Enhanced Detection of Community-Acquired Pneumonia Pathogens With the BioFire® Pneumonia FilmArray® Panel.

BACKGROUND: Although most observational studies identify viral or bacterial pathogens in 50% or less of patients hospitalized with community-acquired pneumonia (CAP), we previously demonstrated that a multi-test bundle (MTB) detected a potential pathogen in 73% of patients. This study compares detection rates for potential pathogens with the MTB versus the Biofire® Pneumonia FilmArray® panel (BPFA) multiplex PCR platform and presents an approach for integrating BPFA results as a foundation for subsequent antibiotic stewardship (AS) activities. METHODS: Between January 2017 to March 2018, all patients admitted for CAP were enrolled. Patients were considered evaluable if all elements of the MTB and the BPFA were completed, and they met other a priori inclusion criteria. The primary endpoint was the percentage of potential pathogens detected using the MTB (8 viral and 6 bacterial targets) versus the BPFA (8 viral and 18 bacterial targets). Blood and sputum cultures were performed on all patients. Two or more procalcitonin (PCT) levels assisted clinical assessments as to whether detected bacteria were invading or colonizing. RESULTS: Of 585 enrolled patients, 274 were evaluable. A potential viral pathogen was detected in 40.5% with MTB versus 60.9% of patients with BPFA with an odds ratio (95% CI) of 9.00 (4.12 to 23.30) p<0.01. A potential bacterial pathogen was identified in 66.4% with the MTB vs 75.5% with the BPFA odds ratio (95% CI) of 2.09 (1.24 to 3.59), p 0.003). Low PCT levels helped identify detected bacteria as colonizers.

Multidisciplinary COPD disease management program: impact on clinical outcomes.

OBJECTIVES: We hypothesized performance improvement interventions would improve COPD guideline-recommended care and decrease COPD exacerbations in primary care clinic practices. METHODS: We initiated a performance improvement project in 12 clinics to improve COPD outcomes incorporating physician education, case management, web-based decision support (CareManager(TM)), and performance feedback. We collected baseline and one-year follow up data on 242 patients who had COPD with acute exacerbations. We analyzed data by two methods. First, the 12 clinics were cluster randomized to 4 intervention (117 patients) and 8 control (125 patients) clinics which all had access to CareManager(TM) but only intervention clinic physicians received case management, academic detailing, and decision support assistance. Exacerbation rates and guideline adherence were compared. Second, data from all 12 clinics were pooled in a quasi-experimental design comparing baseline and post-implementation of CareManager(TM) to determine the value of system-wide performance improvement during the study period. RESULTS: In the randomized analysis, baseline demographics were similar. No differences (p = 0.79) occurred in exacerbation rates between intervention and control clinics although both groups had decreased numbers of exacerbations from baseline to follow up (p < 0.05). The pooled data from all 12 clinics demonstrated a reduction (p < 0.05) in mean exacerbations/patient from 2.3 (CI 2.0-2.6) during baseline to 1.4 (CI 1.1-1.7) at one-year follow up. Emergency department visits and hospitalizations/patient decreased (p = 0.003). Patients naïve at study start to depression screening, pneumococcal vaccination, inhaled control medications or smoking cessation had fewer (p < 0.05) exacerbations after these interventions. CONCLUSION: We observed no difference in exacerbation rates between clinics receiving case management, academic detailing, and ongoing assistance with decision support and controls. Implementation of a web-based disease management system (CareManager(TM)) along with health system-wide COPD performance improvement efforts was associated with fewer COPD exacerbations and increased adherence to guideline recommendations.

An official American Thoracic Society workshop report: assessment and palliative management of dyspnea crisis.

