Audit and Feedback Processes Among Antimicrobial Stewardship Programs: A Survey of the Society for Healthcare Epidemiology of America Research Network.

Optimal implementation of audit-and-feedback is an important part of advancing antimicrobial stewardship programs. Our survey demonstrated variability in how 61 programs approach audit-and-feedback. The median (interquartile range) number of recommendations per week was 9 (5-19) per 100 hospital-beds. A major perceived barrier to more comprehensive stewardship was lack of resources. Infect Control Hosp Epidemiol 2016;37:704-706.

Peripherally inserted central catheter-related deep vein thrombosis: contemporary patterns and predictors.

BACKGROUND: Despite growing use, peripherally inserted central catheters (PICCs) are associated with risk of deep vein thrombosis (DVT). We designed a study to determine patient, provider and device factors associated with this outcome. METHODS: This was a retrospective cohort study of adults who underwent PICC placement between 1 June 2009 to 30 June 2012. Symptomatic PICC-associated DVT was confirmed by ultrasound. Because PICCs are also recognized risk factors for lower-extremity DVT, lower-extremity DVT occurring while the PICC was in situ was included. Multivariable logistic and Cox-proportional hazards regression models were fit to examine the association between covariates specified a priori and PICC-DVT. Odds ratios (ORs) and hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) were generated. RESULTS: Of 966 unique PICC placements, 33 patients developed symptomatic PICC-associated DVT and 9 developed lower-extremity DVT, accounting for 42 thrombotic events. On bivariate analysis, recent diagnosis of cancer, interventional radiology placement, chemotherapy administration, number of lumens and PICC-gauge were associated with PICC-DVT. Following multivariable adjustment, recent cancer diagnosis (OR 1.95 [95% CI 1.01-3.76]) and PICC gauge (HR 2.21 [95%CI 1.04-4.70] and HR 3.56 [95%CI 1.31-9.66] for 5-Fr and 6-Fr PICCs, respectively) remained associated with thrombosis. CONCLUSIONS: Recent diagnosis of cancer and PICC gauge are associated with PICC-DVT. These findings have important clinical ramifications and suggest that placement of large gauge PICCs or PICCs in patients with cancer may provoke thrombosis. Improved policies and procedural oversights in these areas appear necessary to prevent PICC-DVT.

The role of the champion in infection prevention: results from a multisite qualitative study.

BACKGROUND: Although 20% or more of healthcare-associated infections can be prevented, many hospitals have not implemented practices known to reduce infections. We explored the types and numbers of champions who lead efforts to implement best practices to prevent hospital-acquired infection in US hospitals. METHODS: Qualitative analyses were conducted within a multisite, sequential mixed methods study of infection prevention practices in Veteran Affairs and non-Veteran Affairs hospitals in the USA. The first phase included telephone interviews conducted in 2005-2006 with 38 individuals at 14 purposively selected hospitals. The second phase used findings from phase 1 to select six hospitals for site visits and interviews with another 48 individuals in 2006-2007. RESULTS: It was possible for a single well-placed champion to implement a new technology, but more than one champion was needed when an improvement required people to change behaviours. Although the behavioural change itself may appear to be an inexpensive and simple solution, implementation was often more complicated than changing technology because behavioural changes required interprofessional coalitions working together. Champions in hospitals with low-quality working relationships across units or professions had a particularly challenging time implementing behavioural change. Merely appointing champions is ineffective; rather, successful champions tended to be intrinsically motivated and enthusiastic about the practices they promoted. Even when broad implementation is stymied, champions can implement change within their own sphere of influence. CONCLUSIONS: The types and numbers of champions varied with the type of practice implemented and the effectiveness of champions was affected by the quality of organisational networks.

Avoiding pitfalls in chronic disease quality measurement: a case for the next generation of technical quality measures.

The true utility of quality measurement lies in its ability to inspire quality improvement, with resultant enhancements in the processes and outcomes of care. Because quality measurement is expensive, it is difficult to justify using measures that are not likely to lead to important improvements in health. Many current measures of chronic disease technical quality, however, have one or more pitfalls that prevent them from motivating quality improvement reactions. These pitfalls include that: (1) measured processes of care lack strong links to outcomes; (2) actionable processes of care are not measured; (3) measures do not target those at highest risk; (4) measures do not allow for patient exceptions; and (5) intermediate outcome measures are not severity adjusted. To exemplify recent advancements and current pitfalls in chronic disease quality measurement, we examine the evolution of quality measures for diabetes mellitus and discuss the limitations of many currently used diabetes mellitus care measures. We then propose more clinically meaningful "tightly linked" measures that examine clinical processes directly linked to outcomes, target populations with specific diagnoses or intermediate disease outcomes that contribute to risk for poor downstream health outcomes, and explicitly incorporate exceptions. We believe that using more tightly linked measures in quality assessment will identify important quality of care problems and is more likely to produce improved outcomes for those with chronic diseases.

