30-day readmission rates among upper gastrointestinal bleeds: A systematic review and meta-analysis.

BACKGROUND AND AIM: Upper gastrointestinal bleeding (UGIB) is a common emergency, with high rates of hospitalization and in-patient mortality compared to other gastrointestinal diseases. Despite readmission rates being a common quality metric, little data are available for UGIBs. This study aimed to determine readmission rates for patients discharged following an UGIB. METHODS: Adhering to PRISMA guidelines, MEDLINE, Embase, CENTRAL, and Web of Science were searched to October 16, 2021. Randomized and non-randomized studies that reported hospital readmission for patients following an UGIB were included. Abstract screening, data extraction, and quality assessment were conducted in duplicate. A random-effects meta-analysis was performed, with statistical heterogeneity measured using I2 . The GRADE framework, with a modified Downs and Black tool, was used to determine certainty of evidence. RESULTS: Seventy studies were included of 1847 screened abstracted, with moderate interrater reliability. Within these studies, 4 292 714 patients were analyzed with a mean age of 66.6 years, and 54.7% male. UGIB had a 30-day all-cause readmission rate of 17.4% (95% confidence interval [CI] 16.7-18.2%), stratification revealed a higher rate for variceal UGIB [19.6% (95% CI 17.6-21.5%)] than non-variceal [16.8% (95% CI 16.0-17.5%)]. Only one third were readmitted due to recurrent UGIB (4.8% [95% CI 3.1-6.4%]). UGIB due to peptic ulcer bleeding had the lowest 30-day readmission rate [6.9% (95% CI 3.8-10.0%)]. Certainty of evidence was low or very low for all outcomes. CONCLUSIONS: Almost one in five patients discharged after an UGIB are readmitted within 30 days. These data should prompt clinicians to reflect on their own practice to identify areas of strength or improvement.

Implementation strategies for hospital-based probiotic administration in a stepped-wedge cluster randomized trial design for preventing hospital-acquired Clostridioides difficile infection.

BACKGROUND: Clostridioides difficile infection (CDI) is associated with considerable morbidity and mortality in hospitalized patients, especially among older adults. Probiotics have been evaluated to prevent hospital-acquired (HA) CDI in patients who are receiving systemic antibiotics, but the implementation of timely probiotic administration remains a challenge. We evaluated methods for effective probiotic implementation across a large health region as part of a study to assess the real-world effectiveness of a probiotic to prevent HA-CDI (Prevent CDI-55 +). METHODS: We used a stepped-wedge cluster-randomized controlled trial across four acute-care adult hospitals (n = 2,490 beds) to implement the use of the probiotic Bio-K + ® (Lactobacillus acidophilus CL1285®, L. casei LBC80R® and L. rhamnosus CLR2®; Laval, Quebec, Canada) in patients 55 years and older receiving systemic antimicrobials. The multifaceted probiotic implementation strategy included electronic clinical decision support, local site champions, and both health care provider and patient educational interventions. Focus groups were conducted during study implementation to identify ongoing barriers and facilitators to probiotic implementation, guiding needed adaptations of the implementation strategy. Focus groups were thematically analyzed using the Theoretical Domains Framework and the Consolidated Framework of Implementation Research. RESULTS: A total of 340 education sessions with over 1,800 key partners and participants occurred before and during implementation in each of the four hospitals. Site champions were identified for each included hospital, and both electronic clinical decision support and printed educational resources were available to health care providers and patients. A total of 15 individuals participated in 2 focus group and 7 interviews. Key barriers identified from the focus groups resulted in adaptation of the electronic clinical decision support and the addition of nursing education related to probiotic administration. As a result of modifying implementation strategies for identified behaviour change barriers, probiotic adherence rates were from 66.7 to 75.8% at 72 h of starting antibiotic therapy across the four participating acute care hospitals. CONCLUSIONS: Use of a barrier-targeted multifaceted approach, including electronic clinical decision support, education, focus groups to guide the adaptation of the implementation plan, and local site champions, resulted in a high probiotic adherence rate in the Prevent CDI-55 + study.

Antimicrobial use over a four-year period using days of therapy measurement at a Canadian pediatric acute care hospital.

