Risk factors for the development of acute pyelonephritis in women with a positive urine culture.

INTRODUCTION: In treating lower urinary tract symptoms (LUTS), the risk of overtreatment with antibiotics must be reconciled with the risk of an untreated urinary tract infection (UTI) progressing to acute pyelonephritis (APN). Using Cerner HealthFacts, a longitudinal clinical informatics database, we aimed to determine risk factors associated with the development of APN from UTI in an effort to guide the initiation of empiric antibiotics. METHODS: We queried the Cerner HealthFacts database for women over age 18 with a positive urine culture. Any patient with an International Classification of Disease (ICD) code indicating chronic pyelonephritis was excluded. Development of APN within 30 days of the positive culture, specified by ICD coding, was our primary outcome. Patient and facility factors were assessed as potential risk factors for the development of APN using multivariable regression. RESULTS: Out of 58 344 women with a positive urine culture, 3.9% (2296) developed APN. Mean patient age was 54.4 ± 25.3 years. Overall, 12 variables were predictive for APN and 11 variables were protective against APN. Presence of obstructive and reflux uropathies (OR 4.58), presentation to an acute care facility (OR 3.19), urinary retention (OR 2.30), history of UTI (OR 2.19), and renal comorbidities (OR 2.07) conferred the highest odds of APN development. The most protective variable against APN development was cognitive impairment (OR 0.49). CONCLUSIONS: Identified risk factors associated with APN development may aid decisions regarding empiric antibiotic initiation for patients presenting with LUTS while awaiting urine culture results. The relationship between cognitive impairment and progression to APN deserves further study.

Characterizing Opioid Use Disorder Encounters in the Midwest Region, USA.

INTRODUCTION: The opioid epidemic has taken its toll on the Midwest, a census region of the USA. The Midwest includes two census divisions: East North Central and West North Central. This study aimed (1) to characterize patient encounters of opioid use disorder (OUD) in the Midwest using the Health Facts® database; and (2) to compare selected patient and facility characteristics between the two census divisions. METHODS: This study was a sub-analysis of a retrospective analysis of the Health Facts® database. For the first objective, the unit of analysis was a patient encounter. Selected patient characteristics were age, gender, marital status, race, length of stay, and patient type. Selected facility characteristics were census division and urban versus rural areas. Descriptive statistics were conducted, and population-based rates of OUD were calculated for categorical variables. For the second objective, t tests were performed for age and length of stay, and chi-square tests for categorical variables. RESULTS: A total of 13,129 (23.7%) encounters were in East North Central, and 42,271 (76.3%) in West North Central. Patient characteristics that were associated with the highest frequency of encounters were Caucasian, male, single, and other patient types. In addition, rural areas had a higher number of encounters than urban areas. Compared with East North Central, West North Central had a greater average age and a longer average length of stay (p < 0.001). West North Central had a significantly higher proportion of patient encounters associated with patients being male, African American, single, and facilities being in rural areas (p < 0.001). CONCLUSION: Compared to East North Central, patient encounters of OUD were more frequent and the average length of stay was longer than in West North Central. A significantly higher proportion of patient encounters in West North Central were associated with patients being male, African American, and single, and facilities being in rural areas.

Inpatient prescribing patterns of long-acting injectables and their oral or short-acting injectable equivalent formulations.

Background: Long-acting injectable (LAI) antipsychotics (APs) each have an oral equivalent formulation, while aripiprazole, olanzapine, and ziprasidone each also have a short-acting injectable (SAI) equivalent formulation. Inpatient prescribing patterns of LAIs and their oral/SAI equivalents are less characterized in populations other than Medicaid, Medicare, and Veterans Affairs populations. Mapping out inpatient prescribing patterns remains an important first step to ensure appropriate use of antipsychotics during this critical juncture of patient care prior to discharge. This study determined inpatient prescribing patterns of first- (FGA) and second-generation antipsychotic (SGA) LAIs and their oral/SAI formulations. Methods: This was a large retrospective study using the Cerner Health Facts® database. Hospital admissions due to schizophrenia, schizoaffective disorder, or bipolar disorder from 2010 to 2016 were identified. AP utilization was defined as the proportion of inpatient stays during which at least 1 AP was administered to the total number of inpatient visits over the observed period. Descriptive analyses were used to determine prescribing patterns for APs. Chi-square tests were used to determine utilization differences across years. Results: 94,989 encounters were identified. Encounters during which oral/SAI of SGA LAIs were administered were most common (n = 38,621, 41%). Encounters during which FGA LAIs or SGA LAIs were administered were the least common (n = 1,047, 1.1%). Prescribing patterns differed across years (p < 0.05) within the SGA LAI subgroup analysis (N = 6,014). Paliperidone palmitate (63%, N = 3,799) and risperidone (31%, N = 1,859) were the most frequently administered. Paliperidone palmitate utilization increased from 30% to 72% (p < 0.001), while risperidone utilization decreased from 70% to 18% (p < 0.001). Conclusions: Compared with their oral or SAI formulations, LAIs were underutilized from 2010 to 2016. Among SGA LAIs, the prescribing patterns of paliperidone palmitate and risperidone changed significantly.

