Mitochondrial Phosphopantetheinylation is Required for Oxidative Function.

Sub-cellular compartmentalization of metabolism has important implications for the local production of metabolites and redox co-factors, as well as pathway regulation. 4'-phosphopantetheinyl (4'PP) groups are essential co-factors derived from coenzyme A and added to target proteins in both the cytoplasm and mitochondria by p hospho p antetheinyl transferase (PPTase) enzymes. Mammals express only one PPTase, thought to localize to the cytoplasm: aminoadipate semialdehyde dehydrogenase phosphopantetheinyl transferase (AASDHPPT); raising the question of how mitochondrial proteins are 4'PP-modified. We found that AASDHPPT is required for mitochondrial respiration and oxidative metabolism via the mitochondrial fatty acid synthesis (mtFAS) pathway. Moreover, we discovered that a pool of AASDHPPT localizes to the mitochondrial matrix via an N-terminal mitochondrial targeting sequence contained within the first 13 amino acids of the protein. Our data show that mitochondrial localization of AASDHPPT is required to support mtFAS function, and further identify two variants in Aasdhppt that are likely pathogenic in humans.

Improving Appropriate Use of Peripherally Inserted Central Catheters Through a Statewide Collaborative Hospital Initiative: A Cost-Effectiveness Analysis.

BACKGROUND: Quality improvement (QI) programs require significant financial investment. The authors evaluated the cost-effectiveness of a physician-led, performance-incentivized, QI intervention that increased appropriate peripherally inserted central catheter (PICC) use. METHODS: The authors used an economic evaluation from a health care sector perspective. Implementation costs included incentive payments to hospitals and costs for data abstractors and the coordinating center. Effectiveness was calculated from propensity score-matched observations across two time periods for complications (venous thromboembolism [VTE], central line-associated bloodstream infection [CLABSI], and catheter occlusion): preintervention period (January 2015 through December 2016) and intervention period (January 2017 through December 2021). Cost-effectiveness was presented as the cost-offset per averted complication, reflecting the health care costs avoided due to having lower complication rates. RESULTS: Across 35 hospitals, this study sampled 17,418 PICCs placed preintervention and 26,004 placed during the intervention period. PICC complications decreased significantly following the intervention. CLABSIs decreased from 2.1% to 1.5%, VTEs from 3.2% to 2.3%, and catheter occlusions from 10.8% to 7.0% (all p < 0.01). Estimated number of complications prevented included 871 CLABSIs, 2,535 VTEs, and 8,743 catheter occlusions. Project implementation costs were $31.8 million, and the cost-offset related to avoided complications was $64.4 million. Each participating hospital averaged $932,073 in cost-offset over seven years, and the average cost-offset per complication averted was $2,614 (95% CI [confidence interval] $2,314-$3,003). CONCLUSION: A large-scale, multihospital QI initiative to improve appropriate PICC use yielded substantial return on investment from cost-offset of prevented complications.

Development of patient safety measures to identify inappropriate diagnosis of common infections.

BACKGROUND: Inappropriate diagnosis of infections results in antibiotic overuse and may delay diagnosis of underlying conditions. Here, we describe the development and characteristics of two safety measures of inappropriate diagnosis of urinary tract infection (UTI) and community-acquired pneumonia (CAP), the most common inpatient infections on general medicine services. METHODS: Measures were developed from guidelines and literature and adapted based on data from patients hospitalized with UTI and CAP in 49 Michigan hospitals and feedback from end-users, a technical expert panel (TEP), and a patient focus group. Each measure was assessed for reliability, validity, feasibility, and usability. RESULTS: Two measures, now endorsed by the National Quality Forum (NQF), were developed. Measure reliability (derived from 24,483 patients) was excellent (0.90 for UTI; 0.91 for CAP). Both measures had strong validity demonstrated through a) face validity by hospital users, the TEPs, and patient focus group, b) implicit case review (ĸ 0.72 for UTI; ĸ 0.72 for CAP), and c) rare case misclassification (4% for UTI; 0% for CAP) due to data errors (<2% for UTI; 6.3% for CAP). Measure implementation through hospital peer comparison in Michigan hospitals (2017 to 2020) demonstrated significant decreases in inappropriate diagnosis of UTI and CAP (37% and 32%, respectively, p < 0.001), supporting usability. CONCLUSIONS: We developed highly reliable, valid, and usable measures of inappropriate diagnosis of UTI and CAP for hospitalized patients. Hospitals seeking to improve diagnostic safety, antibiotic use, and patient care should consider using these measures to reduce inappropriate diagnosis of CAP and UTI.