BACKGROUND: Antimicrobial resistance is a concern that is challenging the ability to treat common infections. Surveillance of antimicrobial use in pediatric acute care institutions is complicated because the common metric unit, the defined daily dose, is problematic for this population. OBJECTIVE: During a four-year period in which no specific antimicrobial stewardship initiatives were conducted, pediatric antimicrobial use was quantified using days of therapy (DOT) per 100 patient days (PD) (DOT/100 PD) at the Alberta Children's Hospital (Calgary, Alberta) for benchmarking purposes. METHODS: Drug use data for systemic antimicrobials administered on wards at the Alberta Children's Hospital were collected from electronic medication administration records. DOT were calculated and rates were determined using 100 PD as the denominator. Changes over the surveillance period and subgroup proportions were represented graphically and assessed using linear regression. RESULTS: Total antimicrobial use decreased from 93.6 DOT/100 PD to 75.7 DOT/100 PD (19.1%) over the 2010/2011 through to the 2013/2014 fiscal years. During this period, a 20.0% increase in PD and an essentially stable absolute count of DOT (2.9% decrease) were observed. Overall, antimicrobial use was highest in the pediatric intensive care and oncology units. DISCUSSION: The exact changes in prescribing patterns that led to the observed reduction in DOT/100 PD with associated increased PD are unclear, but may be a topic for future investigations. CONCLUSION: Antimicrobial use data from a Canadian acute care pediatric hospital reported in DOT/100 PD were compiled for a four-year time period. These data may be useful for benchmarking purposes.

HISTORIQUE: La résistance aux antimicrobiens nuit à la capacité de traiter les infections courantes. Il est difficile de surveiller l'utilisation d'antimicrobiens dans les établissements de soins aigus en pédiatrie, parce qu'il est difficile d'établir l'unité métrique habituelle, qui est la dose quotidienne définie, au sein de cette population. OBJECTIF: Après quatre ans sans initiative de gérance des antimicrobiens précise, les chercheurs ont quantifié l'utilisation des antimicrobiens pédiatriques au moyen des jours de traitement (JdT) par 100 jours-patients (JP) (JdT/100 JP) à l'Alberta Children's Hospital de Calgary en vue d'une analyse comparative. MÉTHODOLOGIE: À partir des dossiers électroniques sur l'administration des médicaments, les chercheurs ont colligé les données sur l'utilisation des antimicrobiens systémiques administrés dans les services de l'Alberta Children's Hospital. Ils ont calculé les JdT et déterminé les taux à l'aide du dénominateur 100 JP. Ils ont représenté graphiquement les changements pendant la période de surveillance et les proportions des sous-groupes et les ont évalués à l'aide de la régression linéaire. RÉSULTATS: L'utilisation totale d'antimicrobiens a reculé de 93,6 JdT/100 JP à 75,7 JdT/100 JP (19,1 %) entre les exercices 2010­2011 et 2013­2014. Pendant cette période, les chercheurs ont observé une augmentation de 20,0 % des JP et une numération absolue de JdT pratiquement stable (diminution de 2,9 %). Dans l'ensemble, l'utilisation d'antimicrobiens était plus élevée dans les unités pédiatriques de soins intensifs et d'oncologie. EXPOSÉ: On ne sait pas exactement quels changements aux profils de prescription ont donné lieu à la réduction observée de JdT/100 JP et à l'augmentation connexe de JP, mais cette question pourrait faire l'objet de prochaines recherches. CONCLUSION: Pendant quatre ans, les chercheurs ont compilé les données sur l'utilisation d'antimicrobiens en JdT/100 JP dans un hôpital pédiatrique canadien de soins aigus. Ces données peuvent être utiles dans une analyse comparative.

Likelihood of coronary angiography among First Nations patients with acute myocardial infarction.

