Association Between Initial Route of Fluoroquinolone Administration and Outcomes in Patients Hospitalized for Community-acquired Pneumonia.

BACKGROUND: Fluoroquinolones have equivalent oral and intravenous bioavailability, but hospitalized patients with community-acquired pneumonia (CAP) generally are treated intravenously. Our objectives were to compare outcomes of hospitalized CAP patients initially receiving intravenous vs oral respiratory fluoroquinolones. METHODS: This was a retrospective cohort study utilizing data from 340 hospitals involving CAP patients admitted to a non-intensive care unit (ICU) setting from 2007 to 2010, who received intravenous or oral levofloxacin or moxifloxacin. The primary outcome was in-hospital mortality. Secondary outcomes included clinical deterioration (transfer to ICU, initiation of vasopressors, or invasive mechanical ventilation [IMV] initiated after the second hospital day), antibiotic escalation, length of stay (LOS), and cost. RESULTS: Of 36 405 patients who met inclusion criteria, 34 200 (94%) initially received intravenous treatment and 2205 (6%) received oral treatment. Patients who received oral fluoroquinolones had lower unadjusted mortality (1.4% vs 2.5%; P = .002), and shorter mean LOS (5.0 vs 5.3; P < .001). Multivariable models using stabilized inverse propensity treatment weighting revealed lower rates of antibiotic escalation for oral vs intravenous therapy (odds ratio [OR], 0.84; 95% confidence interval [CI], .74-.96) but no differences in hospital mortality (OR, 0.82; 95% CI, .58-1.15), LOS (difference in days 0.03; 95% CI, -.09-.15), cost (difference in $-7.7; 95% CI, -197.4-182.0), late ICU admission (OR, 1.04; 95% CI, .80-1.36), late IMV (OR, 1.17; 95% CI, .87-1.56), or late vasopressor use (OR, 0.94; 95% CI, .68-1.30). CONCLUSIONS: Among hospitalized patients who received fluoroquinolones for CAP, there was no association between initial route of administration and outcomes. More patients may be treated orally without worsening outcomes.

Association of guideline-based antimicrobial therapy and outcomes in healthcare-associated pneumonia.

OBJECTIVES: Guidelines for treatment of healthcare-associated pneumonia (HCAP) recommend empirical therapy with broad-spectrum antimicrobials. Our objective was to examine the association between guideline-based therapy (GBT) and outcomes for patients with HCAP. PATIENTS AND METHODS: We conducted a pharmacoepidemiological cohort study at 346 US hospitals. We included adults hospitalized between July 2007 and June 2010 for HCAP, defined as patients admitted from a nursing home, with end-stage renal disease or immunosuppression, or discharged from a hospital in the previous 90 days. Outcome measures included in-hospital mortality, length of stay and costs. RESULTS: Of 85 097 patients at 346 hospitals, 31 949 (37.5%) received GBT (one agent against MRSA and at least one against Pseudomonas). Compared with patients who received non-GBT, those who received GBT had a heavier burden of chronic disease and more severe pneumonia. GBT was associated with higher mortality (17.1% versus 7.7%, P < 0.001). Adjustment for demographics, comorbidities, propensity for treatment with GBT and initial severity of disease decreased, but did not eliminate, the association (OR 1.39, 95% CI 1.32-1.47). Using an adaptation of an instrumental variable analysis, GBT was not associated with higher mortality (OR 0.93, 95% CI 0.75-1.16). Adjusted length of stay and costs were also higher with GBT. CONCLUSIONS: Among patients who met HCAP criteria, GBT was not associated with lower adjusted mortality, length of stay or costs in any analyses. Better criteria are needed to identify patients at risk for MDR infections who might benefit from broad-spectrum antimicrobial coverage.

Curating a media-linked curriculum.