Use and Outcomes of Peripheral Vasopressors in Early Sepsis-Induced Hypotension Across Michigan Hospitals: A Retrospective Cohort Study.

BACKGROUND: Vasopressors traditionally are administered via central access, but newer data suggest that peripheral administration may be safe and may avoid delays and complications associated with central line placement. RESEARCH QUESTION: How commonly are vasopressors initiated through peripheral IV lines in routine practice? Is vasopressor initiation route associated with in-hospital mortality? STUDY DESIGN AND METHODS: This retrospective cohort study included adults hospitalized with sepsis (November 2020-September 2022) at 29 hospitals in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan. We assessed route of early vasopressor initiation, factors and outcomes associated with peripheral initiation, and timing of central line placement. RESULTS: Five hundred ninety-four patients received vasopressors within 6 h of hospital arrival and were included in this study. Peripheral vasopressor initiation was common (400/594 [67.3%]). Patients with peripheral vs central initiation were similar; BMI was the only patient factor associated independently with initiation route (adjusted OR [aOR] of peripheral initiation [per 1-kg/m2 increase], 0.98; 95% CI, 0.97-1.00; P = .015). The specific hospital showed a large impact on initiation route (median OR, 2.19; 95% CI, 1.31-3.07). Compared with central initiation, peripheral initiation was faster (median, 2.5 h vs 2.7 h from hospital arrival; P = .002), but was associated with less initial norepinephrine use (84.3% vs 96.8%; P = .001). We found no independent association between initiation route and in-hospital mortality (32.3% vs 42.2%; aOR, 0.66; 95% CI, 0.39-1.12). No tissue injury from peripheral vasopressors was documented. Of patients with peripheral initiation, 135 of 400 patients (33.8%) never received a central line. INTERPRETATION: Peripheral vasopressor initiation was common across Michigan hospitals and had practical benefits, including expedited vasopressor administration and avoidance of central line placement in one-third of patients. However, the findings of wide practice variation that was not explained by patient case mix and lower use of first-line norepinephrine with peripheral administration suggest that additional standardization may be needed.

Trends in engagement with cognitive-behavioral therapy for chronic pain conditions after referral.

Cognitive-behavioral therapy for chronic pain (CBT-CP) is an important evidence-based non-pharmacologic treatment for chronic back and neck pain that is frequently recommended as a component of multidisciplinary treatment. However, the success of CBP-CP's implementation in clinical settings is affected by a variety of poorly understood obstacles to patient engagement with CBT-CP. Expanding upon the limited prior research conducted in heterogeneous practice settings, this study examines patterns of treatment initiation for CBT-CP at an interdisciplinary, hospital-based chronic pain practice and conducts exploratory comparisons between groups of patients who did and did not engage in CBT-CP after receiving a referral. Patients' descriptive data, including pain severity, work status, prior therapy, and behavioral health questionnaire scores at intake visit, were obtained through a retrospective chart review of electronic medical records. Data were then analyzed using inter-group comparisons and logistic regression modeling to determine factors that predicted treatment initiation for CBT-CP. On multivariate analysis, we found that patient's depression level as measured by their Patient Health Questionnaire 9 (PHQ-9) score was solely predictive of treatment initiation, as chronic pain patients with a higher level of depression were found to be more likely to attend their recommended appointments of CBT-CP. Anxiety score as measured by GAD-7, work status, pain scores, and prior therapy engagement were not independently predictive. No single "profile" of patient-level factors was found to delineate patients who did and did not initiate CBT-CP, demonstrating the limitations of clinical variables as predictors of uptake.

Cognitive-behavioral therapy (CBT) is a frequently used therapy option, and can be helpful for patients with chronic low back and/or neck pain. However, patients do not always choose to engage in CBT when offered in the context of chronic pain. Reasons patients choose not to pursue CBT, when recommended, are not well understood. This study used data from a hospital-based chronic pain practice in order to identify reasons that patients choose to begin CBT and those who do not. Data about these patients was collected from electronic medical records (EMRs) and was used to conduct statistical analyses, with the goal of determining what factors were significantly different between the two groups of patients. We identified that patients who have more severe depression symptoms based on a specific mental health questionnaire (the Patient Health Questionnaire 9, or PHQ-9) were more likely to engage with CBT. Study results imply that patients without comorbid depression may benefit from additional counseling on the potential benefits of CBT in the management of chronic pain. These results also suggest that reasons other than clinical factors are impacting whether or not patients engage with CBT.

