Achieving a Healthy Oklahoma: Cross-Sector Cooperation to Improve Public Health Preparedness and Pandemic Response.

In response to the COVID-19 pandemic, the University of Oklahoma Hudson College of Public Health launched the Achieving a Healthy Oklahoma (AHO) initiative in 2021. The goals of AHO were to assess lessons learned in Oklahoma from COVID-19 and set the foundation for enhanced public-private community collaboration by developing recommendations to prepare for future public health crises and promote health across all major economic sectors. Over 700 stakeholders were engaged in surveys, interviews, workgroup meetings, community listening sessions, and steering committee meetings over 8 months to accomplish these goals. Stakeholders produced 60 sector- and stakeholder-specific policy recommendations to address the major issues uncovered during the initiative. The AHO team then distilled them into 5 recommendations: (1) invest in the future of Oklahoma's health workforce to include critically needed public health professions in Oklahoma's healthcare loan repayment programs; (2) establish contracts between higher education institutions in Oklahoma and state and local health departments to monitor health sector workforce needs and provide training; (3) strengthen the delivery of coordinated public health services within local communities during emergencies and daily operations by dedicating health department roles to coordinate public health projects and services; (4) improve preparedness by coordinating annual emergency management exercises across local and state health departments; and (5) emphasize the efficiency and effectiveness of cross-sector collaborative efforts between public, private, and tribal partners. The AHO initiative serves as an action guide for assessing and improving state-level public health emergency responses and strengthening public health infrastructure. Implementing the recommendations in Oklahoma and assessing and addressing similar needs across the nation are necessary to prepare the United States for future public health emergencies.

Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update.

The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Cancer-associated venous thromboembolism: Incidence and features in a racially diverse population.

BACKGROUND: Data on the population-based incidence of cancer-associated venous thromboembolism (VTE) from racially diverse populations are limited. OBJECTIVE: To evaluate the incidence and burden of cancer-associated VTE, including demographic and racial subgroups in the general population of Oklahoma County-which closely mirrors the United States. DESIGN: A population-based prospective study. SETTING: We conducted surveillance of VTE at tertiary care facilities and outpatient clinics in Oklahoma County, Oklahoma, from 2012-2014. Surveillance included reviewing all imaging reports used to diagnose VTE and identifying VTE events from hospital discharge data and death certificates. Cancer status was determined by linkage to the Oklahoma Central Cancer Registry. MEASUREMENTS: We used Poisson regression to calculate crude and age-adjusted incidence rates of cancer-associated VTE per 100 000 general population per year, with 95% confidence intervals (95% CI). RESULTS: The age-adjusted incidence (95% CI) of cancer-associated VTE among adults age ≥ 18 was 70.0 (65.1-75.3). The age-adjusted incidence rates (95% CI) were 85.9 (72.7-101.6) for non-Hispanic Blacks, 79.5 (13.2-86.5) for non-Hispanic Whites, 18.8 (8.9-39.4) for Native Americans, 15.6 (7.0-34.8) for Asian/Pacific Islanders, and 15.2 (9.2-25.1) for Hispanics. Recurrent VTE up to 2 years after the initial diagnosis occurred in 38 of 304 patients (12.5%) with active cancer and in 34 of 424 patients (8.0%) with a history of cancer > 6 months previously. CONCLUSION: Age-adjusted incidence rates of cancer-associated VTE vary substantially by race and ethnicity. The relatively high incidence rates of first VTE and of recurrence warrant further assessment of strategies to prevent VTE among cancer patients.

Incidence of Venous Thromboembolism in a Racially Diverse Population of Oklahoma County, Oklahoma.

