Meds to Beds at Hospital Discharge Improves Medication Adherence and Readmission Rates in Select Populations.

OBJECTIVES: Medication nonadherence caused by difficulty obtaining and paying for medicines can increase hospital readmissions. This project implemented Medications to Beds ("Meds to Beds," M2B), a multidisciplinary predischarge medication delivery program, at a large urban academic hospital that provided subsidized medications for uninsured and underinsured patients to reduce readmissions. METHODS: This 1-year retrospective analysis of patients discharged from the hospitalist service after implementing M2B contained two groups: one with subsidized medications (M2B-S) and one with unsubsidized medications (M2B-U). Primary analysis was 30-day readmission rates for patients, stratified by Charlson Comorbidity indexes (CCIs) of 0, 1-3, ≥4 to represent low, medium, and high comorbidity burden. Secondary analysis included readmission rates by Medicare Hospital Readmission Reduction Program diagnoses. RESULTS: Compared with controls, the M2B-S and M2B-U programs had significantly reduced readmission rates among patients with CCIs of 0 (10.5% [controls] vs 9.4% [M2B-U] and 5.1% [M2B-S], P < 0.05). A nonsignificant reduction occurred in readmissions for patients with CCIs ≥4 (20.4% [controls] vs 19.4% [M2B-U] vs 14.7% [M2B-S], P < 0.07). Patients with CCIs of 1 to 3 showed a significant increase in readmission rates in the M2B-U, but a decrease in readmission rates among the M2B-S (15.4% [controls] vs 20% [M2B-U] vs 13.1% [M2B-S], P < 0.05). Secondary analyses found no significant differences in readmission rates when patients were stratified by Medicare Hospital Readmission Reduction Program diagnosis. Cost analyses demonstrated that subsidizing medicines cost less per patient for every 1% readmission reduction than delivery alone. CONCLUSIONS: Providing medicine to patients predischarge tends to lower readmission rates for populations with no comorbidities or with a high burden of disease. This effect is amplified when prescription costs are subsidized.

Differences in diabetes control in telemedicine vs. in-person only visits in ambulatory care setting.

There is limited information regarding how telemedicine visits compare with in-person visits regarding diabetes outcomes in an ambulatory care setting. Our objective was to compare proportions of patients in ambulatory setting with uncontrolled diabetes among those with telemedicine visits versus in-person only visits and examine differences by age, race, gender, ethnicity, and insurance status. Adults with diabetes who attended an ambulatory primary or specialty clinic visit between May 2020 and May 2021 were included. Demographics including age, race, ethnicity, gender, insurance, and comorbidities were extracted from the electronic medical record. Patients were compared among three visit groups: those with in-person only visits, those with only one telemedicine visit, and those with 2 + telemedicine visits. The primary outcome was uncontrolled diabetes, defined as HbA1c ≥ 9.0 %. Multivariable logistic regression was used to assess differences in uncontrolled diabetes between visit groups following risk adjustment. A total of 18,148 patients met inclusion criteria and 2,101 (11.6 %) had uncontrolled diabetes. There was no difference in proportion of patients with uncontrolled diabetes between visit groups (in-person only visits: 834 (11.6 %); one telemedicine visit: 558 (11.8 %); 2 + telemedicine visits: 709 (11.4 %); p = 0.80)). Patients with 2 + telemedicine visits had significantly lower odds of uncontrolled diabetes compared to in-person only visits after risk adjustment (OR: 0.88; 95 % CI: 0.79-0.99, p = 0.03). Compared with in-person ambulatory visits, telemedicine visits were associated with a lower odds of uncontrolled diabetes. Further work is warranted to explore the relationship between telemedicine visits and diabetes outcomes.

Clinical characteristics and social determinants of health associated with 30-day hospital readmissions of patients with COVID-19.

COVID-19 readmissions are associated with increased patient mortality and healthcare system strain. This retrospective cohort study of PCR-confirmed COVID-19 positive adults (>18 years) hospitalized and readmitted within 30 days of discharge from index admission was performed at eight Atlanta hospitals from March to December 2020. The objective was to describe COVID-19 patient-level demographics and clinical characteristics, and community-level social determinants of health (SDoH) that contribute to 30-day readmissions. Demographics, comorbidities, COVID-19 treatment, and discharge disposition data were extracted from the index admission. ZIP codes were linked to a demographic/lifestyle database interpolating to community-level SDoH. Of 7155 patients with COVID-19, 463 (6.5%) had 30-day, unplanned, all-cause hospital readmissions. Statistically significant differences were not found in readmissions stratified by age, sex, race, or ethnicity. Patients with a high-risk Charlson Comorbidity Index had higher odds of readmission (OR 4.8 (95% CI: 2.1 to 11.0)). Remdesivir treatment and intensive care unit (ICU) care were associated with lower odds of readmission (OR 0.5 (95% CI: 0.4 to 0.8) and OR 0.5 (95% CI: 0.4 to 0.7), respectively). Patients residing in communities with larger average household size were less likely to be readmitted (OR 0.7 (95% CI: 0.5 to 0.9). In this cohort, patients who received remdesivir, were cared for in an ICU, and resided in ZIP codes with higher proportions of residents with increased social support had lower odds of readmission. These patient-level factors and community-level SDoH may be used to identify patients with COVID-19 who are at increased risk of readmission.

