Effects of Medicare comprehensive medication review on racial/ethnic disparities in nonadherence to statin medications among patients with Alzheimer's Disease: an observational analysis.

BACKGROUND: Alzheimer's Disease (AD) is the mostcommon cause of dementia, a neurological disorder characterized by memory loss and judgment impairment. Hyperlipidemia, a commonly co-occurring condition, should be treated to prevent associated complications. Medication adherence may be difficult for individuals with AD due to the complexity of AD management. Comprehensive Medication Reviews (CMRs), a required component of Medicare Part D Medication Therapy Management (MTM), have been shown to improve medication adherence. However, many MTM programs do not target AD. Additionally, racial/ethnic disparities in MTM eligibility have been revealed. Thus, this study examined the effects of CMR receipt on reducing racial/ethnic disparities in the likelihood of nonadherence to hyperlipidemia medications (statins) among the AD population. METHODS: This retrospective study used 2015-2017 Medicare data linked to the Area Health Resources Files. The likelihood of nonadherence to statin medications across racial/ethnic groups was compared between propensity-score-matched CMR recipients and non-recipients in a ratio of 1 to 3. A difference-in-differences method was utilized to determine racial/ethnic disparity patterns using a logistic regression by including interaction terms between dummy variables for CMR receipt and each racial/ethnic minority group (non-Hispanic Whites, or Whites, as reference). RESULTS: The study included 623,400 Medicare beneficiaries. Blacks and Hispanics had higher statin nonadherence than Whites: Compared to Whites, Blacks' nonadherence rate was 4.53% higher among CMR recipients and 7.35% higher among non-recipients; Hispanics' nonadherence rate was 2.69% higher among CMR recipients and 7.38% higher among non-recipients. Differences in racial/ethnic disparities between CMR recipients and non-recipients were significant for each minority group (p < 0.05) except Others. The difference between Whites and Hispanics in the odds of statin nonadherence was 11% lower among CMR recipients compared to non-recipients (OR = 0.89; 95% Confidence Interval = 0.85-0.94 for the interaction term between dummy variables for CMR and Hispanics). Interaction terms between dummy variables for CMR and other racial/ethnic minorities were not significant. CONCLUSIONS: Receiving a CMR was associated with a disparity reduction in nonadherence to statin medications between Hispanics and Whites among patients with AD. Strategies need to be explored to increase the number of MTM programs that target AD and promote CMR completion.

Impact of a Pharmacist-Driven Poststroke Transitions of Care Clinic on 30 and 90-Day Hospital Readmission Rates.

BACKGROUND: Stroke impacts nearly 800,000 people annually and the risk of recurrent stroke and hospital readmission is increased early following the initial event. Due to the increase in morbidity and mortality associated with secondary events, a pharmacist-driven poststroke transitions of care clinic was created at Methodist University Hospital to provide risk factor modification in an effort to decrease risk of recurrence and hospital readmissions. METHODS: A retrospective matched-cohort study was conducted between 9/1/2017 and 2/28/2019. Adult patients with a primary diagnosis of stroke, discharged to home, and attended a poststroke transitions of care clinic visit were included. Patients were matched on the basis of age ±3 years, race, gender, and type of stroke to those who did not receive pharmacist intervention during the same time period. The primary endpoint was 30-day hospital readmissions. Secondary endpoints included 90-day readmissions, 30 and 90-day emergency department visits, and recurrent stroke rates. Type and quantity of pharmacist interventions was also assessed. RESULTS: One hundred and eighty-eight patients were included in the analysis. Baseline differences existed between the groups in the following: history of transient ischemic attack, stroke severity score, and insurance status. No significant difference was found in 30-day readmissions. There was a significant difference found in 90-day readmissions (5.3% versus 21.3%, P = .001). There were no significant differences in emergency department utilization at 30 or 90 days or stroke recurrence rates. Pharmacists made a mean of 3.5 interventions made during each visit. CONCLUSIONS: Although the primary goal to reduce 30-day readmission was not met, a pharmacist-driven poststroke transitions of care clinic significantly decreased 90-day hospital readmission rates.