BACKGROUND: Contemporary incidence data for venous thromboembolism (VTE) from racially diverse populations are limited. The racial distribution of Oklahoma County closely mirrors that of the United States. OBJECTIVE: To evaluate VTE incidence and mortality, including demographic and racial subgroups. DESIGN: Population-based prospective study. SETTING: We conducted VTE surveillance at all relevant tertiary care facilities and outpatient clinics in Oklahoma County, Oklahoma during 2012 to 2014, using both active and passive methods. Active surveillance involved reviewing all imaging reports used to diagnose VTE. Passive surveillance entailed identifying VTE events from hospital discharge data and death certificate records. MEASUREMENTS: We used Poisson regression to calculate crude, age-stratified, and age-adjusted incidence and mortality rates per 1,000 population per year and 95% confidence intervals (CIs). RESULTS: The incidence rate of all VTE was 3.02 (2.92-3.12) for those age ≥18 years and 0.05 (0.04-0.08) for those <18 years. The age-adjusted incidence rates of all VTE, deep vein thrombosis, and pulmonary embolism were 2.47 (95% CI: 2.39-2.55), 1.47 (1.41-1.54), and 0.99 (0.93-1.04), respectively. The age-adjusted VTE incidence and the 30-day mortality rates, respectively, were 0.63 and 0.121 for Asians/Pacific Islanders, 3.25 and 0.355 for blacks, 0.67 and 0.111 for Hispanics, 1.25 and 0.195 for Native Americans, and 2.71 and 0.396 for whites. CONCLUSION: The age-adjusted VTE incidence and mortality rates vary substantially by race. The incidence of three per 1,000 adults per year indicates an important disease burden, and is informative of the burden in the U.S.

How Do You Measure Up: Quality Measurement for Improving Patient Care and Establishing the Value of Infectious Diseases Specialists.

The shift from volume-based to value-based reimbursement has created a need for quantifying clinical performance of infectious diseases (ID) physicians. Nationally recognized ID specialty-specific quality measures will allow stakeholders, such as patients and payers, to determine the value of care provided by ID physicians and will promote clinical quality improvement. Few ID-specific measures have been developed; herein, we provide an overview of the importance of quality measurement for ID, discuss issues in quality measurement specific to ID, and describe standards by which candidate quality measures can be evaluated. If ID specialists recognize the need for quality measurement, then ID specialists can direct ID-related quality improvement, quantify the impact of ID physicians on patient outcomes, compare their performance to that of peers, and convey to stakeholders the value of the specialty.

Antibiotic prophylaxis for surgical site infections as a risk factor for infection with Clostridium difficile.

OBJECTIVE: We aimed to measure the association between 2013 guideline concordant prophylactic antibiotic use prior to surgery and infection with Clostridium difficile. DESIGN: We conducted a retrospective case-control study by selecting patients who underwent a surgical procedure between January 1, 2012 and December 31, 2013. SETTING: Large urban community hospital. PATIENTS: Cases and controls were patients age 18+ years who underwent an eligible surgery (i.e., colorectal, neurosurgery, vascular/cardiac/thoracic, hysterectomy, abdominal/pelvic and orthopedic surgical procedures) within six months prior to infection diagnosis. Cases were diagnosed with C. difficile infection while controls were not. METHODS: The primary exposure was receiving (vs. not receiving) the recommended prophylactic antibiotic regimen, based on type and duration. Potential confounders included age, sex, length of hospital stay, comorbidities, type of surgery, and prior antibiotic use. Crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated using logistic regression. RESULTS: We enrolled 68 cases and 220 controls. The adjusted OR among surgical patients between developing C. difficile infection and not receiving the recommended prophylactic antibiotic regimen (usually receiving antimicrobial prophylaxis for more than 24 hours) was 6.7 (95% CI: 2.9-15.5). Independent risk factors for developing C. difficile infection included having severe comorbidities, receiving antibiotics within the previous 6 months, and undergoing orthopedic surgery. CONCLUSIONS: Adherence to the recommended prophylactic antibiotics among surgical patients likely reduces the probability of being case of C. difficile. Antibiotic stewardship should be a priority in strategies to decrease the morbidity, mortality, and costs associated with C. difficile infection.

Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017.

IMPORTANCE: The human and financial costs of treating surgical site infections (SSIs) are increasing. The number of surgical procedures performed in the United States continues to rise, and surgical patients are initially seen with increasingly complex comorbidities. It is estimated that approximately half of SSIs are deemed preventable using evidence-based strategies. OBJECTIVE: To provide new and updated evidence-based recommendations for the prevention of SSI. EVIDENCE REVIEW: A targeted systematic review of the literature was conducted in MEDLINE, EMBASE, CINAHL, and the Cochrane Library from 1998 through April 2014. A modified Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to assess the quality of evidence and the strength of the resulting recommendation and to provide explicit links between them. Of 5759 titles and abstracts screened, 896 underwent full-text review by 2 independent reviewers. After exclusions, 170 studies were extracted into evidence tables, appraised, and synthesized. FINDINGS: Before surgery, patients should shower or bathe (full body) with soap (antimicrobial or nonantimicrobial) or an antiseptic agent on at least the night before the operative day. Antimicrobial prophylaxis should be administered only when indicated based on published clinical practice guidelines and timed such that a bactericidal concentration of the agents is established in the serum and tissues when the incision is made. In cesarean section procedures, antimicrobial prophylaxis should be administered before skin incision. Skin preparation in the operating room should be performed using an alcohol-based agent unless contraindicated. For clean and clean-contaminated procedures, additional prophylactic antimicrobial agent doses should not be administered after the surgical incision is closed in the operating room, even in the presence of a drain. Topical antimicrobial agents should not be applied to the surgical incision. During surgery, glycemic control should be implemented using blood glucose target levels less than 200 mg/dL, and normothermia should be maintained in all patients. Increased fraction of inspired oxygen should be administered during surgery and after extubation in the immediate postoperative period for patients with normal pulmonary function undergoing general anesthesia with endotracheal intubation. Transfusion of blood products should not be withheld from surgical patients as a means to prevent SSI. CONCLUSIONS AND RELEVANCE: This guideline is intended to provide new and updated evidence-based recommendations for the prevention of SSI and should be incorporated into comprehensive surgical quality improvement programs to improve patient safety.

Working together: Using a unique approach to evaluate an interactive and clinic-based longitudinal interprofessional education experience with 13 professions.

Interprofessional education (IPE) involving an interactive and longitudinal clinic experience at an inner-city charitable clinic from September to May 2013/2014 was evaluated. Pre-, mid-, and post-intervention data were collected from students in 13 different professions including medicine (medical and physician assistant), dentistry (dental and dental hygiene), nursing (undergraduate and clinical nurse specialist), public health, pharmacy, physical therapy, occupational therapy, nutritional sciences, speech and language pathology, and social work. To evaluate their interprofessional attitudes, students completed the TeamSTEPPS Teamwork Attitudes Questionnaire (T-TAQ) and Readiness for Interprofessional Learning Scale (RIPLS). They also completed a unique measure, healthcare professionals circles diagrams (HPCDs), that indicated student conceptualisation of a healthcare team caring for a complex patient, along with perception of their team's progress towards meeting patient goals. Results from the T-TAQ and RIPLS scores indicated small but significant increases from pre- to post-intervention (p = 0.005 and 0.012, respectively). Analysis of the HPCDs revealed significant increases in students' perceptions of the types of interprofessional team members, relationships, and communication between professions to provide medical care to patients (p < 0.01). Most HPCDs included pharmacists, nurses, and physicians as part of the care team at all time points. Students significantly increased their inclusion of dentistry, public health, social work, and physician assistants as members of the healthcare team from pre- to post-intervention. Implications of our data indicated the importance of IPE interventions that include not only classroom-based sessions, but actual patient care experiences within interprofessional teams. It also reinforced the importance of new and unique methods to assess IPE.

