Replacing the Guaiac Fecal Occult Blood Test With the Fecal Immunochemical Test Increases Proportion of Individuals Screened in a Large Healthcare Setting.

BACKGROUND & AIMS: The most commonly used noninvasive test for colorectal cancer (CRC) screening has been the guaiac fecal occult blood test (gFOBT). The fecal immunochemical test (FIT) detects CRC and colorectal polyps with higher levels of sensitivity than the gFOBT, and may be more acceptable to patients. However, the FIT has not replaced the gFOBT in many clinical settings. We analyzed data from a large healthcare system that replaced the gFOBT with the FIT to determine the effects on CRC screening. METHODS: We conducted a retrospective observational study of 7898 patients at the Veterans' Administration San Diego Healthcare System, 50-75 years old, who were offered stool-based CRC screening as part of primary care March 2014 through January 2015. Test orders and results were extracted from electronic health records; we performed manual reviews of colonoscopy and pathology reports for Veterans with positive results from the tests. Our primary outcome was test completion within 1 year of order; secondary outcomes were positive results and detection of advanced neoplasia by diagnostic colonoscopy. The primary analysis used an intention-to-screen approach, which included all patients with test orders; as-screened analyses were also performed. RESULTS: Among 7898 patients, 3236 had gFOBT and 4662 FIT orders. In the intention to screen analysis, a significantly higher proportion of subjects completed a FIT (42.6%) than a gFOBT (33.4%) (P < .001); advanced neoplasia was detected in a significantly higher proportion of subjects offered a FIT (0.79%) than a gFOBT (0.28%) (P = .003). The numbers needed to invite to achieve 1 additional completed test and identify 1 additional patient with advanced neoplasia were 11 and 196, respectively. CONCLUSIONS: In a retrospective study of patients at a Veterans' administration healthcare system, replacing the gFOBT with the FIT increased the proportion of patients who completed CRC screening. Replacement of the gFOBT with the FIT should be strongly considered by all healthcare systems.

Assessment of a modified MINDS-based protocol for management of alcohol withdrawal syndrome on an inpatient medical service.

OBJECTIVE: To determine if a novel symptom-based alcohol withdrawal syndrome (AWS) protocol in a US Veterans cohort leads to significant clinical improvements in patient outcomes and safety. BACKGROUND: Prior studies of AWS management, oftentimes using the revised version of the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) index, have demonstrated the effectiveness of symptom-triggered therapy for AWS. The Minnesota Detoxification Scale (MINDS) is an alternative to the CIWA-Ar index but remains unevaluated outside of the intensive care unit (ICU) setting. This study assesses outcomes in AWS management prior to and after the implementation of a novel MINDS-based AWS protocol (SDAWP) utilizing a revised MINDS index (MINDS-rev) in an inpatient medical ward setting. METHODS: Retrospective cohort study including encounters prior to (n = 342) and after (n = 338) the implementation of the protocol. Pre- and post-protocol encounters were selected by combinations of diagnostic codes and charting elements. Outcome measures of AWS management were obtained in both groups. The primary endpoint was median total benzodiazepine exposure. Secondary outcomes included median length of hospitalization, median duration of benzodiazepine administration, and the incidence of complications. RESULTS: The median total benzodiazepine exposure in the post-SDAWP group was significantly lower than the pre-SDAWP group (21.2 vs. 12.0 mg, p < 0.0001) and for a significantly shorter median duration of time (4.0 vs. 3.0 days, p < 0.0001). There was no significant difference in the median length of stay (4.0 vs. 4.0 days, p = 0.50). The incidence of delirium tremens (21 vs. 7, p = 0.01) and need for transfer to a higher level of care (33 vs. 12, p = 0.002) was significantly lower in the post-SDAWP group. CONCLUSION: The SDAWP has provided significant improvements in AWS management in our institution and may potentially serve as a template for wider use in other inpatient settings.

Using diagnostic stewardship to reduce rates, healthcare expenditures and accurately identify cases of hospital-onset Clostridioides difficile infection.

