Emergency hospitalizations for adverse drug events in older Americans.

BACKGROUND: Adverse drug events are important preventable causes of hospitalization in older adults. However, nationally representative data on adverse drug events that result in hospitalization in this population have been limited. METHODS: We used adverse-event data from the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project (2007 through 2009) to estimate the frequency and rates of hospitalization after emergency department visits for adverse drug events in older adults and to assess the contribution of specific medications, including those identified as high-risk or potentially inappropriate by national quality measures. RESULTS: On the basis of 5077 cases identified in our sample, there were an estimated 99,628 emergency hospitalizations (95% confidence interval [CI], 55,531 to 143,724) for adverse drug events in U.S. adults 65 years of age or older each year from 2007 through 2009. Nearly half of these hospitalizations were among adults 80 years of age or older (48.1%; 95% CI, 44.6 to 51.6). Nearly two thirds of hospitalizations were due to unintentional overdoses (65.7%; 95% CI, 60.1 to 71.3). Four medications or medication classes were implicated alone or in combination in 67.0% (95% CI, 60.0 to 74.1) of hospitalizations: warfarin (33.3%), insulins (13.9%), oral antiplatelet agents (13.3%), and oral hypoglycemic agents (10.7%). High-risk medications were implicated in only 1.2% (95% CI, 0.7 to 1.7) of hospitalizations. CONCLUSIONS: Most emergency hospitalizations for recognized adverse drug events in older adults resulted from a few commonly used medications, and relatively few resulted from medications typically designated as high-risk or inappropriate. Improved management of antithrombotic and antidiabetic drugs has the potential to reduce hospitalizations for adverse drug events in older adults.

Clinical preventive services for older adults: the interface between personal health care and public health services.

Healthy aging must become a priority objective for both population and personal health services, and will require innovative prevention programming to span those systems. Uptake of essential clinical preventive services is currently suboptimal among adults, owing to a number of system- and office-based care barriers. To achieve maximum health results, prevention must be integrated across community and clinical settings. Many preventive services are portable, deliverable in either clinical or community settings. Capitalizing on that flexibility can improve uptake and health outcomes. Significant reductions in health disparities, mortality, and morbidity, along with decreases in health spending, are achievable through improved collaboration and synergy between population health and personal health systems.

Identification of hospital-acquired catheter-associated urinary tract infections from Medicare claims: sensitivity and positive predictive value.

BACKGROUND AND OBJECTIVE: Hospital-acquired catheter-associated urinary tract infection (CAUTI) is one of the first 6 conditions Medicare is targeting to reduce payment associated with hospital-acquired conditions under Congressional mandate. This study was to determine the positive predictive value (PPV) and sensitivity in identifying patients in Medicare claims who had urinary catheterization and who had hospital-acquired CAUTIs. RESEARCH DESIGN: CAUTIs identified by ICD-9-CM codes in Medicare claims were compared with those revealed by medical record abstraction in random samples of Medicare discharges in 2005 to 2006. Hospital discharge abstracts (2005) from the states of New York and California were used to estimate the potential impact of a present-on-admission (POA) indicator on PPV. RESULTS: ICD-9-CM procedure codes for urinary catheterization appeared in only 1.4% of Medicare claims for patients who had urinary catheters. As a proxy, claims with major surgery had a PPV of 75% and sensitivity of 48%, and claims with any surgical procedure had a PPV of 53% and sensitivity of 79% in identifying urinary catheterization. The PPV and sensitivity for identifying hospital-acquired CAUTIs varied, with the PPV at 30% and sensitivity at 65% in claims with major surgery. About 80% of the secondary diagnosis codes indicating UTIs were flagged as POA, suggesting that the addition of POA indicators in Medicare claims would increase PPV up to 86% and sensitivity up to 79% in identifying hospital-acquired CAUTIs. CONCLUSIONS: The validity in identifying urinary catheter use and CAUTIs from Medicare claims is limited, but will be increased substantially upon addition of a POA indicator.

Importance of bacterial burden among methicillin-resistant Staphylococcus aureus carriers in a long-term care facility.

