Publications by authors named "Brie N Noble"

39 Publications

Frequency and Characteristics of Patients Prescribed Antibiotics on Admission to Hospice Care.

J Palliat Med 2021 Nov 24. Epub 2021 Nov 24.

Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA.

Little is known about antibiotic prescribing on hospice admission despite known risks and limited evidence for potential benefits. To describe the frequency and characteristics of patients prescribed antibiotics on hospice admission. Cross-sectional study. Adult (age ≥18 years) decedents of a national, for-profit hospice chain across 19 U.S. states who died between January 1, 2017 and December 31, 2019. The primary outcome was having an antibiotic prescription on hospice admission. Patient characteristics of interest were demographics, hospice referral location, hospice care location, census region, primary diagnosis, and infectious diagnoses on admission. We used multivariable logistic regression to quantify associations between study variables. Among 66,006 hospice decedents, 6080 (9.2%) had an antibiotic prescription on hospice admission. Fluoroquinolones (22%) were the most frequently prescribed antibiotic class. Patients more likely to have an antibiotic prescription on hospice admission included those referred to hospice care from the hospital (adjusted odds ratio [aOR] 1.13, 95% confidence interval [CI] 1.00-1.29) compared with an assisted living facility, those receiving hospice care in a private home (aOR 3.85, 95% CI 3.50-4.24), nursing home (aOR 3.65, 95% CI 3.24-4.11), assisted living facility (aOR 4.04, 95% CI 3.51-4.64), or hospital (aOR 2.43, 95% CI 2.18-2.71) compared with inpatient hospice, and those with a primary diagnosis of liver disease (aOR 2.23, 95% CI 1.82-2.74) or human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (aOR 3.89, 95% CI 2.27-6.66) compared with those without these diagnoses. Approximately 9% of hospice patients had an antibiotic prescription on hospice admission. Patients referred to hospice from a hospital, those receiving care in a noninpatient hospice facility, and those with liver disease or HIV/AIDS were more likely to have an antibiotic prescription. These results may inform future antimicrobial stewardship interventions among patients transitioning to hospice care.
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http://dx.doi.org/10.1089/jpm.2021.0062DOI Listing
November 2021

Are there sex differences in potentially inappropriate prescribing in adults with multimorbidity?

J Am Geriatr Soc 2021 08 6;69(8):2163-2175. Epub 2021 May 6.

Department of Family Medicine, Oregon Health and Science University, Portland, Oregon, USA.

Background/objectives: Limited knowledge exists regarding sex differences in prescribing potentially inappropriate medications (PIMs) for various multimorbidity patterns. This study sought to determine sex differences in PIM prescribing in older adults with cardiovascular-metabolic patterns.

Design: Retrospective cohort study.

Setting: Health and Retirement Study (HRS) 2004-2014 interview data, linked to HRS-Medicare claims data annualized for 2005-2014.

Study Sample: Six thousand three-hundred and forty-one HRS participants aged 65 and older with two and more chronic conditions.

Measurements: PIM events were calculated using 2015 American Geriatrics Society Beers Criteria. Multimorbidity patterns included: "cardiovascular-metabolic only," "cardiovascular-metabolic plus other physical conditions," "cardiovascular-metabolic plus mental conditions," and "no cardiovascular-metabolic disease" patterns. Logistic regression models were used to determine the association between PIM and sex, including interaction between sex and multimorbidity categories in the model, for PIM overall and for each PIM drug class.

Results: Women were prescribed PIMs more often than men (39.4% vs 32.8%). Overall, women had increased odds of PIM (Adj. odds ratio [OR] = 1.30, 95% confidence interval [CI]: 1.16-1.46). Women had higher odds of PIM than men with cardiovascular-metabolic plus physical patterns (Adj. OR = 1.25, 95% CI: 1.07-1.45) and cardiovascular-metabolic plus mental patterns (Adj. OR = 1.25, 95% CI: 1.06-1.48), and there were no sex differences in adults with a cardiovascular-metabolic only patterns (Adj. OR = 1.13, 95% CI: 0.79-1.62). Women had greater odds of being prescribed the following PIMs: anticholinergics, antidepressants, antispasmodics, benzodiazepines, skeletal muscle relaxants, and had lower odds of being prescribed pain drugs and sulfonylureas compared with men.

Conclusion: This study evaluated sex differences in PIM prescribing among adults with complex cardiovascular-metabolic multimorbidity patterns. The effect of sex varied across multimorbidity patterns and by different PIM drug classes. This study identified important opportunities for future interventions to improve medication prescribing among older adults at risk for PIM.
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http://dx.doi.org/10.1111/jgs.17194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8373665PMC
August 2021

Interfacility transfer communication of multidrug-resistant organism colonization or infection status: Practices and barriers in the acute-care setting.

Infect Control Hosp Epidemiol 2021 Apr 16:1-6. Epub 2021 Apr 16.

Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon.

Objective: To describe interfacility transfer communication (IFTC) methods for notification of multidrug-resistant organism (MDRO) status in a diverse sample of acute-care hospitals.

Design: Cross-sectional survey.

Participants: Hospitals within the Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN).

Methods: SRN members completed an electronic survey on protocols and methods for IFTC. We assessed differences in IFTC frequency, barriers, and perceived benefit by presence of an IFTC protocol.

Results: Among 136 hospital representatives who were sent the survey, 54 (40%) responded, of whom 72% reported having an IFTC protocol in place. The presence of a protocol did not differ significantly by hospital size, academic affiliation, or international status. Of those with IFTC protocols, 44% reported consistent notification of MDRO status (>75% of the time) to receiving facilities, as opposed to 13% from those with no IFTC protocol (P = .04). Respondents from hospitals with IFTC protocols reported significantly fewer barriers to communication compared to those without (2.8 vs 4.3; P = .03). Overall, however, most respondents (56%) reported a lack of standardization in communication. Presence of an IFTC protocol did not affect whether respondents perceived IFTC protocols as having a significant impact on infection prevention or antimicrobial stewardship.