Improvements in the distribution of hospital performance for the care of patients with acute myocardial infarction, heart failure, and pneumonia, 2006-2011.

BACKGROUND: Medicare hospital core process measures have improved over time, but little is known about how the distribution of performance across hospitals has changed, particularly among the lowest performing hospitals. METHODS: We studied all US hospitals reporting performance measure data on process measures for acute myocardial infarction (AMI), heart failure (HF), and pneumonia (PN) to the Centers for Medicare & Medicaid Services from 2006 to 2011. We assessed changes in performance across hospital ranks, variability in the distribution of performance rates, and linear trends in the 10th percentile (lowest) of performance over time for both individual measures and a created composite measure for each condition. RESULTS: More than 4000 hospitals submitted measure data each year. There were marked improvements in hospital performance measures (median performance for composite measures: AMI: 96%-99%, HF: 85%-98%, PN: 83%-97%). A greater number of hospitals reached the 100% performance level over time for all individual and composite measures. For the composite measures, the 10th percentile significantly improved (AMI: 90%-98%, P<0.0001 for trend; HF: 70%-92%, P=0.0002; PN: 71%-92%, P=0.0003); the variation (90th percentile rate minus 10th percentile rate) decreased from 9% in 2006 to 2% in 2011 for AMI, 25%-8% for HF, and 20%-7% for PN. CONCLUSIONS: From 2006 to 2011, not only did the median performance improve but the distribution of performance narrowed. Focus needs to shift away from processes measures to new measures of quality.

Quality and equity of care in U.S. hospitals.

BACKGROUND: Nearly every U.S. hospital publicly reports its performance on quality measures for patients who are hospitalized for acute myocardial infarction, heart failure, or pneumonia. Because performance rates are not reported according to race or ethnic group, it is unclear whether improvements in equity of care have accompanied aggregate improvements in health care quality over time. METHODS: We assessed performance rates for quality measures covering three conditions (six measures for acute myocardial infarction, four for heart failure, and seven for pneumonia). These rates, adjusted for patient- and hospital-level covariates, were compared among non-Hispanic white, non-Hispanic black, and Hispanic patients who received care between 2005 and 2010 in acute care hospitals throughout the United States. RESULTS: Adjusted performance rates for the 17 quality measures improved by 3.4 to 57.6 percentage points between 2005 and 2010 for white, black, and Hispanic adults (P<0.001 for all comparisons). In 2005, as compared with adjusted performance rates for white patients, adjusted performance rates were more than 5 percentage points lower for black patients on 3 measures (range of differences, 12.3 to 14.2) and for Hispanic patients on 6 measures (5.6 to 14.5). Gaps decreased significantly on all 9 of these measures between 2005 and 2010, with adjusted changes for differences between white patients and black patients ranging from -8.5 to -11.8 percentage points and from -6.2 to -15.1 percentage points for differences between white patients and Hispanic patients. Decreasing differences according to race or ethnic group were attributable to more equitable care for white patients and minority patients treated in the same hospital, as well as to greater performance improvements among hospitals that disproportionately serve minority patients. CONCLUSIONS: Improved performance on quality measures for white, black, and Hispanic adults hospitalized for acute myocardial infarction, heart failure, or pneumonia was accompanied by increased racial and ethnic equity in performance rates both within and among U.S. hospitals. (Funded by the Centers for Medicare and Medicaid Services and the Veterans Affairs Health Services Research and Development Career Development Program.).

Quality of care for elderly patients hospitalized for pneumonia in the United States, 2006 to 2010.