OBJECTIVE: To evaluate the prevalence and transmission of methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization, as well as risk factors associated with MRSA carriage, among residents of a long-term care facility (LTCF). DESIGN: Prospective, longitudinal cohort study. SETTING: A 100-bed Veterans Administration LTCF. PARTICIPANTS: All current and newly admitted residents of the LTCF during an 8-week study period. METHODS: Nasal swab samples were obtained weekly and cultured on MRSA-selective media, and the cultures were graded for growth on a semiquantitative scale from 0 (no growth) to 6 (heavy growth). Epidemiologic data for the periods before and during the study were collected to assess risk factors for MRSA carriage. RESULTS: Of 83 LTCF residents, 49 (59%) had 1 or more nasal swab cultures that were positive for MRSA; 34 (41%) were consistently culture-negative (designated "noncarriers"). Of the 49 culture-positive residents, 30 (36% of the total of 83 residents) had all cultures positive for MRSA (designated "persistent carriers"), and 19 (23% of the 83 residents) had at least 1 culture, but not all cultures, positive for MRSA (designated "intermittent carriers"). Multivariate analysis showed that participants with at least 1 nasal swab culture positive for MRSA were likely to have had previous hospitalization (odds ratio, 3.9) or wounds (odds ratio, 8.2). Persistent carriers and intermittent carriers did not differ in epidemiologic characteristics but did differ in mean MRSA growth score (3.7 vs 0.7; P<.001). CONCLUSIONS: Epidemiologic characteristics differed between noncarriers and subjects with at least 1 nasal swab culture positive for MRSA. However, in this LTCF population, only the degree of bacterial colonization (as reflected by mean MRSA growth score) distinguished persistent carriers from intermittent carriers. Understanding the burden of colonization may be important when determining future surveillance and control strategies.

Medication use leading to emergency department visits for adverse drug events in older adults.

BACKGROUND: The Beers criteria identify inappropriate use of medications in older adults. The number of and risk for adverse events from these medications are unknown. OBJECTIVE: To estimate the number of and risk for emergency department visits for adverse events involving Beers criteria medications compared with other medications. DESIGN: Nationally representative, public health surveillance of adverse drug events and a cross-sectional survey of outpatient medical visits. SETTING: National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance System, 2004-2005; National Ambulatory Medical Care Survey, 2004; and National Hospital Ambulatory Medical Care Survey, 2004. PARTICIPANTS: Persons 65 years of age or older seeking emergency department and outpatient care. MEASUREMENTS: Estimated number of and risks for emergency department visits for adverse drug events involving Beers criteria medications and other medications. RESULTS: Among U.S. patients 65 years of age or older, an estimated 177,504 emergency department visits (95% CI, 100,155 to 254,854 visits) for adverse drug events occurred both years. An estimated 3.6% (CI, 2.8% to 4.5%) of these visits were for adverse events medications considered to be always potentially inappropriate, according to the Beers criteria, and 33.3% (CI, 27.8% to 38.7%) of visits were for adverse events from 3 other medications (warfarin [17.3%], insulin [13.0%], and digoxin [3.2%]). Accounting for outpatient prescription frequency, the risk for emergency department visits for adverse events due to these 3 medications was 35 times (CI, 9.6 to 61) greater than that for medications considered to be always potentially inappropriate. LIMITATION: Adverse events were identified only in emergency departments. CONCLUSION: Compared with other medications, Beers criteria medications caused low numbers of and few risks for emergency department visits for adverse events. Performance measures and interventions targeting warfarin, insulin, and digoxin use could prevent more emergency department visits for adverse events.

Collection of Data on Race, Ethnicity, Language, and Nativity by US Public Health Surveillance and Monitoring Systems: Gaps and Opportunities.