In 2009, the American Thoracic Society (ATS) funded an assembly project, Palliative Management of Dyspnea Crisis, to focus on identification, management, and optimal resource utilization for effective palliation of acute episodes of dyspnea. We conducted a comprehensive search of the medical literature and evaluated available evidence from systematic evidence-based reviews (SEBRs) using a modified AMSTAR approach and then summarized the palliative management knowledge base for participants to use in discourse at a 2009 ATS workshop. We used an informal consensus process to develop a working definition of this novel entity and established an Ad Hoc Committee on Palliative Management of Dyspnea Crisis to further develop an official ATS document on the topic. The Ad Hoc Committee members defined dyspnea crisis as "sustained and severe resting breathing discomfort that occurs in patients with advanced, often life-limiting illness and overwhelms the patient and caregivers' ability to achieve symptom relief." Dyspnea crisis can occur suddenly and is characteristically without a reversible etiology. The workshop participants focused on dyspnea crisis management for patients in whom the goals of care are focused on palliation and for whom endotracheal intubation and mechanical ventilation are not consistent with articulated preferences. However, approaches to dyspnea crisis may also be appropriate for patients electing life-sustaining treatment. The Ad Hoc Committee developed a Workshop Report concerning assessment of dyspnea crisis; ethical and professional considerations; efficient utilization, communication, and care coordination; clinical management of dyspnea crisis; development of patient education and provider aid products; and enhancing implementation with audit and quality improvement.

The story of oxygen.

The history of oxygen from discovery to clinical application for patients with chronic lung disease represents a long and storied journey. Within a relatively short period, early investigators not only discovered oxygen but also recognized its importance to life and its role in respiration. The application of oxygen to chronic lung disease, however, took several centuries. In the modern era, physiologists pursued the chemical nature of oxygen and its physiologic interaction with cellular metabolism and gas transport. It took brazen clinicians, however, to pursue oxygen as a therapeutic resource for patients with chronic lung disease because of the concern in the 20th century of the risks of oxygen toxicity. Application of ambulatory oxygen devices allowed landmark investigations of the long-term effects of continuous oxygen that established its safety and efficacy. Although now well established for hypoxic patients, many questions remain regarding the benefits of oxygen for varying severity and types of chronic lung disease.

A guide to guidelines for professional societies and other developers of recommendations: introduction to integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report.

Organizations around the world are recognizing that guidelines should be based on the best available evidence, that the development of recommendations needs to be transparent, and that appropriate processes should be followed. In June 2007, we convened an American Thoracic Society (ATS)/European Respiratory Society (ERS)-sponsored workshop with over 60 representatives from 36 international organizations to provide advice to guideline developers about the required steps and processes for guideline development using the management of chronic obstructive pulmonary disease (COPD) as an example. Following the workshop, participants completed a series of 14 review articles that underwent peer review and incorporated key new literature until June 2011 for most articles in this series. The review articles evaluate the guideline cycle including: priority setting, question formulation, managing conflict of interest, defining appropriate outcomes, stakeholder involvement, grading the quality of evidence and strength of recommendations, integration of values and preferences, considering resource use, reporting of guidelines, implementation, and adaptation. In this Introduction we frame the background and methods of these reviews and provide the key conclusions of the workshop. A summary of the workshop's conclusions and recommendations was published in The Lancet. Given the enormous resources that are spent on research and the importance of providing the best guidance to healthcare decision makers, attributing appropriate funds to research syntheses and transparent, independent guidance for the development of evidence-based guidelines is justified. Furthermore, given the immense amount of work that is required, individuals and organizations need to collaborate to achieve the best possible and cost-effective coordination of these efforts.

Moving from evidence to developing recommendations in guidelines: article 11 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report.