End-Stage Renal Disease Increases Rates of Adverse Glucose Events When Treating Diabetic Ketoacidosis or Hyperosmolar Hyperglycemic State.

IN BRIEF Treatment guidelines for diabetic emergencies are well described in patients with normal to moderately impaired kidney function. However, management of patients with end-stage renal disease (ESRD) is an ongoing challenge. This article describes a retrospective study comparing the rates of adverse glucose events (defined as hypoglycemia or a decrease in glucose >200 mg/dL/h) between patients with ESRD and those with normal kidney function who were admitted with diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS). These results indicate that current treatment approaches to DKA or HHS in patients with ESRD are suboptimal and require further evaluation.

Notes from the Field: Cluster of Lymphogranuloma Venereum Cases Among Men Who Have Sex with Men - Michigan, August 2015-April 2016.

Lymphogranuloma venereum (LGV) is a sexually transmitted disease (STD) caused by infection with invasive Chlamydia trachomatis serovars L1-L3 (1). LGV is characterized by inguinal and/or femoral lymphadenopathy, typically following a transient, self-limited genital ulcer or papule that might go unnoticed. Rectal infection can result in proctocolitis that can present with mucoid and/or hemorrhagic rectal discharge, anal pain, constipation, fever, and tenesmus, and signs of granulomas and/or ulcerations on anoscopy (1,2). LGV can be an invasive, systemic infection, and if it is not treated early, LGV proctocolitis can lead to chronic colorectal fistulas and strictures (2). In Europe, outbreaks of LGV have been reported among men who have sex with men (MSM), often in association with human immunodeficiency virus (HIV) coinfection (3-5). The prevalence of LGV in the United States is unknown (1), because diagnostic tests to differentiate LGV from non-LGV Chlamydia trachomatis are not widely available (6), and providers might not know that they should report cases that are presumptively treated.

Inhaler Use in Hospitalized Patients with Chronic Obstructive Pulmonary Disease or Asthma: Assessment of Wasted Doses.

BACKGROUND: Hospitalized patients with chronic obstructive pulmonary disease (COPD) or asthma routinely have inhaled medications ordered for acute and maintenance therapy. Treatment may be administered via metered-dose inhaler (MDI) or dry-powder inhaler (DPI). These products must be appropriately labeled to be released home with the patient or discarded before discharge. OBJECTIVE: To assess the amount and estimated cost of wasted doses of medications via MDI or DPI for hospitalized patients with COPD/asthma. METHODS: A retrospective study was conducted at a university-affiliated hospital. Patients admitted between January 2011 and June 2012 with a primary diagnosis of COPD or COPD with asthma and who were ≥40 years of age were included. Information collected included use of albuterol, ipratropium, inhaled corticosteroids, long-acting beta agonist, or tiotropium and whether treatments were given by nebulizer, MDI, MDI plus valved holding chamber (VHC), or DPI. The number of doses dispensed, as well as doses not used, via MDI, MDI + VHC, or DPI were collected from electronic medical records. Costs associated with wasted medications were evaluated. RESULTS: Of 555 patient admissions screened, 478 (mean age, 66 years; 58% women; 74% African American) met study criteria. Of the total MDI or DPI doses dispensed, 87% were wasted, and associated hospital cost was approximately $86,973. CONCLUSIONS: Substantial waste of inhaled medications was found in our study. Practical strategies are needed to reduce wasted inhalers. Further assessment of this problem is needed in other US hospitals.

Incorrect use of peak flow meters: are you observing your patients?