OBJECTIVE: Despite increasing diversity in the US population, substantial gaps in collecting data on race, ethnicity, primary language, and nativity indicators persist in public health surveillance and monitoring systems. In addition, few systems provide questionnaires in foreign languages for inclusion of non-English speakers. We assessed (1) the extent of data collected on race, ethnicity, primary language, and nativity indicators (ie, place of birth, immigration status, and years in the United States) and (2) the use of data-collection instruments in non-English languages among Centers for Disease Control and Prevention (CDC)-supported public health surveillance and monitoring systems in the United States. METHODS: We identified CDC-supported surveillance and health monitoring systems in place from 2010 through 2013 by searching CDC websites and other federal websites. For each system, we assessed its website, documentation, and publications for evidence of the variables of interest and use of data-collection instruments in non-English languages. We requested missing information from CDC program officials, as needed. RESULTS: Of 125 data systems, 100 (80%) collected data on race and ethnicity, 2 more collected data on ethnicity but not race, 26 (21%) collected data on racial/ethnic subcategories, 40 (32%) collected data on place of birth, 21 (17%) collected data on years in the United States, 14 (11%) collected data on immigration status, 13 (10%) collected data on primary language, and 29 (23%) used non-English data-collection instruments. Population-based surveys and disease registries more often collected data on detailed variables than did case-based, administrative, and multiple-source systems. CONCLUSIONS: More complete and accurate data on race, ethnicity, primary language, and nativity can improve the quality, representativeness, and usefulness of public health surveillance and monitoring systems to plan and evaluate targeted public health interventions to eliminate health disparities.

Group a streptococcal disease in long-term care facilities: descriptive epidemiology and potential control measures.

Group A streptococci (GAS) are an important cause of severe, life-threatening illness among the elderly population, particularly those individuals residing in long-term care facilities (LTCFs). Outbreaks of GAS infection are potentially devastating in this vulnerable population and often require large-scale control efforts involving LTCF staff, public health officials, and infectious diseases practitioners. Although multiple outbreaks of GAS infection in LTCFs have been described in the medical literature, this topic has not been reviewed for 15 years, and there is a need for updated guidance on how to approach GAS infection outbreak control. We reviewed published documents on GAS infection in LTCFs to describe the current understanding of the disease's epidemiology in this setting, identify techniques for outbreak investigation and prevention, and expose areas where additional research is needed. We highlight well-accepted prevention and control strategies that can be employed during investigation and control of GAS infection outbreaks in LTCFs.

Estimating health care-associated infections and deaths in U.S. hospitals, 2002.

OBJECTIVE: The purpose of this study was to provide a national estimate of the number of healthcare-associated infections (HAI) and deaths in United States hospitals. METHODS: No single source of nationally representative data on HAIs is currently available. The authors used a multi-step approach and three data sources. The main source of data was the National Nosocomial Infections Surveillance (NNIS) system, data from 1990-2002, conducted by the Centers for Disease Control and Prevention. Data from the National Hospital Discharge Survey (for 2002) and the American Hospital Association Survey (for 2000) were used to supplement NNIS data. The percentage of patients with an HAI whose death was determined to be caused or associated with the HAI from NNIS data was used to estimate the number of deaths. RESULTS: In 2002, the estimated number of HAIs in U.S. hospitals, adjusted to include federal facilities, was approximately 1.7 million: 33,269 HAIs among newborns in high-risk nurseries, 19,059 among newborns in well-baby nurseries, 417,946 among adults and children in ICUs, and 1,266,851 among adults and children outside of ICUs. The estimated deaths associated with HAIs in U.S. hospitals were 98,987: of these, 35,967 were for pneumonia, 30,665 for bloodstream infections, 13,088 for urinary tract infections, 8,205 for surgical site infections, and 11,062 for infections of other sites. CONCLUSION: HAIs in hospitals are a significant cause of morbidity and mortality in the United States. The method described for estimating the number of HAIs makes the best use of existing data at the national level.

Preventing antimicrobial-resistant bacterial infections among older adults in long-term care facilities.

For older adults in long-term care facilities (LTCFs), the rate of infections caused by antimicrobial resistant strains of bacteria has increased and is prompting renewed interest in investing health care resources for prevention and control of these pathogens. This document offers a simple framework to combat infections due to antimicrobial resistant bacteria in LTCF residents by providing a multi-step approach consisting of four major strategies: prevent infection, diagnose and treat infection effectively, use antimicrobials wisely, and prevent transmission. Recommendations from this multi-step approach are directed at LTCF medical directors and practicing clinicians involved with the medical care of older adult LTCF residents.

