Impact of Mandatory Infectious Disease Specialist Approval on Hospital-Onset Clostridioides difficile Infection Rates and Testing Appropriateness.

BACKGROUND: Inappropriate Clostridioides difficile testing is common in the hospital setting, leading to potential overdiagnosis of infection when single-step nucleic acid amplification testing is used. The potential role of infectious diseases (ID) specialists in enforcing appropriate C. difficile testing is unclear. METHODS: At a single 697-bed academic hospital, we performed a retrospective study from 1 March 2012 to 31 December 2019 comparing hospital-onset C. difficile infection (HO-CDI) rates during 3 consecutive time periods: baseline 1 (37 months, no decision support), baseline 2 (32 months, computer decision support), and intervention period (25 months, mandatory ID specialist approval for all C. difficile testing on hospital day 4 or later). We used a discontinuous growth model to assess the impact of the intervention on HO-CDI rates. RESULTS: During the study period, we evaluated C. difficile infections across 331 180 admission and 1 172 015 patient-days. During the intervention period, a median of 1 HO-CDI test approval request per day (range, 0-6 alerts/day) was observed; adherence by providers with obtaining approval was 85%. The HO-CDI rate was 10.2, 10.4, and 4.3 events per 10 000 patient-days for each consecutive time period, respectively. In adjusted analysis, the HO-CDI rate did not differ significantly between the 2 baseline periods (P = .14) but did differ between the baseline 2 period and intervention period (P < .001). CONCLUSIONS: An ID-led C. difficile testing approval process was feasible and was associated with a >50% decrease in HO-CDI rates, due to enforcement of appropriate testing.

Random variation drives a critical bias in the comparison of healthcare-associated infections.

OBJECTIVE: To evaluate random effects of volume (patient days or device days) on healthcare-associated infections (HAIs) and the standardized infection ratio (SIR) used to compare hospitals. DESIGN: A longitudinal comparison between publicly reported quarterly data (2014-2020) and volume-based random sampling using 4 HAI types: central-line-associated bloodstream infections, catheter-associated urinary tract infections, Clostridioides difficile infections, methicillin-resistant Staphylococcus aureus infections. METHODS: Using 4,268 hospitals with reported SIRs, we examined relationships of SIRs to volume and compared distributions of SIRs and numbers of reported HAIs to the outcomes of simulated random sampling. We included random expectations into SIR calculations to produce a standardized infection score (SIS). RESULTS: Among hospitals with volumes less than the median, 20%-33% had SIRs of 0, compared to 0.3%-5% for hospitals with volumes higher than the median. Distributions of SIRs were 86%-92% similar to those based on random sampling. Random expectations explained 54%-84% of variation in numbers of HAIs. The use of SIRs led hundreds of hospitals with more infections than either expected at random or predicted by risk-adjusted models to rank better than other hospitals. The SIS mitigated this effect and allowed hospitals of disparate volumes to achieve better scores while decreasing the number of hospitals tied for the best score. CONCLUSIONS: SIRs and numbers of HAIs are strongly influenced by random effects of volume. Mitigating these effects drastically alters rankings for HAI types and may further alter penalty assignments in programs that aim to reduce HAIs and improve quality of care.

Risk Factors Associated With SARS-CoV-2 Seropositivity Among US Health Care Personnel.

Importance: Risks for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among health care personnel (HCP) are unclear. Objective: To evaluate the risk factors associated with SARS-CoV-2 seropositivity among HCP with the a priori hypothesis that community exposure but not health care exposure was associated with seropositivity. Design, Setting, and Participants: This cross-sectional study was conducted among volunteer HCP at 4 large health care systems in 3 US states. Sites shared deidentified data sets, including previously collected serology results, questionnaire results on community and workplace exposures at the time of serology, and 3-digit residential zip code prefix of HCP. Site-specific responses were mapped to a common metadata set. Residential weekly coronavirus disease 2019 (COVID-19) cumulative incidence was calculated from state-based COVID-19 case and census data. Exposures: Model variables included demographic (age, race, sex, ethnicity), community (known COVID-19 contact, COVID-19 cumulative incidence by 3-digit zip code prefix), and health care (workplace, job role, COVID-19 patient contact) factors. Main Outcome and Measures: The main outcome was SARS-CoV-2 seropositivity. Risk factors for seropositivity were estimated using a mixed-effects logistic regression model with a random intercept to account for clustering by site. Results: Among 24 749 HCP, most were younger than 50 years (17 233 [69.6%]), were women (19 361 [78.2%]), were White individuals (15 157 [61.2%]), and reported workplace contact with patients with COVID-19 (12 413 [50.2%]). Many HCP worked in the inpatient setting (8893 [35.9%]) and were nurses (7830 [31.6%]). Cumulative incidence of COVID-19 per 10 000 in the community up to 1 week prior to serology testing ranged from 8.2 to 275.6; 20 072 HCP (81.1%) reported no COVID-19 contact in the community. Seropositivity was 4.4% (95% CI, 4.1%-4.6%; 1080 HCP) overall. In multivariable analysis, community COVID-19 contact and community COVID-19 cumulative incidence were associated with seropositivity (community contact: adjusted odds ratio [aOR], 3.5; 95% CI, 2.9-4.1; community cumulative incidence: aOR, 1.8; 95% CI, 1.3-2.6). No assessed workplace factors were associated with seropositivity, including nurse job role (aOR, 1.1; 95% CI, 0.9-1.3), working in the emergency department (aOR, 1.0; 95% CI, 0.8-1.3), or workplace contact with patients with COVID-19 (aOR, 1.1; 95% CI, 0.9-1.3). Conclusions and Relevance: In this cross-sectional study of US HCP in 3 states, community exposures were associated with seropositivity to SARS-CoV-2, but workplace factors, including workplace role, environment, or contact with patients with known COVID-19, were not. These findings provide reassurance that current infection prevention practices in diverse health care settings are effective in preventing transmission of SARS-CoV-2 from patients to HCP.