Institutional Structures and Processes to Support Sepsis Care: A Multihospital Study.

OBJECTIVES: To identify opportunities for improving hospital-based sepsis care and to inform an ongoing statewide quality improvement initiative in Michigan. DESIGN: Surveys on hospital sepsis processes, including a self-assessment of practices using a 3-point Likert scale, were administered to 51 hospitals participating in the Michigan Hospital Medicine Safety Consortium, a Collaborative Quality Initiative sponsored by Blue Cross Blue Shield of Michigan, at two time points (2020, 2022). Forty-eight hospitals also submitted sepsis protocols for structured review. SETTING: Multicenter quality improvement consortium. SUBJECTS: Fifty-one hospitals in Michigan. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the included hospitals, 92.2% (n = 47/51) were nonprofit, 88.2% (n = 45/51) urban, 11.8% (n = 6/51) rural, and 80.4% (n = 41/51) teaching hospitals. One hundred percent (n = 51/51) responded to the survey, and 94.1% (n = 48/51) provided a sepsis policy/protocol. All surveyed hospitals used at least one quality improvement approach, including audit/feedback (98.0%, n = 50/51) and/or clinician education (68.6%, n = 35/51). Protocols included the Sepsis-1 (18.8%, n = 9/48) or Sepsis-2 (31.3%, n = 15/48) definitions; none (n = 0/48) used Sepsis-3. All hospitals (n = 51/51) used at least one process to facilitate rapid sepsis treatment, including order sets (96.1%, n = 49/51) and/or stocking of commonly used antibiotics in at least one clinical setting (92.2%, n = 47/51). Treatment protocols included guidance on antimicrobial therapy (68.8%, n = 33/48), fluid resuscitation (70.8%, n = 34/48), and vasopressor administration (62.5%, n = 30/48). On self-assessment, hospitals reported the lowest scores for peridischarge practices, including screening for cognitive impairment (2.0%, n = 1/51 responded "we are good at this") and providing anticipatory guidance (3.9%, n = 2/51). There were no meaningful associations of the Centers for Medicare and Medicaid Services' Severe Sepsis and Septic Shock: Management Bundle performance with differences in hospital characteristics or sepsis policy document characteristics. CONCLUSIONS: Most hospitals used audit/feedback, order sets, and clinician education to facilitate sepsis care. Hospitals did not consistently incorporate organ dysfunction criteria into sepsis definitions. Existing processes focused on early recognition and treatment rather than recovery-based practices.

Using latent variable models to make gaming-the-system detection robust to context variations.

Gaming the system, a behavior in which learners exploit a system's properties to make progress while avoiding learning, has frequently been shown to be associated with lower learning. However, when we applied a previously validated gaming detector across conditions in experiments with an algebra tutor, the detected gaming was not associated with reduced learning, challenging its validity in our study context. Our exploratory data analysis suggested that varying contextual factors across and within conditions contributed to this lack of association. We present a new approach, latent variable-based gaming detection (LV-GD), that controls for contextual factors and more robustly estimates student-level latent gaming tendencies. In LV-GD, a student is estimated as having a high gaming tendency if the student is detected to game more than the expected level of the population given the context. LV-GD applies a statistical model on top of an existing action-level gaming detector developed based on a typical human labeling process, without additional labeling effort. Across three datasets, we find that LV-GD consistently outperformed the original detector in validity measured by association between gaming and learning as well as reliability. LV-GD also afforded high practical utility: it more accurately revealed intervention effects on gaming, revealed a correlation between gaming and perceived competence in math and helped understand productive detected gaming behaviors. Our approach is not only useful for others wanting a cost-effective way to adapt a gaming detector to their context but is also generally applicable in creating robust behavioral measures.

Sepsis Program Activities in Acute Care Hospitals - National Healthcare Safety Network, United States, 2022.