Electronic health record data quality variability across a multistate clinical research network.

Background: Electronic health record (EHR) data have many quality problems that may affect the outcome of research results and decision support systems. Many methods have been used to evaluate EHR data quality. However, there has yet to be a consensus on the best practice. We used a rule-based approach to assess the variability of EHR data quality across multiple healthcare systems. Methods: To quantify data quality concerns across healthcare systems in a PCORnet Clinical Research Network, we used a previously tested rule-based framework tailored to the PCORnet Common Data Model to perform data quality assessment at 13 clinical sites across eight states. Results were compared with the current PCORnet data curation process to explore the differences between both methods. Additional analyses of testosterone therapy prescribing were used to explore clinical care variability and quality. Results: The framework detected discrepancies across sites, revealing evident data quality variability between sites. The detailed requirements encoded the rules captured additional data errors with a specificity that aids in remediation of technical errors compared to the current PCORnet data curation process. Other rules designed to detect logical and clinical inconsistencies may also support clinical care variability and quality programs. Conclusion: Rule-based EHR data quality methods quantify significant discrepancies across all sites. Medication and laboratory sources are causes of data errors.

Hemoglobin A1c and Reoperation After Surgery for Stress Incontinence or Prolapse.

IMPORTANCE: Few studies compare the link between hemogobin A1c (HbA1c) and urogynecologic surgical complications. OBJECTIVE: The objective of this study was to determine the association between HbA1c and reoperation in women undergoing surgery for stress urinary incontinence (SUI) or pelvic organ prolapse (POP). STUDY DESIGN: We performed 2 separate retrospective cohort analyses using Cerner's HealthFacts Database (750 hospitals; 519,000,000 patient encounters from January 1, 2010, to November 30, 2018). We included women undergoing surgery for (1) SUI or (2) apical POP by International Classification of Diseases coding who had HbA1c at the initial procedure. Each analysis compared those undergoing reoperation for complications or recurrence and those who did not. Multivariable logistic regression assessed the association between reoperation and HbA1c both as a continuous variable and comparing the commonly accepted cutoff ≥8. RESULTS: Of 30,180 SUI surgical procedures and 26,389 POP surgical procedures, 1,625 (5.4%) and 805 (3.1%) had HbA1c. Median (interquartile range) HbA1c in grams per deciliter was similar by reoperation status (SUI: 6.0 [5.6-6.8] vs 6.1 [5.6-6.9], P = 0.35; POP: 6.2 [5.6-6.6] vs 6.1 [5.7-6.8], P = 0.60). Reoperation was also similar using the HbA1c ≥8% cutoff (SUI: 6.9% vs 7.4%, P = 0.79; POP: 6.3% vs 5.4%, P = 0.77). On multivariate analysis, HbA1c value was not a significant predictor of reoperation either as a continuous (SUI: odds ratio [OR] = 0.966, 95% CI = 0.833-1.119; POP: OR = 1.040, 95% CI = 0.801-1.350) or dichotomous variable ≥8 (SUI: OR = 0.767, 95% CI = 0.407-1.446; POP: OR = 0.988, 95% CI = 0.331-2.951). Mean follow-up was 4.28-5.13 years. CONCLUSION: Although other studies have shown a link between diabetes and complications, we were unable to show an association between HbA1c values and rates of reoperation.

Examining Geographic Variation of Opioid Use Disorder Encounters in the USA.

OBJECTIVES: The objectives were (1) to characterize patient encounters of opioid use disorder (OUD) using Health Facts® database; and (2) to identify geographic variation, patient characteristics, and facility characteristics impacting patients' reduced OUD encounters over time. METHODS: Patient encounters were included if the patient (1) was 18 years old or greater; (2) had an index encounter; (3) survived at least 30 days after the discharge. The OUD encounter was based on ICD-10 codes. The date at which a patient first had an OUD encounter was the index date. For the first objective, OUD encounters were described according to patient characteristics, facility characteristics, and geographic variation. Patient characteristics were age, gender, marital status, race, health insurance coverage, discharge disposition, and patient type. Facility characteristics were care setting, medical specialty, census region, census division, urban vs. rural, acute vs. non-acute, and teaching hospital status. For the second objective, patients were examined 1 year prior to through 1 year after the index date. A logistic regression was used to determine the likelihood of reduced OUD encounters over time, conditional upon geographic variation, patient characteristics, and facility characteristics. RESULTS: A total of 265,643 OUD encounters were identified. East South Central was associated with the highest population-based rate of OUD among nine census divisions. In the logistic regression (n = 10,762), discharged to home, outpatient, emergency room, psychiatry, East North Central, West North Central, and urban areas were significant positive predictors for reduced OUD encounters over time, whereas age and Mountain were significant negative predictors. CONCLUSIONS: East South Central was associated with the highest population-based rate of OUD. Compared with East South Central, East North Central and West North Central had a significantly positive impact on fewer encounters of OUD over time.