Evaluating the Effectiveness of Written Dry Powder Inhaler Instructions and Health Literacy in Subjects Diagnosed With COPD.

BACKGROUND: Improper inhaler use results in decreased drug deposition in the lungs. The impact of health literacy and poor vision on the patient's ability to learn inhaler technique by reading instructions has not been confirmed. This study evaluated the effectiveness of learning inhaler technique from written instructions and the impact of health literacy for patients diagnosed with COPD who used a dry powder inhaler (DPI). METHODS: This pilot study recruited subjects diagnosed with COPD. A trained assessor scored subjects' inhaler technique before and after reading the appropriate American College of Chest Physicians handouts. Peak inspiratory flows (PIFs) were measured using an InCheck Dial. Health literacy was measured by the S-TOFHLA (Short Test of Functional Health Literacy in Adults), and visual acuity was measured by a Snellen chart. Associations between health literacy and visual acuity and changes in subjects' inhaler technique scores were assessed by Spearman's rho. Inhaler technique change scores were assessed by the Wilcoxon signed-rank test at P = .05. RESULTS: Of the 24 participants enrolled, 63% were female, mean age was 65.6 y, and 83% were Global Initiative for Chronic Obstructive Lung Disease air-flow limitation 2 or 3. Wilcoxon scores were significant for improved total scores for both the Diskus and HandiHaler, with medians improving from 6.5 to 7.0 (interquartile range 6.0-7.8) (P = .047) and from 6.0 to 7.5 (interquartile range 7.0-9.0) (P = .002), respectively. The minimum required PIF was achieved by 93.8% of the Diskus and 94.4% of the HandiHaler groups. There were no associations detected between the handout intervention (Diskus and HandiHaler) and health literacy level and vision. CONCLUSIONS: The educational handouts for DPIs helped participants already using a DPI to improve their inhaler technique. Stable participants diagnosed with COPD are able to generate appropriate PIFs to properly use DPIs. Neither vision nor health literacy was associated with the inability to learn inhaler technique from patient education inhaler device handouts.

Consumer Rankings and Health Care: Toward Validation and Transparency.

BACKGROUND: Differences between the Centers for Medicare & Medicaid Services (CMS)-measured rates of safety events for Rush University Medical Center (RUMC; Chicago) and the U. S. News & World Report (USNWR)-deter mined patient safety score were evaluated in an attempt to validate the USNWR patient safety score-based ranking. METHODS: The USNWR findings for Patient Safety Indicators (PSIs) were compared with findings derived from RUMC internal billing data, and sensitivity analyses were conducted using a simulated data set derived from the Healthcare Cost and Utilization Project (HCUP) state inpatient data sets. RESULTS: Discrepancies were found for PSIs 3 (Pressure Ulcer Rate), 9 (Perioperative Hemorrhage or Hematoma Rate), and 11 (Postoperative Respiratory Failure Rate)-an excess of 0.72, 0.63, and 0.26 cases/1,000 admissions, in USNWR versus RUMC, respectively). The sensitivity analysis, which included missing present on admission (POA) flags and dates, resulted in an increase of rates by 1.83 (95% confidence interval [CI] = 1.10-2.56) cases/1,000 hospital- izations, 2.72 (CI = 0.00-5.90) cases/1,000 hospitalizations, and 3.89 (CI = 1.60-6.20) cases/1,000 hospitalizations for PSI 3, 9, and 11, respectively. Regression modeling showed that each 1% increase in transfers was associated with an in- crease of 0.06 cases of PSI 3/1,000 admissions; each 1,000 increase in admissions was associated with an increase of 0.04 cases of PSI 9/1,000 admissions. CONCLUSION: The USNWR data set produced inaccurate PSI rates for RUMC, and false-positive event rates were more common among high-transfer and high-volume hos- pitals. More transparency and validation is needed for con- sumer-based benchmarking methods. In response to these findings and concerns raised by others, in 2016 USNWR made changes to its methodology and data sources and reported them in announcing its 2016-17 Best Hospitals.

