Sarah L. Krein

Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients' treatment priorities and self-management?

BACKGROUNDThe majority of older adults have 2 or more chronic conditions and among patients with diabetes, 40% have at least three.OBJECTIVEWe sought to understand how the number, type, and severity of comorbidities influence diabetes patients’ self-management and treatment priorities.DESIGNCross-sectional observation study.PATIENTSA total of 1,901 diabetes patients who responded to the 2003 Health and Retirement Study (HRS) diabetes survey.MEASUREMENTSWe constructed multivariate models to assess the association between presence of comorbidities and each of 2 self-reported outcomes, diabetes prioritization and self-management ability, controlling for patient demographics. Comorbidity was characterized first by a count of all comorbid conditions, then by the presence of specific comorbidity subtypes (microvascular, macrovascular, and non-diabetes related), and finally by severity of 1 serious comorbidity: heart failure (HF).RESULTS40% of respondents had at least 1 microvascular comorbidity, 79% at least 1 macrovascular comorbidity, and 61% at least 1 non-diabetes-related comorbidity. Patients with a greater overall number of comorbidities placed lower priority on diabetes and had worse diabetes self-management ability scores. However, only macrovascular and non-diabetes-related comorbidities, but not microvascular comorbidities, were associated with lower diabetes prioritization, whereas higher numbers of microvascular, macrovascular, and non-diabetes-related conditions were all associated with lower diabetes self-management ability scores. Severe, but not mild, HF was associated with lower diabetes prioritization and self-management scores.CONCLUSIONSThe type and severity of comorbid conditions, and not just the comorbidity count, influence diabetes patients’ self-management. Patients with severely symptomatic comorbidities and those with conditions they consider to be unrelated to diabetes may need additional support in making decisions about care priorities and self-management activities.

Racial Disparities in Diabetes Care Processes, Outcomes, and Treatment Intensity

Background. Black Americans with diabetes have a higher burden of illness and mortality than do white Americans. However, the extent to which differences in medical care processes and treatment intensity contribute to poorer diabetes outcomes is unknown. Objective. To assess racial disparities in the quality of diabetes care processes, intermediate outcomes, and treatment intensity. Methods. We conducted an observational study of 801 white and 115 black patients who completed the Diabetes Quality Improvement Project survey (response rate = 72%) in 21 Veterans Affairs (VA) facilities using survey data; medical record information on receipt of diabetes services (A1c, low-density lipoprotein [LDL], nephropathy screen, and foot and dilated eye examinations), and intermediate outcomes (glucose control measured by A1c; cholesterol control measured by LDL; and achieved level of blood pressure); and pharmacy data on filled prescriptions. Results. There were no racial differences in receipt of an A1c test or foot examination. Blacks were less likely than whites to have LDL checked in the past 2 years (72% vs. 80%, P <0.05) and to have a dilated eye examination (50% vs. 63%, P <0.01). Even after adjusting for patients’ age, education, income, insulin use, diabetes self-management, duration, severity, comorbidities, and health services utilization, racial disparities in receipt of an LDL test and eye examination persisted. After taking into account the nested structure of the data using a random intercepts model, blacks remained significantly less likely to have LDL testing than whites who received care within the same facility (68% vs. 83%, P <0.01). In contrast, there were no longer differences in receipt of eye examinations, suggesting that black patients were more likely to be receiving care at facilities with overall lower rates of eye examinations. After adjusting for patient characteristics and facility effects, black patients were substantially more likely than whites to have poor cholesterol control (LDL ⩾130) and blood pressure control (BP ⩾140/90 mm Hg) (P <0.01). Among those with poor blood pressure and lipid control, blacks received as intensive treatment as whites for these conditions. Conclusions. We found racial disparities in some diabetes care process and intermediate outcome quality measures, but not in intensity of treatment for those patients with poor control. Disparities in receipt of eye examinations were the result of black patients being more likely to receive care at lower-performing facilities, whereas for other quality measures, racial disparities within facilities were substantial.

Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study

BACKGROUND Although urinary tract infection (UTI) is the most common hospital-acquired infection in the United States, to our knowledge, no national data exist describing what hospitals in the United States are doing to prevent this patient safety problem. We conducted a national study to examine the current practices used by hospitals to prevent hospital-acquired UTI. METHODS We mailed written surveys to infection control coordinators at a national random sample of nonfederal US hospitals with an intensive care unit and >or=50 hospital beds (n=600) and to all Veterans Affairs (VA) hospitals (n=119). The survey asked about practices to prevent hospital-acquired UTI and other device-associated infections. RESULTS The response rate was 72%. Overall, 56% of hospitals did not have a system for monitoring which patients had urinary catheters placed, and 74% did not monitor catheter duration. Thirty percent of hospitals reported regularly using antimicrobial urinary catheters and portable bladder scanners; 14% used condom catheters, and 9% used catheter reminders. VA hospitals were more likely than non-VA hospitals to use portable bladder scanners (49% vs. 29%; P=.001), condom catheters (46% vs. 12%; P=.001), and suprapubic catheters (22% vs. 9%; P=.001); non-VA hospitals were more likely to use antimicrobial urinary catheters (30% vs. 14%; P=.001). CONCLUSIONS Despite the strong link between urinary catheters and subsequent UTI, we found no strategy that appeared to be widely used to prevent hospital-acquired UTI. The most commonly used practices--bladder ultrasound and antimicrobial catheters--were each used in fewer than one-third of hospitals, and urinary catheter reminders, which have proven benefits, were used in <10% of US hospitals.

Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review

Background Catheter-associated urinary tract infections (CAUTI) are costly, common and often preventable by reducing unnecessary urinary catheter (UC) use. Methods To summarise interventions to reduce UC use and CAUTIs, we updated a prior systematic review (through October 2012), and a meta-analysis regarding interventions prompting UC removal by reminders or stop orders. A narrative review summarises other CAUTI prevention strategies including aseptic insertion, catheter maintenance, antimicrobial UCs, and bladder bundle implementation. Results 30 studies were identified and summarised with interventions to prompt removal of UCs, with potential for inclusion in the meta-analyses. By meta-analysis (11 studies), the rate of CAUTI (episodes per 1000 catheter-days) was reduced by 53% (rate ratio 0.47; 95% CI 0.30 to 0.64, p<0.001) using a reminder or stop order, with five studies also including interventions to decrease initial UC placement. The pooled (nine studies) standardised mean difference (SMD) in catheterisation duration (days) was −1.06 overall (p=0.065) including a statistically significant decrease in stop-order studies (SMD −0.37; p<0.001) but not in reminder studies (SMD, −1.54; p=0.071). No significant harm from catheter removal strategies is supported. Limited research is available regarding the impact of UC insertion and maintenance technique. A recent randomised controlled trial indicates antimicrobial catheters provide no significant benefit in preventing symptomatic CAUTIs. Conclusions UC reminders and stop orders appear to reduce CAUTI rates and should be used to improve patient safety. Several evidence-based guidelines have evaluated CAUTI preventive strategies as well as emerging evidence regarding intervention bundles. Implementation strategies are important because reducing UC use involves changing well-established habits.

Building a better quality measure: are some patients with 'poor quality' actually getting good care?