Reoperation rates of stress incontinence surgery in rural vs urban hospitals.

BACKGROUND: XXX. OBJECTIVE: This study aimed to determine the impact of a rural vs urban hospital location on the risk of undergoing a second surgery for stress urinary incontinence. STUDY DESIGN: Using the Cerner Health Facts nationwide electronic medical record database, we identified patients who underwent surgeries for stress incontinence between January 1, 2010 and November 30, 2018. Stress incontinence surgeries included synthetic midurethral slings, fascial slings, retropubic urethral suspension, and other surgeries for stress urinary incontinence, such as the laparoscopic sling or the Pereyra procedure. Patients were divided into 2 cohorts, namely those who had a single operation and those who had a reoperation, defined as any second stress incontinence surgery or revision after initial incontinence surgery. Logistic regression analysis was performed to determine whether urban vs rural hospital location impacted reoperation rates. We adjusted for significant sociodemographic variables identified in the univariate analysis with a P value <.1. RESULTS: Of the 25,085 women who underwent stress incontinence procedures, 669 (2.7%) underwent a second surgery. Of these, 346 (51.7%) patients underwent were a second stress incontinence procedure, 307 (45.9%) underwent revisions of the index case, and 16 (2.4%) underwent both. Women in the single surgery cohort were older (median age, 54 vs 53 years; P=.029). In the total sample, 85.5% identified as White and 4.5% identified as Black. Of the study cohort, 7720 (30.8%) had obesity and 2660 (10.6%) had diabetes. There was a higher rate of reoperation among patients with obesity (3.0% vs 2.5%; P=.017). Among patients who underwent a concomitant prolapse surgery with their index surgery, there were fewer reoperations (2.2% vs 2.8%; P=.012). In the univariate analysis, we did not detect a difference between women who lived in rural vs urban areas (3.0% vs 2.6%; P=.16). After adjusting for confounders, we still did not see a significant association between rural hospital location and the risk for repeat surgery (odds ratio, 1.00; 95% confidence interval, 0.76-1.31). In this multivariable regression, obesity increased the risk for having a reoperation (odds ratio, 1.20; 95% confidence interval, 1.02-1.41), whereas patients who had concomitant prolapse procedures with their index surgery had a reduced risk for having a reoperation (odds ratio, 0.80; 95% confidence interval, 0.66-0.98). CONCLUSION: We did not detect an association between hospital location (rural vs urban) and the risk for reoperation among women undergoing stress incontinence surgery. With low reoperation rates, patients can be reassured that they are receiving excellent care in either setting.

Tailoring Rule-Based Data Quality Assessment to the Patient-Centered Outcomes Research Network (PCORnet) Common Data Model (CDM).

Individual researchers and research networks have developed and applied different approaches to assess the data quality of electronic health record (EHR) data. A previously published rules-based method to evaluate the data quality of EHR data provides deeper levels of data quality analysis. To examine the effectiveness and generalizability of the rule-based framework, we reprogrammed and translated published rule templates to operate against the PCORnet Common Data Model and executed them against a database for a single center of the Greater Plains Collaborative (GPC) PCORnet Clinical Research Network. The framework detected additional data errors and logical inconsistencies not revealed by current data quality procedures. Laboratory and medication data were more vulnerable to errors. Hemolyzed samples in the emergency department and metformin prescribing in ambulatory clinics are further described to illustrate application of specific rule-based findings by researchers to engage their health systems in evaluating healthcare delivery and clinical quality concerns.

Health Facts Medication Adherence in Transplantation (H-MAT) Study: A Secondary Analysis of Determinants and Outcomes of Medication Nonadherence in Adult Kidney Transplant Recipients.