The validity of International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for identifying patients hospitalized for COPD exacerbations.

BACKGROUND: Acute exacerbations of COPD (AE-COPD) are a leading cause of hospitalizations in the United States. To estimate the burden of disease (eg, prevalence and cost), identify opportunities to improve care quality (eg, performance measures), and conduct observational comparative effectiveness research studies, various algorithms based on the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes have been used to identify patients with COPD. However, the validity of these algorithms remains unclear. METHODS: We compared the test characteristics (sensitivity, specificity, positive predictive value, and negative predictive value) of four different coding algorithms for identifying patients hospitalized for an exacerbation of COPD with chart review (reference standard) using a stratified probability sample of 200 hospitalizations at two urban academic medical centers. Sampling weights were used when calculating prevalence and test characteristics. RESULTS: The prevalence of COPD exacerbations (based on the reference standard) was 7.9% of all hospitalizations. The sensitivity of all ICD-9-CM algorithms was very low and varied by algorithm (12%-25%), but the negative predictive value was similarly high across algorithms (93%-94%). The specificity was > 99% for all algorithms, but the positive predictive value varied by algorithm (81%-97%). CONCLUSIONS: Algorithms based on ICD-9-CM codes will undercount hospitalizations for AE-COPD, and as many as one in five patients identified by these algorithms may be misidentified as having a COPD exacerbation. These findings suggest that relying on ICD-9-CM codes alone to identify patients hospitalized for AE-COPD may be problematic.

Hospitalizations for acute exacerbations of chronic obstructive pulmonary disease: how you count matters.

ICD-9-CM diagnosis codes are increasingly used to estimate the burden of disease, as well as to evaluate the quality of care and outcomes of various conditions. Acute exacerbations of COPD (AE-COPD) are common and associated with substantial health and financial burden in the U.S. Whether published algorithms that employ different combinations of ICD-9-CM codes to identify patients hospitalized for AE-COPD yield similar or different estimates of disease burden is unclear. In this study, the Nationwide Inpatient Sample from years 2000-2006 was used to identify and compare the number of hospitalizations, healthcare utilization, and outcomes for patients hospitalized for AE-COPD in the U.S. AE-COPD was identified using five different published ICD-9-CM algorithms. Estimates of the annual number of hospitalizations for AE-COPD in the U.S. varied more than 2-fold (e.g., 421,000 to 870,000 in 2006). Outcomes and healthcare utilization of patients hospitalized for AE-COPD varied substantially, depending on the algorithm used (e.g., in-hospital mortality 2.0% to 5.1%, total hospital days 2.0 to 5.1 million in 2006). Observed trends in the number of hospitalizations over the 7-year period varied depending on which algorithm was used. In conclusion, the estimated health burden and trends in hospitalizations for AE-COPD in the United States differ, depending on which ICD-9-CM algorithm is used. To improve our understanding of the burden of AE-COPD and to ensure that quality of care initiatives are not misdirected, a validated approach to identifying patients hospitalized for AE-COPD is needed.

Perception of airflow obstruction in patients hospitalized for acute asthma.

BACKGROUND: Little is known about the perception of airflow obstruction in patients hospitalized for acute asthma. OBJECTIVES: To evaluate patient perception of airflow obstruction at hospital discharge and at a 2-week follow-up visit and to determine whether symptom control and/or severity of airflow obstruction identified patients at risk for acute asthma after discharge. METHODS: In a prospective cohort study of inner-city adults hospitalized for acute asthma from April 1, 2001, through October 31, 2002, symptom control (Asthma Control Questionnaire) and airflow obstruction (forced expiratory volume in 1 second [FEV1] percentage predicted) were evaluated at discharge and 2 weeks after discharge. We evaluated perception of airflow obstruction (symptom control vs FEV1 percentage predicted) and perception of change in airflow obstruction (change in symptom control vs percentage change in FEV1) between the 2 visits. Acute asthma after discharge was defined as an emergency department visit or hospitalization for asthma within 90 days of discharge. RESULTS: In fifty-one participants, symptom control was not significantly associated with airflow obstruction at hospital discharge (P = .30), indicating poor perception of airflow obstruction. Among the 41 participants (80.4% of those enrolled) who completed the follow-up visit, change in symptom control was not significantly associated with change in airflow obstruction (P = .20), indicating poor perception of change in airflow obstruction. Greater airflow obstruction at follow-up (P = .02) and a smaller improvement in airflow obstruction (P = .03), but not symptom control, were associated with a higher risk of acute asthma after discharge. CONCLUSIONS: Patients hospitalized for acute asthma have poor perception of airflow obstruction and change in airflow obstruction. Objective measurements of lung function should guide treatment decisions after discharge in this population.