OBJECTIVE: Lack of judicious testing can result in the incorrect diagnosis of Clostridioides difficile infection (CDI), unnecessary CDI treatment, increased costs and falsely augmented hospital-acquired infection (HAI) rates. We evaluated facility-wide interventions used at the VA San Diego Healthcare System (VASDHS) to reduce healthcare-onset, healthcare-facility-associated CDI (HO-HCFA CDI), including the use of diagnostic stewardship with test ordering criteria. DESIGN: We conducted a retrospective study to assess the effectiveness of measures implemented to reduce the rate of HO-HCFA CDI at the VASDHS from fiscal year (FY)2015 to FY2018. INTERVENTIONS: Measures executed in a stepwise fashion included a hand hygiene initiative, prompt isolation of CDI patients, enhanced terminal room cleaning, reduction of fluoroquinolone and proton-pump inhibitor use, laboratory rejection of solid stool samples, and lastly diagnostic stewardship with C. difficile toxin B gene nucleic acid amplification testing (NAAT) criteria instituted in FY2018. RESULTS: From FY2015 to FY2018, 127 cases of HO-HCFA CDI were identified. All rate-reducing initiatives resulted in decreased HO-HCFA cases (from 44 to 13; P ≤ .05). However, the number of HO-HCFA cases (34 to 13; P ≤ .05), potential false-positive testing associated with colonization and laxative use (from 11 to 4), hospital days (from 596 to 332), CDI-related hospitalization costs (from $2,780,681 to $1,534,190) and treatment cost (from $7,158 vs $1,476) decreased substantially following the introduction of diagnostic stewardship with test criteria from FY2017 to FY2018. CONCLUSIONS: Initiatives to decrease risk for CDI and diagnostic stewardship of C. difficile stool NAAT significantly reduced HO-HCFA CDI rates, detection of potential false-positives associated with laxative use, and lowered healthcare costs. Diagnostic stewardship itself had the most dramatic impact on outcomes observed and served as an effective tool in reducing HO-HCFA CDI rates.

Development and implementation of the Ebola Exposure Window Calculator: A tool for Ebola virus disease outbreak field investigations.

During an Ebola virus disease (EVD) outbreak, calculating the exposure window of a confirmed case can assist field investigators in identifying the source of infection and establishing chains of transmission. However, field investigators often have difficulty calculating this window. We developed a bilingual (English/French), smartphone-based field application to assist field investigators in determining the exposure window of an EVD case. The calculator only requires the reported date of symptoms onset and the type of symptoms present at onset or the date of death. Prior to the release of this application, there was no similar electronic capability to enable consistent calculation of EVD exposure windows for field investigators. The Democratic Republic of the Congo Ministry of Health endorsed the application and incorporated it into trainings for field staff. Available for Apple and Android devices, the calculator continues to be downloaded even as the eastern DRC outbreak resolved. We rapidly developed and implemented a smartphone application to estimate the exposure window for EVD cases in an outbreak setting.

Development of a language-independent functional evaluation.

UNLABELLED: Haig AJ, Jayarajan S, Maslowski E, Yamakawa KS, Tinney M, Beier KP, Juang D, Chan L, Boggess T, Loar J, Owusu-Ansah B, Kalpakjian C. Development of a language-independent functional evaluation. OBJECTIVE: To design, validate, and critique a tool for self-report of physical functioning that is independent of language and literacy. DESIGN: Software design and 2 prospective trials followed by redesign. SETTING: United States and African university hospitals. PARTICIPANTS: Outpatient and inpatient competent adults with diverse physical impairments. INTERVENTIONS: (1) Software design process leading to a Preliminary Language-Independent Functional Evaluation (Pre-L.I.F.E.); (2) patient surveys using a printed Pre-L.I.F.E. and a computer-animated Pre-L.I.F.E. tested in random order, followed by a questionnaire version of the standard Barthel Index; and (3) software redesign based on objective and qualitative experiences with Pre-L.I.F.E. MAIN OUTCOME MEASURES: Validation of the general concept that written and spoken language can be eliminated in assessment of function. Development of a refined Language-Independent Functional Evaluation (L.I.F.E.). RESULTS: A viable Pre-L.I.F.E. software was built based on design parameters of the clinical team. Fifty Americans and 51 Africans demonstrated excellent (Cronbach alpha>0.8 Americans) and good (alpha>.425 Africans) reliability. In general, the relations between Pre-L.I.F.E. and Barthel scores were excellent in the United States (interclass correlation coefficient for stair climbing, .959) but somewhat less good in Africa, with elimination functions very poorly related. The computer-animated Pre-L.I.F.E. was faster and trended to be more reliable than the printed Pre-L.I.F.E. in both the United States and Africa. Redesign meetings corrected statistical and qualitative challenges, resulting in a new tool, the L.I.F.E. CONCLUSIONS: Literacy and language translation can be eliminated from some aspects of functional assessment. The new L.I.F.E., based on solid empirical evidence and design principles, may be a practical solution to assessment of function in the global culture.

