Jesse Theisen-Toupal

The Landscape of Inappropriate Laboratory Testing: A 15-Year Meta-Analysis

Background Laboratory testing is the single highest-volume medical activity and drives clinical decision-making across medicine. However, the overall landscape of inappropriate testing, which is thought to be dominated by repeat testing, is unclear. Systematic differences in initial vs. repeat testing, measurement criteria, and other factors would suggest new priorities for improving laboratory testing. Methods A multi-database systematic review was performed on published studies from 1997–2012 using strict inclusion and exclusion criteria. Over- vs. underutilization, initial vs. repeat testing, low- vs. high-volume testing, subjective vs. objective appropriateness criteria, and restrictive vs. permissive appropriateness criteria, among other factors, were assessed. Results Overall mean rates of over- and underutilization were 20.6% (95% CI 16.2–24.9%) and 44.8% (95% CI 33.8–55.8%). Overutilization during initial testing (43.9%; 95% CI 35.4–52.5%) was six times higher than during repeat testing (7.4%; 95% CI 2.5–12.3%; P for stratum difference <0.001). Overutilization of low-volume tests (32.2%; 95% CI 25.0–39.4%) was three times that of high-volume tests (10.2%; 95% CI 2.6–17.7%; P<0.001). Overutilization measured according to restrictive criteria (44.2%; 95% CI 36.8–51.6%) was three times higher than for permissive criteria (12.0%; 95% CI 8.0–16.0%; P<0.001). Overutilization measured using subjective criteria (29.0%; 95% CI 21.9–36.1%) was nearly twice as high as for objective criteria (16.1%; 95% CI 11.0–21.2%; P = 0.004). Together, these factors explained over half (54%) of the overall variability in overutilization. There were no statistically significant differences between studies from the United States vs. elsewhere (P = 0.38) or among chemistry, hematology, microbiology, and molecular tests (P = 0.05–0.65) and no robust statistically significant trends over time. Conclusions The landscape of overutilization varies systematically by clinical setting (initial vs. repeat), test volume, and measurement criteria. Underutilization is also widespread, but understudied. Expanding the current focus on reducing repeat testing to include ordering the right test during initial evaluation may lead to fewer errors and better care.

Suboptimal Addiction Interventions for Patients Hospitalized with Injection Drug Use-Associated Infective Endocarditis

BACKGROUND Infective endocarditis is a serious infection, often resulting from injection drug use. Inpatient treatment regularly focuses on management of infection without attention to the underlying addiction. We aimed to determine the addiction interventions done in patients hospitalized with injection drug use-associated infective endocarditis. METHODS This is a retrospective review of patients hospitalized with injection drug use-associated infective endocarditis from January, 2004 through August, 2014 at a large academic tertiary care center in Boston, Massachusetts. For the initial and subsequent admissions, data were collected regarding addiction interventions, including consultation by social work, addiction clinical nurse and psychiatry, documentation of addiction in the discharge summary plan, plan for medication-assisted treatment and naloxone provision. RESULTS There were 102 patients admitted with injection drug use-associated infective endocarditis, 50 patients (49.0%) were readmitted and 28 (27.5%) patients had ongoing injection drug use at readmission. At initial admission, 86.4% of patients had social work consultation, 23.7% had addiction consultation, and 24.0% had psychiatry consultation. Addiction was mentioned in 55.9% of discharge summary plans, 7.8% of patients had a plan for medication-assisted treatment, and naloxone was never prescribed. Of 102 patients, 26 (25.5%) are deceased. The median age at death was 40.9 years (interquartile range 28.7-48.7). CONCLUSIONS We found that patients hospitalized with injection drug use-associated infective endocarditis had high rates of readmission, recurrent infective endocarditis and death. Despite this, addiction interventions were suboptimal. Improved addiction interventions are imperative in the treatment of injection drug use-associated infective endocarditis.