An interprofessional approach to reducing hospital-onset Clostridioides difficile infections.

BACKGROUND: Clostridioides difficile is the most prevalent hospital-onset (HO) infection. There are significant financial and safety impacts associated with HO-C. difficile infections (HO-CDIs) for both patients and health care organizations. The incidence of HO-CDIs at our community hospital within an academic acute health care system was continuously above the national benchmark. METHODS: In response to the high HO-CDI rates at our facility, an interprofessional team selected evidence-based interventions with the goal of reducing HO-CDI incidence rates. Interventions included: diagnostic stewardship, enhanced environmental cleaning, antimicrobial stewardship and education and accountability. RESULTS: After one year, we achieved a 63% reduction in HO-CDI and have sustained a 77% reduction. The infection rate remained below national benchmark for HO-CDI for over 4 years at a rate of 2.80 per 10,000 patient days and a SIR of 0.43 in 2020. DISCUSSION: Multiple evidence-based interventions were successfully implemented over several service lines over a 4-year period through the collaboration of an interprofessional team. The addition of an accountability processes further improved compliance with standards of practice. CONCLUSIONS: Collaboration of an interprofessional team led to substantial and sustained reductions in HO-CDI.

Age, Comorbid Conditions, and Racial Disparities in COVID-19 Outcomes.

BACKGROUND: Black patients are disproportionately affected by COVID-19. The purpose of this study was to compare risks of hospitalization of Black and non-Black COVID-19 patients presenting to the emergency department and, of those hospitalized, to compare mortality and acute kidney injury. METHODS: A retrospective cohort of 831 adult COVID-19 patients (68.5% Black) who presented to the emergency departments of four academic hospitals, March 1, 2020-May 31, 2020. The primary outcome was risk of hospitalization among Blacks vs. non-Blacks. Secondary outcomes were mortality and acute kidney injury, among hospitalized patients. RESULTS: The crude odds of hospitalization were not different in Black vs. non-Black patients; however, with adjustment for age, Blacks had 55% higher odds of hospitalization. Mortality differed most in the model adjusted for age alone. Acute kidney injury was more common in the Black hospitalized patients, regardless of adjustment. Stratified analyses suggested that disparities in the risk of hospitalization and of in-hospital acute kidney injury were highest in the youngest patients. CONCLUSIONS: Our report shows that Black and non-Black patients presenting to the emergency department with COVID-19 had similar risks of hospitalization and, of those who were hospitalized, similar mortality when adjusted for multiple factors. Blacks had higher risk of acute kidney injury. Our results suggest that examination of disparities without exploration of the individual effects of age and comorbidities may mask important patterns. While stratified analyses suggest that disparities in outcomes may differ substantially by age and comorbid conditions, further exploration among these important subgroups is needed to better target interventions to reduce disparities in COVID-19 clinical outcomes.

Reductions in inpatient fluoroquinolone use and postdischarge Clostridioides difficile infection (CDI) from a systemwide antimicrobial stewardship intervention.

Objective: To determine the impact of an inpatient stewardship intervention targeting fluoroquinolone use on inpatient and postdischarge Clostridioides difficile infection (CDI). Design: We used an interrupted time series study design to evaluate the rate of hospital-onset CDI (HO-CDI), postdischarge CDI (PD-CDI) within 12 weeks, and inpatient fluoroquinolone use from 2 years prior to 1 year after a stewardship intervention. Setting: An academic healthcare system with 4 hospitals. Patients: All inpatients hospitalized between January 2017 and September 2020, excluding those discharged from locations caring for oncology, bone marrow transplant, or solid-organ transplant patients. Intervention: Introduction of electronic order sets designed to reduce inpatient fluoroquinolone prescribing. Results: Among 163,117 admissions, there were 683 cases of HO-CDI and 1,104 cases of PD-CDI. In the context of a 2% month-to-month decline starting in the preintervention period (P < .01), we observed a reduction in fluoroquinolone days of therapy per 1,000 patient days of 21% after the intervention (level change, P < .05). HO-CDI rates were stable throughout the study period. In contrast, we also detected a change in the trend of PD-CDI rates from a stable monthly rate in the preintervention period to a monthly decrease of 2.5% in the postintervention period (P < .01). Conclusions: Our systemwide intervention reduced inpatient fluoroquinolone use immediately, but not HO-CDI. However, a downward trend in PD-CDI occurred. Relying on outcome measures limited to the inpatient setting may not reflect the full impact of inpatient stewardship efforts.