IMPORTANCE: Nearly every US acute care hospital reports publicly on adherence to recommended processes of care for patients hospitalized with pneumonia. However, it remains uncertain how much performance of these process measures has improved over time or whether performance is associated with superior patient outcomes. OBJECTIVES: To describe trends in processes of care, mortality, and readmission for elderly patients hospitalized for pneumonia and to assess the independent associations between processes and outcomes of care. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study conducted from January 1, 2006, to December 31, 2010, at 4740 US acute care hospitals. The cohort included 1 818 979 cases of pneumonia in elderly (≥65 years), Medicare fee-for-service patients who were eligible for at least 1 of 7 pneumonia inpatient processes of care tracked by the Centers for Medicare & Medicaid Services (CMS). MAIN OUTCOMES AND MEASURES: Annual performance rates for 7 pneumonia processes of care and an all-or-none composite of these measures; and 30-day, all-cause mortality and hospital readmission, adjusted for patient and hospital characteristics. RESULTS: Adjusted annual performance rates for all 7 CMS processes of care (expressed in percentage points per year) increased significantly from 2006 to 2010, ranging from 1.02 for antibiotic initiation within 6 hours to 5.30 for influenza vaccination (P < .001). All 7 measures were performed in more than 92% of eligible cases in 2010. The all-or-none composite demonstrated the largest adjusted relative increase over time (6.87 percentage points per year; P < .001) and was achieved in 87.4% of cases in 2010. Adjusted annual mortality decreased by 0.09 percentage points per year (P < .001), driven primarily by decreasing mortality in the subgroup not treated in the intensive care unit (ICU) (-0.18 percentage points per year; P < .001). Adjusted annual readmission rates decreased significantly by 0.25 percentage points per year (P < .001). All 7 processes of care were independently associated with reduced 30-day mortality, and 5 were associated with reduced 30-day readmission. CONCLUSIONS AND RELEVANCE: Performance of processes of care for elderly patients hospitalized for pneumonia improved substantially from 2006 to 2010. Adjusted 30-day mortality declined slightly over time primarily owing to improved survival among non-ICU patients, and all individual processes of care were independently associated with reduced mortality.

Medicare claims can be used to identify US hospitals with higher rates of surgical site infection following vascular surgery.

BACKGROUND: Surgical site infections (SSIs) following vascular surgery have high morbidity and costs, and are increasingly tracked as hospital quality measures. OBJECTIVE: To assess the ability of Medicare claims to identify US hospitals with high SSI rates after vascular surgery. RESEARCH DESIGN: Using claims from fee-for-service Medicare enrollees of age 65 years and older who underwent vascular surgery from 2005 to 2008, we derived hospital rankings using previously validated codes suggestive of SSI, with individual-level adjustment for age, sex, and comorbidities. We then obtained medical records for validation of SSI from hospitals ranked in the best and worst deciles of performance, and used logistic regression to calculate the risk-adjusted odds of developing an SSI in worst-decile versus best-decile hospitals. RESULTS: Among 203,023 Medicare patients who underwent vascular surgery at 2512 US hospitals, a patient undergoing surgery in a hospital ranked in the worst-performing decile based on claims had 2.5 times higher odds of developing a chart-confirmed SSI relative to a patient with the same age, sex, and comorbidities in a hospital ranked in the best-performing decile (95% confidence interval, 2.0-3.1). SSI confirmation among patients with claims suggesting infection was similar across deciles, and we found similar findings in analyses limited to deep and organ/space SSIs. We report on diagnosis codes with high sensitivity for identifying deep and organ/space SSI, with one-to-one mapping to ICD-10-CM codes. CONCLUSIONS: Claims-based surveillance offers a standardized and objective methodology that can be used to improve SSI surveillance and to validate hospitals' publicly reported data.

Activity of commonly used antimicrobial prophylaxis regimens against pathogens causing coronary artery bypass graft and arthroplasty surgical site infections in the United States, 2006-2009.