Conclusions: Most respondents reported having an IFTC protocol, which was associated with reduced communication barriers at transfer. Standardization of protocols and clarity about expectations for sending and receipt of information related to MDRO status may facilitate IFTC and promote appropriate and timely infection prevention practices.
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http://dx.doi.org/10.1017/ice.2021.131DOI Listing
April 2021

Decreasing Trends in Opioid Prescribing on Discharge to Hospice Care.

J Pain Symptom Manage 2021 11 10;62(5):1026-1033. Epub 2021 Apr 10.

Division of General Internal Medicine & Geriatrics, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA.

Context: There are concerns that policies aimed to prevent opioid misuse may unintentionally reduce access to opioids for patients at end-of-life.

Objective: We assessed trends in opioid prescribing among patients on discharge from the hospital to hospice care.

Methods: This was a retrospective cohort study among adult (age ≥18 years) patients discharged from a 544-576 bed, academic medical center to hospice care between January 1, 2010 to December 31, 2018. Study data were collected from a repository of patients' electronic health record data. Our primary outcome was the frequency of opioid prescribing on discharge to hospice care. Our primary exposure was the calendar year of discharge. We also investigated non-opioid analgesic prescribing and stratified opioid prescribing trends by patient characteristics (e.g., demographics, cancer diagnosis, and location of hospice care).

Results: Among 2,648 discharges to hospice care, mean (standard deviation) age was 65.8 (16.0) years, 46.3% were female, and 58.7% had a cancer diagnosis. Opioid prescribing on discharge to hospice care decreased significantly from 91.2% (95% confidence interval (CI) = 87.1%-94.1%) in 2010 to 79.3% (95% CI = 74.3%-83.5%) in 2018 adjusting for age, sex, cancer diagnosis, and location of hospice care. Prescribing of non-opioid analgesic medications increased over the same time period.

Conclusions: We observed a statistically significant decreasing trend in opioid prescribing on discharge to hospice care. Further research should aim to confirm these findings and to identify opportunities to ensure optimal pain management among patients transitioning to hospice care.
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http://dx.doi.org/10.1016/j.jpainsymman.2021.03.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8502178PMC
November 2021

Variation in Hospice Patient and Admission Characteristics by Referral Location.

Med Care 2020 12;58(12):1069-1074

Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA.

Background: Little is known regarding differences between patients referred to hospice from different care locations.

Objective: The objective this study was to describe the associations between hospice referral locations and hospice patient and admission characteristics.

Research Design: Cross-sectional analysis of hospice administrative data.

Subjects: Adult (age older than 18 y) decedents of a national, for-profit, hospice chain across 19 US states who died between January 1, 2012, and December 31, 2016.

Measures: Patients' primary hospice diagnosis, hospice length stay, and hospice care site. We also determined the frequency of opioid prescriptions with and without a bowel regimen on hospice admission.

Results: Among 78,647 adult decedents, the mean age was 79.2 (SD=13.5) years, 56.4% were female, and 69.9% were a non-Hispanic White race. Most hospice referrals were from the hospital (51.9%), followed by the community (21.9%), nursing homes (17.4%), and assisted living (8.8%). Cancer (33.6%) was the most prevalent primary hospice diagnosis; however, this varied significantly between referral locations (P<0.001). Similarly, home hospice (32.8%) was the most prevalent site; however, this also varied significantly between referral locations (P<0.001). More hospital-referred patients (55.6%) had a hospice length of stay <7 days compared with patients referred from nursing homes (30.3%), the community (28.9%), or assisted living (18.7%), P<0.001. Hospital-referred patients also had the lowest frequency (58.4%) of coprescribed opioids and bowel regimen on hospice admission compared with other referral locations.

Conclusion: We observed significant differences in hospice patient and admission characteristics by referral location.
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http://dx.doi.org/10.1097/MLR.0000000000001415DOI Listing
December 2020

Opioid prescribing on discharge to skilled nursing facilities.

Pharmacoepidemiol Drug Saf 2020 09 29;29(9):1183-1188. Epub 2020 Jul 29.

Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA.

Purpose: Skilled nursing facility (SNF) residents are at increased risk for opioid-related harms. We quantified the frequency of opioid prescribing among patients discharged from an acute care hospital to SNFs.

Methods: This was a retrospective cohort study among adult (≥18 years) inpatients discharged from a quaternary-care academic referral hospital in Portland, OR to a SNF between January 1, 2017 and December 31, 2018. Our primary outcome was receipt of an opioid prescription on discharge to a SNF. Our exposures included patient demographics (eg, age, sex), comorbid illnesses, surgical diagnosis related group (DRG), receiving opioids on the first day of the index hospital admission, and inpatient hospital length of stay.

Results: Among 4374 patients discharged to a SNF, 3053 patients (70%) were prescribed an opioid on discharge. Among patients prescribed an opioid, 61% were over the age of 65 years, 50% were male, and 58% had a surgical Medicare severity diagnosis related group (MS-DRG). Approximately 70% of patients discharged to a SNF were prescribed an opioid on discharge, of which 68% were for oxycodone, and 52% were for ≥90 morphine milligram equivalents per day. Surgical DRG, diagnoses of cancer or chronic pain, last pain score, and receipt of an opioid on first day of the index hospital admission were independently associated with being prescribed an opioid on discharge to a SNF.

Conclusion: Opioids were frequently prescribed at high doses to patients discharged to a SNF. Efforts to improve opioid prescribing safety during this transition may be warranted.
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http://dx.doi.org/10.1002/pds.5075DOI Listing
September 2020

Cytomegalovirus serologic matching in deceased donor kidney allocation optimizes high- and low-risk (D+R- and D-R-) profiles and does not adversely affect transplant rates.

Am J Transplant 2020 12 23;20(12):3502-3508. Epub 2020 Jun 23.

Division of Nephrology, Oregon Health and Science University, Portland, Oregon, USA.

