Publications by authors named "J Wayne Meredith"

559 Publications

Implementation of a comprehensive intervention focused on hospitalized patients with HIV by an existing stewardship program: successes and lessons learned.

Ther Adv Infect Dis 2021 Jan-Dec;8:20499361211010590. Epub 2021 Apr 19.

Department of Internal Medicine, Atrium Health, Charlotte, NC, USA.

Background: Several national organizations have advocated for inpatient antiretroviral stewardship to prevent the consequences of medication-related errors. This study aimed to evaluate the impact of a stewardship initiative on outcomes in people with HIV (PWH).

Methods: A pharmacist-led audit and review of adult patients admitted with an ICD-10 code for HIV was implemented to an existing antimicrobial stewardship program. A quasi-experimental, retrospective cohort study was conducted comparing PWH admitted during pre- and post-intervention periods. Rates of antiretroviral therapy (ART)-related errors and infectious diseases (ID) consultation with linkage to care were evaluated through selection of a random sample of patients receiving ART in each period. Length of stay (LOS) and mortality were assessed by analyzing all admissions in the post-intervention period. Clinical outcomes including LOS, 30-day all-cause hospital readmission, and in-hospital and 30-day mortality in the post-intervention group were stratified by patients not on ART, on ART at admission, and started on ART as a result of the intervention.

Results: A total of 100 patients in the pre-intervention period and 103 patients in the post-intervention period were included to assess ART-related errors and linkage to care. A reduction in errors (70.0 25.7%,  < 0.001) and increased linkage to care (19.0 39.6%,  < 0.01) were demonstrated. Of 389 admissions during the post-intervention period, 30-day mortality rates were similar between PWH on ART at admission and those initiated on ART during admission (5% 8%, respectively), but less than those not on ART (21%). A longer LOS was observed in the patients started on ART during admission (5 days if ART started during admission 3 days if not started during admission,  < 0.01).

Conclusions: This interdisciplinary intervention was successful in reducing inpatient ART-related errors and increasing ID consultation with linkage to care among PWH.
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http://dx.doi.org/10.1177/20499361211010590DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8058799PMC
April 2021

Outcomes Following Cholecystectomy on a Service Designed to Maximize Chief Resident Entrustment.

J Surg Res 2021 Apr 12;264:474-480. Epub 2021 Apr 12.

Department of Surgery, Wake Forest Baptist Health, Wake Forest University School of Medicine, Winston-Salem, NC. Electronic address:

Background: The chief resident service provides surgical trainees in their final year of training the opportunity to maximize responsibility, continuity, and decision-making. Although supervised, chief residents operate according to personal preferences instead of adapting to their attendings' preferences. We hypothesized that outcomes following cholecystectomy are equivalent between the chief resident service and standard academic services.

Methods: We matched adults undergoing cholecystectomy from 07/2016-06/2019 on the chief resident service to two standard academic service patients based on operative indication and age. We compared demographics, operative details, and 30-d complications.

Results: This study included 186 patients undergoing cholecystectomy. Body mass index (32.4 versus 32.0, P = 0.49) and Charlson comorbidity index (0.9 versus 1.4, P = 0.16) were similar between chief resident and standard academic services, respectively. Operative approach was similar (95.2% laparoscopic on chief resident service versus 94.4% on standard service), but residents on the chief resident service performed cholangiograms more often (48.4% versus 22.6%, P < 0.01) and averaged longer operative times during laparoscopic cholecystectomy with cholangiogram (146±28 versus 85±22 min, P < 0.01) and without (94±31 versus 76±35 min, P < 0.01) compared with standard academic services, respectively. 30-d complication rates were similar (5.2% chief resident versus 5.0% standard, P = 0.95). No patients suffered bile leak, bile duct injury, or reoperation. Emergency Department visits were similar (12.1% chief resident versus 7.4% standard, P = 0.32); readmissions were less frequent on the chief resident service (0.0% versus 5.0% standard, P = 0.03).

Conclusions: With appropriate supervision, chief residents provide safe care for patients undergoing cholecystectomy while directing medical decisions and practicing according to their preferences.
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http://dx.doi.org/10.1016/j.jss.2021.02.042DOI Listing
April 2021

Invited Commentary.

Authors:
J Wayne Meredith

J Am Coll Surg 2021 Apr;232(4):422-423

Winston-Salem, NC.

