Melanie D. Spencer

Predictors of Unplanned Hospitalization in Patients Receiving Outpatient Parenteral Antimicrobial Therapy Across a Large Integrated Healthcare Network

Summary Patients discharged on outpatient parenteral antimicrobial therapy (OPAT) to skilled nursing facilities have an associated 46% (incident risk ratio = 1.46; 95% confidence interval = 1.04–2.06) greater risk of having an unplanned hospitalization within 90 days of discharge compared with patients receiving OPAT at home after adjusting for demographics, treatment duration, indication, antimicrobial class, comorbidities, and time at risk.

Prevalence of Metabolic Syndrome in a Large Integrated Health Care System in North Carolina

BACKGROUND Metabolic syndrome (MetS) is a cluster of conditions—including abdominal obesity, dyslipidemia, hypertension, and hyperglycemia—that are associated with a significantly increased risk of developing diabetes and cardiovascular diseases. No information currently exists regarding the prevalence of MetS in North Carolina. This study determined the prevalence of MetS among adults receiving care in a large integrated health care system in North Carolina. METHODS This study used data from the Carolinas HealthCare Systems electronic medical record system and included adults receiving care during 2014. The association between patient demographic characteristics and MetS was determined using multivariable logistic regression. RESULTS The prevalence of MetS was approximately 22.5%. Individuals aged 18–29 years were less likely to have MetS compared with those aged 80 years and older (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.56–0.67). Groups that were more likely to have MetS included women (OR, 1.07; 95% CI, 1.05–1.10), Hispanics (OR, 1.14; 95% CI, 1.05–1.23), individuals with Medicare (OR, 1.38; 95% CI, 1.33–1.42), and those with Medicaid (OR, 1.68; 95% CI, 1.58–1.78) compared with men, whites, and those with commercial insurance, respectively. LIMITATIONS We excluded individuals with missing data for any of the conditions that define MetS, which may underestimate the actual prevalence of this condition. CONCLUSIONS The considerable prevalence of MetS in our North Carolina sample suggests that interventions are needed to achieve the states population health goals.

Not a magic pill: a qualitative exploration of provider perspectives on antibiotic prescribing in the outpatient setting

BackgroundInappropriate prescribing of antibiotics poses an urgent public health threat. Limited research has examined factors associated with antibiotic prescribing practices in outpatient settings. The goals of this study were to explore elements influencing provider decisions to prescribe antibiotics, identify provider recommendations for interventions to reduce inappropriate antibiotic use, and inform the clinical management of patients in the outpatient environment for infections that do not require antibiotics.MethodsThis was a qualitative study using semi-structured interviews with key informants. Seventeen outpatient providers (10 medical doctors and 7 advanced care practitioners) within a large healthcare system in Charlotte, North Carolina, participated. Interviews were audio recorded, transcribed, and analyzed for themes.ResultsPrimary barriers to reducing inappropriate antibiotic prescribing included patient education and expectations, system-level factors, and time constraints. Providers indicated they would be interested in having system-wide, evidence-based guidelines to inform their prescribing decisions and that they would also be receptive to efforts to improve their awareness of their own prescribing practices. Results further suggested that providers experience a high demand for antibiotic prescriptions; consequently, patient education around appropriate use would be beneficial.ConclusionsFindings suggest that antibiotic prescribing in the outpatient setting is influenced by many pressures, including patient demand and patient satisfaction. Training on appropriate antibiotic prescribing, guideline-based decision support, feedback on prescribing practices, and patient education are recommended interventions to improve levels of appropriate prescribing.

Exploring Patient Awareness and Perceptions of the Appropriate Use of Antibiotics: A Mixed-Methods Study

In the outpatient setting, estimates suggest that 30% of the antibiotics prescribed are unnecessary. This study explores patient knowledge and awareness of appropriate use of antibiotics and expectations regarding how antibiotics are used for their treatment in outpatient settings. A survey was administered to a convenience sample of patients, parents, and caregivers (n = 190) at seven primary care clinics and two urgent care locations. Fisher’s exact tests compared results by patient characteristics. Although 89% of patients correctly believed that antibiotics work well for treating infections from bacteria, 53% incorrectly believed that antibiotics work well for treating viral infections. Patients who incorrectly believed that antibiotics work well for treating viral infections were more than twice as likely to expect a provider to give them an antibiotic when they have a cough or common cold. Patients who completed the survey also participated in semi-structured interviews (n = 4), which were analyzed using thematic analysis. Patients reported experiencing confusion about which illnesses may be treated by antibiotics and unclear communication from clinicians about the appropriate use of antibiotics. Development of easy to understand patient educational materials can help address patients’ incorrect perceptions of appropriate antibiotic use and facilitate patient-provider communication.