Cytomegalovirus (CMV) is a major cause of infection-related morbidity and mortality in kidney transplantation. The most significant risk for developing CMV infection after transplant depends upon donor (D) and recipient (R) CMV serostatus. In 2012, our Organ Procurement Organization (OPO) began a novel pretransplant CMV prevention strategy via matching deceased kidney donors and recipients by CMV serostatus. Prior to the matching protocol, our distribution of seropositive and seronegative donors and recipients was similar to the United States at large. After the matching protocol, high-risk D+R- were reduced from 18.5% to 2.9%, whereas low-risk D-R- were increased from 13.5% to 24%. There was no adverse effect on transplant rates and no differential effect on waiting times for R+ vs R- after the protocol was implemented. This protocol could be implemented on a regional or national level to optimize low and high-risk CMV seroprofiles and potentially improve CMV-related outcomes in kidney transplantation.
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http://dx.doi.org/10.1111/ajt.15976DOI Listing
December 2020

Health Care Worker Perceptions of Gaps and Opportunities to Improve Hospital-to-Hospice Transitions.

J Palliat Med 2020 07 31;23(7):900-906. Epub 2019 Dec 31.

Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, Oregon, USA.

Care transitions from the hospital to hospice are a difficult time, and gaps during this transitions could cause poor care experiences and outcomes. However, little is known about what gaps exist in the hospital-to-hospice transition. To understand the process of hospital-to-hospice transition and identify common gaps in the transition that result in unsafe or poor patient and family caregiver experiences. We conducted a qualitative descriptive study using semistructured interviews with health care workers who are directly involved in hospital-to-hospice transitions. Participants were asked to describe the common practice of discharging patients to hospice or admitting patients from a hospital, and share their observations about hospital-to-hospice transition gaps. Fifteen health care workers from three hospitals and three hospice programs in Portland, Oregon. All interviews were audio recorded and analyzed using qualitative descriptive methods to describe current practices and identify gaps in hospital-to-hospice transitions. Three areas of gaps in hospital-to-hospice transitions were identified: (1) low literacy about hospice care; (2) changes in medications; and (3) hand-off information related to daily care. Specific concerns included hospital providers giving inaccurate descriptions of hospice; discharge orders not including comfort medications for the transition and inadequate prescriptions to manage medications at home; and lack of information about daily care hindering smooth transition and continuity of care. Our findings identify gaps and suggest opportunities to improve hospital-to-hospice transitions that will serve as the basis for future interventions to design safe and high-quality hospital-to-hospice care transitions.
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http://dx.doi.org/10.1089/jpm.2019.0513DOI Listing
July 2020

Compliance with statewide regulations for communication of patients' multidrug-resistant organism and Clostridium difficile status during transitions of care.

Am J Infect Control 2020 04 8;48(4):451-453. Epub 2019 Oct 8.

Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, OR. Electronic address:

In 2014, Oregon implemented an interfacility transfer communication law requiring notification of multidrug-resistant organism status on patient transfer. Based on 2015 and 2016 statewide facility surveys, compliance was 77% and 87% for hospitals, and 67% and 68% for skilled nursing facilities. Methods for complying with the rule were heterogeneous, and fewer than half of all facilities surveyed reported use of a standardized interfacility transfer communication form to assess a patient's multidrug-resistant organism status on transfer.
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http://dx.doi.org/10.1016/j.ajic.2019.08.025DOI Listing
April 2020

Isavuconazole Prophylaxis in Patients With Hematologic Malignancies and Hematopoietic Cell Transplant Recipients.

Clin Infect Dis 2020 02;70(5):723-730

Division of Infectious Diseases, Oregon Health and Science University, Portland.

Background: Isavuconazole (ISA) is an attractive candidate for primary mold-active prophylaxis in high-risk patients with hematologic malignancies or hematopoietic cell transplant (HCT) recipients. However, data supporting the use of ISA for primary prophylaxis in these patients are lacking.

Methods: We conducted a retrospective review of breakthrough invasive fungal infections (bIFIs) among adult hematologic malignancy patients and HCT recipients who received ≥7 days of ISA primary prophylaxis between 1 September 2016 and 30 September 2018. The incidence of bIFIs in patients receiving ISA was compared to those receiving posaconazole (POS) and voriconazole (VOR) during the same time period.

Results: One hundred forty-five patients received 197 courses of ISA prophylaxis. Twelve bIFIs (Aspergillus fumigatus [5], Aspergillus species [2], Mucorales [2], Fusarium species [2], and Candida glabrata [1]) occurred, representing 8.3% of patients and 6.1% of courses, after a median duration of 14 days of ISA prophylaxis. All bIFIs occurred during periods of neutropenia. Seven patients (58.3%) died within 42 days of onset of bIFI. In addition, bIFIs complicated 10.2% of ISA, 4.1% of POS, and 1.1% of VOR courses among patients with de novo or relapsed/refractory acute myeloid leukemia during the study period, with invasive pulmonary aspergillosis (IPA) complicating 6.8% of ISA, 1.3% of POS, and zero VOR courses.

Conclusions: Although ISA has been approved for treatment of invasive Aspergillus and mucormycosis, we observed an increased rate of bIFI, notably IPA, using ISA for primary prophylaxis. These results support the need for further study to determine the role of ISA as primary prophylaxis.
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http://dx.doi.org/10.1093/cid/ciz282DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7931837PMC
February 2020

Frequency and Documentation of Medication Decisions on Discharge from the Hospital to Hospice Care.

J Am Geriatr Soc 2019 06 10;67(6):1258-1262. Epub 2019 Mar 10.

Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon.

Objectives: To quantify the frequency and type of medication decisions on discharge from the hospital to hospice care.

Design: Retrospective cohort study.

Setting: A 544-bed academic tertiary care hospital in Portland, Oregon.

Participants: A total of 348 adult patients (age ≥18 y) discharged to hospice care between January 1, 2010, and December 31, 2016.

Measurements: Data were collected from an electronic repository of medical record data and a manual review of patients' discharge summaries. Our outcomes of interest were the frequency and type of medication decisions documented in patients' discharge summaries. Medication decisions were categorized as continuation, continuation but with changes in dose, route of administration, and/or frequency, discontinuation, and initiation of new medications. We also collected data on the frequency of patient/family in the participation of medication-related decisions.