BACKGROUND: Morbidity due to cardiovascular disease is high among First Nations people. The extent to which this may be related to the likelihood of coronary angiography is unclear. We examined the likelihood of coronary angiography after acute myocardial infarction (MI) among First Nations and non-First Nations patients. METHODS: Our study included adults with incident acute MI between 1997 and 2008 in Alberta. We determined the likelihood of angiography among First Nations and non-First Nations patients, adjusted for important confounders, using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) database. RESULTS: Of the 46,764 people with acute MI, 1043 (2.2%) were First Nations. First Nations patients were less likely to receive angiography within 1 day after acute MI (adjusted odds ratio [OR] 0.73, 95% confidence interval [CI] 0.62-0.87). Among First Nations and non-First Nations patients who underwent angiography (64.9%), there was no difference in the likelihood of percutaneous coronary intervention (PCI) (adjusted hazard ratio [HR] 0.92, 95% CI 0.83-1.02) or coronary artery bypass grafting (CABG) (adjusted HR 1.03, 95% CI 0.85-1.25). First Nations people had worse survival if they received medical management alone (adjusted HR 1.38, 95% CI 1.07-1.77) or if they underwent PCI (adjusted HR 1.38, 95% CI 1.06-1.80), whereas survival was similar among First Nations and non-First Nations patients who received CABG. INTERPRETATION: First Nations people were less likely to undergo angiography after acute MI and experienced worse long-term survival compared with non-First Nations people. Efforts to improve access to angiography for First Nations people may improve outcomes.

Are Guideline-concordant Processes of Care Consistent Across the Rural-Urban Continuum? A Retrospective Cohort Study of Adults Newly Treated for Type 2 Diabetes.

OBJECTIVES: Our aim in this study was to identify the association between place of residence (metropolitan, urban, rural) and guideline-concordant processes of care in the first year of type 2 diabetes management. METHODS: We conducted a retrospective cohort study of new metformin users between April 2015 and March 2020 in Alberta, Canada. Outcomes were identified as guideline-concordant processes of care through the review of clinical practice guidelines and published literature. Using multivariable logistic regression, the following outcomes were examined by place of residence: dispensation of a statin, angiotensin-converting enzyme inhibitor (ACEi) or angiotensin II receptor blocker (ARB), eye examination, glycated hemoglobin (A1C), cholesterol, and kidney function testing. RESULTS: Of 60,222 new metformin users, 67% resided in a metropolitan area, 10% in an urban area, and 23% in a rural area. After confounder adjustment, rural residents were less likely to have a statin dispensed (adjusted odds ratio [aOR] 0.83, 95% confidence interval [CI] 0.79 to 0.87) or undergo cholesterol testing (aOR 0.86, 95% CI 0.83 to 0.90) when compared with metropolitan residents. In contrast, rural residents were more likely to receive A1C and kidney function testing (aOR 1.14, 95% CI 1.08 to 1.21 and aOR 1.17, 95% CI 1.11 to 1.24, respectively). ACEi/ARB use and eye examinations were similar across place of residence. CONCLUSIONS: Processes of care varied by place of residence. Limited cholesterol management in rural areas is concerning because this may lead to increased cardiovascular outcomes.

Rurality is associated with lower likelihood of dipeptidyl peptidase 4 inhibitor use for treatment intensification.

Background: Antihyperglycemic drug utilization studies are conducted frequently and describe the uptake of new drug therapies across may jurisdictions. An increasingly important, yet often absent, aspect of these studies is the impact of rurality on drug utilization. Objectives: The objective of this study was to explore the association between place of residence (rural, urban, metropolitan) and the use of dipeptidyl peptidase 4 inhibitors (DPP-4i) for first treatment intensification of type 2 diabetes. Methods: A retrospective cohort study was conducted from April 1, 2008 to March 31, 2019 of new metformin users. A multivariable logistic regression analysis was performed to determine the association between place of residence (using postal codes) and likelihood of DPP-4i dispensing. Results: After adjusting for confounders, analysis revealed that rural-dwellers are less likely to have a DPP-4i dispensed, compared with metropolitan-dwellers (aOR:0.64; 95%CI:0.61-0.67) and over-time, the uptake in rural areas was slower. Conclusions: This study demonstrates that rurality can have an impact on drug therapy decisions at first treatment intensification, with respect to the utilization of new therapies.

Rural Residence Is Associated With a Delayed Trend Away From Sulfonylurea Use for Treatment Intensification of Type 2 Diabetes.

