Appointment-based models: A comparison of three model designs in a large chain community pharmacy setting.

OBJECTIVES: To compare the effects of 3 different appointment-based model (ABM) designs on medication adherence and medication use outcomes controlling for patient and pharmacy characteristics. METHODS: This study was a retrospective cohort analysis in a large grocery store chain from January 1, 2012, to October 31, 2015. A total of 500 comparison and 613 intervention patients in 3 different model designs were analyzed. The outcome measures were proportion of days covered for selected medication classes, number of fills, administered vaccinations, number of trips, statin use in persons with diabetes, use of high-risk medications in older adults, and medication therapy for persons with asthma. RESULTS: After adjusting for relevant covariates, the authors found that all of the ABM designs significantly increased the number of fills after enrollment. Model designs 1 and 3 also significantly reduced the number of trips after enrollment: 4.5 fewer trips (95% CI -5.3 to -3.8; P < 0.05) for model 1 and 1.9 fewer trips (95% CI -3 to -0.9; P < 0.05) for model 3. Models 1 and 3 increased the percentage of patients considered to be adherent for diabetes medications and increased the number of vaccinations patients received. Models 1 and 2 significantly increased the percentage of patients considered to be adherent for statins. No model design was significantly associated with statin use in diabetes, high-risk medication use in older adults, nor percentage of patients considered to be adherent for the hypertension measure. CONCLUSION: All of the ABM designs were effective at increasing the number of fills after enrollment. This paralleled an increase in percentage of patients considered to be adherent to diabetes and statin therapies after enrollment. Models that included face-to-face delivery of the appointment and telephonic synchronization, or face-to-face delivery for all components, increased the number of vaccinations that patients received after enrollment and significantly reduced the number of trips a patient made to the pharmacy.

Influenza testing and antiviral prescribing practices among emergency department clinicians in 9 states during the 2006 to 2007 influenza season.

STUDY OBJECTIVE: Influenza causes significant widespread illness each year. Emergency department (ED) clinicians are often first-line providers to evaluate and make treatment decisions for patients presenting with influenza. We sought to better understand ED clinician testing and treatment practices in the Emerging Infections Program Network, a federal, state, and academic collaboration that conducts active surveillance for influenza-associated hospitalizations. METHODS: During 2007, a survey was administered to ED clinicians who worked in Emerging Infections Program catchment area hospitals' EDs. The survey encompassed the role of the clinician, years since completing clinical training, hospital type, influenza testing practices, and use of antiviral medications during the 2006 to 2007 influenza season. We examined factors associated with influenza testing and antiviral use. RESULTS: A total of 1,055 ED clinicians from 123 hospitals responded to the survey. A majority of respondents (85.3%; n=887) reported they had tested their patients for influenza during the 2006 to 2007 influenza season (Emerging Infections Program site range: 59.3 to 100%; P<.0001). When asked about antiviral medications, 55.7% (n=576) of respondents stated they had prescribed antiviral medications to some of their patients in 2006 to 2007 (Emerging Infections Program site range 32.9% to 80.3%; P<.0001). A positive association between influenza testing and prescribing antiviral medications was observed. Additionally, the type of hospital, location in which an ED clinician worked, and the number of years since medical training were associated with prescribing antiviral influenza medications. CONCLUSION: There is much heterogeneity in clinician-initiated influenza testing and treatment practices. Additional exploration of the role of hospital testing and treatment policies, clinicians' perception of influenza disease, and methods for educating clinicians about new recommendations is needed to better understand ED clinician testing and treatment decisions, especially in an environment of rapidly changing influenza clinical guidelines. Until influenza testing and treatment guidelines are better promulgated, clinicians may continue to test and treat influenza with inconsistency.

Characteristics of Intracranial Group A Streptococcal Infections in US Children, 1997-2014.

