Publications by authors named "Jennifer Czerwinski"

20 Publications

  • Page 1 of 1

The impact of genetic counseling on women's grief and coping following termination of pregnancy for fetal anomaly.

J Genet Couns 2021 Apr 26;30(2):522-532. Epub 2020 Oct 26.

The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX, USA.

Pregnancy termination for fetal anomaly (TFA) is a unique experience that can cause women to develop long-term complicated grief. Although a woman's experience with her healthcare providers has been previously identified as an important factor in coping, studies have shown that many women report their health care as lacking to some extent. Given the overlap in women's needs and the practice scope of a genetic counselor (GC), this study aimed to examine how genetic counseling may impact coping and explore women's expectations of GCs pre- and post-TFA. An online survey, which included the brief COPE and the short version of the Perinatal Grief Scale, was distributed among private online support groups. Appropriate statistical analysis tools, such as the Wilcoxon rank-sum and t test, were utilized for quantitative analysis of the 124 responses, and inductive content analysis was utilized for qualitative analysis. Of those who underwent TFA within the last two years, women who saw a GC utilized active coping, planning, and positive reframing significantly more than women who did not see a GC (p = 0.001, p = 0.031, p = 0.027, respectively). GCs were perceived to have a positive impact on coping when providing information, objective care, emotional support, support resources, and follow-up care; these practices encouraged confidence in their personal decision-making and gave women hope for the future. This study not only identified key counseling roles for GCs prior to a TFA, but also demonstrated that genetic counseling prior to TFA may be beneficial to coping. Further studies are warranted to explore the needs of a more diverse population and to identify appropriate genetic counseling training methods to support women pursuing TFA.
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http://dx.doi.org/10.1002/jgc4.1338DOI Listing
April 2021

Examining genetic counselors' implicit attitudes toward disability.

J Genet Couns 2019 12 23;28(6):1098-1106. Epub 2019 Aug 23.

The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX, USA.

Genetic counselors have a unique role in healthcare that requires a balance between being a patient educator and patient advocate when discussing disability. This study aimed to determine genetic counselors' implicit attitudes toward disability, and identify what factors affect these implicit attitudes. Case scenarios involving disability were used to examine hypothetical estimates of time spent on different topics within a genetic counseling session. Implicit attitudes were measured using the validated Disability Attitudes Implicit Association Test (DA-IAT), and personal/professional experiences with disability were assessed. Analysis of 382 respondents of the electronic survey revealed that personal experience with individuals with disabilities was not significantly associated with implicit attitudes scores. In addition, results demonstrated that genetic counselors have a stronger bias toward ability (D  = 0.62, D = ±0.45) compared to previous participants of the DA-IAT (p < .005). Practice specialty, length of time in the genetic counseling field, or whether the participant was a practicing counselor or genetic counseling student were not associated with implicit attitudes scores. The bias toward ability observed across practice specialties may be due to shared factors that influence interest in this field, but may also potentially reflect the inability of the DA-IAT to capture the complexity of genetic counselors' relationship to individuals with disability. This study emphasizes the importance of incorporating patients' individual definitions of disability into genetic counseling sessions and building an environment of patient advocacy and education around their personal perspectives and needs.
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http://dx.doi.org/10.1002/jgc4.1160DOI Listing
December 2019

Clinical applicability of proposed algorithm for identifying individuals at risk for hereditary hematologic malignancies.

Leuk Lymphoma 2019 12 5;60(12):3020-3027. Epub 2019 Jul 5.

Department of Leukemia, The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA.

Multiple genes have been identified to cause hereditary predispositions to hematologic malignancies, and characterized by an increased risk to develop myelodysplastic syndromes (MDS), acute myeloid leukemia (AML), and/or aplastic anemia (AA). Referral algorithms for patients who may be at higher risk have been proposed, with limited data regarding applicability. Our study aimed to evaluate referral criteria on a population of MDS/AML/AA patients. Demographic information and medical history were obtained from 608 patients referred over a 9-month period. Median age at diagnosis was 67 years (56-73), 387 (64%) were male, and the majority of individuals (54.9%) had AML. Overall, 406 individuals (66.8%) had insufficient documentation to determine whether certain criteria were met. Two hundred and two (33.2%) individuals met at least one criteria for genetic counseling referral; however, only nine (4.5%) were referred. Increased documentation of personal and family history is necessary to better assess and validate the applicability of these criteria.
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http://dx.doi.org/10.1080/10428194.2019.1630618DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858528PMC
December 2019

Common Risk Stratification of Hospital and Ambulatory Patients.