OBJECTIVE: To examine the intersection between location of residence along the rural-urban continuum (metropolitan, urban, and rural) and sulfonylurea dispensation records for the management of type 2 diabetes. RESEARCH DESIGN AND METHODS: This retrospective cohort study used administrative health records of adult new metformin users between April 2008 and March 2019 in Alberta, Canada. Multivariable logistic regression was performed to examine the association between sulfonylurea-based treatment intensification and location of residence. RESULTS: Treatment was intensified in 66,084 (38%) of 171,759 new metformin users after a mean of 1.5 years. At treatment intensification, mean age was 55 years, 62% of users were male, and 27% were rural residents. The most common antihyperglycemic drug, given to 30,297 people (46%) for treatment intensification, was a sulfonylurea. At the beginning of our observation period, the proportion of people dispensed a sulfonylurea at first treatment intensification was highest in rural (57%), compared with urban (54%) and metropolitan (52%) areas (P = 0.009). Although proportions decreased over time across the province, rural residents continued to constitute the highest proportion of sulfonylurea users (45%), compared with urban (35%) and metropolitan (37%) residents (P < 0.001), and the trend away from sulfonylurea use was delayed by ∼4 years for rural residents. Adjusting for potential sources of confounding, rural residence was associated with a significantly higher likelihood of using a sulfonylurea compared with metropolitan residence (adjusted odds ratio 1.34; 95% CI 1.29-1.39). CONCLUSIONS: Variation in sulfonylurea dispensation across the rural-urban continuum provides a basis for continued research in the differences in process of care by location.

Association between GFR, proteinuria, and adverse outcomes among White, Chinese, and South Asian individuals in Canada.

BACKGROUND: We investigated the association between proteinuria, estimated glomerular filtration rate (eGFR), and risk of mortality and kidney failure in white, Chinese, and South Asian populations. STUDY DESIGN: Population-based cohort study. SETTING & PARTICIPANTS: Participants from Alberta, Canada, with a serum creatinine and urine protein dipstick measurement from January 1, 2005, to December 31, 2005. PREDICTOR: White, Chinese, or South Asian ethnicity. OUTCOMES: Prevalence of proteinuria by level of eGFR (estimated using the MDRD [Modification of Diet in Renal Disease] Study equation) and the association between eGFR, proteinuria, and all-cause mortality and kidney failure. MEASUREMENTS: Rates of all-cause mortality and kidney failure per 1,000 person-years were calculated using Poisson regression by ethnicity, eGFR level, and proteinuria level while adjusting for sociodemographic variables and comorbid conditions. RESULTS: Of 491,729 participants, 5.3% were Chinese and 4.7% were South Asian. For participants with eGFR <60 mL/min/1.73 m(2), the prevalence of heavy proteinuria was higher in Chinese and South Asians compared with whites. Compared with whites, adjusted rates of death were significantly lower for Chinese and South Asian populations (rate ratios, 0.67 [95% CI, 0.56-0.80] and 0.73 [95% CI, 0.59-0.88], respectively); these rate ratios did not vary by eGFR and proteinuria levels. LIMITATIONS: Using surname to identify ethnicity has the potential for misclassification due to name changes and identical last names from different ethnic groups. Also, to be eligible for inclusion, participants had to have a measurement of serum creatinine and urine dipstick proteinuria. CONCLUSIONS: Although increasing proteinuria and lower eGFR predicted mortality and progression to kidney failure in all 3 ethnic groups, both Chinese and South Asian populations experienced a lower risk of death and similar risk of kidney failure compared with whites at all eGFR and proteinuria levels. Studies exploring this association further are required.

Substantial changes in prescription recommendations for bipolar disorder in Canada: 2002-2010.

OBJECTIVES: We examined trends in prescription recommendations for treatment of bipolar disorder (BD) in Canada during 2002-2010. METHODS: Data collected by IMS Brogan in a database known as the Canadian Disease and Therapeutic Index were used for this analysis. These data are collected from a representative physician panel who record each drug recommendation and reason for recommendation in their practices for 2 consecutive days each calendar quarter of the year. Prescription patterns of medications for BD, including lithium, anticonvulsants, antipsychotic agents, anxiolytics, and antidepressants, were evaluated both for general practitioners and for specialists. RESULTS: The number of prescription recommendations for BD increased by 72.1% from 2002 to 2009, and then dropped by 24.8% from 2009 to 2010. This increase from 2002 to 2009, and subsequent decrease from 2009 to 2010, was observed for all classes of medications. The overall increase from 2002 to 2010 was statistically significant for the atypical antipsychotics (P = 0.04). The largest change for an individual drug during this period was a 438% increase in recommendations for quetiapine (P = 0.01). CONCLUSIONS: The number of prescription recommendations for BD increased substantially from 2002 to 2009 and sharply dropped in the following year. These results suggest that the influence of the concept of the bipolar spectrum and its promotion may have resulted in a substantial increase in treatment that has recently begun to wane.