BACKGROUND: Monitoring peak expiratory flow (PEF) values is one option as part of asthma action plans per national guidelines. PEF assessment is also recommended in emergency department and hospitalized patients. Incorrect use of peak flow meters (PFM) has obvious implications for appropriate decisions by patients and clinicians. METHODS: We searched the English literature via PubMed and SCOPUS using the following search terms: PEF maneuver; incorrect use of PFM. When pertinent articles were found, we assessed publications cited in those papers. All studies related to incorrect use of PFM in patients with asthma were included. RESULTS: Nine studies have reported errors in performing the PEF maneuver, including three pediatric and six adult studies. Errors were found at most steps of the maneuver, and inability to perform all steps correctly was common in these investigations. Examples of errors included failure to inhale fully or give maximum effort on exhalation, accelerating air with the tongue and buccal musculature, and performing only one attempt versus three. Gender differences in correct use of PFM are suggested by three adult studies. One study described falsifying PEF values by manipulating the PFM indicator, and another investigation assessed the PEF maneuver in two positions in bed versus the correct posture of standing. CONCLUSION: Many pediatric and adult patients do not use PFM correctly. Clinicians should regularly observe patients use PFM to detect errors and help ensure correct use and accurate PEF measurements.

Leading beyond the Script: A Cross-Sectional Study Exploring Preparedness of Pharmacy Academic Administrators.

Limited research exists on the preparedness of pharmacy academic administrators for their roles. This cross-sectional survey aimed to explore the self-perceptions of pharmacy academic administrators, including deans, associate deans, assistant deans, department chairs, and directors, within United States-based Colleges or Schools of Pharmacy. Participants answered questions regarding their demographics, self-perceived readiness for administrative roles, self-perceived leadership skills, and strategies used to develop these skills. Data were analyzed using descriptive statistics, and subgroup comparisons were made using Student's t-test for normally distributed continuous variables, Mann-Whitney tests for ordinal variables or non-normally distributed continuous variables, and Chi-squared tests for nominal variables. A total of 193 responses were analyzed. Respondents reported feeling least prepared in two areas: entrepreneurial revenue and handling grievances and appeals. There were gender differences noted in preparedness to conduct performance reviews, manage unit finances, and develop entrepreneurial revenue, with men rating themselves significantly higher than women in all three areas. Despite high self-ratings of leadership skills in the overall cohort, significant gender differences were noted in micromanagement with men rating themselves lower than women. Seeking advice from senior colleagues was the most used development strategy, and women showed a significantly higher preference for programs facilitated by professional organizations. This study contributes valuable insights into the preparedness of pharmacy academic administrators to inform future strategies that better support individuals to be successful in their roles.

Effects of Medicare Part D medication therapy management on racial/ethnic disparities in adherence to antidementia medications among patients with Alzheimer's disease and related dementias: An observational study.

Background: Evidence is sparse on the effects of Medicare medication therapy management (MTM) on racial/ethnic disparities in medication adherence among patients with Alzheimer's disease and related dementias. Objectives: This study examined the Medicare MTM program's effects on racial/ethnic disparities in the adherence to antidementia medications among patients with Alzheimer's disease and related dementias. Methods: This is a retrospective analysis of 100% of 2010-2017 Medicare Parts A, B, and D data linked to Area Health Resources Files. The study outcome was nonadherence to antidementia medications, and intervention was defined as new MTM enrollment in 2017. Propensity score matching was conducted to create intervention and comparison groups with comparable characteristics. A difference-in-differences model was employed with logistic regression, including interaction terms of dummy variables for the intervention group and racial/ethnic minorities. Results: Unadjusted comparisons revealed that Black, Hispanic, and Asian/Pacific Islander patients were more likely to be nonadherent than non-Hispanic White (White) patients in 2016. Differences in odds of nonadherence between Black and White patients among the intervention group were lower in 2017 than in 2016 by 27% (odds ratios [OR]: 0.73, 95% confidence interval [CI]: 0.65-0.82). A similar lowering was seen between Hispanic and White patients by 26% (OR: 0.74, 95% CI: 0.63-0.87). MTM enrollment was associated with reduced disparities in nonadherence for Black-White patients of 33% (OR: 0.67, 95% CI: 0.57-0.78) and Hispanic-White patients of 19% (OR: 0.81, 95% CI: 0.67-0.99). Discussion: The Medicare MTM program was associated with lower disparities in adherence to antidementia medications between Black and White patients, and between Hispanic and White patients in the population with Alzheimer's disease and related dementias. Conclusions: Expanding the MTM program may particularly benefit racial/ethnic minorities in Alzheimer's disease and related dementia care.

