Cost-Effectiveness of Ventricular Assist Device Destination Therapy for Advanced Heart Failure in Duchenne Muscular Dystrophy.

Destination ventricular assist device therapy (DT-VAD) is well accepted in select adults with medically refractory heart failure (HF) who are not transplant candidates; however, its use in younger patients with progressive diseases is unclear. We sought to evaluate the cost-effectiveness of DT-VAD in Duchenne muscular dystrophy (DMD) patients with advanced HF. We created a Markov-state transition model (5-year horizon) to compare survival, costs, and quality of life (QOL) between medical management and DT-VAD in DMD with advanced HF. Model input parameters were derived from the literature. We used sensitivity analyses to explore uncertainty around model assumptions. DT-VAD had higher costs ($435,602 vs. $125,696), survival (3.13 vs. 0.60 years), and quality-adjusted survival (1.99 vs. 0.26 years) than medical management. The incremental cost-effectiveness ratio (ICER) for DT-VAD was $179,086 per quality-adjusted life year (QALY). In sensitivity analyses that were widely varied to account for uncertainty in model assumptions, the DT-VAD strategy generally remained more costly and effective than medical management. Only when VAD implantation costs were <$113,142 did the DT-VAD strategy fall below the $100,000/QALY willingness-to-pay threshold commonly considered to be "cost-effective." In this exploratory analysis, DT-VAD for patients with DMD and advanced HF exceeded societal expectations for cost-effectiveness but had an ICER similar to the accepted practice of DT-VAD in adult HF patients. While more experience and research in this population is needed, our analysis suggests that DT-VAD for advanced HF in DMD should not be dismissed solely based on cost.

Evaluation of Patients' Adverse Events During Contact Isolation for Vancomycin-Resistant Enterococci Using a Matched Cohort Study With Propensity Score.

Importance: Although contact isolation has been widely recommended for multidrug-resistant organisms, contact isolation has raised some concerns that it may bring unintended patient harms. Objective: To compare adverse events between a contact isolation group with vancomycin-resistant Enterococcus (VRE) and a matched comparison group using a relatively large data set from full electronic medical records (EMR) and propensity score-matching methods. Design, Setting, and Participants: This retrospective, matched cohort study was conducted at Seoul National University Bundang Hospital (SNUBH) in Korea, a tertiary, university-affiliated hospital that has 1337 inpatient beds. Participants included a total of 98 529 hospitalized adult patients (aged ≥18 years) during 2015 to 2017. Exposures: Contact isolation in a single or shared double room. Main Outcomes and Measures: As adverse contact isolation-related outcomes, falls and pressure ulcers were included. All relevant EMR data were extracted from the SNUBH clinical data warehouse. Risk factors for adverse events were included in the propensity score model based on literature reviews, such as Braden scale score and Hendrich II fall risk score. A fine stratification and weighting (FSW) and a 1:10 nearest neighbor (NN) propensity score matching as a sensitivity analysis were adopted to compare adverse events between the 2 groups for the observation period from the study entry date and the exit date. Time-to-event analyses with a Cox proportional hazard model were conducted in December 2021. Results: For comparison of outcomes in wards, 177 patients (mean [SD] age, 67.38 [14.12] years; 98 [55.4%] female) with VRE and 93 022 patients (mean [SD] age, 56.44 [16.88] years; 49 462 [53.2%] female) without VRE were included and no difference was found in basic characteristics from the FSW (VRE contact isolation [n = 172] vs comparison [n = 69 434]) as well as from the 1:10 NN (VRE contact isolation [n = 168] vs comparison [n = 1650]). Among 177 patients with VRE contact isolation, 8 pressure ulcers and 3 falls occurred during their hospital stays; incidence rates of adverse events were 2.5 and 0.9 per 1000 patient-days, respectively (pressure ulcer incidence rate from the FSW: 2.53 per 1000 patient-days [95% CI, 1.09-4.99 per 1000 patient-days]; pressure ulcer incidence rate from the 1:10 NN: 2.54 per 1000 patient-days [95% CI, 1.10-5.01 per 1000 patient-days]; fall incidence rate from the FSW: 0.87 per 1000 patient-days [95% CI, 0.18-2.54 per 1000 patient-days]; fall incidence rate from the 1:10 NN: 0.87 per 1000 patient-days [95% CI, 0.18-2.55 per 1000 patient-days]). The hazard ratios for adverse events showed no statistically significant differences for both groups: 1.42 (95% CI, 0.67-2.99) for pressure ulcer and 0.66 (95% CI, 0.20-2.13) for fall from the FSW. Conclusions and Relevance: In this cohort study, no association was found between the likelihood of adverse events and contact isolation using propensity score-matching methods and closely related covariates for adverse events.