Antimicrobial Prescribing Rates Comparing On-Site Visits with Two Types of Virtual Care Visits Across a Large Integrated Healthcare System

Abstract Background In 2014, Carolinas Healthcare System (CHS) implemented virtual visits and Electronic visits (eVisits) as an alternative to on-site visits to provide novel and convenient ways for patients to access care for non-emergent conditions. With virtual visits, patients have a face-to-face consultation with a provider by logging onto any device equipped with a camera. eVisits offer a lower tech alternative that allow patients to email their health concerns through a series of health-related questions. Providers respond via email with recommendations. No face-to-face interaction is included with eVisits. This study aimed to compare prescribing rates across these care delivery options. Methods We identified 2,478 virtual visits, 269 eVisits and 655,329 on-site visits between Jan 2014 to Feb 2017 where there was any diagnosis of bronchitis, sinusitis, non-suppurative otitis media and upper respiratory infection. Antimicrobial prescribing rates were standardized to per 100 visits (reported as a %) for each indication. Prescribing rates are reported for each visit type and indication. Chi square tests were used to compare rates across the visit types. Results Across all visit types and indications, on-site visits had the highest rate of antimicrobial prescribing and eVisits the lowest (onsite: 55.0; virtual: 51.3; eVisit 33.8; P < 0.001). Sinusitis was the most frequent indication for which an antimicrobial was prescribed, with on-site visits (86.6%), virtual (72.9%) and eVisits(57.8%) showing significantly different rates (P < 0.001). For upper respiratory infections, where an antimicrobial is not indicated, 34.5% of on-site, 11.0% of virtual and 2.0% of eVisits received an antimicrobial prescription (P < 0.001). Conclusion The mechanism of care delivery significantly impacts whether or not an antimicrobial is prescribed for specific diagnoses where a prescription may not be indicated. eVisits had the lowest rates of inappropriate prescribing for URI while on-site care showed significantly higher antimicrobial prescriptions. Further investigation is needed into the underlying causes of prescribing rate variances and how these care delivery options may affect efforts to reduce inappropriate utilization of antimicrobials. Disclosures All authors: No reported disclosures.

Racial/ethnic differences in healthcare use among patients with uncontrolled and controlled diabetes

ABSTRACT Objectives: To examine racial/ethnic differences in healthcare use among patients classified as having controlled and uncontrolled diabetes. Design: Data from the Carolinas HealthCare System electronic data warehouse were used. Glycemic control was defined as glycosylated hemoglobin (HbA1c) < 8% (64 mmol/mol) in 2012 (n = 9996). Patients with HbA1c ≥ 8% (64 mmol/mol) in 2012 were classified as uncontrolled (n = 2576). Race and ethnicity were jointly classified as non-Hispanic Black, non-Hispanic White or Other. Separate mixed effects negative binomial models estimated the independent effect of race/ethnicity on the number of emergency department (ED) visits, hospitalizations and physician office visits in 2013, in each patient group, adjusting for significant confounding variables. Results: Rates of diabetes-related ED visits were two to three times higher for non-Hispanic Blacks compared to non-Hispanic Whites (uncontrolled rate ratio [RR]: 3.41 95% CI: 1.41–8.22; controlled RR: 2.95; 95% CI: 1.78–4.91). Similar differences were observed for all-cause ED visits (uncontrolled RR: 1.83, 95% CI: 1.50–2.24; controlled RR: 2.45, 95% CI: 2.17–2.77). Non-Hispanic Blacks with controlled and uncontrolled diabetes also had lower rates of all-cause physician office visits when compared to non-Hispanic Whites (uncontrolled RR: 0.84, 95% CI: 0.77–0.91; controlled RR: 0.81, 95% CI: 0.78–0.84). Conclusion: Notable racial/ethnic disparities exist in the use of emergency services and physician offices for diabetes care. Strategies such as patient education and care delivery changes that address healthcare access issues in racial/ethnic minorities should be considered to offer better diabetes management and address diabetes disparities.

Retrospective Analysis of Catheter-Acquired Urinary Tract Infection: Relationship to Stroke Diagnosis

Aims: The objective of this study was to determine if a diagnosis of stroke was associated with a higher incidence of catheter-associated urinary tract infections (CAUTIs). Secondary aims included examining the effect of healthcare-related variables including antibiotic and steroid use, length of stay before catheter insertion, and duration of catheter use on the incidence of CAUTI in stroke patients. Design: This was a retrospective chart review analysis set in a large teaching hospital in the Southeastern United States. Methods: A total of 300 patients with indwelling urinary catheter use who also had a stroke diagnosis were randomly selected and matched (on age, gender, race, and admission date) to 300 randomly selected patients with indwelling urinary catheter use and without stroke. Bivariate statistical tests included Wilcoxon signed-rank test and McNemar’s test, whereas the multivariate test consisted of generalized estimating equations. Results: The incidence of CAUTIs in stroke patients was significantly higher than that in nonstroke patients (6.0% vs 1.7%, P = .005). In the multivariable generalized estimating equations analysis, stroke patients were found to be approximately 3.5 times more likely to experience CAUTI compared with nonstroke patients (odds ratio = 3.53; 95% confidence interval, 1.24–10.03; P = .018). The proportion of patients who used steroids was greater among stroke patients who experienced CAUTI compared with those who did not experience CAUTI (55.6% vs 24.5%, P = .004). Conclusion: Stroke patients were more likely to develop CAUTI compared with nonstroke patients. These patients should be considered as key targets when implementing interventions aimed at reducing CAUTIs. Use of steroids may be associated with a higher likelihood of CAUTI in stroke patients. Implications: Clinical nurse specialists are directly influential in preventing CAUTIs. This study provides evidence regarding the association between stroke and CAUTI to clinical nurse specialists to help them plan CAUTI prevention initiatives.