Laboratory testing and antihypertensive medication adherence following initial treatment of incident, uncomplicated hypertension: A real-world data analysis.

In this study on medication adherence among newly diagnosed patients with uncomplicated, incident hypertension, we conducted a retrospective cohort study using available administrative and laboratory data from April 1, 2012 to March 31, 2017 in Alberta, Canada to understand the extent to which baseline laboratory assessment and/or subsequent follow-up was associated with persistence with antihypertensive therapy. We determined the frequency of baseline and follow-up testing and compared the rates of medication persistence by patient-, neighbourhood-, and treatment-related factors. Of 103 232 patients with newly diagnosed, uncomplicated hypertension who filled their first prescription within our study timeframe, 52.5% were non-persistent within 6 months. Persistent patients were more often female and residing in neighbourhoods with higher social status (with exception to rurality). Aside from older age, the strongest predictor of persistence was performance of laboratory testing related to hypertension with an apparent effect in which higher levels of medication persistence were seen with more frequent laboratory testing. We concluded that medication persistence was far from optimal, dropping off considerably after 6 months for more than half of patients. Medication persistence is a substantial barrier to realizing the full societal benefits of antihypertensive treatment. Ongoing follow up with patients, including laboratory testing, may be a critical component of better long term treatment persistence.

Health State Utility Values in People With Stroke: A Systematic Review and Meta-Analysis.

Background Health state utility values are commonly used to provide summary measures of health-related quality of life in studies of stroke. Contemporaneous summaries are needed as a benchmark to contextualize future observational studies and inform the effectiveness of interventions aimed at improving post-stroke quality of life. Methods and Results We conducted a systematic search of the literature using Medline, EMBASE, and Web of Science from January 1995 until October 2020 using search terms for stroke, health-related quality of life, and indirect health utility metrics. We calculated pooled estimates of health utility values for EQ-5D-3L, EQ-5D-5L, AQoL, HUI2, HUI3, 15D, and SF-6D using random effects models. For the EQ-5D-3L we conducted stratified meta-analyses and meta-regression by key subgroups. We screened 14 251 abstracts and 111 studies met our inclusion criteria (sample size range 11 to 12 447). EQ-5D-3L was reported in 78% of studies (study n=87; patient n=56 976). The pooled estimate for EQ-5D-3L at ≥3 months following stroke was 0.65 (95% CI, 0.63-0.67), which was ≈20% below population norms. There was high heterogeneity (I2>90%) between studies, and estimates differed by study size, case definition of stroke, and country of study. Women, older individuals, those with hemorrhagic stroke, and patients prior to discharge had lower pooled EQ-5D-3L estimates. Conclusions Pooled estimates of health utility for stroke survivors were substantially below population averages. We provide reference values for health utility in stroke to support future clinical and economic studies and identify subgroups with lower healthy utility. Registration URL: https://www.crd.york.ac.uk/prospero/. Unique Identifier: CRD42020215942.

Antimicrobial stewardship in rural nursing homes: Impact of interprofessional education and clinical decision tool implementation on urinary tract infection treatment in a cluster randomized trial.