Results: Patients were prescribed a mean of 7.1 medications (standard deviation [SD] = 4.8) on discharge to hospice care. The most prevalent medications prescribed on discharge were strong opioids (82.5%), anxiolytics/sedatives (62.9%), laxatives (57.5%), antiemetics (54.3%), and nonopioid analgesics (45.4%). However, only 67.8% (213/341) of patients who were prescribed an opioid on discharge to hospice care were also prescribed a laxative. Discharging providers made a mean of 15.0 decisions (SD = 7.2) per patient of which 28.5% were to continue medications without changes, 6.7% were to continue medications with changes, 30.3% were to initiate new medications, and 34.5% were to discontinue existing medications. Patients and/or family members were involved in medication decisions during 21.6% of discharges; patients were involved in 15.2% of decisions.

Conclusion: Patients averaged more than 15 medication decisions on discharge to hospice care. However, it was rarely documented that patients and/or their families participated in these decisions. J Am Geriatr Soc, 2019.
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http://dx.doi.org/10.1111/jgs.15860DOI Listing
June 2019

Antibiotic prescribing upon discharge from the hospital to long-term care facilities: Implications for antimicrobial stewardship requirements in post-acute settings.

Infect Control Hosp Epidemiol 2019 01 9;40(1):18-23. Epub 2018 Nov 9.

1Department of Pharmacy Practice,Oregon State University,Oregon Health & Science University College of Pharmacy,Portland,Oregon.

Objective: To quantify the frequency and outcomes of receiving an antibiotic prescription upon discharge from the hospital to long-term care facilities (LTCFs).

Design: Retrospective cohort study.

Setting: A 576-bed, academic hospital in Portland, Oregon.PatientsAdult inpatients (≥18 years of age) discharged to an LTCF between January 1, 2012, and June 30, 2016.

Methods: Our primary outcome was receiving a systemic antibiotic prescription upon discharge to an LTCF. We also quantified the association between receiving an antibiotic prescription and 30-day hospital readmission, 30-day emergency department (ED) visit, and Clostridium difficile infection (CDI) on a readmission or ED visit at the index facility within 60 days of discharge.

Results: Among 6,701 discharges to an LTCF, 22.9% were prescribed antibiotics upon discharge. The most prevalent antibiotic classes prescribed were cephalosporins (20.4%), fluoroquinolones (19.1%), and penicillins (16.7%). The medical records of ~82% of patients included a diagnosis code for a bacterial infection on the index admission. Among patients prescribed an antibiotic upon discharge, the incidence of 30-day hospital readmission to the index facility was 15.9%, the incidence of 30-day ED visit at the index facility was 11.0%, and the incidence of CDI on a readmission or ED visit within 60 days of discharge was 1.6%. Receiving an antibiotic prescription upon discharge was significantly associated with 30-day ED visits (adjusted odds ratio [aOR], 1.2; 95% confidence interval [CI], 1.02-1.5) and with CDI within 60 days (aOR, 1.7; 95% CI, 1.02-2.8) but not with 30-day readmissions (aOR, 1.01; 95% CI, 0.9-1.2).

Conclusions: Antibiotics were frequently prescribed upon discharge to LTCFs, which may be associated with increased risk of poor outcomes post discharge.
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http://dx.doi.org/10.1017/ice.2018.288DOI Listing
January 2019

A Prospective Cohort Study Examining the Associations of Maternal Arsenic Exposure With Fetal Loss and Neonatal Mortality.

Am J Epidemiol 2019 02;188(2):347-354

Environmental and Occupational Health Program, College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon.

Arsenic crosses the placenta, possibly increasing the risk of adverse reproductive outcomes. We aimed to examine the association between maternal arsenic exposure and fetal/neonatal survival using data from a prospective cohort study of 1,616 maternal-infant pairs recruited at a gestational age of ≤16 weeks in Bangladesh (2008-2011). Arsenic concentration in maternal drinking water was measured at enrollment. Extended Cox regression (both time-dependent coefficients and step functions) was used to estimate the time-varying association between maternal arsenic exposure and fetal/neonatal death (all mortality between enrollment and 1 month after birth). In a sensitivity analysis, we assessed gestational arsenic exposure using maternal urine samples taken at enrollment. We observed 203 fetal losses and 20 neonatal deaths. Higher arsenic exposure was associated with a slightly decreased mortality rate up to the middle of the second trimester, and then the mortality rate switched directions around 20 weeks' gestation. In the step function model, the hazard ratios for combined mortality (fetal loss and neonatal death) per unit increase in the natural log of drinking water arsenic concentration (μg/L) ranged from 1.35 (95% CI: 1.08, 1.69) in weeks 25-28 to 0.81 (95% CI: 0.65, 1.02) in weeks 9-12. This nonlinear association suggests that arsenic may exert survival pressure on developing fetuses, potentially contributing to survival bias, and may also indicate that arsenic toxicity differs by fetal developmental stage.
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http://dx.doi.org/10.1093/aje/kwy243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6357795PMC
February 2019

Clinical Outcomes of Oral Suspension versus Delayed-Release Tablet Formulations of Posaconazole for Prophylaxis of Invasive Fungal Infections.

Antimicrob Agents Chemother 2018 10 24;62(10). Epub 2018 Sep 24.

Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, Oregon, USA

Posaconazole is used for prophylaxis for invasive fungal infections (IFIs) among patients with hematologic malignancies. We compared the incidence of breakthrough IFIs and early discontinuation between patients receiving delayed-release tablet and oral suspension formulations of posaconazole. This was a retrospective cohort study of patients receiving posaconazole between 1 January 2010 and 30 June 2016. We defined probable or proven breakthrough IFIs using the European Organization for Research and Treatment of Cancer (EORTC) criteria. Overall, 547 patients received 860 courses of posaconazole (53% received the oral suspension and 48% received the tablet); primary indications for prophylaxis were acute myeloid leukemia (69%), graft-versus-host disease (18%), and myelodysplastic syndrome (3%). There were no significant differences in demographics or indications between patients receiving the different formulations. The incidence and incidence rate of probable or proven IFIs were 1.6% and 3.2 per 10,000 posaconazole days, respectively. There was no significant difference in the rate of IFIs between suspension courses (2.8 per 10,000 posaconazole days) and tablet courses (3.7 per 10,000 posaconazole days) (rate ratio = 0.8, 95% confidence interval [CI] = 0.3 to 2.3). Of the 14 proven or probable cases of IFI, 8/14 had posaconazole serum concentrations measured, and the concentrations in 7/8 were above 0.7 μg/ml. Posaconazole was discontinued early in 15.5% of courses; however, the frequency of discontinuation was also not significantly different between the tablet (16.5%) and oral suspension (14.6%) formulations (95% CI for difference = -0.13 to 0.06). In conclusion, the incidence of breakthrough IFIs was low among patients receiving posaconazole prophylaxis and not significantly different between patients receiving the tablet formulation and those receiving the oral suspension formulation.
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http://dx.doi.org/10.1128/AAC.00893-18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153813PMC
October 2018

Clinical Intentions of Antibiotics Prescribed Upon Discharge to Hospice Care.

