registered nurse/diabetes educator and geriatrician. Veterans were recruited from the VA clinics. Enrolled patients received a pedometer at an initial face-to-face visit, were followed with weekly phone calls to monitor steps/day, received encouragement, and participated in a final face-to-face visit at the end of 6 weeks. In a sub-set of patients with T2D, we performed a chart review and recorded Hemoglobin A1c (HbA1c) at 3, 6, and 12 months after completion of the program. Timed Gait, a major characteristic of frailty, was measured at baseline and after completing the program. Change in HbA1c and timed gait compared to baseline was examined using paired t-tests. Sixty-two patients had HbA1c values available and were included in this analysis. Of these, 36, 52, and 61 patients had repeat HbA1c at 3, 6, and 12 months after the intervention, respectively. Mean age was 68 ± 6 years, 58% were Hispanic, and 92% males. HbA1c improved at 3 months (–0.49, 95% CI: –0.87 to –0.12, p=0.013), at 6 months (–0.40, 95% CI: –0.68 to –0.12, p=0.006), and at 12 months (–0.30, 95% CI: –0.57 to –0.029, p=0.031) compared to baseline. Timed Gait also improved (9.3 ±1.7 vs. 10.2 ±1.8, p<0.001). The finding highlights that older patients with T2D benefit from a GWC with improved glycemic control and timed gait.

An Individualized Low-Intensity Walking Clinic Leads to Improvement in Frailty Characteristics in Older Veterans

BackgroundSedentary lifestyle leads to worse health outcomes with aging, including frailty. Older adults can benefit from regular physical activity, but exercise promotion in the clinical setting is challenging.ObjectivesThe objective of this clinical demonstration project was to implement a Geriatric Walking Clinic for older adults and determine whether this clinical program can lead to improvements in characteristics of frailty.DesignThis was a clinical demonstration project/quality improvement project.SettingOutpatient geriatrics clinic at the South Texas Veterans Health Care System (STVHCS).ParticipantsOlder Veterans, aged ≥60 years.InterventionA 6-week structured walking program, delivered by a registered nurse and geriatrician. Patients received a pedometer and a comprehensive safety evaluation at an initial face-to-face visit. They were subsequently followed with weekly phone calls and participated in a final face-to-face follow-up visit at 6 weeks.MeasurementsGrip strength (handheld dynamometer), gait speed (10-ft walk), Timed Up and Go (TUG), and body mass index (BMI) were assessed at baseline and follow-up. Frailty status for gait speed was assessed using Fried criteria.ResultsOne hundred eighty five patients completed the program (mean age: 68.4 ±7 years, 88% male). Improvements from baseline to follow-up were observed in average steps/day, gait speed, TUG, and BMI. Improvement in gait speed (1.13 ±0.20 vs. 1.24 ± 0.23 meter/second, p<0.0001) resulted in reduced odds of meeting frailty criteria for slow gait at follow-up compared to the baseline examination (odds ratio = 0.31, 95% confidence interval: 0.13–0.72, p = 0.01).ConclusionsOur findings demonstrate that a short duration, low-intensity walking intervention improves gait speed and TUG. This new clinical model may be useful for the promotion of physical activity, and for the prevention or amelioration of frailty characteristics in older adults.

513. Effectiveness of Pulsed Xenon Ultraviolet Light Disinfection System to Decrease Clostridium difficile Infections at the South Texas Veterans Health Care System