Factors Associated with Influenza Vaccination Uptake among U.S. Adults: Focus on Nativity and Race/Ethnicity.

To support implementation strategies for upcoming influenza (flu) vaccinations for foreign-born and racial/ethnic minority groups, we analyzed the 2018 National Health Interview Survey (NHIS) database and performed logistic regression to examine the factors associated with, and the interaction between nativity and race/ethnicity in directing flu vaccination rates during the past 12 months (n = 25,045). As a result, we found nativity and race/ethnicity were associated with flu vaccination rates; foreign-born and non-Hispanic black respondents were less likely to take the vaccine than U.S.-born and non-Hispanic white respondents. The odds ratios were largest for the elderly, those working in the healthcare industry, those with health insurance, and those with a usual source of care (ORs = 3.058, 2.871, 2.317, and 2.342, respectively), suggesting that access to healthcare resources is critical for the uptake of the flu vaccine. There was a significant interaction effect between nativity and race/ethnicity. For improving flu vaccination rates, more support is necessary for foreign-born people and racial/ethnic minorities who have lower health insurance rates and usual sources of care than U.S.-born people and non-Hispanic whites, and thus are less able to adequately access healthcare resources in a timely manner.

Minimizing contamination in the use of personal protective equipment: Simulation results through tracking contamination and enhanced protocols.

BACKGROUND: Due to variations and the inadequate use of personal protective equipment (PPE), this study aimed to evaluate our enhanced PPE protocols for minimizing doffing contamination. METHODS: Among 3 PPE kits (simple, Level D, and Level C), 30 participants conducted the first simulation in their adapted way and the second following enhanced protocols. After donning, participants performed a 1-minute simulation of direct care on a patient simulator covered with fluorescent powder. For tracking contamination routes between doffing processes, fluorescent powder contamination was examined with ultraviolet lamps in the darkened room. RESULTS: Participants were mostly registered nurses (N = 27, 90%), female (87%), and on average 31.7 years old with 8.5 years of clinical experience. Among 61 total simulations, 32 had at least 1 contamination (52.5%); "Noticeable" level (40%) at the "hands-fingers" and "shirt" body areas were most frequent. For first and second simulations with identical PPE kits, compared to the first with adapted practice, the second with enhanced protocols showed a significant reduction in doffing contamination rates (72.7% vs 22.7%, P = .0009 for both Level C and D; 77.8% vs 27.8%, P = .0027 for Level D). CONCLUSIONS: Our enhanced protocols could significantly reduce contaminations. More studies are necessary to provide safer PPE protocol options.

South Korea's responses to stop the COVID-19 pandemic.

BACKGROUND: South Korea's aggressive responses to the coronavirus disease 2019 (COVID-19) have greatly slowed the epidemic without regional lockdowns. METHODS: The Korean Centers for Disease Control and Prevention's daily briefings were thoroughly reviewed. Information about hospital countermeasures and government coordination was collected via telephone interviews with 4 infection control team leaders, 1 emergency department nurse, and 1 infectious disease physician in Korea. RESULTS: After the 2015 Middle East Respiratory Syndrome outbreak, the government and hospitals prepared for the inevitable outbreak of emerging infectious diseases by reforming the epidemic preparedness system. As a result, COVID-19 diagnostic test kits were quickly developed, enabling extensive early detection of potential cases. Other key steps were tracking cases, finding exposed individuals, coordinating case assignments with health care facilities, and selective clinic screenings for visitors' entering hospitals with mandatory mask wearing. Consequently, after overcoming the initial peak of the outbreak, which was related to a religious group, Korea has been able to maintain daily new cases at around 100 and to less than 50 daily cases in the second week of April. CONCLUSIONS: To counter the COVID-19 pandemic, which may persist, long-term, sustained response strategies must be prepared along with coordination between government and health systems.

Human Papillomavirus Vaccine Predictors Among U.S. Adults Aged 18 to 45 by Sexual Orientation.