Sepsis, life-threatening organ dysfunction secondary to infection, contributes to at least 1.7 million adult hospitalizations and at least 350,000 deaths annually in the United States. Sepsis care is complex, requiring the coordination of multiple hospital departments and disciplines. Sepsis programs can coordinate these efforts to optimize patient outcomes. The 2022 National Healthcare Safety Network (NHSN) annual survey evaluated the prevalence and characteristics of sepsis programs in acute care hospitals. Among 5,221 hospitals, 3,787 (73%) reported having a committee that monitors and reviews sepsis care. Prevalence of these committees varied by hospital size, ranging from 53% among hospitals with 0-25 beds to 95% among hospitals with >500 beds. Fifty-five percent of all hospitals provided dedicated time (including assigned protected time or job description requirements) for leaders of these committees to manage a program and conduct daily activities, and 55% of committees reported involvement with antibiotic stewardship programs. These data highlight opportunities, particularly in smaller hospitals, to improve the care and outcomes of patients with sepsis in the United States by ensuring that all hospitals have sepsis programs with protected time for program leaders, engagement of medical specialists, and integration with antimicrobial stewardship programs. CDC's Hospital Sepsis Program Core Elements provides a guide to assist hospitals in developing and implementing effective sepsis programs that complement and facilitate the implementation of existing clinical guidelines and improve patient care. Future NHSN annual surveys will monitor uptake of these sepsis core elements.

A Statewide Quality Initiative to Reduce Unnecessary Antibiotic Treatment of Asymptomatic Bacteriuria.

Importance: Hospitalized patients with asymptomatic bacteriuria (ASB) often receive unnecessary antibiotic treatment, which increases antibiotic resistance and adverse events. Objective: To determine whether diagnostic stewardship (avoiding unnecessary urine cultures) or antibiotic stewardship (reducing unnecessary antibiotic treatment after an unnecessary culture) is associated with better outcomes in reducing antibiotic use for ASB. Design, Setting, and Participants: This 3-year, prospective quality improvement study included hospitalized general care medicine patients with a positive urine culture among 46 hospitals participating in a collaborative quality initiative, the Michigan Hospital Medicine Safety Consortium. Data were collected from July 1, 2017, through March 31, 2020, and analyzed from February to October 2022. Exposure: Participation in the Michigan Hospital Medicine Safety Consortium with antibiotic and diagnostic stewardship strategies at hospital discretion. Main Outcomes and Measures: Overall improvement in ASB-related antibiotic use was estimated as change in percentage of patients treated with antibiotics who had ASB. Effect of diagnostic stewardship was estimated as change in percentage of patients with a positive urine culture who had ASB. Effect of antibiotic stewardship was estimated as change in percentage of patients with ASB who received antibiotics and antibiotic duration. Results: Of the 14 572 patients with a positive urine culture included in the study (median [IQR] age, 75.8 [64.2-85.1] years; 70.5% female); 28.4% (n = 4134) had ASB, of whom 76.8% (n = 3175) received antibiotics. Over the study period, the percentage of patients treated with antibiotics who had ASB (overall ASB-related antibiotic use) declined from 29.1% (95% CI, 26.2%-32.2%) to 17.1% (95% CI, 14.3%-20.2%) (adjusted odds ratio [aOR], 0.94 per quarter; 95% CI, 0.92-0.96). The percentage of patients with a positive urine culture who had ASB (diagnostic stewardship metric) declined from 34.1% (95% CI, 31.0%-37.3%) to 22.5% (95% CI, 19.7%-25.6%) (aOR, 0.95 per quarter; 95% CI, 0.93-0.97). The percentage of patients with ASB who received antibiotics (antibiotic stewardship metric) remained stable, from 82.0% (95% CI, 77.7%-85.6%) to 76.3% (95% CI, 68.5%-82.6%) (aOR, 0.97 per quarter; 95% CI, 0.94-1.01), as did adjusted mean antibiotic duration, from 6.38 (95% CI, 6.00-6.78) days to 5.93 (95% CI, 5.54-6.35) days (adjusted incidence rate ratio, 0.99 per quarter; 95% CI, 0.99-1.00). Conclusions and Relevance: This quality improvement study showed that over 3 years, ASB-related antibiotic use decreased and was associated with a decline in unnecessary urine cultures. Hospitals should prioritize reducing unnecessary urine cultures (ie, diagnostic stewardship) to reduce antibiotic treatment related to ASB.

The Association of Vasopressor Administration through a Midline Catheter with Catheter-related Complications.