Background Clostridium difficile is the leading pathogen implicated in healthcare-associated infections. C. difficile spores can survive for months on surfaces, allowing for transmission between patients; thus, environmental disinfection is a cornerstone for C. difficile infection (CDI) prevention. Pulsed xenon ultraviolet (PX-UV) light disinfection effectively eliminates C. difficile spores from surfaces and can be used as an adjunct to manual cleaning; however, few studies have evaluated the effects of this technology on healthcare facility-onset CDI (HO-CDI) rates. The objective of this study was to compare HO-CDI rates prior to and post-implementation of PX-UV disinfection in an acute care hospital.MethodsThis was a quasi-experimental study in the South Texas Veterans Health Care System (STVHCS), San Antonio, Texas from 2011 to 2018. The PX-UV system was implemented beginning January 1, 2013. HO-CDI rates were calculated as CDI cases per 10,000 patient-days. Rates were compared between the pre-PX-UV period (2011–2012) and post-PX-UV period (2013–2018) using the conditional maximum likelihood estimate of rate ratio. The association between number of beds cleaned and HO-CDI incidence was evaluated using Pearson correlation.ResultsDuring the 2-year preintervention period, the HO-CDI rate was 9.09 per 10,000 patient-days compared with 9.44 per 10,000 patient days in the postintervention period (RR 1.038; 95% CI 0.817 – 1.328) (P = 0.7703). HO-CDI rates peaked in 2015 (13.60 per 10,000) and declined steadily thereafter through 2018 (6.86 per 10,000). There was not a significant correlation between number of beds cleaned and HO-CDI incidence (R=0.3713; 95% CI −0.0597–0.6856; P = 0.0889).ConclusionPX-UV disinfection did not significantly reduce HO-CDI rates in the first 5 years of use; however, more recent data demonstrate HO-CDI rates lower than that of the preintervention period.Disclosures All authors: No reported disclosures.

Local Antibiogram Predicts Appropriate Antibiotic Selection for Prostate Biopsy Prophylaxis

PurposeWe evaluate our local antibiogram to determine the accuracy of its use in antibiotic augmentation prior to transrectal prostate biopsy (TRPB). Materials and MethodsWe analyzed pre-TRPB rectal swabs from January 2016 to September 2017 at the South Texas Veterans Health Care System (STVHCS). A query was run on pre-procedure rectal swabs positive for fluoroquinolone resistance in men undergoing TRPB during this time. Culture results and antibiotic resistance profiles were recorded and compared to the proportion of antibiotic resistance in the STVHCS 2016 antibiogram. ResultsWe identified 611 patients who underwent pre-TRPB rectal culture, of which 98 were ciprofloxacin resistant E.coli (CRE) isolates. Our cohort demonstrated 80% sensitivity to ciprofloxacin as compared to the STVHCS antibiogram sensitivity of 65% (p<0.001). Gentamicin demonstrated similar sensitivities between the antibiogram and cohort (90% and 88% respectively). There were no statistically significant differences between the STVHCS antibiogram and the sensitivity profiles of our rectal swab cohort as demonstrated in figure 1, except for Ampicillin/Sulbactam, which was 57% in the antibiogram and 32% in our cohort (p=0.019). Of the CRE identified, 4% (4/98) were considered extended spectrum beta-lactamase producers (ESBL). ConclusionsOverall, resistance patterns in CRE isolates from our study population are consistent with the STVHCS antibiogram therefore; a local antibiogram may be utilized in an implementation strategy for targeted antibiotics or augmentation of fluoroquinolone prophylaxis for TRPB.

Integrating a mental health clinical pharmacy specialist into the Homeless Patient Aligned Care Teams.

Introduction:To address the complex needs of the homeless veteran population, the US Department of Veterans Affairs created the Homeless Patient Aligned Care Team (H-PACT) model. The South Texas Veterans Health Care System has an established H-PACT model, however it does not include a clinical pharmacy specialist in mental health (MH).Methods:An H-PACT MH pharmacy resident clinic was created and managed by a postgraduate year-2 psychiatric pharmacy resident. Improvements in access to MH care, Veterans Health Administration performance metrics, and estimated cost savings associated with resident interventions were reviewed to evaluate clinic utility.Results:Over the 6-month clinic time frame, there were a total of 40 patient encounters in which 21 veterans had MH medication evaluation on at least 1 occasion. The average wait time for Veterans previously followed by the H-PACT psychiatrist was approximately 8 weeks. The H-PACT MH pharmacy resident clinic enabled veterans to be evaluated every 4 to 6 weeks. Interventions made by the resident included identification of medication administration errors, medication adjustments, adherence education, reduction in polypharmacy, and referral to other services. Estimated cost savings from clinic interventions totaled $33 613.67.Discussion:The H-PACT MH pharmacy resident clinic allowed for an improvement in wait time for psychiatric pharmacotherapy follow-up for homeless veterans, with interventions that were associated with significant estimated cost savings.