Michigan Diabetes Outreach Networks: a public health approach to strengthening diabetes care.

This study describes a statewide public health approach to strengthen diabetes care; evaluates diabetes-related processes of care for individuals enrolled in the Michigan Diabetes Outreach Network (MDON) program; and, examines MDON in the context of priorities for diabetes care and public health policy. Organizational information was obtained through semi-structured interviews. Program outcomes are examined using data from client intake and follow-up assessment forms. We report percentages and mean values overall and across networks. Logistic regression is used to identify factors associated with clients receiving recommended diabetes care. Within two years, five of the networks recruited 125 providers and collected information on over 8,000 individuals with diabetes. The percentage of enrollees with a glycosylated hemoglobin measure, eye exam, and dietician visit is greater at follow-up than at intake and an intake "referral" is strongly associated with clients being trieated for high blood pressure at follow-up. The MDON model is a promising public health approach for improving diabetes care but it is necessary to identify program elements that are most effective.

Department of Veterans Affairs' Quality Enhancement Research Initiative for Diabetes Mellitus.

Diabetes is a common disease, which frequently leads to serious, high-cost complications. Estimates show that in fiscal year 1994 (FY94), 12.5% of outpatients in the Veterans Health Administration (VHA) received diabetes-specific medications, accounted for almost 25% of all VHA pharmacy costs, had a hospitalization rate 1.6 times that of veterans without diabetes, and made 3.6 million outpatient visits to VA clinics. Research demonstrates that much of the mortality and morbidity associated with diabetes can be prevented, and rigorous evidence-based guidelines have been developed. The short-term objectives of the Quality Enhancement Research Initiative for Diabetes Mellitus (QUERI-DM) are to (1) gather baseline information on how current VHA diabetes care differs from the VHA guidelines, (2) develop an efficient, validated system for monitoring key diabetes quality standards in the VHA, (3) evaluate the effectiveness of current approaches to diabetes care and the success of guideline implementation initiatives, and (4) initiate 2 to 4 large-scale quality improvement projects to enhance adherence to practice guidelines and evaluate their impact on patient outcomes, including quality of life.

The adoption of provider-based rural health clinics by rural hospitals: a study of market and institutional forces.

OBJECTIVE: To examine the response of rural hospitals to various market and organizational signals by determining the factors that influence whether or not they establish a provider-based rural health clinic (RHC) (a joint Medicare/Medicaid program). DATA SOURCES/STUDY SETTING: Several secondary sources for 1989-1995: the AHA Annual Survey, the PPS Minimum Data Set and a list of RHCs from HCFA, the Area Resource File, and professional associations. The analysis includes all general medical/surgical rural hospitals operating in the United States during the study period. STUDY DESIGN: A longitudinal design and pooled cross-sectional data were used, with the rural hospital as the unit of analysis. Key variables were examined as sets and include measures of competitive pressures (e.g., hospital market share), physician resources, nurse practitioner/physician assistant (NP/PA) practice regulation, hospital performance pressures (e.g., operating margin), innovativeness, and institutional pressure (i.e., the cumulative force of adoption). PRINCIPAL FINDINGS: Adoption of provider-based RHCs by rural hospitals appears to be motivated less as an adaptive response to observable economic or internal organizational signals than as a reaction to bandwagon pressures. CONCLUSIONS: Rural hospitals with limited resources may resort to imitating others because of uncertainty or a limited ability to fully evaluate strategic activities. This can result in actions or behaviors that are not consistent with policy objectives and the perceived need for policy changes. Such activity in turn could have a negative effect on some providers and some rural residents.

Expanding rural managed care: enrollment patterns and prospects.

This paper synthesizes national data on rural HMO enrollment in commercial plans, Medicaid HMOs and prepaid plans, and Medicare risk-based plans. Although most rural counties now are included in the service area of at least one commercial HMO, rural HMO enrollment rates are still very low. The expansion of HMO capacity to serve rural enrollees, the continued implementation of Medicaid waivers, and the recent passage of the Balanced Budget Act of 1997 with substantial Medicare program revisions suggest increased rural managed care enrollment in the future.