Rationale: Little is known about the safety of infusing vasopressors through a midline catheter. Objectives: To evaluate safety outcomes after vasopressor administration through a midline. Methods: We conducted a cohort study of adults admitted to 39 hospitals in Michigan (December 2017-March 2022) who received vasopressors while either a midline or peripherally inserted central catheter (PICC) was in place. Patients receiving vasopressors through a midline were compared with those receiving vasopressors through a PICC and, separately, to those with midlines in place but who received vasopressors through a different catheter. We used descriptive statistics to characterize and compare cohort characteristics. Multivariable mixed effects logistic regression models were fit to determine the association between vasopressor administration through a midline with outcomes, primarily catheter-related complications (bloodstream infection, superficial thrombophlebitis, exit site infection, or catheter occlusion). Results: Our cohort included 287 patients with midlines through which vasopressors were administered, 1,660 with PICCs through which vasopressors were administered, and 884 patients with midlines who received vasopressors through a separate catheter. Age (median [interquartile range]: 68.7 [58.6-75.7], 66.6 [57.1-75.0], and 67.6 [58.7-75.8] yr) and gender (percentage female: 50.5%, 47.3%, and 43.8%) were similar in all groups. The frequency of catheter-related complications was lower in patients with midlines used for vasopressors than PICCs used for vasopressors (5.2% vs. 13.4%; P < 0.001) but similar to midlines with vasopressor administration through a different device (5.2% vs. 6.3%; P = 0.49). After adjustment, administration of vasopressors through a midline was not associated with catheter-related complications compared with PICCs with vasopressors (adjusted odds ratios [aOR], 0.65 [95% confidence interval, 0.31-1.33]; P = 0.23) or midlines with vasopressors elsewhere (aOR, 0.85 [0.46-1.58]; P = 0.59). Midlines used for vasopressors were associated with greater risk of systemic thromboembolism (vs. PICCs with vasopressors: aOR, 2.69 [1.31-5.49]; P = 0.008; vs. midlines with vasopressors elsewhere: aOR, 2.42 [1.29-4.54]; P = 0.008) but not thromboses restricted to the ipsilateral upper extremity (vs. PICCs with vasopressors: aOR, 2.35 [0.83-6.63]; P = 0.10; model did not converge for vs. midlines with vasopressors elsewhere). Conclusions: We found no significant association of vasopressor administration through a midline with catheter-related complications. However, we identified increased odds of systemic (but not ipsilateral upper extremity) venous thromboembolism warranting further evaluation.

Femoral access site complications following neurointerventional procedures: economic implications at a single center.

OBJECTIVE: Transfemoral access (TFA) has been the traditional route of arterial access for neurointerventional procedures. Femoral access site complications may occur in 2%-6% of patients. Management of these complications often requires additional diagnostic tests or interventions, each of which may increase the cost of care. The economic impact of a femoral access site complication has not yet been described. The objective of this study was to evaluate the economic consequences of femoral access site complications. METHODS: The authors conducted a retrospective review of patients undergoing neuroendovascular procedures at their institute and identified those who experienced femoral access site complications. The subset of patients experiencing these complications during elective procedures was matched in a 1:2 fashion to a control group undergoing similar procedures and not experiencing an access site complication. RESULTS: Femoral access site complications were identified in 77 patients (4.3%) over a 3-year period. Thirty-four of these complications were considered major, requiring blood transfusion or additional invasive treatment. There was a statistically significant difference in total cost ($39,234.84 vs $23,535.32, p = 0.001), total reimbursement ($35,500.24 vs $24,861.71, p = 0.020) and reimbursement minus cost (-$3734.60 vs $1326.39, p = 0.011) between the complication and control cohorts in elective procedures, respectively. CONCLUSIONS: Although occurring relatively infrequently, femoral artery access site complications increase the cost of care for patients undergoing neurointerventional procedures; how this influences the cost effectiveness of neurointerventional procedures warrants further investigation.

An astonishing regularity in student learning rate.

Leveraging a scientific infrastructure for exploring how students learn, we have developed cognitive and statistical models of skill acquisition and used them to understand fundamental similarities and differences across learners. Our primary question was why do some students learn faster than others? Or, do they? We model data from student performance on groups of tasks that assess the same skill component and that provide follow-up instruction on student errors. Our models estimate, for both students and skills, initial correctness and learning rate, that is, the increase in correctness after each practice opportunity. We applied our models to 1.3 million observations across 27 datasets of student interactions with online practice systems in the context of elementary to college courses in math, science, and language. Despite the availability of up-front verbal instruction, like lectures and readings, students demonstrate modest initial prepractice performance, at about 65% accuracy. Despite being in the same course, students' initial performance varies substantially from about 55% correct for those in the lower half to 75% for those in the upper half. In contrast, and much to our surprise, we found students to be astonishingly similar in estimated learning rate, typically increasing by about 0.1 log odds or 2.5% in accuracy per opportunity. These findings pose a challenge for theories of learning to explain the odd combination of large variation in student initial performance and striking regularity in student learning rate.