INTRODUCTION: Professional societies, like many other organizations around the world, have recognized the need to use more rigorous processes to ensure that healthcare recommendations are informed by the best available research evidence. This is the 11th of a series of 14 articles that methodologists and researchers from around the world prepared to advise guideline developers for respiratory and other diseases on how to achieve this goal. For this article, we developed five key questions and updated a review of the literature on moving from evidence to recommendations. METHODS: We addressed the following specific questions.What is the strength of a recommendation and what determines the strength? What are the implications of strong and weak recommendations for patients, clinicians, and policy makers? Should guideline panels make recommendations in the face of very low-quality evidence? Under which circumstances should guideline panels make research recommendations? How should recommendations be formulated and presented? We searched PubMed and other databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct systematic reviews ourselves. Our conclusions are based on available evidence, consideration of what guideline developers are doing, and pre- and postworkshop discussions. RESULTS AND DISCUSSION: The strength of a recommendation reflects the extent to which guideline developers can, across the range of patients for whom the recommendations are intended, be confident that the desirable effects of following the recommendation outweigh the undesirable effects. Four factors influence the strength of a recommendation: the quality of evidence supporting the recommendation, the balance between desirable and undesirable effects, the uncertainty or variability of patient values and preferences, and costs. Strong and weak (also called "conditional") recommendations have distinct implications for patients, clinicians, and policy makers. Adherence to strong recommendations or, in the case of weak (conditional) recommendations, documentation of discussion or shared decision making with a patient, might be used as quality measures or performance indicators. Clinicians desire guidance regardless of the quality of the underlying evidence. Very low-quality evidence should ideally result in either appropriately labeled recommendations (i.e., as based on very low-quality evidence) or a statement that the guideline panel did not reach consensus on the recommendation due to the lack of confidence in the effect estimates. However, guideline panels often have more resources, time, and information than practicing clinicians. Therefore, they may be in a position to use their best judgments to make recommendations even when there is very low-quality evidence, although some guideline developers disagree with this approach and prefer a general approach of not making recommendations in the face of very low-quality evidence. Guideline panels should consider making research recommendations when there is important uncertainty about the desirable and undesirable effects of an intervention, further research could reduce that uncertainty, and the potential benefits and savings of reducing the uncertainty outweigh the potential harms of not making the research recommendation. Recommendations for additional research should be as precise and specific as possible.

Disseminating and implementing guidelines: article 13 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report.

BACKGROUND: Professional societies, like many other organizations around the world, have recognized the need to use rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the thirteenth of a series of 14 articles that were prepared to advise guideline developers in respiratory and other diseases. This article focuses on current concepts and research evidence about how to disseminate and implement guidelines optimally on a national and international level to improve quality of care. METHODS: In this article we address the following questions: What frameworks can aid guideline dissemination and implementation; what are the effects of different guideline dissemination and implementation strategies; and, what is the role of guideline developers in guideline dissemination and implementation? We identified existing systematic reviews and relevant methodological research. Our conclusions are based on evidence from published literature, experience from guideline developers, and workshop discussions. RESULTS AND CONCLUSIONS: The Knowledge to Action cycle proposed by Graham and colleagues (J Contin Educ Health Prof 2006;26:13-24) provides a useful framework for planning dissemination and implementation activities that emphasize the need for tailored approaches based on an assessment of local barriers. There are a broad range of interventions that are generally effective at improving the uptake of evidence. The best intervention depends on likely barriers, available resources, and other practical considerations. Financial interventions (such as pay for performance) appear to be as effective as other interventions that aim to change professional behavior. Guideline developers who do not have responsibility for guideline implementation in their jurisdiction should support those with responsibility for implementation by considering the "implementability" of their guidelines.

Creating a web-based incident analysis and communication system.

BACKGROUND: Hospitals perform root cause analyses (RCA) and implement action plans for sentinel events (SE) to prevent similar adverse events. Dissemination of RCA action plans between hospitals has been limited by an absence of universal definitions of terms and classification frameworks, which have been recently proposed by the World Health Organization's International Classification for Patient Safety (ICPS). Tools do not exist, however, to assist hospitals in performing SE reviews aligned with the ICPS framework. METHODS: We developed an intranet-based decision support tool that aligns SE reviews with the ICPS framework, and captures SEs and action plans into a searchable database for aggregate reporting. Its structural elements include: 1) encrypted database on a secure server; 2) decision support resources that align SE analyses with the ICPS classification; 3) drop-down lists and help tools to standardize input; 4) standardized individual and aggregate SE reports that vary depending on recipients; 5) real-time access to Web-based RCA resources; 6) fishbone diagramming; and 7) query functions for database searches. RESULTS: Entry of 15 SE reports into the database framework identified gaps in our previous reviews. Safety personnel and health system leadership have expressed positive assessments of the database and approved funding for evaluation of system-wide implementation. DISCUSSION: Expansion of our database to all safety incidents beyond SEs provides a resource for communicating safety opportunities between hospitals. We demonstrate how the ICPS classifications can be migrated into a decision support tool that has potential for standardizing root cause analyses, disseminating action plans, and improving patient safety.