Characteristics and Outcomes of Methamphetamine Abuse Among Veterans With Heart Failure.

Methamphetamine is one of the most commonly abused illicit substances worldwide. Chronic methamphetamine abuse (MA) is associated with the development of a dilated cardiomyopathy. MA in patients with heart failure (MethHF) is increasingly reported yet poorly characterized. This was a retrospective cohort study of veterans treated at the VA Medical Center in San Diego between 2005 and 2015 with a diagnosis of HF and a history of MA. The incidence of MA each year was calculated, and clinical characteristics and outcomes of veterans with HF with and without MA were compared. Among 9,491 veterans with HF, 429 were identified as having a history of MA. Between 2006 and 2015, the incidence of MA in veterans with HF doubled from 3.44% to 6.70%. Of the 429 identified, 106 veterans had a hospitalization for HF and they were compared with veterans with HF without evidence of MA (HF). Compared with veterans with HF, veterans with MethHF were significantly younger (60.7 ± 7.3 vs 71.6 ± 11.6 years, p <0.001), with more frequent co-morbid post-traumatic stress disorder (16.8% vs 4.4%, p = 0.006), depression (28.7% vs 11.0%, p = 0.002), homelessness (27.9% vs 8.9%, p = 0.001), and unemployment (55.8% vs 30.0%, p <0.001). Despite their younger age, veterans with MethHF had high rates of HF readmission or emergency room visit (49% vs 38% in MethHF vs HF, p = 0.34) and mortality at 6 months (27% vs 38% in MethHF vs HF, p = 0.10) compared with HF. In conclusion, MA in veterans with HF is on the rise. Certain demographic and clinical characteristics of veterans with MethHF may contribute to their poor outcomes.

Exploring simulation in the internal medicine clerkship.

BACKGROUND: Simulation-based medical education has been shown to produce substantial educational benefits; however, the integration and effectiveness of high-fidelity simulation within the internal medicine (IM) clerkship remains largely unexplored. Investigators sought to determine the effectiveness of simulation in improving student confidence in acute coronary syndrome (ACS) and the Advanced Cardiac Life Support (ACLS) curriculum. Secondary goals included examining student perceptions of the role of simulation in medical education. METHODS: Investigators implemented a formative high-fidelity simulation curriculum in the IM clerkship at a large teaching institution. Third-year medical students enrolled in the IM clerkship between January and June 2014 attended a simulation course during their ambulatory block. Following a 2-hour session, participants completed a 17-item questionnaire. Descriptive statistical analyses and a thematic qualitative analysis were performed. Integration of high-fidelity simulation within the internal medicine clerkship remains largely unexplored RESULTS: The response rate was 100 per cent (n = 43). Students reported improvements in their ability to identify and manage ACS and ACLS before and after the simulation course: 93 per cent felt that simulation boosted their self-confidence in performing these tasks on a real patient; 86 per cent reported receiving useful feedback during the training sessions; 98 per cent agreed that their experience was enjoyable; and 95 per cent would recommend this course to other students. CONCLUSIONS: Internal medicine (IM) clerkship students participating in our pilot course demonstrated increased confidence in identifying and managing pathologies associated with ACS and arrhythmias. Students viewed simulation as an engaging and useful activity, desiring additional training sessions.