Barriers and facilitators for implementing peripherally inserted central catheter (PICC) appropriateness guidelines: A longitudinal survey study from 34 Michigan hospitals.

Peripherally inserted central catheters (PICCs) are prevalent devices for medium-to-long-term intravenous therapy but are often associated with morbid and potentially lethal complications. This multi-center study sought to identify barriers and facilitators of implementing evidence-based appropriateness criteria to improve PICC safety and patient outcomes in a pay-for-performance model. Participating hospitals received an online toolkit with five recommendations: establishing a vascular access committee; implementing a clinical decision tool for PICC appropriateness; avoiding short-term PICC use (≤5 days); increasing use of single-lumen PICCs; and avoiding PICC placement in patients with chronic kidney disease. Longitudinal online surveys conducted biannually October 2014-November 2018 tracked implementation efforts. A total of 306 unique surveys from 34 hospitals were completed. The proportion of hospitals with a dedicated committee overseeing PICC appropriateness increased from 53% to 97%. Overall, 94% of hospitals implemented an initiative to reduce short-term and multi-lumen PICC use, and 91% integrated kidney function into PICC placement decisions. Barriers to implementation included: achieving agreement from diverse disciplines, competing hospital priorities, and delays in modifying electronic systems to enable appropriate PICC ordering. Provision of quarterly benchmarking reports, a decision algorithm, access to an online toolkit, and presence of local champion support were cited as crucial in improving practice. Structured quality improvement efforts including a multidisciplinary vascular access committee, clear targets, local champions, and support from an online education toolkit have led to sustained PICC appropriateness and improved patient safety.

Eligibility for Posthospitalization Venous Thromboembolism Prophylaxis in Hospitalized Patients With COVID-19: A Retrospective Cohort Study.

Background A recent randomized trial, the MICHELLE trial, demonstrated improved posthospital outcomes with a 35-day course of prophylactic rivaroxaban for patients hospitalized with COVID-19 at high risk of venous thromboembolism. We explored how often these findings may apply to an unselected clinical population of patients hospitalized with COVID-19. Methods and Results Using a 35-hospital retrospective cohort of patients hospitalized between March 7, 2020, and January 23, 2021, with COVID-19 (MI-COVID19 database), we quantified the percentage of hospitalized patients with COVID-19 who would be eligible for rivaroxaban at discharge per MICHELLE trial criteria and report clinical event rates. The main clinical outcome was derived from the MICHELLE trial and included a composite of symptomatic venous thromboembolism, pulmonary embolus-related death, nonhemorrhagic stroke, and cardiovascular death at 35 days. Multiple sensitivity analyses tested different eligibility and exclusion criteria definitions to determine the effect on eligibility for postdischarge anticoagulation prophylaxis. Of 2016 patients hospitalized with COVID-19 who survived to discharge and did not have another indication for anticoagulation, 25.9% (n=523) would be eligible for postdischarge thromboprophylaxis per the MICHELLE trial criteria (range, 2.9%-39.4% on sensitivity analysis). Of the 416 who had discharge anticoagulant data collected, only 13.2% (55/416) were actually prescribed a new anticoagulant at discharge. Of patients eligible for rivaroxaban per the MICHELLE trial, the composite clinical outcome occurred in 1.2% (6/519); similar outcome rates were 5.7% and 0.63% in the MICHELLE trial's control (no anticoagulation) and intervention (rivaroxaban) groups, respectively. Symptomatic venous thromboembolism events and all-cause mortality were 6.2% (32/519) and 5.66% in the MI-COVID19 and MICHELLE trial control cohorts, respectively. Conclusions Across 35 hospitals in Michigan, ≈1 in 4 patients hospitalized with COVID-19 would qualify for posthospital thromboprophylaxis. With only 13% of patients actually receiving postdischarge prophylaxis, there is a potential opportunity for improvement in care.

Opioid and benzodiazepine prescribing after COVID-19 hospitalization.

Opioid and benzodiazepine prescribing after COVID-19 hospitalization is not well understood. We aimed to characterize opioid and benzodiazepine prescribing among naïve patients hospitalized for COVID and to identify the risk factors associated with a new prescription at discharge. In this retrospective study of patients across 39 Michigan hospitals from March to November 2020, we identified 857 opioid- and benzodiazepine-naïve patients admitted with COVID-19 not requiring mechanical ventilation. Of these, 22% received opioids, 13% received benzodiazepines, and 6% received both during the hospitalization. At discharge, 8% received an opioid prescription, and 3% received a benzodiazepine prescription. After multivariable adjustment, receipt of an opioid or benzodiazepine prescription at discharge was associated with the length of inpatient opioid or benzodiazepine exposure. These findings suggest that hospitalization represents a risk of opioid or benzodiazepine initiation among naïve patients, and judicious prescribing should be considered to prevent opioid-related harms.