Rural enrollment in MinnesotaCare.

Many rural Americans remain underserved and uninsured. Attempts to initiate national health care reform and universal health insurance coverage have stalled. The impetus to continue reform and universal coverage efforts has shifted back to the state level. Minnesota's health reform efforts resulted in the 1992 MinnesotaCare legislation, which included a subsidized insurance program. As of October 21, 1995, a total of 91,140 people were enrolled in MinnesotaCare. Enrollees are found in every county in the state and represent approximately 2.1% of Minnesota's total population and 2.4% of the state's population under age 65. Estimates of Minnesotans who are uninsured and therefore potentially eligible for this subsidized insurance plan range from 6% to 13%. MinnesotaCare enrollment estimates vary from a high of 10.8% of Red Lake County's population who are under age 65 and report incomes over 100% of the poverty level to a low of 1.5% for similar residents of Nicollet County. Counties with the lowest percentage of MinnesotaCare enrollees are clustered in southern Minnesota, especially the southeastern counties. Those with the highest percentage of enrollees appear to cluster in central Minnesota. MinnesotaCare enrollment is negatively associated with the size of the county's minority population and population density.

Rural radiology: who is producing images and who is reading them?

The purpose of this study is to identify the local availability and trends in local availability of imaging technology and interpretation services in rural hospitals in the northwestern United States during the period between 1991 to 1994. Another objective is to describe hospital and community factors associated with the diffusion of image production and interpretation services. The information for this study was gathered through telephone surveys of rural hospital administrators in eight northwestern states in 1991 and 1994. The availability of magnetic resonance imaging (MRI) equipment, computed tomography (CT) scanners, ultrasonography equipment, and dedicated mammography equipment increased between 1991 and 1994. The increases in MRI units were primarily in mobile equipment, while ultrasonography and mammography equipment increases were primarily fixed hospital-based units. In 1994, image interpretation in the rural hospitals was provided by both primary care and radiology physicians. Forty-six (11.5%) of the rural hospitals had no on-site radiology services and only 73 (18%) had daily radiology services. Between 1991 and 1994, 12 hospitals gained at least once-a-week radiology services, but 24 lost all radiology services. Teleradiology availability more than doubled during the three years. Radiology technology has diffused widely into rural communities in this region of the United States at differing rates for large and small hospitals. Radiologists are available to these hospitals only 46 percent of the days each year, with more days of availability in the larger hospitals and fewer days in the smaller hospitals. Teleradiology capability is increasing more rapidly in the larger hospitals that have radiologists more readily available.

The employment and use of nurse practitioners and physician assistants by rural hospitals.

Nurse practitioners and physician assistants are both important resources for the delivery of health care services in rural areas. Nevertheless, little is known about the demand for their services by rural employers. The purpose of this study was: (1) to describe and compare the employment and use of nurse practitioners and physician assistants by rural hospitals in an eight-state region in the northwestern United States (Minnesota, North Dakota, South Dakota, Iowa, Montana, Idaho, Oregon and Washington); and (2) to examine how different market and organizational factors influence the employment of nurse practitioners and physician assistants by rural hospitals. Data for the study were collected through telephone interviews of rural hospital administrators (N = 407) and analyzed using both descriptive tables and logistic regression. Study results show that rural hospitals are important employers of both nurse practitioners and physician assistants, although there is a greater demand for than supply of both types of practitioners. Moreover, there are several differences in the characteristics of hospitals that employ the different types of practitioners. Rural hospitals use nurse practitioners and physician assistants to enhance their delivery of outpatient services, and a major factor related to the employment of nurse practitioners and physician assistants by rural hospitals is the Rural Health Clinic program. The majority of hospitals that use nurse practitioners, as well as those that use physician assistants, indicate that nurse practitioners and physician assistants can prescribe medications and order lab tests and X-rays, but considerably fewer report that nurse practitioners and physician assistants have admitting or discharge privileges. Physician assistants appear to provide a more expanded scope of services in rural hospitals. Nonetheless, rural hospitals seem to employ nurse practitioners and physician assistants for similar reasons: (1) to extend care, assist physicians, or increase access to primary care; (2) because physicians are unavailable or too difficult to recruit; (3) because nurse practitioners or physician assistants are considered cost-effective or more economical for rural areas; and, (4) for Rural Health Clinic certification.