J Am Geriatr Soc 2018 03 18;66(3):565-569. Epub 2018 Jan 18.

Department of Pharmacy Practice, College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, Oregon.

Objectives: To better understand the clinical intentions for antibiotic prescribing upon discharge from acute care to hospice care.

Design: Retrospective cohort study.

Setting: Five hundred forty-four-bed academic, acute-care, tertiary referral hospital in Portland, Oregon.

Participants: Adults (≥18) who received an outpatient prescription for antibiotics on discharge from an acute care hospital to hospice care between January 1, 2009 and December 31, 2011 (N = 149).

Measurements: We determined whether antibiotics were indicated for treatment of an active infection, palliative treatment, prophylaxis, or prescribed according to family or participant preference.

Results: Antibiotics were prescribed to 17.6% (n = 149) of individuals discharged to hospice care over the 3-year study period. Antibiotics were most frequently prescribed for pneumonia (19.5%), urinary tract infections (18.9%), and gastrointestinal tract infections (17.0%). The explicit rationale for antibiotic prescription was documented for only 72 prescriptions (45.3%). For 84 (52.8%) participants, antibiotics were used to treat an active infection in the hospital. Of prescriptions with a documented rationale, 37.5% indicated that the intent was curative, 26.4% prophylaxis, and 22.2% to suppress an infection. For 19.4% of prescriptions, participants or their family members specifically wanted to be treated with antibiotics. Only 9.7% of prescriptions specifically indicated that antibiotics were prescribed for palliative reasons.

Conclusion: Antibiotics were frequently prescribed for treatment of active infection in individuals discharged to hospice care. Further research is needed to document antibiotic benefits and risks and optimize medication management at the end of life.
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http://dx.doi.org/10.1111/jgs.15246DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5849491PMC
March 2018

Prevalence and Clinical Intentions of Antithrombotic Therapy on Discharge to Hospice Care.

J Palliat Med 2017 Nov 5;20(11):1225-1230. Epub 2017 Jun 5.

2 Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy , Portland, Oregon.

Background: There are no guidelines for antithrombotic therapy on admission to hospice care. Antithrombotic therapy may offer some benefit in these patients, but is also associated with well-described risks.

Objective: We quantified the frequency and characteristics of patients prescribed antithrombotic therapy on discharge from acute care to hospice care.

Design: Retrospective cohort study. Settings/Subjects: Adult (age> = 21 years) patients discharged from acute care to hospice care between January 1, 2010 and June 30, 2014.

Measures: Our primary outcome of interest was receiving an outpatient prescription for antithrombotic therapy on discharge to hospice care.

Results: Among 1141 eligible patients, 77 (6.7%) patients received a prescription for antithrombotic therapy on discharge to hospice care, most frequently, aspirin (57.1%), enoxaparin (26.0%), and warfarin (20.8%). Patients actively treated for deep vein thromboembolism or pulmonary embolism, or with a history of atrial fibrillation or aortic/mitral valve replacement were significantly more likely to receive antithrombotic therapy. Patients with a history of cancer, cerebrovascular disease, or liver disease were significantly less likely to receive antithrombotic therapy (p < 0.05 for all). Among patients who received antithrombotic therapy, 22% were not receiving antithrombotic therapy before the index admission. Among patients previously receiving antithrombotic therapy, 55% continued on the same medication, of which 54.5% did not have any documented rationale for continuation.

Conclusions: Prescriptions for antithrombotic therapy were infrequent and often lacked a documented rationale. Further research is needed on the safety and effectiveness of antithrombotic therapy in hospice care and what drives current medication decisions in the absence of these data.
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http://dx.doi.org/10.1089/jpm.2016.0487DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5672614PMC
November 2017

Feasibility of Retrospective Pharmacovigilance Studies in Hospice Care: A Case Study of Antibiotics for the Treatment of Urinary Tract Infections.

J Palliat Med 2017 04 5;20(4):316-317. Epub 2017 Jan 5.

3 Palliative Care Service, Oregon Health & Science University Hospitals and Clinics , Portland, Oregon.

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http://dx.doi.org/10.1089/jpm.2016.0531DOI Listing
April 2017

Should we refrain from antibiotic use in hospice patients?

Expert Rev Anti Infect Ther 2016 6;14(3):277-80. Epub 2016 Jan 6.

b Division of Hematology and Medical Oncology, Knight Cancer Institute , Oregon Health & Science University , Portland , OR , USA.

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http://dx.doi.org/10.1586/14787210.2016.1128823DOI Listing
October 2016

Antibiotic Policies and Utilization in Oregon Hospice Programs.

Am J Hosp Palliat Care 2016 Sep 12;33(8):777-81. Epub 2015 Aug 12.

Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy, Portland, OR, USA

Antibiotics are frequently used in hospice care, despite limited data on safety and effectiveness in this patient population. We surveyed Oregon hospice programs on antibiotic policies and prescribing practices. Among 39 responding hospice programs, the median reported proportion of current census using antibiotics was 10% (interquartile range = 3.5%-20.0%). Approximately 31% of responding hospice programs had policies for antibiotic initiation, 17% of hospice programs had policies for antibiotic discontinuation, and 95% of hospice programs had policies for managing drug interactions. Diarrhea, nausea/vomiting, and yeast infections were the most frequently reported antibiotic-associated adverse events, occurring "sometimes" or "often" among 62%, 47%, and 62% of respondents, respectively. In conclusion, less than a third of participating hospice programs reported having a policy for antibiotic initiation and even less frequently a policy for discontinuation. More data are needed on the risks and benefits of antibiotic use in hospice care to inform these policies and optimize outcomes in this vulnerable patient population.
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http://dx.doi.org/10.1177/1049909115599951DOI Listing
September 2016

Frequency of outpatient antibiotic prescription on discharge to hospice care.