J Healthc Qual 2020 Jan/Feb;42(1):37-45

The care of patients with multiple chronic conditions and those near the end-of-life is often compromised by miscommunications among the healthcare teams. These might be improved by using common risk strata for both hospital and ambulatory settings. We developed, validated, and implemented an all-payer ambulatory risk stratification based on the patients' predicted probability of dying within 30 days, for a large multispecialty practice. Strata had comparable 30-day mortality rates to hospital strata already in use. The high-risk ambulatory strata contained less than 20% of the ambulatory population yet captured 85% of those with 3 or more comorbidities, more than 80% of those who would die 30 or 180 days from the date of scoring, and two-thirds of those with a nonsurgical hospitalization within the next 30 days. We provide examples how the practice and partner hospital have begun to use this common framework for their clinical care model.
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http://dx.doi.org/10.1097/JHQ.0000000000000203DOI Listing
November 2020

Introduction of cell-free DNA screening is associated with changes in prenatal genetic counseling indications.

J Genet Couns 2019 06 21;28(3):692-699. Epub 2019 Feb 21.

Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, UTHealth, Houston, Texas.

The introduction of cell-free DNA screening, or non-invasive prenatal testing (NIPT), for chromosome abnormalities has greatly impacted prenatal care since its introduction in late 2011. We aimed to evaluate the association between the introduction of cell-free DNA screening and indication and referral patterns for genetic counseling at a large US academic medical center by comparing the percentage of each counseling indication between the time period prior to the introduction of cell-free DNA screening (2006-2011) and following its introduction (2012-2016) using multivariable Poisson regression models. Genetic counseling indications for positive carrier screens, average risk patients, abnormal ultrasound findings, and family history indications were significantly higher following the introduction of NIPT while advanced maternal age and abnormal maternal serum screening indications dropped significantly. We also showed that the uptake of amniocentesis dropped significantly after the introduction of cell-free DNA screening, while chorionic villus sampling uptake increased. These results provide evidence that the introduction of new genetic screening technologies is associated with a shift in genetic counseling referral indications and an increased uptake in genetic screening. Additional research is needed to explore the impact of expanded testing options on the need for genetic counseling services.
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http://dx.doi.org/10.1002/jgc4.1095DOI Listing
June 2019

Prenatal chromosomal microarray uptake with invasive prenatal diagnosis: How many patients take the leap?

Prenat Diagn 2018 09 17;38(10):748-754. Epub 2018 Jul 17.

Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.

Objective: Characterize the uptake of chromosomal microarray analysis (CMA) among women undergoing invasive prenatal diagnosis at a large academic institution over a 4-year time period.

Methods: Retrospective database review of women who underwent invasive prenatal diagnosis via chorionic villus sampling (CVS) or amniocentesis. Entries were reviewed for demographic and clinical information.

Results: Nine hundred forty-six diagnostic procedures were performed at our institution over a 4-year time period including 259 CVS and 687 amniocentesis procedures. Overall, 32% elected CMA, with a significant increase in uptake over time. Women with Medicaid/CHIP insurance were more likely to elect CMA than those with private insurance (OR = 1.59, 95% CI, 1.18-2.14), while multigravida women were less likely than primigravidas to elect CMA (P = 0.003). Women with ultrasound findings were more likely to elect CMA than any other indication. Those with structural abnormalities in multiple systems (OR = 3.75, 95% CI, 1.60-8.79) or abnormalities in a single system (OR = 3.22, 95% CI, 1.47-7.05) were more likely to elect CMA than with any other types of ultrasound findings.

Conclusion: The uptake of CMA significantly increased over a 4-year period at a large academic institution. Women with ultrasound indications, specifically structural abnormalities, are the most likely to elect CMA.
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http://dx.doi.org/10.1002/pd.5324DOI Listing
September 2018

Attitudes Toward and Uptake of Prenatal Genetic Screening and Testing in Twin Pregnancies.

J Genet Couns 2018 09 10;27(5):1238-1247. Epub 2018 Mar 10.

Genetic Counseling Program, University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, 6431 Fannin Street, MSB 3.142, Houston, TX, 77030, USA.