Despite increased incidence rates of human papillomavirus (HPV)-associated cancers among sexual minorities, their HPV vaccine uptake remains suboptimal. This cross-sectional, correlational study aimed to investigate factors associated with HPV vaccination among a nationally representative sample of U.S. young adults by sexual orientation. We used the 2014 to 2017 Behavioral Risk Factor Surveillance System data for adults aged 18 to 45 years. HPV vaccination initiation was associated with being female and Hispanic, having higher educational attainment, and having ever been tested for HIV, whereas completion was associated with being female and non-Hispanic White and having higher educational attainment. Compared with those who reported identifying as straight, the lesbian or gay respondents were found to have been less likely not to complete the series. Providers should play a crucial part in addressing missed opportunities for HPV vaccination by implementing culturally competent communication strategies to empower sexual minorities to make informed HPV vaccine decisions.

Difficulties in using personal protective equipment: Training experiences with the 2015 outbreak of Middle East respiratory syndrome in Korea.

This study aimed to evaluate practical barriers to personal protective equipment (PPE) use found through health care personnel (HCP) training sessions held during and after the 2015 Middle East respiratory syndrome outbreak in Korea. Difficulties observed were ill-fitting sizes, anxiety, confusion from unstandardized protocols, doubts about PPE quality and effectiveness, and complexity of using several PPE items together. Further research to generate robust evidence and repeated HCP trainings are necessary to ensure HCP and patient safety in future outbreaks.

Use of personal protective equipment among health care personnel: Results of clinical observations and simulations.

BACKGROUND: Very little is known about how health care personnel (HCP) actually use personal protective equipment (PPE). METHODS: The clinical PPE practices of 50 HCP from selected units at the University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital were videotaped with HCP consent. For 2 PPE simulation sessions (simple and full-body sets), 82 HCP were recruited throughout the UPMC system. Simulation practices were videotaped and examined using fluorescent powder with ultraviolet lighting. All participants completed an electronic survey. For a follow-up evaluation simulation, 12 HCP were recruited among simulation participants. RESULTS: Among 130 total sessions from 65 participants, contamination occurred in 79.2% of simulations during the doffing process with various PPE items: simple set (92.3%) and full-body set (66.2%). Among 11 follow-up evaluation participants, contaminations still occurred in 82% after receiving individual feedback, but the overall contamination level was reduced. Using the contamination information gained during the simulation analysis, 66% of potential contamination was estimated for the clinical observation. Concerns and barriers in PPE use from HCP survey responses were as follows: time-consuming, cumbersomeness, and PPE effectiveness. CONCLUSIONS: Although HCP knew they were being videotaped, contamination occurred in 79.2% of the PPE simulations. Devising better standardized PPE protocols and implementing innovative PPE education are necessary to ensure HCP safety.

Survey of North Carolina hospital policies regarding visitor use of personal protective equipment for entering the rooms of patients under isolation precautions.

OBJECTIVE: To explore the range of hospital policies for visitor use of personal protective equipment (PPE) when entering the room of patients under isolation precautions. DESIGN: Survey using an online questionnaire. SETTING: Acute care hospitals registered in the North Carolina Statewide Program for Infection Control and Epidemiology (SPICE). METHODS: A total of 136 North Carolina hospitals were invited to participate in an online survey. The survey questionnaire was developed, reviewed, and pilot tested, and then it was distributed through SPICE listserv registered e-mail addresses. The survey was conducted from February 6 to March 30, 2012. RESULTS: Among 93 respondent hospitals (response rate, 68.4%), 82 acute care hospitals (60.3%) were included in the analyses. Substantial variation was observed with regard to hospital policies for visitor PPE use when visiting patients under isolation precautions. A total of 71% of hospitals had a hospital visitor policy, and 96% of respondents agreed that hospitals should have a visitor policy. Only 14% of hospitals monitored visitor compliance with PPE. Reported compliance rates varied from "very low" to 97%. Many hospitals (28%) reported difficulties related to visitor compliance with isolation precautions, including hostility and refusal to comply. CONCLUSIONS: Our study results illuminated hospital policy variations for visitor isolation precautions. Reported problems with hospital visitor policies (eg, different policies across departments or facilities) suggest the need for standard guidelines and for enhanced public awareness about the importance of visitor compliance with isolation precautions.