Evaluation of Hospitalized Patients Receiving High versus Low-Dose Opioids for Non-Cancer Pain.

Limited studies suggest that opioid-related adverse effects (ORAEs) may worsen hospitalized patient outcomes, but there is insufficient data related to the impact of high-dose opioids compared to low-dose on adverse patient events. Given the paucity of data, our study aims to evaluate these ORAEs in the general hospitalized patient with non-cancer pain. A retrospective study of adult patients receiving opioids with a primary diagnoses of myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, sepsis, or diabetes was conducted. Average oral morphine milligram equivalents (MMEs) administered over the entire LOS was collected, and patients were categorized as high-dose (≥50 MMEs/day) or low-dose (<50 MMEs/day). The primary composite endpoint was the incidence of ORAEs (naloxone use, decreased oxygen saturations, nausea/vomiting). Secondary outcomes included LOS, 30-day readmission, ORAEs with >100 MMEs/day. A total of 100 patients were included (n = 58 low-dose group; n = 42 high-dose group). For the primary outcome, more patients in the high-dose group experienced ORAEs (50% high-dose vs. 22.4% low-dose; p < 0.006). No statistically significant differences in LOS or 30-day readmission rates were identified between the groups. For patients receiving >100 MMEs/day, ORAEs occurred in 61% of patients. Hospitalized patients receiving high-dose opioids for non-cancer pain may have an increased incidence of ORAEs.

Pharmacist Transition-of-Care Services Improve Patient Satisfaction and Decrease Hospital Readmissions.

BACKGROUND: Pharmacists ability to directly impact patient satisfaction through increases in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys utilizing transitions-of-care (TOC) services is unclear. METHODS: Retrospective analysis of TOC patients from 07/01/2018 to 03/31/2019 was conducted. Intervention (INV) patients received pharmacist medication reconciliation and education prior to discharge and post-discharge telephone follow-up. All other patients served as control group (CON). Primary outcome: Evaluate impact of TOC services on HCAHPS scores for "Communication about Medicines" and "Care Transitions." Secondary outcomes: 30-day readmissions, quantification of prevented potential safety events, assessment of discharge prescriptions sent to the academic medical center outpatient pharmacy (MOP) for TOC patients. RESULTS: Of 1,728 patients screened, 414 patients met inclusion criteria (INV = 414, CON = 1314). A significant improvement (14.7%; p = <0.0001) in overall medication-related HCAHPS results was seen when comparing pre- vs post-implementation of the TOC service. Statistically significant increases for individual questions "staff told you what the medicine was for" (14.2%; p = 0.018), "staff describe possible effects" (21.2%; p = 0.004), and "understood the purpose of taking medications" (11.4%; p = 0.035) were observed. A non-significant decrease in 30-day readmission rates for the groups was observed (CON 16.4%, INV 13.3%; p = 0.133); however, an unplanned subgroup analysis evaluating impact of discharge phone calls on 30-day readmission rates revealed a significant reduction of 17.3% to 12.4% (p = 0.007). One hundred forty-three medication safety event(s) were potentially prevented by the TOC pharmacist. Lastly, 562 prescriptions were captured at the MOP as a result of the TOC initiative. CONCLUSIONS: Pharmacy-based TOC models can improve patient satisfaction, prevent hospital readmissions, and generate revenue.

Racial/ethnic disparities in the enrollment of Medication Therapy Management programs among Medicare beneficiaries with Alzheimer's disease and related dementias.