The composition of rural hospital medical staffs: the influence of hospital neighbors.

The local supply of physicians has a strong influence on the availability and the quality of services provided by rural hospitals. Nevertheless, there are no published studies that describe the composition of rural hospital medical staffs and, in particular, the availability of specialists on these staffs. This study uses 1991 and 1994 survey data from rural hospitals located in eight states to describe the specialty composition and factors that influence the presence of specialists on rural hospital medical staffs. The results show a strong, positive association between the level of medical staff specialization in rural hospitals and the level of medical specialization of their closet rural neighbors, which suggests there is competition among rural hospitals based on the composition of the hospital medical staff. Analysis by specialty type, however, indicates that the degree of competition may differ for different types of specialists.

Availability of rural Minnesota obstetric services: is it a problem?

In the late 1980s several published articles predicted a crisis in the availability of obstetric care due to declining numbers of rural obstetrical providers. Several state and national studies documented the adverse impact of malpractice and time demands on both urban and rural physicians. But only limited information is available to document current trends in rural obstetrical practice and assess whether or not the predicted crisis occurred. This study sought to provide that updated information for rural Minnesota. A telephone survey of all rural Minnesota obstetrical providers was used to document the number, location, and specialty of rural obstetrical providers, their practice limitations, and plans for future practice. This data was combined with state perinatal statistics for each county to further assess obstetrical care availability and perinatal outcomes. All rural Minnesota obstetricians and certified nurse midwives provide obstetrical care as did 69 percent of all rural family physicians. Only 27 percent of rural obstetrical providers put any type of restrictions on their obstetrical practices. During the past year, 67 currently practicing rural physicians have stopped providing obstetrical care while 55 new obstetrical providers have begun rural practice. Two to 3 percent of current rural providers plan to retire or discontinue obstetrical services during the next five years. The provider demographics from the survey identified eight counties with no prenatal providers, and 12 additional communities of decreased provider availability. However, only two of the counties with no prenatal providers and five of the counties with areas of limited providers had increased percentages of adverse prenatal outcomes such as low birthweight or late prenatal care. This study concluded that Minnesota does not have a serious statewide problem with availability of rural obstetrical providers. However, a few isolated regions of the state have limited provider availability, including limited availability of local high-risk services and consultants.

Educational attainment of children from single-parent families: differences by exposure, gender, and race.

This article examines the effect of living in a single-parent family on educational attainment by gender and race. According to household production theory, the reduction in parental resources for human capital investment in children living in a single-parent family should lower their educational attainment. Using matched mother-daughter and mother-son samples from the National Longitudinal Surveys, we constructed precise measures of the age and length of time a child lived in a single-parent family. Empirical findings show that the negative effect of living in a single-parent family (1) increases with the number of years spent in this type of family, (2) is greatest during the preschool years, and (3) is larger for boys than girls.

Effects of alcohol on event-related brain potentials produced by viewing a simulated traffic signal.

The P-300 event-related brain potential was monitored during simulated traffic signal tasks for 10 subjects who were tested at three levels of mean blood alcohol content: 0.00%, 0.06%, and 0.13%. A significant increase in latency occurred for the 0.13% level indicating that an increased mental processing time was required to determine if a red or a green light had been presented.

Biomechanics of bipolar hip endoprostheses.

The bipolar endoprosthesis was designed to alleviate problems encountered with conventional hip endoprostheses. Recent designs have advocated the use of offset centers of rotation between the inner and outer joint-bearing surfaces to generate a valgus-producing moment on loading (antivarus head dynamics). This study was undertaken to justify this biomechanical feature by performing (a) cyclic loading of the bipolar head in the varus position, (b) analysis of motion between the inner and outer bearing surfaces, and (c) evaluation of antivarus head dynamic function. Four endoprosthetic designs were studied: the Bateman UPF, Osteonics UHR, Giliberty II, and Bi-Centric. Significant plastic deformation occurred in the UPF and UHR prostheses when loaded in an extreme varus position. Theoretically, motion is most likely to occur at the inner bearing if the frictional coefficients are equal at both surfaces. The UHR prosthesis with eccentric offset of bearing centers can provide the antivarus effect in laboratory conditions. Whether the antivarus effect and/or the dominant inner bearing motion will occur in vivo awaits careful clinical study.