Associations of telemedicine vs. in-person ambulatory visits and cancellation rates and 30-day follow-up hospitalizations and emergency department visits.

Little is known about cancellation frequencies in telemedicine vs. in-person appointments and its impact on clinical outcomes. Our objective was to examine differences between in-person and video telemedicine appointments in terms of cancellation rates by age, race, ethnicity, gender, and insurance, and compare 30-day inpatient hospitalizations rates and 30-day emergency department visit rates between the two visit types. Demographic characteristics and comorbidities for adults scheduled for an Emory Healthcare ambulatory clinic appointment from June 2020 to December 2020 were extracted from the electronic medical record. Each appointment was identified as either a video telemedicine or in-person clinic appointment. The outcomes were ambulatory clinic cancellation rates, 30-day hospitalization rates, and 30-day emergency department visit rates. Multivariable logistic regression was used to assess differences between appointment types. A total of 1,652,623 ambulatory clinic appointments were scheduled. Ambulatory appointment cancellations rates were significantly lower among telemedicine compared to in-person appointments overall (20.4% vs. 31.0%, p < .001) and regardless of gender, age, race, ethnicity, insurance, or specialty (p < .05 for all sub-groups). Telemedicine appointments were associated with lower 30-day hospitalization rates compared to in-person appointments (AOR: 0.72, 95% CI: 0.71-0.74). There was no difference in 30-day emergency department visit rates between telemedicine and in-person appointment patients (AOR: 1.00, 95% CI: 0.98-1.02). Our findings suggest that there are fewer barriers to attending an ambulatory care visit via telemedicine relative to in-person. Using video telemedicine was not associated with more frequent adverse clinical events compared with in-person visits.

Evaluating Movement of Patients With Carbapenem-resistant Enterobacteriaceae Infections in the Greater Atlanta Metropolitan Area Using Social Network Analysis.

BACKGROUND: Carbapenem-resistant Enterobacteriaceae (CRE) are an urgent threat with potential for rapid spread. We evaluated the role of Medicare patient movement between facilities to model the spread of CRE within a region. METHODS: Through population-based CRE surveillance in the 8-county Atlanta (GA) metropolitan area, all Escherichia coli, Enterobacter spp., or Klebsiella spp. resistant to ≥1 carbapenem were reported from residents. CRE was attributed to a facility based on timing of culture and facility exposures. Centrality metrics were calculated from 2016 Medicare data and compared to CRE-transfer derived centrality metrics by Spearman correlation. RESULTS: During 2016, 283 incident CRE cases with concurrent or prior year facility stays were identified; cases were attributed mostly to acute care hospitals (ACHs; 141, 50%) and skilled nursing facilities (SNFs; 113, 40%), and less frequently to long-term acute care hospitals (LTACHs; 29, 10%). Attribution was widespread, originating at 17 of 20 ACHs (85%), 7 of 8 (88%) LTACHs, but only 35 of 65 (54%) SNFs. Betweenness of Medicare patient transfers strongly correlated with betweenness of CRE case-transfer data in ACHs (r = 0.75; P < .01) and LTACHs (r = 0.77; P = .03), but not in SNFs (r = 0.02; P = 0.85). We noted 6 SNFs with high CRE-derived betweenness but low Medicare-derived betweenness. CONCLUSIONS: CRE infections originate from almost all ACHs and half of SNFs. We identified a subset of SNFs central to the CRE transfer network but not the Medicare transfer network; other factors may explain CRE patient movement in these facilities.

Do effects of early life interventions on linear growth correspond to effects on neurobehavioural development? A systematic review and meta-analysis.