Background. National performance measures monitor the proportion of diabetic patients with low-density lipoprotein (LDL) levels ≥130 mg/dL, but such simple intermediate outcomes measure poor control, not necessarily poor care. “Tightly linked” quality measures define good quality either by a good intermediate outcome (LDL <130 mg/dL) or by evidence of appropriate responses to poor control (eg, starting or optimizing medications for high LDL or not doing so in the face of contraindications). Objectives. We examined hyperlipidemia therapy for patients with diabetes to determine the relative accuracy of quality assessment using simple intermediate outcome versus tightly linked quality measures. Research Design. Retrospective longitudinal cohort. Subjects. A total of 1154 diabetic patients with an LDL test done between October 1, 1998, and March 31, 1999, in 2 large VA facilities. M>easures. LDL levels, medication treatment, and explanations for poor quality. Results. Although 27% (307 of 1154) of patients had an LDL ≥130 mg/dL using the simple intermediate outcome measure, only 13% (148 of 1154) were classified as having substandard quality using the tightly linked measure. Among the 159 reclassified to adequate quality, 117 had lipid-lowering medication started or increased within 6 months of an LDL ≥130 mg/dL, 8 were already on high-dose medication, 12 had a repeat LDL <130 mg/dL, and 22 had contraindications to treatment. Conclusion. Simple intermediate outcome measures can be an inaccurate reflection of true quality of care, and many patients classified as having substandard quality by “poor control” might actually be receiving good quality of care.

Translating health care-associated urinary tract infection prevention research into practice via the bladder bundle.

BACKGROUND Catheter-associated urinary tract infection (CAUTI), a frequent health care-associated infection (HAI), is a costly and common condition resulting in patient discomfort, activity restriction, and hospital discharge delays. The Centers for Medicare & Medicaid Services (CMS) no longer reimburses hospitals for the extra cost of caring for patients who develop CAUTI. The Michigan Health and Hospital Association (MHA) Keystone Center for Patient Safety & Quality has initiated a statewide initiative, MHA Keystone HAI, to help ameliorate the burden of disease associated with indwelling catheterization. In addition, a long-term research project is being conducted to evaluate the current initiative and to identify practical strategies to ensure the effective use of proven infection prevention and patient safety practices. OVERVIEW OF THE BLADDER BUNDLE INITIATIVE IN MICHIGAN The bladder bundle as conceived by MHA Keystone HAI focuses on preventing CAUTI by optimizing the use of urinary catheters with a specific emphasis on continual assessment and catheter removal as soon as possible, especially for patients without a clear indication. COLLABORATION BETWEEN RESEARChERS AND STATE WIDE PATIENT SAFETY ORGANIZATIONS: A synergistic collaboration between patient safety researchers and a statewide patient safety organization is aimed at identifying effective strategies to move evidence from peer-reviewed literature to the bedside. Practical strategies that facilitate implementation of the bundle will be developed and tested using mixed quantitative and qualitative methods. DISCUSSION Simply disseminating scientific evidence is often ineffective in changing clinical practice. Therefore, learning how to implement these findings is critically important to promoting high-quality care and a safe health care environment.

The role of the “champion” in infection prevention: results from a multisite qualitative study

Background: Although 20% or more of healthcare-associated infections can be prevented, many hospitals have not implemented practices known to reduce infections. We explored the types and numbers of champions who lead efforts to implement best practices to prevent hospital-acquired infection in US hospitals. Methods: Qualitative analyses were conducted within a multisite, sequential mixed methods study of infection prevention practices in Veteran Affairs and non-Veteran Affairs hospitals in the USA. The first phase included telephone interviews conducted in 2005–2006 with 38 individuals at 14 purposively selected hospitals. The second phase used findings from phase 1 to select six hospitals for site visits and interviews with another 48 individuals in 2006–2007. Results: It was possible for a single well-placed champion to implement a new technology, but more than one champion was needed when an improvement required people to change behaviours. Although the behavioural change itself may appear to be an inexpensive and simple solution, implementation was often more complicated than changing technology because behavioural changes required interprofessional coalitions working together. Champions in hospitals with low-quality working relationships across units or professions had a particularly challenging time implementing behavioural change. Merely appointing champions is ineffective; rather, successful champions tended to be intrinsically motivated and enthusiastic about the practices they promoted. Even when broad implementation is stymied, champions can implement change within their own sphere of influence. Conclusions: The types and numbers of champions varied with the type of practice implemented and the effectiveness of champions was affected by the quality of organisational networks.