The rate of twinning is rising and since the introduction of non-invasive prenatal testing, interest in and uptake of genetic screening and testing in twin pregnancies has not been investigated. This study aimed to explore the attitudes toward and uptake of current prenatal genetic screening and diagnostic testing options for fetal aneuploidy in twin pregnancies. Women being seen for genetic counseling with twin gestations were recruited for participation in a descriptive study with questionnaire (n = 42) and semi-structured phone interview (n = 15). Women were significantly more in favor of screening than diagnostic testing (p = 0.049). Sixty-nine (n = 25) percent elected screening, while one participant had a diagnostic procedure. Women were interested in screening for preparation or reassurance despite having concerns about accuracy and uncertainty. Most women (86%) felt they would make the same decision in a singleton pregnancy. Despite this, 48% cited twin pregnancy as influential to some degree. Information learned from providers, past experiences, and family and friends were also cited as influencing and anchoring factors, suggesting that tailoring prenatal genetic counseling sessions for twins might parallel that of singletons. No significant differences between natural and assisted conception patients were found. Although it did not alter patient decisions, genetic counseling was used as a platform to raise concerns and gather information.
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http://dx.doi.org/10.1007/s10897-018-0246-4DOI Listing
September 2018

Attitudes Towards Prenatal Genetic Counseling, Prenatal Genetic Testing, and Termination of Pregnancy among Southeast and East Asian Women in the United States.

J Genet Couns 2017 Oct 2;26(5):1041-1058. Epub 2017 Mar 2.

Genetic Counseling Program, The University of Texas Graduate School of Biomedical Sciences at Houston, Houston, TX, USA.

Recognizing the heterogeneity of the Asian population with regards to acculturation, education, health awareness, and cultural values is vital for tailoring culturally sensitive and appropriate care. Prior studies show that cultural values influence perceptions of genetics within Asian populations. The reputation of the family unit factors into decisions such as pregnancy termination and disclosure of family medical history, and the nondirective model of American genetic counseling may conflict with the historical Asian model of paternalistic health care. Previous studies also provide conflicting evidence regarding correlations between education, acculturation, age, and awareness and perceptions of genetic testing. The aims of this study were to describe attitudes towards prenatal genetics among Southeast and East Asian women living in the United States for varying amounts of time and to explore sociocultural factors influencing those attitudes. Twenty-three Asian women who were members of Asian cultural organizations in the United States were interviewed via telephone about their attitudes towards prenatal genetic counseling, prenatal genetic testing, and termination of pregnancy. Responses were transcribed and coded for common themes using a thematic analysis approach. Four major themes emerged. In general, participants: (1) had diverse expectations for genetic counselors; (2) tended to weigh risks and benefits with regards to genetic testing decisions; (3) had mixed views on termination for lethal and non-lethal genetic conditions; and (4) identified cultural factors which influenced testing and termination such as lack of available resources, societal shame and stigma, and family pressure. These findings may allow prenatal genetic counselors to gain a richer, more nuanced understanding of their Asian patients and to offer culturally tailored prenatal genetic counseling.
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http://dx.doi.org/10.1007/s10897-017-0084-9DOI Listing
October 2017

The risk-outcome-experience triad: Mortality risk and the hospital consumer assessment of healthcare providers and systems survey.

J Hosp Med 2016 09 2;11(9):628-35. Epub 2016 Jun 2.

Department of Emergency Medicine, St. Joseph Mercy Hospital, Ann Arbor, Michigan.

Background: Studies have shown an association between the Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS) scores and clinical quality. The mortality risk on admission predicts adverse events. It is not known if this risk also portends a suboptimal patient experience.

Objective: To determine if the admission mortality risk identifies an experience of care risk.

Design: A retrospectively assembled cohort in which individual HCAHPS survey responses were linked to the admission risk of dying.

Setting: Five community hospitals of various sizes in Michigan.

Patients: There were 17,509 HCAHPS medical and surgical respondents; 2513 (14.4%) were at high risk of dying.

Measurements: Odds ratio (OR) (high-risk patients to low-risk patients) for providing a top box score for HCAHPS dimensions, controlling for hospital and the standard HCAHPS patient mix adjustment factors.