OBJECTIVES: To measure the impact of an antimicrobial stewardship initiative on the rate of urine culture testing and antimicrobial prescribing for urinary tract infections (UTIs) between control and intervention sites. Secondary objectives included evaluation of potential harms of the intervention and identifying characteristics of the population prescribed antimicrobials for UTI. DESIGN: Cluster randomized controlled trial. SETTING: Nursing homes in rural Alberta, Canada. PARTICIPANTS: The study included 42 nursing homes ranging from 8 to 112 beds.Methods/interventions:Intervention sites received on-site staff education, physician academic detailing, and integrated clinical decision-making tools. Control sites provided standard care. Data were collected for 6 months prior to and 12 months after the intervention. RESULTS: Resident age (83.0 vs 83.8 years) and sex distribution (female, 62.5% vs 64.5%) were similar between the groups. Statistically significant decreases in the rate of urine culture testing (-2.1 tests per 1,000 resident days [RD]; 95% confidence interval [CI], -2.5 to -1.7; P < .001) and antimicrobial prescribing for UTIs (-0.7 prescriptions per 1,000 RD; 95% CI, -1.0 to -0.4; P < .001) were observed in the intervention group. There was no difference in hospital admissions (0.00 admissions per 1,000 RD; 95% CI, -0.4 to 0.3; P = .76), and the mortality rate decreased by 0.2 per 1,000 RD in the intervention group (95% CI, -0.5 to -0.1; P = .002). Chart reviews indicated that UTI symptoms were charted in 16% of cases and that urine culture testing occurred in 64.5% of cases. CONCLUSION: A multimodal antimicrobial stewardship intervention in rural nursing homes significantly decreased the rate of urine culture testing and antimicrobial prescriptions for UTI, with no increase in hospital admissions or mortality.

Frequency of and Risk Factors for Acute Kidney Injury Associated With Vancomycin Use in the Pediatric Intensive Care Unit.

BACKGROUND: Published information evaluating frequency of and risk factors for vancomycin-induced acute kidney injury (AKI) in the pediatric intensive care unit (PICU) population is conflicting. OBJECTIVES: The primary objective was to describe the proportion of our PICU patients who developed AKI with intravenous (IV) vancomycin. The secondary objective was to describe the associated potential risk factors. METHODS: Pediatric patients (0-18 years) who received their first IV vancomycin dose in the PICU were evaluated in this retrospective chart review. AKI was defined based on Pediatric-Modified RIFLE (pRIFLE) criteria. Patient demographics, vancomycin trough concentrations, concomitant nephrotoxins, and estimated creatinine clearance changes were analyzed. RESULTS: Of 265 patients included, the primary outcome of AKI (defined by meeting any pRIFLE criteria) occurred in 62 (23.4%) patients (48 category R, 11 category I, 3 category F). Patients who received vancomycin treatment for = 5 days were more likely to develop AKI (unadjusted odds ratio [uOR]: 2.52; 95% confidence interval [CI]: 1.11-5.73), as were patients with a maximum vancomycin trough level = 20 mg/L (OR: 2.99; 95% CI: 1.54-5.78) and patients on 1 (uOR: 2.29; 95% CI: 1.12-4.66) or more concurrent nephrotoxin (uOR: 3.11; 95% CI: 1.43-6.77). Among nephrotoxins, patients receiving furosemide concomitantly with vancomycin were more likely to develop AKI (uOR: 3.47; 95% CI: 1.92-6.27). After adjustment, only furosemide was a significant predictor of risk of AKI/AKI (adjusted OR: 3.52; 95% CI: 1.88-6.62). The study was limited by its retrospective and observational design, and confounding variables. CONCLUSIONS: Patients who were receiving vancomycin with concurrent furosemide were at highest risk of developing AKI.

Assessment of antimicrobial utilization metrics: days of therapy versus defined daily doses and pharmacy dispensing records versus nursing administration data.

OBJECTIVE: To compare antimicrobial utilization data derived from pharmacy dispensing records and nursing administration record data by 2 commonly used units of measure. DESIGN, PARTICIPANTS, AND METHODS: Data from nursing administration records and pharmacy dispensing records were obtained for 32 medical wards. From nursing and pharmacy data, defined daily doses (DDD) were calculated, and from the nursing data, days of therapy were derived. Direct comparison of total antimicrobial use was performed by graphical analysis and linear regression. Slope of trend line was used to quantify the difference between pairs of measures. Bland-Altman plots were constructed to determine constant and proportional bias. At the level of individual agents, difference between pairs of measures was calculated and presented graphically and the average (95% CI) for the difference between measures was determined. RESULTS: Nursing administration record-derived DDD were on average 23% lower than corresponding rates of pharmacy dispensing record-derived DDD. The difference between rates of utilization by days of therapy vs DDD from the same source (nursing) was relatively small. Results from analysis of different individual agents were highly variable with wide 95% CIs. CONCLUSIONS: In our setting, we found clinically relevant differences in antimicrobial utilization associated with data from different sources. This outweighed the importance of the metric (DDD or days of therapy). However, measurement of use of individual agents was highly variable and sensitive to both metric unit and data sources.