Preventing antimicrobial-resistant bacterial infections among older adults in long-term care facilities.

For older adults in long-term care facilities (LTCFs), the rate of infections caused by antimicrobial resistant strains of bacteria has increased and is prompting renewed interest in investing health care resources for prevention and control of these pathogens. This document offers a simple framework to combat infections due to antimicrobial resistant bacteria in LTCF residents by providing a multi-step approach consisting of four major strategies: prevent infection, diagnose and treat infection effectively, use antimicrobials wisely, and prevent transmission. Recommendations from this multi-step approach are directed at LTCF medical directors and practicing clinicians involved with the medical care of older adult LTCF residents.

Antimicrobial use in post-acute care: a retrospective descriptive analysis in seven long-term care facilities in Georgia.

BACKGROUND: Antimicrobial use in long-term care facilities (LTCF) is an important public health issue, especially regarding its potential role in antimicrobial resistance. Up to two thirds of long-stay LTCF residents receive antimicrobial therapy each year. However, little is known specifically about antimicrobial use in short-stay LTCF residents receiving post-acute care. METHODS: The authors conducted a retrospective chart review of a random sample of residents admitted for post-acute care in seven LTCFs in Georgia from September 1, 1999 to August 31, 2000 to determine the rates and characteristics of antimicrobial prescribing in this population. RESULTS: Of 221 post-acute care residents, 105 (48%) received 152 courses of antimicrobial therapy during their post-acute stay. At least one antimicrobial was prescribed on 796 of 5220 resident-days (15%). Antimicrobial therapy was split evenly between hospital-initiated antimicrobial therapy (n = 53, 50%) and antimicrobial therapy initiated in the LTCF during post-acute care (n = 52, 50%). Levofloxacin was the most commonly prescribed antimicrobial. Where documentation on the suspected infection was present, the most common infections were urinary tract infections (UTIs) and pneumonias. For residents with post-acute care-initiated therapy, documentation regarding the presumed source of infection was absent for 44% of antimicrobial prescriptions. Most antimicrobial courses initiated for presumed infections in post-acute care were by telephone orders (66%). CONCLUSIONS: Utilization of antimicrobial therapy in LTCF residents in post-acute care is relatively high and may be greater than for long-stay LTCF residents. For hospital-initiated therapy, improved communication between hospital and LTCF staff may improve documentation and antimicrobial therapy in LTC. For antimicrobial therapy initiated by telephone orders in post-acute care, improving documentation of suspected source of infection is needed.

Invasive pneumococcal disease in older adults residing in long-term care facilities and in the community.

OBJECTIVES: To examine the epidemiology of invasive pneumococcal disease in older adults hospitalized for invasive pneumococcal disease who are living in the community and in long-term care facilities (LTCFs) in the United States. DESIGN: Analysis of 2402 cases of invasive pneumococcal disease requiring hospitalization in 2000 and 2001 that the Centers for Disease Control and Prevention's Active Bacterial Core Surveillance collected in nine states. SETTING: Hospital. PARTICIPANTS: Hospitalized LTCF residents and community-living older adults in the United States. MEASUREMENTS: Age- and residence-specific pneumococcal disease incidence rates per 100000 persons, case-fatality rates, and trends in antimicrobial resistance. RESULTS: Nationally, the rate of invasive pneumococcal disease in LTCF residents was 194.2 cases per 100000 persons aged 65 and older and 44.6 for community-living older adults (relative risk=4.4, 95% confidence interval (CI)=4.2-4.5). Compared with community-living older adults, case-fatality rates were 1.9 times higher (30.8% vs 16.0%, 95% CI=1.5-2.5). Pneumococcal strains from LTCF residents were significantly more likely to be nonsusceptible to levofloxacin than strains from community- living older adults (5.7% vs 0.4%, P<.001). CONCLUSION: Older adults living in LTCFs are at a higher risk for invasive pneumococcal disease and death than are community-living older adults. Additionally, fluoroquinolone resistance is significantly higher in older adults living in LTCFs and may provide clues to emerging antimicrobial resistance in the general population.