BACKGROUND: Coronary artery bypass graft (CABG) and primary arthroplasty surgical site infection (SSI) rates are declining slower than other healthcare-associated infection rates. We examined antimicrobial prophylaxis (AMP) regimens used for these operations and compared their spectrum of activity against reported SSI pathogens. METHODS: Pathogen distributions of CABG and hip/knee arthroplasty complex SSIs (deep and organ/space) reported to the National Healthcare Safety Network (NHSN) from 2006 through 2009 and AMP regimens (same procedures and time period) reported to the Surgical Care Improvement Project (SCIP) were analyzed. Regimens were categorized as standard (cefazolin or cefuroxime), ß-lactam allergy (vancomycin or clindamycin with or without an aminoglycoside), and extended spectrum (vancomycin and/or an aminoglycoside with cefazolin or cefuroxime). AMP activity of each regimen was predicted on the basis of pathogen susceptibility reports and published spectra of antimicrobial activity. RESULTS: There were 6,263 CABG and arthroplasty complex SSIs reported (680,489 procedures; 880 NHSN hospitals). Among 6,574 pathogens reported, methicillin-sensitive Staphylococcus aureus (23%), methicillin-resistant S. aureus (18%), coagulase-negative staphylococci (17%), and Enterococcus species (7%) were most common. AMP regimens for 2,435,703 CABG and arthroplasty procedures from 3,330 SCIP hospitals were analyzed. The proportion of pathogens predictably susceptible to standard (used in 75% of procedures), ß-lactam (12%), and extended-spectrum (8%) regimens was 41%-45%, 47%-96%, and 81%-96%, respectively. CONCLUSION: Standard AMP, used in three-quarters of CABG and primary arthroplasty procedures, has inadequate activity against more than half of SSI pathogens reported. Alternative strategies may be needed to prevent SSIs caused by pathogens resistant to standard AMP regimens.

Public reporting of health care-associated surveillance data: recommendations from the healthcare infection control practices advisory committee.

Health care-associated infection (HAI) rates are used as measures of a health care facility's quality of patient care. Recently, these outcomes have been used to publicly rank quality efforts and determine facility reimbursement. The value of comparing HAI rates among health care facilities is limited by many factors inherent to HAI surveillance, and incentives that reward low HAI rates can lead to unintended consequences that can compromise medical care surveillance efforts, such as the use of clinical adjudication panels to veto events that meet HAI surveillance definitions.The Healthcare Infection Control Practices Advisory Committee, a federal advisory committee that provides advice and guidance to the Centers for Disease Control and Prevention (CDC) and the Secretary of the Department of Health and Human Services about strategies for surveillance, prevention, and control of HAIs, assessed the challenges associated with using HAI surveillance data for external quality reporting, including the unintended consequences of clinician veto and clinical adjudication panels. Discussions with stakeholder liaisons and committee members were then used to formulate recommended standards for the use of HAI surveillance data for external facility assessment to ensure valid comparisons and to provide as level a playing field as possible.The final recommendations advocate for consistent, objective, and independent application of CDC HAI definitions with concomitant validation of HAIs and surveillance processes. The use of clinician veto and adjudication is discouraged.

Harnessing claims to improve detection of surgical site infections following hysterectomy and colorectal surgery.

Surgical site infection (SSI) surveillance is performed using a variety of methods with unclear performance characteristics. We used claims data to identify records for review following hysterectomy and colorectal surgery. Claims-enhanced screening identified SSIs missed by routine surveillance and could be used for targeted chart review to improve SSI detection.

Evaluating quality of care: the role of peer review.

Peer review for quality of care is often conducted to address issues such as professional staff conflict, hospital or clinic privileging, identified quality concerns or patient complaints, and group practice membership decisions. Inherent to the definition of peer review is independent and unbiased review of the quality of care by a person or persons in the same profession who are of the same or higher ranking or training. While many studies have outlined the limitations of the peer review process, the reliability of the process can be improved by providing more structured assessments to identify differences in patient management, adjusting systematic bias resulting from the individual reviewer and their professional background, summarizing assessments from multiple independent reviewers, and using structured implicit review based on evidence-based guidelines or performance metrics. Active participation in the process by practicing physicians and healthcare professionals is essential for the success of effective peer review.