OBJECTIVE: Previous analysis of policy scenarios reported potential disparities in eligibility in the Medicare Medication Therapy Management (MTM) program. With recently released MTM data, this study aimed to determine if racial/ethnic disparities exist in MTM enrollment among Medicare beneficiaries with Alzheimer's disease and related dementias (ADRD). METHODS: Medicare claims/records (from 2013-2014 and 2016-2017) linked to the Area Health Resources File were examined. Included individuals were patients with ADRD and diabetes, hypertension or hyperlipidemia. The proportions of MTM enrollment were compared between non-Hispanic White (White) patients and racial/ethnic minority groups in descriptive analysis. Racial/ethnic disparities were then examined using a logistic regression adjusting for patient and community characteristics. Disparities across study periods were compared by estimating a logistic regression model with interaction terms between dummy variables for each racial/ethnic minority group and 2016-2017. RESULTS: In unadjusted analyses, minorities had higher enrollment proportions than Whites. In 2016-2017, for example, enrollment percentages for Whites, Blacks, Hispanics, Asian/Pacific Islanders (Asians) and Others were respectively 14.44%, 16.71%, 19.83%, 16.66%, and 17.78%. In adjusted analyses, Blacks had lower enrollment odds than Whites within all cohorts. In the entire study sample in 2016-2017, for example, Blacks with ADRD had 9% lower odds of MTM enrollment (odds ratio 0.91, 95% confidence interval [CI] = 0.86-0.97) than Whites. These disparities decreased over time among the ADRD sample and all sub-groups. The interaction term between Blacks and 2016-2017, for instance, indicated that disparities were lowered by 11% (odds ratio 1.11, 95% CI = 1.05-1.16) across study periods among those with ADRD. CONCLUSIONS: Blacks with ADRD, and diabetes, hypertension or hyperlipidemia have lower likelihood of MTM enrollment than Whites. Racial disparities were reduced over time but not eliminated.

An evaluation of inhaled bronchodilator therapy in patients hospitalized for non-life-threatening COPD exacerbations.

OBJECTIVE: Chronic obstructive pulmonary disease (COPD) increasingly is a cause of morbidity and mortality in and economic burden on the US healthcare system, and COPD exacerbations continue to be among the top 10 causes of hospitalization in adults. The objective of this study was to evaluate the incidence and potential implications of missed scheduled nebulized bronchodilator therapy in the setting of acute, non-life-threatening COPD exacerbations. MATERIALS AND METHODS: This study was a retrospective chart review of all of the patients with a primary diagnosis of severe, non-life-threatening COPD exacerbations admitted from January 2007 to June 2008 at a university-affiliated hospital. Each patient's inhaled bronchodilator treatment regimen, including potential for nebulization to metered-dose inhaler (MDI) with valved holding chamber (VHC) conversion, was assessed. RESULTS: A total of 259 patients met inclusion criteria: 235 (90.7%) patients received inhaled bronchodilators by nebulization alone in the treatment of COPD exacerbations; 81.1% of these patients could have used MDI with VHC. Patients missed 24.3% of their scheduled, nebulized bronchodilator doses. CONCLUSIONS: Patient care can be improved through the initiation of MDI with VHC, especially considering the number of missed nebulizations that these patients experienced. Development of an inhaled bronchodilator treatment algorithm for COPD exacerbations should be considered to ensure an evidence-bassed medicine approach to these patients.

The Hunger for Mirtazapine: A Discontinuation Syndrome.

While mirtazapine is primarily prescribed for major depressive disorder, it is less commonly prescribed for anorexia related to various disease states. Mirtazapine is associated with few adverse events but potential for a discontinuation syndrome does exist. Here we describe a case of a 53-year-old man prescribed mirtazapine 15 mg/day for appetite stimulation who experienced anxiousness, nausea, tremor, loss of appetite, lack of desire for food, and an 8-pound weight loss after abrupt, inadvertent discontinuation. Symptom onset was acute and presented within 48-hours of stopping his medication. Mirtazapine was restarted at the same dose after 14 days of ongoing symptoms and his symptoms subsided immediately. Scant literature exists to highlight the potentially serious adverse events associated with abrupt mirtazapine discontinuation, even at low doses, and this case contributes to advocating for the need of mirtazapine taper when medication cessation is being considered.

Effects of the Medicare Part D comprehensive medication review on medication adherence among patients with Alzheimer's disease.