Impact of a clinical pharmacist-managed clinic in primary care mental health integration at a Veterans Affairs health system.

Introduction:The demand for mental health (MH) services has increased as more veterans seek MH care. At the South Texas Veterans Health Care System, Primary Care Mental Health Integration (PCMHI) was developed to manage patients with uncomplicated MH conditions, including depression, anxiety, or posttraumatic stress disorder (PTSD), within an interdisciplinary primary care (PC) team that includes clinical pharmacy specialists (CPSs). Pharmacists have improved outcomes and access to care for many chronic medical conditions, but limited data demonstrate the impact of MH pharmacists within PC.Methods:This project evaluated the impact of a PCMHI CPS clinic on managing patients with recent antidepressant initiation and CPS clinic intake from September 2015 through December 2016, including follow-up through January 2017. Markers used to evaluate effectiveness of the service included the Patient Health Questionnaire-9 scores, antidepressant medication possession ratio, number of emergency department visits for MH-related concerns, patient engagement in concurrent psychotherapy, and referrals to specialty MH providers.Results:A total of 196 unique patients had intake with the PCMHI CPS in the time specified; 172 of these patients were included in analyses. There were 155 patients maintained in PC. Average Patient Health Questionnaire-9 scores decreased from 14.5 to 8.5, with 63 patients (46%) achieving response and 42 patients (31%) achieving remission. The average antidepressant medication possession ratio was 0.93 for all included patients.Discussion:A PCMHI CPS successfully manages and maintains patients with uncomplicated MH conditions in PC through evidence-based pharmacotherapy, as evidenced by symptom improvement, medication adherence, and low rate of specialty MH referrals.

MP15-20 ANTIBIOTIC SELECTION FOR PROSTATE BIOPSY PROPHYLAXIS USING RECTAL SWAB CULTURES REFLECTS LOCAL ANTIBIOGRAM

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Prostate & Genitalia I1 Apr 2018MP15-20 ANTIBIOTIC SELECTION FOR PROSTATE BIOPSY PROPHYLAXIS USING RECTAL SWAB CULTURES REFLECTS LOCAL ANTIBIOGRAM Elizabeth Ann Rourke, Steven Madsen, Andrea Yunes, Joseph W Basler, and Michael A Liss Elizabeth Ann RourkeElizabeth Ann Rourke More articles by this author , Steven MadsenSteven Madsen More articles by this author , Andrea YunesAndrea Yunes More articles by this author , Joseph W BaslerJoseph W Basler More articles by this author , and Michael A LissMichael A Liss More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.533AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In the recent manuscript ″An Update of the AUA White Paper on the More Common Complications of Prostate Biopsy″, an emphasis was placed on utilization of an antibiogram to determine the community risk of resistant post biopsy infections. However, if an antibiotic augmentation strategy is utilized, there are no current recommendations regarding which antibiotic is preferred within individual communities. Herein, we evaluate the susceptibility profiles of ciprofloxacin resistant E.coli (CRE) identified from rectal swab cultures compared to our local antibiogram to determine if the antibiogram could accurately be utilized in the selection of antibiotic augmentation prior to transrectal prostate biopsy (TRPB). METHODS Pre-TRPB rectal swabs were initiated in January 2016 and data was collected through September 2017 at the South Texas Veterans Health Care System (STVHCS). Culture results and antibiotic resistance profiles were recorded and compared to the proportion of antibiotic resistance in the STVHCS 2016 antibiogram. Fisher Exact test was used for comparisons of proportions in a univariate analysis. RESULTS We identified 611 patients who underwent pre-PNB rectal culture, of which 98 were CRE isolates. Our cohort demonstrated an 80% sensitivity to ciprofloxacin as compared to the STVHCS antibiogram sensitivity of 65% (p<0.001). Gentamicin, a commonly used antibiotic augment, demonstrated similar sensitivities between the antibiogram and cohort (90% and 88% respectively). There were no statistically significant differences between the STVHCS antibiogram and the sensitivity profiles of our rectal swab cohort as demonstrated in figure 1, except for Ampicillin/Sulbactam, which was 57% in the antibiogram and 32% in our cohort (p=0.019). Of the CRE identified, 4% (4/98) were considered extended spectrum betalactamase producers (ESBL). CONCLUSIONS Overall, resistance patterns in CRE isolates from our study population are consistent with the STVHCS antibiogram therefore; a local antibiogram may be utilized in an implementation strategy for targeted antibiotics or augmentation of FQ prophylaxis for PNB. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e197 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Elizabeth Ann Rourke More articles by this author Steven Madsen More articles by this author Andrea Yunes More articles by this author Joseph W Basler More articles by this author Michael A Liss More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Outcomes of mental health pharmacist-managed electronic consults at a Veterans Affairs health care system