Results: High-risk respondents were less likely to provide the most favorable response (unadjusted) for all HCAHPS domains, although the difference was not significant (P = 0.09) for discharge information. Multivariable analyses indicated that high-risk patients were less likely to report a top box experience for doctor communication (OR: 0.85; 95% confidence interval [CI]: 0.77-0.94) and responsiveness of hospital staff (OR: 0.77; 95% CI: 0.69-0.85), but were more likely to have received adequate discharge information (OR: 1.30, 95% CI: 1.14-1.48).

Conclusions: Patients at high risk of dying who completed surveys were less likely to report favorable physician communication and staff responsiveness. Further understanding of these relationships may help design a care model to improve both outcomes and experience. Journal of Hospital Medicine 2016;11:628-635. © 2016 Society of Hospital Medicine.
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http://dx.doi.org/10.1002/jhm.2611DOI Listing
September 2016

Obstetrician and Gynecologist Utilization of the Noninvasive Prenatal Testing Expanded Option.

AJP Rep 2016 Mar 29;6(1):e18-24. Epub 2015 Oct 29.

Department of Obstetrics, Gynecology, and Reproductive Sciences, The University of Texas Health Science Center at Houston, Houston, Texas.

Objective Noninvasive prenatal testing (NIPT) enables the detection of common fetal aneuploidies such as trisomy 21, trisomy 18, trisomy 13, and sex chromosome abnormalities via analysis of cell-free fetal DNA circulating in maternal serum. In October 2013, the option to screen for additional trisomies and select microdeletion syndromes became clinically available. The complex testing methods, oftentimes unclear clinical utility of results, and lack of professional guidelines renders it challenging for clinicians to keep abreast of evolving prenatal screening options. We undertook a survey to assess physicians' awareness of, utilization of, and attitudes toward the expanded NIPT option. Study Design Obstetricians attending hospital service meetings in the Houston Texas Medical Center completed an anonymous survey regarding the utilization patterns of expanded NIPT. Results Overall, 85 obstetricians were surveyed. While all respondents indicated awareness of NIPT in its traditional form, 75% (64/85) were aware of the expanded testing option, and 14% (12/85) reported having ordered the expanded NIPT option. A total of 91% (77/85) expressed that practitioners need more information regarding the screening. Conclusion Based on these findings and the fluid landscape of prenatal screening, education, and reeducation of health care professionals is imperative to ensure responsible patient counseling, informed consent, and appropriate posttest management.
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http://dx.doi.org/10.1055/s-0035-1566313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737634PMC
March 2016

Support Desired by Women Following Termination of Pregnancy for a Fetal Anomaly.

J Genet Couns 2015 Dec 2;24(6):952-60. Epub 2015 Apr 2.

Genetic Counseling Program at The University of Texas Graduate School of Biomedical Science at Houston, Houston, TX, 77030, USA.

With the rapidly evolving field of prenatal testing, there is a growing need to provide support for women pursuing termination of pregnancy following the discovery of a fetal anomaly. Previous studies have documented that women in this situation often feel unsupported, but the type of resources desired by this population remains undetermined. We studied the awareness and utilization of support resources in 51 women at the time of the procedure, at 6 weeks, and at 3 months following the event. Though largely knowledgeable of existing resources at the time of the procedure, only 50 % admitted contemplating their individualized need for support. Most expected to rely on the support of family and friends. Additionally, 50 % expressed the desire to commemorate the pregnancy, though none wanted direct contact with their healthcare provider(s). Responses from the 6 weeks and 3 months assessments were consistent with previous literature as many women indicated not coping as expected and were unprepared for the psychological consequences following the procedure. Our findings indicate that women in these situations may not realize what their long-term support needs will be. They further indicate that guidelines for routine follow-up care should be established among healthcare providers that respect this population's initial desires to avoid reminders of the pregnancy and promote a flexible timeframe for support uptake. Additional support resources that promote flexible uptake as well as meet the desires of anonymity and ease of access need to be developed for this population.
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http://dx.doi.org/10.1007/s10897-015-9832-xDOI Listing
December 2015

Spinal and paraspinal fungal infections associated with contaminated methylprednisolone injections.

Open Forum Infect Dis 2014 Mar 14;1(1):ofu022. Epub 2014 May 14.

Saint Joseph Mercy Hospital , Ann Arbor, Michigan.

Background: A nationwide outbreak of fungal infections was traced to injection of Exserohilum-contaminated methylprednisolone. We describe our experience with patients who developed spinal or paraspinal infection after injection of contaminated methylprednisolone.