BACKGROUND: Faltering in linear growth and neurobehavioural development during early childhood are often assumed to have common causes because of their consistent association. This notion has contributed to a global focus on the promotion of nutrition during pregnancy and childhood to improve both conditions. Our aim was to assess whether effects of interventions on linear growth are associated with effects on developmental scores and to quantify these associations. METHODS: In this systematic review and meta-analysis, we included randomised trials done during pregnancy and in children aged 0-5 years that reported effects of any intervention on length-for-age or height-for-age Z scores (LAZ or HAZ) and on any of the following outcomes: motor, cognitive or mental, language, and social-emotional or behavioural development. We searched MEDLINE (Ovid), CINAHL (EBSCO), and PsycINFO (EBSCO) from database inception to June 25, 2019. Study-level data were extracted and, when required, authors were contacted for missing information. We calculated weighted meta-regression coefficients of the association between standardised effect sizes of interventions on LAZ or HAZ and developmental outcome scores and calculated pooled effect sizes for different types of intervention. FINDINGS: Of the 7207 studies identified, we included 75 studies with 122 comparisons between intervention and control groups and outcomes reported for 72 275 children. Across all interventions, effect sizes on LAZ or HAZ were significantly associated with effect sizes on social-emotional scores (ß 0·23, 95% CI 0·05 to 0·41; p=0·02), but not on cognitive (0·18, -0·36 to 0·72; p=0·51), language (0·12, -0·07 to 0·31; p=0·21), or motor development scores (0·23, -0·05 to 0·50; p=0·11). In studies that provided nutritional supplements, we observed positive significant pooled effect sizes on all five outcomes of LAZ or HAZ (effect size 0·05, 95% CI 0·01-0·09; p=0·01; n=50), cognitive or mental (0·06, 0·03-0·10; p<0·01; n=38), language (0·08, 0·03-0·13; p=0·01; n=21), motor (0·08, 0·04-0·12; p<0·01; n=41), and social-emotional (0·07, 0·02-0·12; p=0·01; n=20) scores. The effect sizes of nutritional supplementation on LAZ or HAZ scores were significantly associated with effect sizes on cognitive (ß 0·40, 95% CI 0·04-0·77; p=0·049) and motor (0·43, 0·11-0·75; p=0·01) scores. In the 14 interventions promoting responsive care and learning opportunities, the pooled effect size on LAZ or HAZ score was not significant (-0·01, 95% CI -0·07 to 0·05; p=0·74), but pooled effect sizes on cognitive, language, and motor scores were 4 to 5 times larger (range 0·38-0·48) than the pooled effect sizes of nutritional supplementation (0·05-0·08). INTERPRETATION: In nutritional supplementation interventions, improvements in linear growth were associated with small improvements in child development, whereas nurturing and stimulation interventions had significant effects on child development but no effects on linear growth. The determinants of linear growth and neurodevelopment are only partly shared. To nurture thriving individuals and communities, interventions should specifically target determinants of neurodevelopment and not simply linear growth. FUNDING: University of California Davis, US Department of Agriculture National Institute of Food and Agriculture.

Effects of increased hemoglobin on child growth, development, and disease: a systematic review and meta-analysis.

In children under 5, a hemoglobin (Hb) cutoff of 11 g/dL is recommended by the World Health Organization to define anemia, yet few studies have examined whether this cut point accurately coincides with negative functional consequences. This systematic review and meta-analysis of iron intervention and observational studies aimed to clarify the consequences of low Hb concentration in children under age 5 years on growth, development, and chronic disease (functional outcomes) across the full range of Hb values. A literature search returned 5049 studies; of these, 56 intervention and 20 observational studies fit the inclusion criteria. Among iron supplementation trials, a metaregression indicated significant associations between intervention effects on Hb and their effects on motor and mental development. For each 1 standard deviation (SD) increase in Hb, motor scores increased by 0.28 SD and mental scores increased by 0.24 SD. Iron supplementation trials among children with lower Hb concentrations at baseline showed stronger associations between their effects on Hb and their effects on mental development (P-interaction = 0.008). Heterogeneity among observational studies precluded calculation of pooled associations between Hb and functional outcomes. Available evidence was not able to establish an inflection point at which decreasing Hb begins to be associated with negative functional outcomes. Future research is needed to examine associations of Hb with growth and development in populations with varying levels of Hb, inflammation, and in different ages and settings.

Factors affecting the geographic variability of antibiotic-resistant healthcare-associated infections in the United States using the CDC Antibiotic Resistance Patient Safety Atlas.

We utilized publicly available data from the Centers for Disease Control to explore possible causes of state-to-state variability in antibiotic-resistant healthcare-associated infections. Outpatient antibiotic prescribing rates of fluoroquinolones and cephalosporins explained some variability in extended-spectrum cephalosporin-resistant Escherichia coli after adjusting for differences in age and healthcare facility composition.