Prevalence of diagnosed sleep apnea among patients with type 2 diabetes in primary care.

BACKGROUND: Although up to 90% of patients with type 2 diabetes mellitus (T2DM) have obstructive sleep apnea (OSA), the rate at which primary care providers diagnose OSA in patients with diabetes has not been assessed. METHODS: A retrospective, population-based, multiclinic study was performed to determine the proportion of patients with T2DM managed in primary care clinics who were given a diagnosis of OSA and to identify factors associated with an OSA diagnosis. Electronic health records of adult patients with a diagnosis of T2DM were reviewed for a coexisting diagnosis of OSA, and the diagnostic prevalence of OSA was compared with the expected prevalence. RESULTS: A total of 16,066 patients with diabetes with one or more primary care office visits in 27 primary care ambulatory practices during an 18-month period from 2009 to 2010 were identified. Analysis revealed that 18% of the study population received an OSA diagnosis, which is less than the 54% to 94% prevalence reported previously. The 23% prevalence of OSA among obese study patients was lower than the expected 87% prevalence. In a logistic model, male sex, BMI, several chronic conditions, and lower low-density lipoprotein levels and hemoglobin A1c identified patients more likely to carry an OSA diagnosis (likelihood ratio, χ(2) = 1,713; P < .0001). CONCLUSIONS: Primary care providers underdiagnose OSA in patients with T2DM. Obese men with comorbid chronic health conditions are more likely to receive a diagnosis of OSA. Efforts to improve awareness of the association of OSA with T2DM and to implement OSA screening tools should target primary care physicians.

Advance care planning in chronic obstructive pulmonary disease: barriers and opportunities.

PURPOSE OF REVIEW: Experts in palliative care have increasingly recognized the global epidemic of chronic obstructive pulmonary disease (COPD), its astonishing rise in prevalence, and its profound impact on patients' quality of life and functional capacity. Unfortunately, patients with COPD receive less advance care planning (ACP) and palliative care as compared with patients with other diseases with similar prognoses. This review highlights recent advances in identifying barriers to ACP and opportunities for providing more effective and timely palliative care. RECENT FINDINGS: Patients with COPD identify dyspnea as their most disabling symptom. Disease-directed care provides only partial relief from dyspnea, which eventually becomes refractory and requires transition to palliative care. Throughout all stages of COPD, however, integrating palliative care with disease-directed treatments improves patients' well being and functional capacities. Observational studies have identified multiple barriers to effective ACP. Because of the unique disease trajectory of COPD, professional groups have proposed new models for palliative care specifically tailored to COPD. SUMMARY: Patients with COPD benefit from better integration of palliative and disease-specific care throughout the course of their disease from diagnosis to death. Pulmonary rehabilitation may provide a platform for coordinating integrated care. Health agencies will increasingly expect better coordination of services for patients with this progressive, disabling, and eventually terminal disease.

Evaluating older patients with diabetes for insulin pump therapy.

The increasing prevalence of diabetes among elderly patients underscores the importance of matching the most effective therapy for diabetes self-management with patients' cognitive and motor skills, as these diminish with advancing age. Although many geriatric patients state interest in insulin pump therapy for tight glycemic control, few studies have examined the effectiveness, safety, and feasibility of insulin pumps compared to traditional injected insulin therapy in older age groups. It is important, therefore, for physicians to recognize the indications and the age-related barriers to insulin pump therapy in geriatric patients. Indications include glucose variability, hypoglycemia, and poor glycemic control with traditional insulin regimens. Common barriers include poor vision, dexterity, and cognitive status. Successful implementation of insulin pump therapy for older patients requires an experienced diabetes management team that can assess patient needs and tailor therapy in the context of age-related disabilities.