Methods: Data were assembled from the Michigan Department of Community Health, electronic medical records, and magnetic resonance imaging (MRI) reports.

Results: Of 544 patients who received an epidural injection from a contaminated lot of methylprednisolone at a pain clinic in southeastern Michigan, 153 (28%) were diagnosed at our institution with probable or confirmed spinal or paraspinal fungal infection at the injection site. Forty-one patients had both meningitis and spinal or paraspinal infection, and 112 had only spinal or paraspinal infection. Magnetic resonance imaging abnormalities included abscess, phlegmon, arachnoiditis, and osteomyelitis. Surgical debridement in 116 patients revealed epidural phlegmon and epidural abscess most often. Among 26 patients with an abnormal MRI but with no increase or change in chronic pain, 19 (73%) had infection identified at surgery. Fungal infection was confirmed in 78 patients (51%) by finding hyphae in tissues, positive polymerase chain reaction, or culture. Initial therapy was voriconazole plus liposomal amphotericin B in 115 patients (75%) and voriconazole alone in 38 patients (25%). As of January 31, 2014, 20 patients remained on an azole agent. Five patients died of infection.

Conclusions: We report on 153 patients who had spinal or paraspinal fungal infection at the site of epidural injection of contaminated methylprednisolone. One hundred sixteen (76%) underwent operative debridement in addition to treatment with antifungal agents.
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http://dx.doi.org/10.1093/ofid/ofu022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4324199PMC
March 2014

Implementation of a mortality prediction rule for real-time decision making: feasibility and validity.

J Hosp Med 2014 Nov 11;9(11):720-6. Epub 2014 Aug 11.

Department of Medicine, St. Joseph Mercy Hospital, Ann Arbor, Michigan; Quality Institute, St. Joseph Mercy Hospital, Ann Arbor, Michigan.

Background: A previously published, retrospectively derived prediction rule for death within 30 days of hospital admission has the potential to launch parallel interdisciplinary team activities. Whether or not patient care improves will depend on the validity of prospectively generated predictions, and the feasibility of generating them on demand for a critical proportion of inpatients.

Objective: To determine the feasibility of generating mortality predictions on admission and to validate their accuracy using the scoring weights of the retrospective rule.

Design: Prospective, sequential cohort.

Setting: Large, tertiary care, community hospital in the Midwestern United States

Patients: Adult patients admitted from the emergency department or scheduled for elective surgery

Results: Mortality predictions were generated on demand at the beginning of the hospitalization for 9312 (92.9%) out of a possible 10,027 cases. The area under the receiver operating curve for 30-day mortality was 0.850 (95% confidence interval: 0.833-0.866), indicating very good to excellent discrimination. The prospectively generated 30-day mortality risk had a strong association with the receipt of palliative care by hospital discharge, in-hospital mortality, and 180-day mortality, a fair association with the risk for 30-day readmissions and unplanned transfers to intensive care, and weak associations with receipt of intensive unit care ever within the hospitalization or the development of a new diagnosis that was not present on admission (ie, complication).

Conclusions: Important prognostic information is feasible to obtain in a real-time, single-assessment process for a sizeable proportion of hospitalized patients.
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http://dx.doi.org/10.1002/jhm.2250DOI Listing
November 2014

Prenatal diagnosis of 5p deletion syndrome in a female fetus leading to identification of the same diagnosis in her mother.

Prenat Diagn 2014 Nov 6;34(11):1115-8. Epub 2014 Aug 6.

Division of Medical Genetics, Department of Pediatrics, University of Texas Health Science Center at Houston, Houston, TX, USA; Graduate School of Biomedical Sciences, University of Texas Health Science Center at Houston, Houston, TX, USA.

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http://dx.doi.org/10.1002/pd.4436DOI Listing
November 2014

The impact of noninvasive prenatal testing on the practice of maternal-fetal medicine.

Am J Perinatol 2014 Oct 11;31(9):759-64. Epub 2013 Dec 11.

Department of Obstetrics, Gynecology, and Reproductive Sciences and Pediatrics, The University of Health Science Center at Houston, Houston, Texas.

Objective: Noninvasive prenatal testing (NIPT) via cell-free fetal DNA in the maternal circulation is a highly sensitive and specific new testing option. The objective of this study was to determine the impact of NIPT on the uptake of first trimester screening (FTS) and invasive genetic testing.