Antimicrob Agents Chemother 2014 Sep 7;58(9):5473-7. Epub 2014 Jul 7.

Palliative Care Service, Oregon Health & Science University, Portland, Oregon, USA Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, Oregon, USA.

The use of antibiotics is common in hospice care despite limited evidence that it improves symptoms or quality of life. Patients receiving antibiotics upon discharge from a hospital may be more likely to continue use following transition to hospice care despite a shift in the goals of care. We quantified the frequency and characteristics for receiving a prescription for antibiotics on discharge from acute care to hospice care. This was a cross-sectional study among adult inpatients (≥18 years old) discharged to hospice care from Oregon Health & Science University (OHSU) from 1 January 2010 to 31 December 2012. Data were collected from an electronic data repository and from the Department of Care Management. Among 62,792 discharges, 845 (1.3%) patients were discharged directly to hospice care (60.0% home and 40.0% inpatient). Most patients discharged to hospice were >65 years old (50.9%) and male (54.6%) and had stayed in the hospital for ≤7 days (56.6%). The prevalence of antibiotic prescription upon discharge to hospice was 21.1%. Among patients discharged with an antibiotic prescription, 70.8% had a documented infection during their index admission. Among documented infections, 40.3% were bloodstream infections, septicemia, or endocarditis, and 38.9% were pneumonia. Independent risk factors for receiving an antibiotic prescription were documented infection during the index admission (adjusted odds ratio [AOR]=7.00; 95% confidence interval [95% CI]=4.68 to 10.46), discharge to home hospice care (AOR=2.86; 95% CI=1.92 to 4.28), and having a cancer diagnosis (AOR=2.19; 95% CI=1.48 to 3.23). These data suggest that a high proportion of patients discharged from acute care to hospice care receive an antibiotic prescription upon discharge.
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http://dx.doi.org/10.1128/AAC.02873-14DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4135830PMC
September 2014

Antimicrobial use for symptom management in patients receiving hospice and palliative care: a systematic review.

J Palliat Med 2013 Dec 23;16(12):1568-74. Epub 2013 Oct 23.

1 Department of Epidemiology and Public Health, University of Maryland School of Medicine , Baltimore, Maryland.

Background: Patients receiving hospice or palliative care often receive antimicrobial therapy; however the effectiveness of antimicrobial therapy for symptom management in these patients is unknown.

Objective: The study's objective was to systematically review and summarize existing data on the prevalence and effectiveness of antimicrobial therapy to improve symptom burden among hospice or palliative care patients.

Design: Systematic review of articles on microbial use in hospice and palliative care patients published from January 1, 2001 through June 30, 2011.

Measurements: We extracted data on patients' underlying chronic condition and health care setting, study design, prevalence of antimicrobial use, whether symptom response following antimicrobial use was measured, and the method for measuring symptom response.

Results: Eleven studies met our inclusion criteria in which prevalence of antimicrobial use ranged from 4% to 84%. Eight studies measured symptom response following antimicrobial therapy. Methods of symptom assessment were highly variable and ranged from clinical assessment from patients' charts to the Edmonton Symptom Assessment Scale. Symptom improvement varied by indication, and patients with urinary tract infections (two studies) appeared to experience the greatest improvement following antimicrobial therapy (range 67% to 92%).

Conclusion: Limited data are available on the use of antimicrobial therapy for symptom management among patients receiving palliative or hospice care. Future studies should systematically measure symptom response and control for important confounders to provide useful data to guide antimicrobial use in this population.
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http://dx.doi.org/10.1089/jpm.2013.0276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3868271PMC
December 2013

Skin cancer prevention in annual performance of total skin examination, photoprotection counseling, and patient instruction of self-skin examination.

Int J Dermatol 2014 Aug 18;53(8):981-4. Epub 2013 Oct 18.

Departments of Dermatology, Mayo Clinic, Scottsdale, AZ, USA.

Background: Prevention of skin cancer includes early diagnosis and photoprotection, such as by physician-performed total skin examination (TSE) and patient-performed self-skin examination (SSE). Hypothesizing that 90% of our patients receive an annual TSE, photoprotection counseling, and SSE instruction, we assessed the extent to which this was documented in patients' records. We also sought to identify differences in documentation of TSE, photoprotection counseling, and instruction on SSE with or without use of a dictation template prompting documentation.

Materials And Methods: Retrospective review of a random sample of 400 patients in an outpatient dermatology practice of a tertiary care academic medical center for any dermatology appointment between May 1 and July 31, 2007. Exclusion criteria included refusal to undergo TSE, lack of access to skin (e.g., wheelchair-bound or in cast), or inappropriate visit type (e.g., for acne, psoriasis, or lupus).

Results: Of 400 randomly selected patients, 313 met inclusion criteria. The dictation template was used in 133; of these, 89% (119/133) had documentation in their clinical note of a TSE (exclusive of the buttocks or groin area), and 98% (130/133) had documentation of instruction on sun protection and SSE. Without use of the dictation template, these percentages dropped to 78% (140/180) and 20% (36/180), respectively. Physicians using a dictation template were more likely to document having conducted a TSE and instructed patients on photoprotection and SSE.

Conclusions: A dictation template aids documentation of annual TSE and patient education efforts on photoprotection and SSE.
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http://dx.doi.org/10.1111/ijd.12066DOI Listing
August 2014

Addressing antibiotic use for acute respiratory tract infections in an academic family medicine practice.

Am J Med Qual 2013 Nov-Dec;28(6):485-91. Epub 2013 Feb 11.

1Mayo Clinic, Scottsdale, AZ.