Advocacy to support climate and health policies: recommended actions for the Society of Behavioral Medicine.

Climate change poses serious threats to public health and is exacerbating health inequities. Policy changes are essential to mitigate climate change impacts on human and planetary health. The purpose was to describe recommendations by the Policy and Advocacy Subgroup of the Society of Behavioral Medicine (SBM) Climate Change, Behavior Change and Health Presidential Working Group (PWG). The Policy and Advocacy subgroup was comprised of experts in public health, climate policy, and health behavior change, who worked together to identify priorities and develop recommendations. We worked under the premise that building political will for climate policy action is the most urgent goal, and we recommended promotion of citizen advocacy for this purpose. Because citizen advocacy is a set of behaviors, SBM members can use behavioral science to identify and scale up interventions, working collaboratively with communities targeted for marginalization. Recommendations for SBM included establishing an organizational home for climate and health work, providing training and resources, engaging in climate advocacy as an organization, and networking with other organizations. Recommendations for a proposed SBM Climate and Health Committee, Council, or Special Interest Group included developing trainings and resources, seeking opportunities for networking and collaborations, and identifying a research agenda. Individual behavior changes are insufficient to address climate change; policy actions are needed. SBM and similar organizations can support their members to work in developing, evaluating, and scaling up advocacy interventions for action on climate policy to magnify the power of the health and medical sectors to protect planetary and human health.

Increasing advocacy for climate protection policies is a top priority. Recommendations are made for research and advocacy engagement by the Society of Behavioral Medicine and its members.

Comparing quality of life improvement after antegrade continence enema (ACE) therapy for patients with organic and functional constipation / encopresis.

BACKGROUND: We compared patient- and family-reported overall and stool-related quality of life (QoL) before and after an antegrade continence enema (ACE) procedure (cecostomy tube insertion) for refractory chronic constipation or fecal incontinence (CCFI). We hypothesized that patients with functional diagnoses experience similar improvements in QoL compared to those with organic diagnoses. METHODS: This is a cross-sectional study of patients undergoing cecostomy tube insertion for CCFI at a tertiary pediatric hospital from 2012 to 2019. Patients and/or primary caregivers completed validated stooling and overall QoL surveys based on three time points: before surgery, three months after surgery, and at the time of survey / date of last follow-up. Repeated measures analyses compared scores over time between subjects and within the diagnostic groups. RESULTS: The response rate was 65% (22/34 patients, 12 organic and 10 functional diagnoses). Mean age was 8.3 years and 32% of the participants were female. Organic diagnoses were: spina bifida (6), anorectal malformation (5), and Hirschsprung Disease (1). There was substantial improvement in stool-related and overall QoL at three months post-ACE procedure (both p<0.001) for all patients; both scores continued to improve significantly until the date of last follow-up (median 4.1 years, IQR 2.3-5.6, p<0.001). There was no statistically significant difference in scores between patients with organic and functional diagnoses. CONCLUSIONS: Caregivers perceive a significant, sustainable improvement in stooling habits and QoL following ACE therapy. The improvement is comparable between patients with a functional diagnosis and those with an underlying organic reason for their CCFI.

Development and psychometric evaluation of an empirically-derived daily checklist of weight control: Consumption-reduction strategies and health-focused strategies in college students.

Objective: Many college women report engaging in weight control strategies, yet little is known about which strategies are used and how often. The current study's goal was to evaluate the factor structure of a comprehensive list of weight control behaviors used in the previous 24-hours. Participants: Undergraduate women (N = 286) were recruited from a southwestern university. Methods: Participants reported their weight control strategies for the previous 24 hours on a checklist compiled from previous studies. Results: Exploratory and confirmatory factor analyses indicated that a 14-item, 2-factor ("Consumption-reduction", "Health-focused" Strategies) structure was a good fit of the data. Tests of longitudinal measurement invariance found support for using the checklist to make meaningful comparisons across time. Conclusions: This study developed a checklist of past 24-hour weight-control strategy usage, thereby providing a step toward developing an instrument that may be used for weight control or early intervention for disordered eating.