BACKGROUND: Few data on intracranial group A Streptococcus (GAS) infection in children are available. Here, we describe the demographic, clinical, and diagnostic characteristics of 91 children with intracranial GAS infection. METHODS: Cases of intracranial GAS infection in persons ≤18 years of age reported between 1997 and 2014 were identified by the Centers for Disease Control and Prevention's population- and laboratory-based Active Bacterial Core surveillance (ABCs) system. Medical charts were abstracted using a active, standardized case report form. All available isolates were emm typed. US census data were used to calculate rates. RESULTS: ABCs identified 2596 children with invasive GAS infection over an 18-year period; 91 (3.5%) had an intracranial infection. Intracranial infections were most frequent during the winter months and among children aged <1 year. The average annual incidence was 0.07 cases per 100000 children. For 83 patients for whom information for further classification was available, the principal clinical presentations included meningitis (35 [42%]), intracranial infection after otitis media, mastoiditis, or sinusitis (34 [41%]), and ventriculoperitoneal shunt infection (14 [17%]). Seven (8%) of these infections progressed to streptococcal toxic shock syndrome. The overall case fatality rate was 15%. GAS emm types 1 (31% of available isolates) and 12 (13% of available isolates) were most common. CONCLUSIONS: Pediatric intracranial (GAS) infections are uncommon but often severe. Risk factors for intracranial GAS infection include the presence of a ventriculoperitoneal shunt and contiguous infections in the middle ear or sinuses.

Assessment of Administrative Medical Claims Data for Public Health Surveillance of Invasive Group A Streptococcal Necrotizing Fasciitis in Tennessee.

OBJECTIVE: Necrotizing fasciitis (NF) is a severe manifestation of invasive group A streptococcal (iGAS) infection. NF is a rapidly progressive infection of the subcutaneous tissues, including the fascia, and accurate diagnosis and prompt treatment are critical. Population-based surveillance is conducted for iGAS, including the severe manifestations of NF, by the federally funded Active Bacterial Core surveillance (ABCs) program. METHODS: We used administrative claims data from a large managed care organization in Tennessee to enhance the public health surveillance for NF iGAS. For the period 2003-2012, we identified cases of NF in Tennessee by searching the claims database for diagnostic codes indicating the diagnosis of NF. We compared these cases with cases detected in selected Tennessee counties by ABCs. RESULTS: Of 356 managed care patients with a diagnostic code indicating NF, we determined that 20 (6%) patients had been hospitalized with iGAS infection and, therefore, were likely to be true NF cases. Of these 20 patients, only 11 matched with patients identified by ABCs; nine patients had not been previously identified by ABCs. During the same time period, 54 patients with NF were ascertained by ABCs. CONCLUSION: Administrative claims data have the potential to augment disease surveillance but require a large investment in resources compared with the few NF cases identified.

Aggregated antibiograms and monitoring of drug-resistant Streptococcus pneumoniae.

Community-specific antimicrobial susceptibility data may help monitor trends among drug-resistant Streptococcus pneumoniae and guide empiric therapy. Because active, population-based surveillance for invasive pneumococcal disease is accurate but resource intensive, we compared the proportion of penicillin-nonsusceptible isolates obtained from existing antibiograms, a less expensive system, to that obtained from 1 year of active surveillance for Georgia, Tennessee, California, Minnesota, Oregon, Maryland, Connecticut, and New York. For all sites, proportions of penicillin-nonsusceptible isolates from antibiograms were within 10 percentage points (median 3.65) of those from invasive-only isolates obtained through active surveillance. Only 23% of antibiograms distinguished between isolates intermediate and resistant to penicillin; 63% and 57% included susceptibility results for erythromycin and extended-spectrum cephalosporins, respectively. Aggregating existing hospital antibiograms is a simple and relatively accurate way to estimate local prevalence of penicillin-nonsusceptible pneumococcus; however, antibiograms offer limited data on isolates with intermediate and high-level penicillin resistance and isolates resistant to other agents.