Use of an electronic medication administration record (eMAR) for surveillance of medication omissions: results of a one year study of antimicrobials in the inpatient setting.

INTRODUCTION: Medication administration omissions (MAO) are usually considered medication errors but not all MAO are clinically relevant. We determined the frequency of clinically relevant MAO of antimicrobial drugs in adult hospitals in Calgary, Alberta, Canada based on electronic medication administration record (eMAR). METHODS: We examined 2011 data from eMAR records on medical wards and developed a reproducible assessment scheme to categorize and determine clinical relevance of MAO. We applied this scheme to records from 2012 in a retrospective cohort study to quantify clinically relevant MAO. Significant predictors of clinically relevant MAO were identified. RESULTS: A total of 294,718 dose records were assessed of which 10,282 (3.49%) were for doses not administered. Among these 4903 (1.66% of total); 47.68% of MAO were considered clinically relevant. Significant positive predictors of clinically relevant MAO included inhaled (OR 4.90, 95% CI 3.54-6.94) and liquid oral (OR 1.32, 95% CI 1.18-1.47) route of medication compared to solid oral and irregular dose schedules. Evening nursing shift compared to night shift (OR 0.77 95% CI 0.70-0.85) and parenteral (OR 0.50, 95% CI 0.46-0.54) were negative predictors, The commonest reasons for relevant MAO were patient preference, unspecified reason, administration access issues, drug not available or patient condition. CONCLUSION: Assessment of MAO by review of computer records provides a greater scope and sample size than directly observed medication administration assessments without "observer" effect. We found that MAO of antimicrobials in inpatients were uncommon but were seen more frequently with orally administered antimicrobials which may have significance to antimicrobial stewardship initiatives.

Serotonin-Norepinephrine Reuptake Inhibitors and the Risk of AKI: A Cohort Study of Eight Administrative Databases and Meta-Analysis.

BACKGROUND AND OBJECTIVES: A safety signal regarding cases of AKI after exposure to serotonin-norepinephrine reuptake inhibitors (SNRIs) was identified by Health Canada. Therefore, this study assessed whether the use of SNRIs increases the risk of AKI compared with selective serotonin reuptake inhibitors (SSRIs) and examined the risk associated with each individual SNRI. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Multiple retrospective population-based cohort studies were conducted within eight administrative databases from Canada, the United States, and the United Kingdom between January 1997 and March 2010. Within each cohort, a nested case-control analysis was performed to estimate incidence rate ratios (RRs) of AKI associated with SNRIs compared with SSRIs using conditional logistic regression, with adjustment for high-dimensional propensity scores. The overall effect across sites was estimated using meta-analytic methods. RESULTS: There were 38,974 cases of AKI matched to 384,034 controls. Current use of SNRIs was not associated with a higher risk of AKI compared with SSRIs (fixed-effect RR, 0.97; 95% confidence interval [95% CI], 0.94 to 1.01). Current use of venlafaxine and desvenlafaxine considered together was not associated with a higher risk of AKI (RR, 0.96; 95% CI, 0.92 to 1.00). For current use of duloxetine, there was significant heterogeneity among site-specific estimates such that a random-effects meta-analysis was performed showing a 16% higher risk, although this risk was not statistically significant (RR, 1.16; 95% CI, 0.96 to 1.40). This result is compatible with residual confounding, because there was a substantial imbalance in the prevalence of diabetes between users of duloxetine and users of others SNRIs or SSRIs. After further adjustment by including diabetes as a covariate in the model along with propensity scores, the fixed-effect RR was 1.02 (95% CI, 0.95 to 1.10). CONCLUSIONS: There is no evidence that use of SNRIs is associated with a higher risk of hospitalization for AKI compared with SSRIs.

Assessment of serum creatinine and kidney function among incident metformin users.