The objective of this study was to educate health care providers and patients to reduce overall antibiotic prescription rates for patients with acute respiratory tract infection (ARTI). An interdisciplinary quality improvement team used the Define, Measure, Analyze, Improve, and Control quality improvement process to change patient expectations and provider antibiotic prescribing patterns. Providers received personal and group academic detailing about baseline behaviors, copies of treatment guidelines, and educational materials to use with patients. Get Smart About Antibiotics Week materials educated patients about appropriate antibiotic use. Providers collected demographic and clinical information about a case series of patients with ARTIs and their subsequent provision of antibiotics. In total, 241 patients with ARTIs were accrued. The antibiotic prescribing rate for patients aged 18 years and older was significantly reduced from 69% at baseline to 56% after interventions (95% confidence interval = 49.1%-63.4%; P<.001). Providers' prescribing behaviors significantly improved after multiple quality improvement interventions.
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http://dx.doi.org/10.1177/1062860613476133DOI Listing
September 2014

Smartphone teleradiology application is successfully incorporated into a telestroke network environment.

Stroke 2012 Nov 11;43(11):3098-101. Epub 2012 Sep 11.

Department of Neurology, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA.

Background And Purpose: ResolutionMD mobile application runs on a Smartphone and affords vascular neurologists access to radiological images of patients with stroke from remote sites in the context of a telemedicine evaluation. Although reliability studies using this technology have been conducted in a controlled environment, this study is the first to incorporate it into a real-world hub and spoke telestroke network. The study objective was to assess the level of agreement of brain CT scan interpretation in a telestroke network between hub vascular neurologists using ResolutionMD, spoke radiologists using a Picture Archiving and Communications System, and independent adjudicators.

Methods: Fifty-three patients with stroke at the spoke hospital consented to receive a telemedicine consultation and participate in a registry. Each CT was evaluated by a hub vascular neurologist, a spoke radiologist, and by blinded telestroke adjudicators, and agreement over clinically important radiological features was calculated.

Results: Agreement (κ and 95% CI) between hub vascular neurologists using ResolutionMD and (1) the spoke radiologist; and (2) independent adjudicators, respectively, were: identification of intracranial hemorrhage 1.0 (0.92-1.0), 1.0 (0.93-1.0), neoplasm 1.0 (0.92-1.0), 1.0 (0.93-1.0), any radiological contraindication to thrombolysis 1.0 (0.92-1.0), 0.85 (0.65-1.0), early ischemic changes 0.62 (0.28-0.96), 0.58 (0.30-0.86), and hyperdense artery sign 0.40 (0.01-0.80), 0.44 (0.06-0.81).

Conclusions: CT head interpretations of telestroke network patients by vascular neurologists using ResolutionMD on Smartphones were in excellent agreement with interpretations by spoke radiologists using a Picture Archiving and Communications System and those of independent telestroke adjudicators using a desktop viewer.

Clinical Trial Registration Information: www.clinicaltrials.gov unique identifier NCT00829361.
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http://dx.doi.org/10.1161/STROKEAHA.112.669325DOI Listing
November 2012

Intraoral metal contact allergy as a possible risk factor for oral squamous cell carcinoma.

Ann Otol Rhinol Laryngol 2012 Jun;121(6):389-94

Department of Dermatology, Mayo Clinic, Phoenix, Arizona 85054, USA.

Objectives: Intraoral exposure to dental restorations can cause contact allergy that may induce carcinogenesis. We investigated the relationship of intraoral metal contact allergy to epithelial carcinogenesis.

Methods: The prevalence of positive patch test reactions to dental restoration metals in 65 prospectively enrolled patients with newly or previously diagnosed oral squamous cell carcinoma (SCC) was compared to that in 48 control patients. The relative risk of oral SCC was estimated by calculating odds ratios for exposure to dental metals resulting in allergy.

Results: Of the 65 patients with oral SCC, 34% were allergic to at least 1 adjacent metal. They were 1.57 times as likely as control patients to have metal contact allergy (odds ratio, 1.57; 95% confidence interval, 0.65 to 3.80) and more than 3 times as likely to react to mercury (odds ratio, 3.20; 95% confidence interval, 0.42 to 33.20).

Conclusions: Patients with oral SCC who have metal dental restorations should undergo patch testing and possible removal of the restorations if their reactions are positive.
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http://dx.doi.org/10.1177/000348941212100605DOI Listing
June 2012

Acute respiratory tract infection: a practice examines its antibiotic prescribing habits.

J Fam Pract 2012 Jun;61(6):330-5

Department of Family Medicine, Mayo Clinic, Scottsdale, AZ 85260, USA.

Purpose: We wanted to better understand our practice behaviors by measuring antibiotic prescribing patterns for acute respiratory tract infections (ARTIs), which would perhaps help us delineate goals for quality improvement interventions. We determined (1) the distribution of ARTI final diagnoses in our practice, (2) the frequency and types of antibiotics prescribed, and (3) the factors associated with antibiotic prescribing for patients with ARTI.

Methods: We looked at office visits for adults with ARTI symptoms that occurred between December 14, 2009, and March 4, 2010. We compiled a convenience sample of 438 patient visits, collecting historical information, physical examination findings, diagnostic impressions, and treatment decisions.

Results: Among the 438 patients, cough was the most common presenting complaint (58%). Acute sinusitis was the most frequently assigned final diagnosis (32%), followed by viral upper respiratory tract infection (29%), and acute bronchitis (24%). Sixty-nine percent of all ARTI patients (304/438) received antibiotic prescriptions, with macrolides being most commonly prescribed (167/304 [55%]). Prescribing antibiotics was associated with a complaint of sinus pain or shortness of breath, duration of illness ≥8 days, and specific abnormal physical exam findings. Prescribing rates did not vary based on patient age or presence of risk factors associated with complication. Variations in prescribing rates were noted between individual providers and groups of providers.

Conclusions: We found that we prescribed antibiotics at high rates. Diagnoses of acute sinusitis and bronchitis may have been overused as false justification for antibiotic therapy. We used broad-spectrum antibiotics frequently. We have identified several gaps between current and desired performance to address in practice-based quality improvement interventions.
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June 2012

Developing a reproductive life plan.

J Midwifery Womens Health 2011 Sep-Oct;56(5):468-74. Epub 2011 Aug 11.