Utility, charge, and cost of inpatient and emergency department serum folate testing

BACKGROUND Serum folate levels are commonly ordered for multiple indications in the inpatient and emergency department settings. Since mandatory folic acid fortification in 1998, there has been a decreasing prevalence of folate deficiency in the United States. OBJECTIVE Our objective was to determine the indications, rate of deficiency, charge and cost per deficient result, and change in management per deficient result in serum folate testing in inpatients and emergency department patients. DESIGN Retrospective analysis of all inpatient and emergency department serum folate tests. METHODS We analyzed all inpatient and emergency department serum folate tests performed over a 12-month period. We reviewed the charts of 250 patients and all low-normal or deficient serum folate levels to determine indications, comorbidities, and change in management based on result. Charge and cost analyses were performed. SETTING/PATIENTS All inpatient and emergency department patients with a serum folate test performed at a major medical center in Boston, Massachusetts. RESULTS A total of 2093 serum folate tests were performed in 1944 patients with 2 deficient levels. The most common indications were anemia without macrocytosis and anemia with macrocytosis. The amount charged per deficient result was

Serum and red blood cell folate testing on hospitalized patients

158,022. The cost to the hospital per deficient result was less than

Reimagining Long-term Antibiotics in Persons Who Inject Drugs: Time to Shift the Status Quo?

2093. CONCLUSIONS In folic acid fortified countries, serum folate testing has low utility and poor cost effectiveness for all indications in inpatients and emergency department patients.

Pulmonary Zygomycosis in a Non-neutropenic Patient With Myelodysplastic Syndrome on Lenalidomide

Medical Service, Veterans Affairs Boston Healthcare System, West Roxbury, Massachusetts; Harvard Medical School, Boston, Massachusetts; Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Divisions of General Internal Medicine and Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland; Johns Hopkins School of Medicine, Baltimore, Maryland.

Inpatient Management of Opioid Use Disorder: A Review for Hospitalists.

Medical Service, Veterans Affairs Medical Center, Washington, DC; George Washington University School of Medicine and Health Sciences, Washington, DC; Uniformed Services University of the Health Sciences, Bethesda, Maryland; DC Partnership for HIV/AIDS Progress, Washington, DC; Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Harvard T.H. Chan School of Public Health, Boston, Massachusetts.

Current Issues in Patients With Injection Drug use Associated Infective Endocarditis

Pulmonary zygomycosis is an uncommon infection that occurs mostly in immunocompromised patients. We report the case of a 75-year-old man with myelodysplastic syndrome, treated with lenalidomide for 3 months, who developed respiratory failure and a rapidly progressive left upper lobe consolidation. An extensive workup was unrevealing of the etiology, and the patient expired. A full autopsy was declined, but an in situ post-mortem transbronchial lung biopsy revealed pulmonary zygomycosis. This unique case illustrates the potential risks of lenalidomide therapy in patients with myelodysplastic syndrome and the difficulties in diagnosing pulmonary zygomycosis. To our knowledge this is the first report of a diagnostic in situ post-mortem transbronchial lung biopsy.

Advantages and Limitations of Anticipating Laboratory Test Results from Regression- and Tree-Based Rules Derived from Electronic Health-Record Data

&NA; The United States is experiencing an epidemic of nonmedical opioid use and opioid overdose‐related deaths. As a result, there have been a number of public health interventions aimed at addressing this epidemic. However, these interventions fail to address care of individuals with opioid use disorder during hospitalizations and, therefore, miss a key opportunity for intervention. The role of hospitalists in managing hospitalized patients with opioid use disorder is not established. In this review, we discuss the inpatient management of individuals with opioid use disorder, including the treatment of withdrawal, benefits of medication‐assisted treatment, and application of harm‐reduction strategies.

Low Yield of Outpatient Serum Folate Testing: Eleven Years of Experience

Conclusions Current patients admitted with IDU-IE present with complicated disease, often manifesting one or more indications for surgical intervention. Many patients experience recurrences of IE, which may be even more complicated and life threatening than initial IE. Optimal management and decisions regarding surgical intervention can be difficult in patients with active IDU. Further evaluation is needed to assess the potential benefit of surgical interventions in patients with IDU-IE, and the role for addiction treatment and harm reduction strategies in preventing recurrent IDU-IE.