Risk factors and outcomes associated with community-onset and hospital-acquired coinfection in patients hospitalized for coronavirus disease 2019 (COVID-19): A multihospital cohort study.

BACKGROUND: We sought to determine the incidence of community-onset and hospital-acquired coinfection in patients hospitalized with coronavirus disease 2019 (COVID-19) and to evaluate associated predictors and outcomes. METHODS: In this multicenter retrospective cohort study of patients hospitalized for COVID-19 from March 2020 to August 2020 across 38 Michigan hospitals, we assessed prevalence, predictors, and outcomes of community-onset and hospital-acquired coinfections. In-hospital and 60-day mortality, readmission, discharge to long-term care facility (LTCF), and mechanical ventilation duration were assessed for patients with versus without coinfection. RESULTS: Of 2,205 patients with COVID-19, 141 (6.4%) had a coinfection: 3.0% community onset and 3.4% hospital acquired. Of patients without coinfection, 64.9% received antibiotics. Community-onset coinfection predictors included admission from an LTCF (OR, 3.98; 95% CI, 2.34-6.76; P < .001) and admission to intensive care (OR, 4.34; 95% CI, 2.87-6.55; P < .001). Hospital-acquired coinfection predictors included fever (OR, 2.46; 95% CI, 1.15-5.27; P = .02) and advanced respiratory support (OR, 40.72; 95% CI, 13.49-122.93; P < .001). Patients with (vs without) community-onset coinfection had longer mechanical ventilation (OR, 3.31; 95% CI, 1.67-6.56; P = .001) and higher in-hospital mortality (OR, 1.90; 95% CI, 1.06-3.40; P = .03) and 60-day mortality (OR, 1.86; 95% CI, 1.05-3.29; P = .03). Patients with (vs without) hospital-acquired coinfection had higher discharge to LTCF (OR, 8.48; 95% CI, 3.30-21.76; P < .001), in-hospital mortality (OR, 4.17; 95% CI, 2.37-7.33; P ≤ .001), and 60-day mortality (OR, 3.66; 95% CI, 2.11-6.33; P ≤ .001). CONCLUSION: Despite community-onset and hospital-acquired coinfection being uncommon, most patients hospitalized with COVID-19 received antibiotics. Admission from LTCF and to ICU were associated with increased risk of community-onset coinfection. Future studies should prospectively validate predictors of COVID-19 coinfection to facilitate the reduction of antibiotic use.

Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals.

BACKGROUND: The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) provides evidence-based criteria for peripherally inserted central catheter (PICC) use. Whether implementing MAGIC improves PICC appropriateness and reduces complications is unknown. METHODS: A quasiexperimental study design to implement MAGIC in 52 Michigan hospitals was used. Data were collected from medical records by trained abstractors. Hospital performance on three appropriateness criteria was measured: short-term PICC use (≤5 days), use of multilumen PICCs and PICC placement in patients with chronic kidney disease. PICC appropriateness and device complications preintervention (January 2013 to December 2016) versus postintervention (January 2017 to January 2020) were compared. Change-point analysis was used to evaluate the effect of the intervention on device appropriateness. Logistic regression and Poisson models were fit to assess the association between appropriateness and complications (composite of catheter occlusion, venous thromboembolism (VTE) and central line-associated bloodstream infection (CLABSI)). RESULTS: Among 38 592 PICCs, median catheter dwell ranged from 8 to 56 days. During the preintervention period, the mean frequency of appropriate PICC use was 31.9% and the mean frequency of complications was 14.7%. Following the intervention, PICC appropriateness increased to 49.0% (absolute difference 17.1%, p<0.001) while complications decreased to 10.7% (absolute difference 4.0%, p=0.001). Compared with patients with inappropriate PICC placement, appropriate PICC use was associated with a significantly lower odds of complications (OR 0.29, 95% CI 0.25 to 0.34), including decreases in occlusion (OR 0.25, 95% CI 0.21 to 0.29), CLABSI (OR 0.61, 95% CI 0.46 to 0.81) and VTE (OR 0.40, 95% CI 0.33 to 0.47, all p<0.01). Patients with appropriate PICC placement had lower rate of complications than those with inappropriate PICC use (incidence rate ratio 0.987, 95% CI 0.98 to 0.99, p<0.001). CONCLUSIONS: Implementation of MAGIC in Michigan hospitals was associated with improved PICC appropriateness and fewer complications. These findings have important quality, safety and policy implications for hospitals, patients and payors.