The role of the obstetrician-gynecologist in emerging infectious diseases: monkeypox and pregnancy.

Early in June 2003, the Centers for Disease Control and Prevention (CDC) announced yet another unique infectious disease outbreak, the first evidence of community-acquired monkeypox in the United States. By July 8, 2003, a total of 71 cases had been reported to CDC from 6 states. When emerging infectious diseases are reported in the United States, particularly when these reports receive widespread media attention, obstetrician-gynecologists may be called upon to rapidly respond to queries from their patients and to address certain infectious disease risks within their clinical practices. In addition, obstetrician-gynecologists may have specific concerns about the implications for an infectious disease outbreak, such as monkeypox, for pregnant women. Therefore, it is important that obstetrician-gynecologists know how to gather up-to-date and accurate information about infectious disease outbreaks and that they be familiar with the public health response system for responding to such outbreaks.

Quality care indicators and staffing levels in a nursing facility subacute unit.

OBJECTIVE: To determine whether admissions to a subacute unit in a university-affiliated nursing facility received equivalent care on weekdays as opposed to on weekends with regard to certified nursing assistant (CNA) and licensed nurse staffing levels. DESIGN/SETTING: A 6-month prospective analytical study conducted from January to July 2000. All subacute unit residents admitted to this unit were monitored for the presence of specific outcome measures that were correlated to CNA and licensed nurse staffing levels during the day shift. The setting was a 14-bed subacute unit within a 150-bed skilled nursing facility in Atlanta, GA. PRIMARY OUTCOME MEASURES: The quality care indicators used were measured by objective data obtained prospectively from the chart and medication administration record. The parameters monitored included medication errors, falls, presence of required daily nursing note and documentation of meals eaten. Each resident served as his or her own control for analyses conducted between Tuesdays and Thursdays (weekdays) as opposed to Saturdays and Sundays (weekends). Median staffing ratios compared the number of CNAs and licensed nurses on duty between weekdays with the number who were on duty on weekends during each resident's stay. RESULTS: From January until July 2000, a total of 31 residents (25 women, 6 men) were admitted to the subacute unit. Among these residents, the total of weekday and weekend 24-hour reviews was equal to 1,044 resident care days during this 6-month study. The age range of these residents was 65 to 104 years, with a mean age of 82.0 years. Median nurse staffing levels were lower on weekend than on weekday day shifts (3 vs. 4; P < 0.001). Median CNA staffing levels were also lower on weekend than on weekday day shifts (4 vs. 5; P < 0.001). A total of 12 (39%) of 31 of residents were missing a total of 22 of 1,044 total required notes. This was 2 (0.3%) of 522 for weekdays as compared with 20 (3.8%) of 522 for weekends (P < 0.001). With regard to documentation of food intake, data were omitted for 199 of 1,884 meals on weekdays as compared with 343 (18.2%) of 1,884 meals on weekends (P < 0.001). The rate for falls was 1 (0.19%) of 522 on weekdays as compared with 4 (0.77%) of 522 on weekends (P < 0.05). There was no significant difference in medication errors detected. CONCLUSIONS: There was a significant decrease in staffing levels for both nurses and CNAs during the day shift on weekends. Increased omission of required daily nursing notes, of meal documentation and increased falls appears to be associated with lower levels of weekend staffing. There were no significant differences in medication errors during this study. Whether the lapses in documentation actually resulted in a lower level of delivered care cannot be determined at this time.

Urinary tract infections in the frail elderly: issues for diagnosis, treatment and prevention.

Urinary tract infections (UTIs) are among the most common infections in frail elderly adults, whether they are community dwelling, live in long term care facilities (LTCFs) or are hospitalized. UTIs cause substantial morbidity and mortality in frail elderly men and women. While many major risk factors in these individuals may not be modifiable, improved attention to incontinence management, judicious use of antimicrobials and urinary catheters, and, in women, appropriate use of topical estrogen may be useful in reducing UTIs. Future strategies may also include the appropriate use of new urinary catheter technology and emerging vaccines.