OBJECTIVE: Metformin is considered the first-line antihyperglycemic therapy for type 2 diabetes, but should be used with caution in people with renal insufficiency. Our study objective was to describe the proportion of patients who have an assessment of kidney function (serum creatinine [SCr] and estimated glomerular filtration rate [eGFR]) around the time of initiation of metformin in new users. METHODS: We used data from the Alberta Kidney Disease Network to identify patients with diabetes (age, ≥66 y) with a new prescription for metformin from November 1, 2002, to March 31, 2008. We assessed whether SCr measurement was completed before and after metformin initiation. The eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and categorized into CKD stages. Frequency of metformin use based on SCr measurement and CKD stage was reported using descriptive statistics. RESULTS: A total of 22 051 subjects were identified as new metformin users. Overall, 25.4% (n=5608) had no measurement of SCr or assessment of eGFR before metformin prescription. In addition, of patients with an eGFR measurement, 38.7% (n=8544) of individuals had an eGFR of less than 60 mL/min/1.73 m(2). CONCLUSIONS: One quarter of patients started on metformin did not have a SCr measurement completed beforehand. Also, metformin was used commonly among patients with diabetes and CKD, potentially putting these individuals at risk for adverse events.

Utilization of general and specialized cardiac care by people with schizophrenia.

OBJECTIVE: Whether access to primary and specialist care has an impact on treatment for people with schizophrenia and comorbid cardiac disease is unclear. The objective of this study was to compare use of general health care and specialized cardiac care by people with schizophrenia and by the rest of the population. METHODS: A population-based period-prevalence study was conducted and included adults (N=2,310,391) in Alberta, Canada, by using administrative databases. People with schizophrenia were identified based on billing codes; all others served as the comparator cohort. Multivariable logistic regression analyses were conducted to compare claims for general (general practitioner visits) health care, urgent and emergent (emergency department visits and hospitalizations) health services, and specialized cardiac (cardiologist visits, revascularization) care. RESULTS: Individuals with schizophrenia (N=28,755) had a higher prevalence of coronary artery disease than those without schizophrenia (N=2,281,636) (20% versus 14%) and were more likely than those without schizophrenia to visit a general practitioner more than four times per year (76% versus 47%; adjusted odds ratio [AOR]=3.60, 95% confidence interval [CI]=3.49-3.71). In contrast, individuals with schizophrenia and coronary artery disease were less likely to visit a cardiologist (50% versus 59%; AOR=. 76, 95% CI=.72-.80) or undergo coronary revascularization (6% versus 12%; AOR=. 55, 95% CI=.49-.61). CONCLUSIONS: In this large population-based study, individuals with schizophrenia were less likely to visit cardiologists or undergo revascularization than were people without schizophrenia. Opportunities exist for better assessment and management of cardiovascular disease and risk factors among people with schizophrenia.

Prevalence of cardiovascular risk factors and disease in people with schizophrenia: a population-based study.

OBJECTIVE: To evaluate the prevalence of cardiovascular risk factors (CV-RF) and disease (CV-D) in people with schizophrenia. METHOD: We conducted a period-prevalence study using a population-based cohort from Alberta administrative databases. Schizophrenia was identified using billing codes; all other individuals served as non-schizophrenic controls. Modifiable CV-RF (hypertension, dyslipidemia, diabetes) and established CV-D (acute coronary syndrome (ACS), chronic ischemic heart disease (IHD), heart failure (HF), stroke, arrhythmia) were identified using previously validated methods. Analyses were conducted using multivariable logistic regression. RESULTS: From 1995 to 2006, 28,755 people (1.2%) were identified with schizophrenia and compared with 2,281,636 non-schizophrenic controls. Individuals with schizophrenia were older (mean age 47.6 years vs. 45.3) and had lower socioeconomic status (59% received healthcare subsidies vs. 21%; OR: 5.55; 95% CI: 5.42-5.69) than controls. Of the CV-RF, diabetes was more common in those with schizophrenia than controls, particularly in younger males (ages 30-39, 3.8% vs. 1.4%, aOR: 1.57; 95% CI: 1.30-1.91) and females (ages 30-39, 5.8% vs. 2.4%, aOR: 1.72; 95% CI: 1.44-2.04). The prevalence of CV-D was significantly higher in people with schizophrenia than controls (27% vs. 17%, OR: 1.76; 95% CI: 1.72-1.81). CONCLUSIONS: On a population-wide basis, people with schizophrenia had a higher prevalence of diabetes and cardiovascular disease than those without schizophrenia, particularly at a younger age. Female sex offered no cardiovascular protection in those with schizophrenia. Our data suggest monitoring for diabetes and other cardiovascular risk factors should begin at the time of diagnosis of schizophrenia, particularly in females with schizophrenia.