Study Design: Uptake of prenatal testing was investigated in women referred for advanced maternal age or abnormal screening to the University of Texas Health Maternal-Fetal Medicine Clinics in Houston. Patients who presented from August to November 2011, before clinical introduction of NIPT, were compared with patients who presented from March to June 2012, after its introduction.

Results: In patients referred between 14 and 22 weeks gestational age, invasive genetic testing was significantly reduced following the introduction of NIPT (35.4 vs. 17.9%, p < 0.05). For patients referred at < 14 weeks gestational age, FTS was significantly reduced with NIPT introduction (89.1 vs. 59.1%, p < 0.05); however, invasive genetic testing was not significantly different (20.0 vs. 14.0%, p > 0.05).

Conclusion: NIPT has made an impact on the practice of maternal-fetal medicine by significantly decreasing the number of second trimester diagnostic tests performed. In addition, patients interested in early screening information appear to prefer the higher sensitivity and specificity of NIPT.
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http://dx.doi.org/10.1055/s-0033-1359717DOI Listing
October 2014

Mortality predictions on admission as a context for organizing care activities.

J Hosp Med 2013 May 19;8(5):229-35. Epub 2012 Dec 19.

Department of Medicine, St. Joseph Mercy Hospital, Ann Arbor, MI 48197, USA.

Background: Favorable health outcomes are more likely to occur when the clinical team recognizes patients at risk and intervenes in consort. Prediction rules can identify high-risk subsets, but the availability of multiple rules for various conditions present implementation and assimilation challenges.

Methods: A prediction rule for 30-day mortality at the beginning of the hospitalization was derived in a retrospective cohort of adult inpatients from a community hospital in the Midwestern United States from 2008 to 2009, using clinical laboratory values, past medical history, and diagnoses present on admission. It was validated using 2010 data from the same and from a different hospital. The calculated mortality risk was then used to predict unplanned transfers to intensive care units, resuscitation attempts for cardiopulmonary arrests, a condition not present on admission (complications), intensive care unit utilization, palliative care status, in-hospital death, rehospitalizations within 30 days, and 180-day mortality.

Results: The predictions of 30-day mortality for the derivation and validation datasets had areas under the receiver operating characteristic curve of 0.88. The 30-day mortality risk was in turn a strong predictor for in-hospital death, palliative care status, 180-day mortality; a modest predictor for unplanned transfers and cardiopulmonary arrests; and a weaker predictor for the other events of interest.

Conclusions: The probability of 30-day mortality provides health systems with an array of prognostic information that may provide a common reference point for organizing the clinical activities of the many health professionals involved in the care of the patient.
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http://dx.doi.org/10.1002/jhm.1998DOI Listing
May 2013

Clinical and economic outcomes from a community hospital's antimicrobial stewardship program.

Am J Infect Control 2013 Feb 10;41(2):145-8. Epub 2012 May 10.

Department of Internal Medicine, Saint Joseph Mercy Health System, Ann Arbor, MI, USA.

Background: Data from community antimicrobial stewardship programs (ASPs) are limited. We describe clinical and economic outcomes from the first year of our hospital's ASP.

Methods: The ASP team comprised 2 infectious disease physicians and 3 intensive care unit pharmacists. The team prospectively audited the new starts and weekly use of 8 target antimicrobials: aztreonam, caspofungin, daptomycin, ertapenem, linezolid, meropenem, tigecycline, and voriconazole. Using administrative data, outcomes from the first year of the program, including death within 30 days of hospitalization, readmission within 30 days of discharge, and development of Clostridium difficile infection (CDI), were compared with outcomes from a similar period before institution of the program.

Results: A total of 510 antimicrobial orders were reviewed, of which 323 (63%) were appropriate, 94 (18%) prompted deescalation, 61 (12%) were denied, and 27 (5%) led to formal consultation with an infectious disease physician. On multivariate analysis, implementation of the ASP was associated with an approximate 50% reduction in the odds of developing CDI (odds ratio, 0.46; 95% confidence interval, 0.25-0.82). The ASP was not associated with decreased mortality at 30 days after discharge or readmission rate. The antimicrobial cost per patient-day decreased by 13.3%, from $10.16 to $8.81. The antimicrobial budget decreased by 15.2%, resulting in a total savings of $228,911. There was a 25.4% decrease in defined daily doses of the target antimicrobials.