The demand for mental health services has increased as more veterans have been diagnosed with-and sought care for-one or more mental health conditions. Within the South Texas Veterans Health Care System (STVHCS), providers may submit electronic consults (e-consults) to mental health clinical pharmacy specialists for medication review and recommendations. These consults aim to manage veterans with uncomplicated mental health conditions in primary care, making specialty mental health providers more available for those who need such services. Pharmacists have improved outcomes and access to care for conditions such as diabetes and hypertension, but currently, there is limited evidence demonstrating the impact of pharmacists in mental health. This quality improvement project assessed the effectiveness of the e-consult service. Information was collected through a retrospective chart review of STVHCS veterans with the corresponding consult note placed in their chart from May 2014 through December 2015. Numbers of recommendations implemented and veterans maintained in primary care were analyzed as markers of effectiveness. Time and cost savings were secondarily explored. A total of 361 consults were submitted for 353 unique patients. Of the 322 patients included in analyses, a total of 301 unique patients (93.5%) were maintained in primary care for at least 3 months. Of the 21 not maintained in primary care, 15 recommendations were implemented; of those maintained in primary care, 271 recommendations were implemented. This service improves mental health care-and patient access-by promoting successful management and maintenance of less complicated patients in primary care.

Cutaneous Diseases among an Aging HIV Cohort, Receiving Care at an Infectious Diseases/Primary Clinic

Background Since the initial description of HIV/AIDS in the USA, cutaneous manifestations have been important in the diagnosis of the disease, and have been frequently associated with immune dysfunction. We sought to describe current dermatologic manifestations in our HIV seropositive veterans who are greater than 50 years of age and compare these to recent reports in HIV seronegative individuals.Methods This was a retrospective cohort study performed at the South Texas Veterans Health Care System Immunosuppression Clinic. The aim was to review the charts of older HIV-positive veterans with a minimum age of 50, evaluated from January 1, 2015 to December 31, 2015, to investigate any manifestations of cutaneous pathology, HIV and non-HIV-related, analyze the correlation of the dermatological diagnoses made by the ID physicians and those made by dermatologists, and stratify the findings by age and CD4 counts.ResultsTwo hundred and Forty-one of the 381 HIV seropositive clinic patients met the criteria (236 males, 5 females), the mean age was 59.95 ± 7.41. The median CD4 count was 446 cell/mm3. There were 558 dermatological diagnoses made in the year of 2015, 172 of these were new diagnoses. Of the 38 patients also seen by dermatologists for the presenting skin condition, 57.9% of the diagnoses agreed with the diagnosis from the referring infectious disease provider.New DiagnosisCases % (total 241 patients)Syphilis5.39% (13)Actinic keratosis4.98% (12)Seborrheic keratosis4.56% (11)Seborrheic dermatitis4.56% (11)Onychomycosis3.73% (9)AIDS-defining cutaneous pathologiesNo. of new casesNo. of remote casesCoccidiomycosis10Cryptococcosis09Chronic herpes complex316Histoplasmosis02Kaposi Sarcoma04ConclusionDermatologic manifestations continue to be common in our aging HIV seropositive population. The most common diagnosis was syphilis, reflecting an ongoing epidemic of this disease in this population, followed by more common diagnoses of actinic keratosis, seborrheic keratosis, seborrheic dermatitis and onychomycosis. Comparison within the population of more current dermatologic diagnoses with more remote diagnoses shows fewer dermatologic manifestations of cryptococcosis, chronic herpes simplex, histoplasmosis and Kaposi Sarcoma.Disclosures All authors: No reported disclosures.