Use of Central Venous Catheter-Related Bloodstream Infection Prevention Practices by US Hospitals

OBJECTIVE To examine the extent to which US acute care hospitals have adopted recommended practices to prevent central venous catheter-related bloodstream infections (CR-BSIs). PARTICIPANTS AND METHODS Between March 16, 2005, and August 1, 2005, a survey of infection control coordinators was conducted at a national random sample of nonfederal hospitals with an intensive care unit and more than 50 hospital beds (n=600) and at all Department of Veterans Affairs (VA) medical centers (n=119). Primary outcomes were regular use of 5 specific practices and a composite approach for preventing CR-BSIs. RESULTS The overall survey response rate was 72% (n=516). A higher percentage of VA compared to non-VA hospitals reported using maximal sterile barrier precautions (84% vs 71%; P=.01); chlorhexidine gluconate for insertion site antisepsis (91% vs 69%; P<.001); and a composite approach (62% vs 44%; P=.003) combining concurrent use of maximal sterile barrier precautions, chlorhexidine gluconate, and avoidance of routine central line changes. Those hospitals having a higher safety culture score, having a certified infection control professional, and participating in an infection prevention collaborative were more likely to use CR-BSI prevention practices. CONCLUSION Most US hospitals are using maximal sterile barrier precautions and chlorhexidine gluconate, 2 of the most strongly recommended practices to prevent CR-BSIs. However, fewer than half of non-VA US hospitals reported concurrent use of maximal sterile barrier precautions, chlorhexidine gluconate, and avoidance of routine central line changes. Wider use of CR-BSI prevention practices by hospitals could be encouraged by fostering a culture of safety, participating in infection prevention collaboratives, and promoting infection control professional certification.

Qualitative research methods: Key features and insights gained from use in infection prevention research

Infection control professionals and hospital epidemiologists are accustomed to using quantitative research. Although quantitative studies are extremely important in the field of infection control and prevention, often they cannot help us explain why certain factors affect the use of infection control practices and identify the underlying mechanisms through which they do so. Qualitative research methods, which use open-ended techniques, such as interviews, to collect data and nonstatistical techniques to analyze it, provide detailed, diverse insights of individuals, useful quotes that bring a realism to applied research, and information about how different health care settings operate. Qualitative research can illuminate the processes underlying statistical correlations, inform the development of interventions, and show how interventions work to produce observed outcomes. This article describes the key features of qualitative research and the advantages that such features add to existing quantitative research approaches in the study of infection control. We address the goal of qualitative research, the nature of the research process, sampling, data collection and analysis, validity, generalizability of findings, and presentation of findings. Health services researchers are increasingly using qualitative methods to address practical problems by uncovering interacting influences in complex health care environments. Qualitative research methods, applied with expertise and rigor, can contribute important insights to infection prevention efforts.

Bloodstream Infection, Venous Thrombosis, and Peripherally Inserted Central Catheters: Reappraising the Evidence

The widespread use of peripherally inserted central catheters (PICCs) has transformed the care of medical and surgical patients. Whereas intravenous antibiotics, parenteral nutrition, and administration of chemotherapy once necessitated prolonged hospitalization, PICCs have eliminated the need for such practice. However, PICCs may not be as innocuous as once thought; a growing body of evidence suggests that these devices also have important risks. This review discusses the origin of PICCs and highlights reasons behind their rapid adoption in medical practice. We evaluate the evidence behind 2 important PICC-related complications--venous thrombosis and bloodstream infections--and describe how initial studies may have led to a false sense of security with respect to these outcomes. In this context, we introduce a conceptual model to understand the risk of PICC-related complications and guide the use of these devices. Through this model, we outline recommendations that clinicians may use to prevent PICC-related adverse events. We conclude by highlighting important knowledge gaps and identifying avenues for future research in this area.