OBJECTIVE: Older patients with Alzheimer's disease (AD) are challenged with adhering to complex medication regimens. We examined effects of Comprehensive Medication Review (CMR), a required Medicare Part D Medication Therapy Management (MTM) program component, on medication adherence among AD patients. METHODS: This retrospective study analyzed 100% of 2016-2017 Medicare claims covering the entire United States, linked to Area Health Resources Files. Medicare beneficiaries aged ≥65 years were included. Propensity score matching identified comparable intervention and comparison groups with the intervention defined as receiving a CMR in 2017. A difference-in-differences analysis included in multivariate logistic regressions an interaction term between CMR receipt and year 2017. The outcome measured was nonadherence to diabetes, hypertension and hyperlipidemia medications, with nonadherence defined as proportion of days covered <80% for study medications. RESULTS: Unadjusted comparisons indicated the proportion of nonadherence for intervention group members decreased from 2016 to 2017 but increased for the comparison group. In adjusted analyses, reduction in medication nonadherence among the intervention group remained higher: odds ratios for the interaction term were 0.62 (95% confidence interval [CI] = 0.54-0.71), 0.54 (95% CI = 0.50-0.58) and 0.50 (95% CI = 0.47-0.53) respectively for diabetes, hypertension and hyperlipidemia medications. This suggests that the likelihood of nonadherence in the intervention group was respectively reduced by 38%, 46% and 50% more than the comparison group. CONCLUSIONS: CMR was found to reduce nonadherence to diabetes, hypertension and hyperlipidemia medications among older Medicare beneficiaries with AD. This provides evidence that the MTM program is effective for a population with unique medication compliance challenges.

Thermoacoustic range verification during pencil beam delivery of a clinical plan to an abdominal imaging phantom.

PURPOSE: The purpose of this phantom study is to demonstrate that thermoacoustic range verification could be performed clinically. Thermoacoustic emissions generated in an anatomical multimodality imaging phantom during delivery of a clinical plan are compared to simulated emissions to estimate range shifts compared to the treatment plan. METHODS: A single-field 12-layerproton pencil beam scanning (PBS)treatment plancreated in Pinnacle prescribing6 Gy/fractionwas delivered by a superconducting synchrocyclotron to a triple modality (CT, MRI, and US) abdominal imaging phantom.Data was acquired by four acoustic receivers rigidly affixed to a linear ultrasound array. Receivers 1-2 were located distal to the treatment volume, whereas 3-4 were lateral. Receivers' room coordinates were computed relative to the ultrasound image plane after co-registration to the planning CT volume. For each prescribed beamlet, a set of thermoacoustic emissions corresponding to varied beam energies were computed. Simulated emissions were compared to measured emissions to estimate shifts of the Bragg peak. RESULTS: Shifts were small for high-dose beamlets that stopped in soft tissue. Signals acquired by channels 1-2 yielded shifts of -0.2±0.7mm relative to Monte Carlo simulations for high dose spots (~40 cGy) in the second layer. Additionally, for beam energy ≥125 MeV, thermoacoustic emissions qualitatively tracked lateral motion of pristine beams in a layered gelatin phantom, and time shifts induced by changing phantom layers were self-consistent within nanoseconds. CONCLUSIONS: Acoustic receivers tuned to spectra of thermoacoustic emissions may enable range verification during proton therapy.

A prospective evaluation and literature review of levetiracetam use in patients with brain tumors and seizures.