Changes in the incidence of health care-associated pathogens at a university hospital from 2005 to 2011.

BACKGROUND: Data on health care-associated infections (HAIs) outside of intensive care units (ICU) are scarce. We assessed hospital-wide changes in the incidence of health care-associated pathogens by infection site and by service between 2005 and 2011. METHODS: All data on health care-associated pathogens in 2005-2011 based on comprehensive hospital-wide surveillance were extracted from an electronic database. The incidence of HAI by pathogen was calculated per 1000 patient-days and per 1000 device-days. Regression analyses were conducted to estimate trend changes in the yearly incidence of pathogens for selected HAIs. RESULTS: The majority (8784 of 10,070; 87.2%) of the HAIs recorded over the 7-year period had at least 1 pathogen; a total of 10,585 pathogens were isolated. Overall, across all major service categories (eg, ICU, medicine), significant trends toward decreasing incidence were observed for all pathogens except Clostridium difficile. The decrease in incidence was greatest for central line-associated bloodstream infections, less for catheter-associated urinary tract infections, and lowest for ventilator-associated pneumonias. CONCLUSIONS: This study showed significant decreases in incidence of the majority of HAIs caused by various pathogens, but significant increases in patient-days during the study period. Only HAIs due to C difficile showed a significantly increased incidence.

Cost-effectiveness analysis of active surveillance screening for methicillin-resistant Staphylococcus aureus in an academic hospital setting.

OBJECTIVE: To evaluate the cost-effectiveness of 3 alternative active screening strategies for methicillin-resistant Staphylococcus aureus (MRSA): universal surveillance screening for all hospital admissions, targeted surveillance screening for intensive care unit admissions, and no surveillance screening. DESIGN: Cost-effectiveness analysis using decision modeling. METHODS: Cost-effectiveness was evaluated from the perspective of an 800-bed academic hospital with 40,000 annual admissions over the time horizon of a hospitalization. All input probabilities, costs, and outcome data were obtained through a comprehensive literature review. Effectiveness outcome was MRSA healthcare-associated infections (HAIs). One-way and probabilistic sensitivity analyses were conducted. RESULTS: In the base case, targeted surveillance screening was a dominant strategy (ie, was associated with lower costs and resulted in better outcomes) for preventing MRSA HAI. Universal surveillance screening was associated with an incremental cost-effectiveness ratio of $14,955 per MRSA HAI. In one-way sensitivity analysis, targeted surveillance screening was a dominant strategy across most parameter ranges. Probabilistic sensitivity analysis also demonstrated that targeted surveillance screening was the most cost-effective strategy when willingness to pay to prevent a case of MRSA HAI was less than $71,300. CONCLUSION: Targeted active surveillance screening for MRSA is the most cost-effective screening strategy in an academic hospital setting. Additional studies that are based on actual hospital data are needed to validate this model. However, the model supports current recommendations to use active surveillance to detect MRSA.

Relative frequency of health care-associated pathogens by infection site at a university hospital from 1980 to 2008.

BACKGROUND: We describe the relative frequency of health care-associated pathogens by infection site over 29 years using hospital-wide surveillance data from a large academic hospital. METHODS: Comprehensive hospital-wide surveillance was provided by trained infection preventionists using Centers for Disease Control and Prevention definitions. Five 5-year blocks and one 4-year block were created for each site: bloodstream infections (BSI), urinary tract infections (UTI), respiratory tract infections (RTI), and surgical site infections (SSI). The blocks of relative frequency of health care-associated pathogens were compared by χ(2) analysis, and trends for each pathogen were estimated by regression analysis. RESULTS: At least 1 pathogen was isolated from 28,208 (83.5%) of 33,797 health care-associated infections (HAI). Staphylococcus aureus, coagulase-negative staphylococci (CoNS), Enterococcus species, and Clostridium difficile and other anaerobes significantly increased, whereas Escherichia coli, Pseudomonas aeruginosa, Klebsiella species, Enterobacter species, and other streptococci significantly decreased in the relative proportion of pathogens during the study period. By infection site, results showed significant increasing trends of S aureus in UTI, RTI, and SSI; CoNS in BSI and SSI; Candida in SSI; and Enterococcus in BSI and UTI. CONCLUSION: Significant changes in relative frequency of health care-associated pathogens by infection site occurred over the 29-year period. These findings have implications for implementation of infection prevention strategies.