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http://dx.doi.org/10.1016/j.jamcollsurg.2020.12.035DOI Listing
April 2021

Withdrawal of Combination Immunotherapy in Paediatric Inflammatory Bowel Disease - An International Survey of Practice.

J Pediatr Gastroenterol Nutr 2021 Mar 1. Epub 2021 Mar 1.

Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, United Kingdom Child Life and Health, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, the Netherlands Edmonton Pediatric IBD Clinic (EPIC), Department of Pediatrics, University of Alberta, Edmonton, Canada.

Objectives: To assess current practices around the use of combination immunosuppression in paediatric inflammatory bowel disease (PIBD) with a focus on the subsequent withdrawal process.

Methods: A web-based, 43 question survey.

Results: Surveys were completed by 70 paediatric gastroenterologists (PG) from 27 nations across Europe, North America, Oceania and Asia from 62 centres covering approximately 15,000 PIBD patients (median of 200 patients (IQR 130-300) per centre). Routine use of co-immunosuppression was significantly higher with infliximab (IFX) versus adalimumab (ADL) {(61/70, 87.1%) compared with (23/70, 32.9%) [p < 0.01]}. Thiopurines [azathioprine (AZA) or 6-mercaptopurine] were the preferred option overall for co-immunosuppression. They were favoured with either IFX or ADL, (76% and 77% respectively) and in both ulcerative colitis (UC) and Crohn's disease (CD) (84% and 69%) compared with methotrexate (MTX).Immunomodulators were the preferred choice as the initial drug to be withdrawn from the combination therapy rather than anti-Tumour Necrosis Factor-alpha (anti-TNF) therapy (59/67, 88% [p < 0.01]). The most common withdrawal time was after 6-12 months, with this decision usually based on clinical assessment rather than a scheduled withdrawal time (51/67, 76% versus 16/67, 24%). Indicators of mucosal healing and therapeutic drug monitoring (TDM) results tended to be the most important "clinical factors" in the withdrawal decision. [p = 0.05].

Conclusion: Most PG's favour initial withdrawal of immunomodulator (usually thiopurines) rather than biologic therapy in the step-down process, usually after 6-12 months based on sustained clinical remission. This survey precedes an in-depth, multicentre study of clinical outcomes of withdrawal of co-immunosuppression in PIBD.
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http://dx.doi.org/10.1097/MPG.0000000000003098DOI Listing
March 2021

Automated Frailty Screening At-Scale for Pre-Operative Risk Stratification Using the Electronic Frailty Index.

J Am Geriatr Soc 2021 Jan 19. Epub 2021 Jan 19.

Center for Health Care Innovation, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.

Background: Frailty is associated with numerous post-operative adverse outcomes in older adults. Current pre-operative frailty screening tools require additional data collection or objective assessments, adding expense and limiting large-scale implementation.

Objective: To evaluate the association of an automated measure of frailty integrated within the Electronic Health Record (EHR) with post-operative outcomes for nonemergency surgeries.

Design: Retrospective cohort study.

Setting: Academic Medical Center.

Participants: Patients 65 years or older that underwent nonemergency surgery with an inpatient stay 24 hours or more between October 8th, 2017 and June 1st, 2019.

Exposures: Frailty as measured by a 54-item electronic frailty index (eFI).

Outcomes And Measurements: Inpatient length of stay, requirements for post-acute care, 30-day readmission, and 6-month all-cause mortality.

Results: Of 4,831 unique patients (2,281 females (47.3%); mean (SD) age, 73.2 (5.9) years), 4,143 (85.7%) had sufficient EHR data to calculate the eFI, with 15.1% categorized as frail (eFI > 0.21) and 50.9% pre-frail (0.10 < eFI ≤ 0.21). For all outcomes, there was a generally a gradation of risk with higher eFI scores. For example, adjusting for age, sex, race/ethnicity, and American Society of Anesthesiologists class, and accounting for variability by service line, patients identified as frail based on the eFI, compared to fit patients, had greater needs for post-acute care (odds ratio (OR) = 1.68; 95% confidence interval (CI) = 1.36-2.08), higher rates of 30-day readmission (hazard ratio (HR) = 2.46; 95%CI = 1.72-3.52) and higher all-cause mortality (HR = 2.86; 95%CI = 1.84-4.44) over 6 months' follow-up.

Conclusions: The eFI, an automated digital marker for frailty integrated within the EHR, can facilitate pre-operative frailty screening at scale.
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http://dx.doi.org/10.1111/jgs.17027DOI Listing
January 2021