To determine the safety and tolerability of IV and oral levetiracetam monotherapy for seizures in brain tumor patients following resection. Brain tumor patients undergoing neurosurgery with >or=1 seizure within the preceding month prior to surgery were enrolled to receive intravenous levetiracetam for a minimum of 48 h, transitioned to oral levetiracetam at the same dose, and followed for 1-month after discharge. Patients were assessed daily in the hospital, provided with a seizure diary, and supplied with 30 days of levetiracetam upon discharge. Study patients were telephoned weekly to assess their cognitive status and seizure frequency. Of the 17 patients enrolled, the baseline seizure types were tonic clonic, partial, and complex partial with secondary generalization. The most common type of tumor was glioblastoma multiforme. Levetiracetam was well tolerated with no medication discontinuation during the study period. Adverse effects reported were somnolence, nausea/vomiting, headache, and insomnia. Eleven patients were evaluable for TICS scores (64.7%) with an average score of 33.3. Two patients were deemed to be cognitively impaired (18.2%). Eleven of twelve patients (91.7%) that completed the study period achieved a >or=50% reduction in their number of seizures. A total of 92 drug interactions were avoided (P = 0.0016) with dexamethasone, acetaminophen, and fentanyl being the most common. Levetiracetam monotherapy was found to be safe and tolerable in this patient population. Nearly all patients achieved a >or=50% reduction in seizure frequency post-op with levetiracetam monotherapy. Levetiracetam also has the potential for less drug interactions compared to phenytoin in these patients.

Comparison of Nafcillin and Cefazolin for the Treatment of Methicillin-Susceptible Staphylococcus aureus Bacteremia.

BACKGROUND: Traditionally, the antibiotic of choice for Methicillin-susceptible Staphylococcus aureus related blood stream infections (MSSA-BSI) are the antistaphylococcal penicillins. Cefazolin is considered an alternative agent, with recent evidence showing similar clinical efficacy. This study further evaluates the utility of nafcillin versus cefazolin in MSSA bacteremia including high disease burden sources of infection and its impact on treatment failure. METHODS: This retrospective study included patients admitted to Methodist LeBonheur Healthcare adult hospitals from 2011 to 2016. Patients were included if they received at least 3 days of either nafcillin or cefazolin and had a positive blood culture for MSSA. The primary objective was to evaluate rates of treatment failure between groups. Secondary outcomes included clinical and microbiological cure, MSSA-BSI associated readmissions, identification of risk factors for treatment failure including disease burden, in-hospital and 90 day mortality. RESULTS: A total of 277 patients were included (nafcillin n = 126; cefazolin n = 151). Treatment failure and microbiologic cure were similar between nafcillin and cefazolin (20.6% vs. 16.6%; 91.2% vs. 87.2%, respectively). Clinical cure was significantly higher in the cefazolin treatment arm (93.4 vs. 83.3%; P = 0.012). However, the total number of patients with high disease burden was greater in the nafcillin group (54.8% vs. 39.1%; P = 0.011). Higher rates of in-hospital mortality were observed in the nafcillin group (15.1% vs. 6%; P = 0.016). CONCLUSIONS: Our study observed significantly higher rates of clinical cure and reduced in-hospital mortality in patients who received cefazolin. Further analysis is warranted to evaluate the effectiveness of these agents and identifying predictors of treatment failure.

Inadequate documentation of asthma management in hospitalized adult patients.

Undocumented patient information in the medical record (MR) is a barrier to providing high quality care. Inadequate documentation has recently been reported for two cardiovascular diseases. This study was designed to evaluate the documentation of asthma management in the MR to determine if it is consistent with the NIH asthma guidelines. We performed a retrospective chart review of patients (ages 18-49) admitted to the hospital with an ICD-9 code for a primary diagnosis of asthma between January 2004 and May 2007. Patients admitted with a hospitalization for >24 hours and had <10 pack per year smoking history were included. We assessed medication regimens, documentation of asthma education, asthma action plans, referrals, and exacerbating factors. There were 233 admissions for 144 unique patients analyzed. At discharge, 85% of patients lacked documentation of asthma education, 97% lacked documentation of a written asthma action plan being given, and 79% did not have referral to an asthma specialist. Respiratory infection was the most common factor associated with admission; 58% of admissions were lacking documentation of the exacerbating factor. Only 47% of patients were receiving inhaled corticosteroids (ICS) prior to admission; 25% of patients did not have ICS prescribed for maintenance therapy upon discharge. Documentation of asthma management, specifically asthma education in the MR, is insufficient and may reflect a deficiency in care. Additionally, an inadequate number of patients were receiving ICS for maintenance therapy. Based on these findings, mechanisms are needed to ensure appropriate documentation and optimal care.