Conclusions: Implementation of the ASP was associated with significant reductions in CDI rate, antimicrobial use, and pharmacy costs.
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http://dx.doi.org/10.1016/j.ajic.2012.02.021DOI Listing
February 2013

First-trimester screening and its impact on uptake of diagnostic testing.

Prenat Diagn 2011 Sep 21;31(9):892-6. Epub 2011 Jun 21.

Department of Pediatrics, University of Texas-Houston Medical School, Houston, TX, USA.

Objective: To determine the influence of first-trimester screening (FTS) on a patient's decision regarding prenatal diagnostic testing (PDT) and if the uptake rate of PDT has changed among women with advanced maternal age (AMA) following the January 2007 American College of Obstetricians and Gynecologists statement regarding FTS.

Methods: A database review was performed for the 2 years before and the 2 years after the January statement. A total of 7424 patient records were evaluated to determine the number of AMA women who obtained PDT, the number of positive and negative FTS results, and how many of those women had PDT. We then surveyed 53 patients and 23 referring physicians to determine what the patient understands about FTS, how patients utilize their FTS results, and how physicians educate their patients about FTS.

Results: We determined that there was a 19.6% decrease in the uptake of PDT since that statement. Prior to their counseling session (2009-2010), 43% of those surveyed were against having PDT. After counseling, only 9% were against PDT. Overall, 91% were either open to or wanted PDT after counseling.

Conclusions: In addition to FTS results, we found that genetic counseling may be an influential factor in the patient's decision regarding PDT.
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http://dx.doi.org/10.1002/pd.2800DOI Listing
September 2011

Maternal serum screening: results disclosure, anxiety, and risk perception.

Am J Perinatol 2010 Apr 15;27(4):279-84. Epub 2009 Oct 15.

Department of Obstetrics, Gynecology, & Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, Texas 77030, USA.

Although increased maternal anxiety following the disclosure of positive second-trimester maternal serum screen (MSS) results has been well documented, how this anxiety correlates with the method of results disclosure has not been well defined. This pilot study aimed to determine how abnormal second-trimester MSS results are disclosed, the level of anxiety experienced by women as a result of this disclosure, and the accuracy of their risk perception. Women referred for prenatal genetic counseling were asked to complete a questionnaire including demographics, standardized Spielberger State-Trait Anxiety Inventory, results disclosure information, and perceived risk. Of the 561 questionnaires distributed, 388 (69.2%) women chose to participate. Of the 136 participants referred for an abnormal MSS, 125 (91.9%) were aware of this indication and elected to complete the results disclosure portion of the questionnaire. The average anxiety level was not significantly different based on the method of results disclosure or who reported the results. We did not identify a definite cause for the anxiety experienced by women receiving abnormal MSS results; however, this study illustrates the need for further research to identify factors that contribute to the elevated anxiety experienced by these women.
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http://dx.doi.org/10.1055/s-0029-1241730DOI Listing
April 2010

An electronic strategy to identify hospitalized heart failure patients.

J Hosp Med 2007 Nov;2(6):409-14

Department of Internal Medicine, Saint Joseph Mercy Hospital, Ann Arbor, Michigan 48197, USA.

Background: A common challenge in improving performance measures regarding heart failure (HF) is identifying patients early in the course of their hospitalization so that multidisciplinary education and clinical interventions can be implemented. We describe the accuracy of using an electronic pharmacy-based strategy to identify hospitalized patients likely to have a principal diagnosis of HF at discharge.

Methods: We evaluated 2 strategies. The first used the receipt of an intravenous loop diuretic as a single predictor; the second incorporated additional lab, pharmacy, and demographic information in a multivariable general estimating equation.

Results: Receipt of an intravenous diuretic predicted a discharge diagnosis of heart failure with a sensitivity of 0.89 and a specificity of 0.87. Adding age, B-type natriuretic peptide level, previous hospitalizations, attending physician specialty, and receipt of spironolactone into the predictor improved the sensitivity to 0.91 and the specificity to 0.89.

Conclusions: The receipt of intravenous loop diuretics is a reasonable and easily implemented screening test to identify patients likely to have a principal diagnosis of heart failure at discharge. The accuracy is improved by incorporating other electronically available variables.
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http://dx.doi.org/10.1002/jhm.284DOI Listing
November 2007