Aims: To explore the relationship between determinants and posttransplant medication nonadherence (MNA) in adult kidney transplant recipients, and to examine the relationship between posttransplant MNA and clinical outcomes. Methods: Using the World Health Organization's model, this retrospective, multicenter, correlational study examined the relationship between determinants, posttransplant MNA, and clinical outcomes in 16,671 adult kidney transplant recipients from the Cerner Health Facts national data warehouse. Results: With 12% MNA, those who were nonadherent were more likely to have the social/economic factors of being younger, single, Caucasian versus Hispanic race, have the condition-related factor of mental health/substance use disorder, and have the healthcare system-related factor of government/health maintenance organization/managed care insurance (p's < 0.05). Bivariate correlations indicated both age (OR = 1.006, p=0.01) and mental health or substance use disorder diagnosis (OR = 1.26, p=0.04) were significant predictors of MNA. Patients were 0.6% more likely to be medication adherent for each year they increased in age and 26% more likely to be MNA if they were diagnosed with a mental health/substance use disorder. Nonadherent patients were less likely to be readmitted, but more likely to have complications after transplant and medication side effects (p's < 0.01). Conclusions: Using one of the largest samples of adult kidney transplant patients, our findings support the WHO model and move the body of medication adherence intervention research forward by clarifying the importance of focusing interventions not only on the patient but on multilevel determinants. Consistent with previous studies, MNA negatively impacts transplant outcomes.

The Risk of Primary Uterine and Cervical Cancer After Hysteropexy.

OBJECTIVE: The aim of the study was to determine the rate of subsequent uterine/cervical cancer after hysteropexy compared with hysterectomy with apical prolapse repair. METHODS: The study used a retrospective cohort of women with uterovaginal prolapse using the Cerner Health Facts database between 2010 and 2018. We identified sacrospinous or uterosacral ligament suspensions or sacral colpopexy/hysteropexy and excluded those with previous hysterectomy. We used the International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes for endometrial cancer/hyperplasia and cervical cancer and then reviewed each case, excluding those whose cancer existed at time of prolapse repair. Given that 0 cancer cases were identified, we used Wilson, Jeffreys, Agresti-Coull, Clopper-Pearson, and Rule of 3 to define 95% confidence intervals to estimate the highest possible rate of cancer in each cohort. RESULTS: A total of 8,927 patients underwent apical prolapse surgery. Of 4,510 with uterovaginal prolapse, 755 (16.7%) underwent hysteropexy. Seventy one with hysterectomy and 5 with hysteropexy had codes for subsequent gynecologic cancer but were excluded on further review. This left 0 gynecologic cancer cases with the largest 95% confidence interval of 0%-0.61% for hysteropexy versus 0%-0.13% for hysterectomy (P > 0.05). The hysteropexy cohort was older (62.6 years vs 57.3 years, P < 0.0001), more likely to have public insurance (51.0% vs 37.9%, P < 0.0001), and less likely to smoke (4.5% vs 7.6%, P = 0.0026). Median follow-up was longer after hysteropexy (1,480 days vs 1,164 days, P < 0.0009). CONCLUSIONS: We can say with 95% certainty that uterine or cervical cancer will develop after hysteropexy in fewer than 0.61% of women, which was not different if hysterectomy was performed. This should be included in preoperative counseling for hysteropexy. Studying longer follow-up after hysteropexy may capture more cases of subsequent cancer development.

High prevalence of comorbid autoimmune diseases in adults with type 1 diabetes from the HealthFacts database.

BACKGROUND: Patients with type 1 diabetes (T1D) are at risk for other autoimmune diseases (ie, polyautoimmunity). The prevalence and risk factors of this phenomenon have been underreported in adults and ethnic minorities, and data are lacking regarding non-endocrine autoimmune diseases. METHODS: Study population data were gathered from HealthFacts, a deidentified patient database compiled from electronic medical records systems in the US. Patients with an International Classification of Diseases diagnosis code specifying T1D were included in the study, whereas those with a diagnosis of type 2 diabetes were excluded. RESULTS: The cross-sectional study cohort comprised 158 865 adults with T1D (mean [±SD] age 51.4 ± 18.9 years, 52.5% female). The most common autoimmune diseases were thyroid disease (20.1%), systemic rheumatic diseases (3.4%), rheumatoid arthritis specifically (2.0%), and gastrointestinal autoimmune diseases (1.4%). Most of the autoimmune diseases were more common in women (eg hypothyroidism, hyperthyroidism, celiac disease, rheumatoid arthritis, lupus, and Sjögren syndrome). Caucasians were more likely than other ethnicities to have an additional autoimmune disease. The prevalence of autoimmune diseases increased with increasing age, significantly in women, such that 38.5% of women over 80 years of age had an additional autoimmune disease, compared with 17.9% of women aged ≤29 years. CONCLUSIONS: Additional autoimmunity represents a significant comorbidity in patients with T1D. Autoimmune diseases are more common in Caucasians and in women, and increase with age. Clinicians treating patients with T1D should be aware of the risk factors for additional autoimmune diseases.