Division of Women’s Health Internal Medicine, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA.

The purpose of this article is 2-fold: to emphasize the importance of a reproductive life plan and to define its key elements. We review the 2006 recommendations from the Centers for Disease Control and Prevention (CDC) regarding ways to improve the delivery of preconception health care to women in the United States, with particular focus on encouraging individual reproductive responsibility throughout the life span and on encouraging every woman to develop a reproductive life plan. We propose recommendations for the content of a reproductive life plan and explore ways to incorporate the guidelines from the CDC into clinical practice. By encouraging women to consider their plans for childbearing before they become pregnant, clinicians have the opportunity to influence behavior before pregnancy, which may decrease the incidence of unintended pregnancies and adverse pregnancy outcomes.
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http://dx.doi.org/10.1111/j.1542-2011.2011.00048.xDOI Listing
March 2013

More hypotension in patients taking antihypertensives preoperatively during shoulder surgery in the beach chair position.

Can J Anaesth 2011 Nov 24;58(11):993-1000. Epub 2011 Aug 24.

Department of Anesthesiology, Mayo Clinic in Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA.

Purpose: Hypotension is common in patients undergoing surgery in the sitting position under general anesthesia, and the risk may be exacerbated by the use of antihypertensive drugs taken preoperatively. The purpose of this study was to compare hypotensive episodes in patients taking antihypertensive medications with normotensive patients during shoulder surgery in the beach chair position.

Methods: Medical records of all patients undergoing shoulder arthroscopy during a 44-month period were reviewed retrospectively. The primary endpoint was the number of moderate hypotensive episodes (systolic blood pressure ≤ 85 mmHg) during the intraoperative period. Secondary endpoints included the frequency of vasopressor administration, total dose of vasopressors, and fluid administered. Values are expressed as mean (standard deviation).

Results: Of 384 patients who underwent shoulder surgery, 185 patients were taking no antihypertensive medication, and 199 were on at least one antihypertensive drug. The antihypertensive medication group had more intraoperative hypotensive episodes [1.7 (2.2) vs 1.2 (1.8); P = 0.01] and vasopressor administrations. Total dose of vasopressors and volume of fluids administered were similar between groups. The timing of the administration of angiotensin-converting enzyme inhibitors and of angiotensin receptor antagonists (≤ 10 hr vs > 10 hr before surgery) had no impact on intraoperative hypotension.

Conclusions: Preoperative use of antihypertensive medication was associated with an increased incidence of intraoperative hypotension. Compared with normotensive patients, patients taking antihypertensive drugs preoperatively are expected to require vasopressors more often to maintain normal blood pressure.
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http://dx.doi.org/10.1007/s12630-011-9575-6DOI Listing
November 2011

Adoption of anesthesia information management systems by US anesthesiologists.

J Clin Monit Comput 2011 Apr 5;25(2):129-35. Epub 2011 Jul 5.

Department of Anesthesiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054, USA.

Objective: Electronic medical records (EMR) may increase the safety and efficiency of healthcare. Anesthesia care is a significant component of the perioperative period, yet little is known about the adoption of anesthesia information management systems (AIMS) by US anesthesiologists, particularly in non-academic settings. Herein, we report the results of a survey of US anesthesiologists regarding adoption of AIMS and anesthesiologist-perceived advantages and barriers to AIMS adoption.

Methods: Using the e-mail database of the American Society of Anesthesiologists, we solicited randomly selected US anesthesiologists to participate in a survey of their AIMS adoption, perceived advantages and barriers to AIMS. Two and then 3 weeks after the initial mailing, a follow-up e-mail was sent to each anesthesiologist. The study was closed 4 weeks after the initial mailing.

Results: Five thousand anesthesiologists were solicited; 615 (12.3%) responses were received. Twenty-four percent of respondents had installed an AIMS, while 13% were either installing a system now or had selected one, and an additional 13% were actively searching. Larger anesthesiology groups with large case loads, urban settings, and government affiliated or academic institutions were more likely to have adopted AIMS. Initial cost was the most frequently cited AIMS barrier. The most commonly cited benefit was more accurate clinical documentation (79%), while unanticipated need for ongoing information technology support (49%) and difficult integration of AIMS with an existing EMR (61%) were the most commonly cited problems. There were no barriers cited significantly more often by non-adopters than adopters.

Conclusions: At least 50% of our survey respondents were currently using, installing, planning to install, or searching for an AIMS. However, the strength of any conclusion is undermined by a low survey response rate and potential bias as respondents using or searching for an AIMS may be more likely to participate. Nonetheless, challenges exist for anesthesiologists considering AIMS adoption including cost. Furthermore, important questions remain regarding payment for anesthesia services and the relationship of AIMS and "meaningful use" as defined by the Centers for Medicare & Medicaid Services.
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http://dx.doi.org/10.1007/s10877-011-9289-xDOI Listing
April 2011

Insulation failure in robotic and laparoscopic instrumentation: a prospective evaluation.

Am J Obstet Gynecol 2011 Aug 7;205(2):121.e1-5. Epub 2011 Apr 7.

Obstetrics and Gynecology Department, Hospital Quirón Madrid, Madrid, Spain.

Objective: The purpose of this study was to detect the incidence, prevalence, and location of insulation failures (IFs) in laparoscopic and robotic instruments.

Study Design: In phase A, a total of 78 robotic and 298 laparoscopic instruments were tested at 20 W and 2.64 kV at Mayo Clinic in Arizona. In phase B, 60 robotic and 308 laparoscopic instruments were tested at 20 W/1 kV and 20 W/4.2 kV, respectively.

Results: In phase A, the robotic group showed a higher prevalence (25/78; 32%) and incidence of IFs after 10 uses (35/44 instruments; 80%) when compared with laparoscopy (prevalence, 39/298 [13%]; incidence, 68/189 [36%]; P<.05). In phase B, IFs were detected in 81.7% of the robotic instruments and in 19.5% of the laparoscopic instruments (P<.005).

Conclusion: There is a high incidence and prevalence of IF in endoscopic instrumentation that is more common in the robotic group.
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http://dx.doi.org/10.1016/j.ajog.2011.03.055DOI Listing
August 2011
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