BACKGROUND: The COVID-19 pandemic motivated considerable educational innovation in technology-enhanced learning (TEL), and educators must now thoughtfully apply identified best practices to both in-person and virtual learning experiences through instructional design and reflective practice. This paper describes the development and evaluation of an innovation utilising TEL to enhance our core curriculum content and students' learning. APPROACH: The curriculum-linked media (CLM) was introduced as a part of a doctoring and clinical skills course for pre-clinical medical students as a structured curriculum that pairs audio and/or video-based content with reflection prompts designed to prime students for active, in-person learning upon arrival to their classrooms. The CLM aimed to help students (1) gain a deeper understanding of the course content, (2) partake in reflective practice and (3) explore diverse perspectives on a particular topic. EVALUATION: All students completed a survey at the end of their academic year to evaluate the activity. Some students found the innovation helpful in that it facilitated perspective taking and prepared them for their in-person class. The reflection questions that paired with the media prompted discussion in class and a deeper connection with the materials. Making the content relevant to the local community and highlighting regional issues made the activity more relatable. IMPLICATIONS: Our experience demonstrated that the CLM model can be a helpful and efficient tool to stretch the educational reach of the classroom. Future applications may consider the implementation and evaluation of the model with clinical students and postgraduate trainees.

Evaluation of a Health Professions Teaching Academy Through the Lens of Social Capital.

INTRODUCTION: Academies of health professions educators can amplify members' social capital, promoting educational innovation and organizational change. However, research in this area is limited. This article attempts to close the gap in literature with the results of a program evaluation of our interprofessional teaching academy through the lens of social capital and organizational culture. METHODS: A program evaluation using a cross-sectional survey was conducted with all members of the Baystate Education Research and Scholarship of Teaching (BERST) Academy. The survey drew on a conceptual framework from previous literature on social capital, communities of practice, and faculty development evaluation. Data were analyzed with descriptive statistics and analysis of variance. RESULTS: Overall survey response rate was 54%. More than 90% of respondents have applied the skills learned through BERST Academy into their practice. Social capital was defined with five items (Cronbach alpha = 0.87), and we found no significant difference between profession and social capital, suggesting that perceptions of social capital did not significantly differ by membership in a specific profession. DISCUSSION: Our results showed that BERST Academy members were able to cultivate social capital through high-quality connections. An academy can serve as a unique culture within an institution to foster collaborative relationships that increase social capital, for members of different professions. In addition, an academy can also provide members with a community that benefits them in the greater organizational culture.

Using highly detailed administrative data to predict pneumonia mortality.

BACKGROUND: Mortality prediction models generally require clinical data or are derived from information coded at discharge, limiting adjustment for presenting severity of illness in observational studies using administrative data. OBJECTIVES: To develop and validate a mortality prediction model using administrative data available in the first 2 hospital days. RESEARCH DESIGN: After dividing the dataset into derivation and validation sets, we created a hierarchical generalized linear mortality model that included patient demographics, comorbidities, medications, therapies, and diagnostic tests administered in the first 2 hospital days. We then applied the model to the validation set. SUBJECTS: Patients aged ≥ 18 years admitted with pneumonia between July 2007 and June 2010 to 347 hospitals in Premier, Inc.'s Perspective database. MEASURES: In hospital mortality. RESULTS: The derivation cohort included 200,870 patients and the validation cohort had 50,037. Mortality was 7.2%. In the multivariable model, 3 demographic factors, 25 comorbidities, 41 medications, 7 diagnostic tests, and 9 treatments were associated with mortality. Factors that were most strongly associated with mortality included receipt of vasopressors, non-invasive ventilation, and bicarbonate. The model had a c-statistic of 0.85 in both cohorts. In the validation cohort, deciles of predicted risk ranged from 0.3% to 34.3% with observed risk over the same deciles from 0.1% to 33.7%. CONCLUSIONS: A mortality model based on detailed administrative data available in the first 2 hospital days had good discrimination and calibration. The model compares favorably to clinically based prediction models and may be useful in observational studies when clinical data are not available.

Four years' experience with a hospitalist-led medical emergency team: an interrupted time series.

BACKGROUND: The effect of Medical Emergency Teams (METs) on cardiopulmonary arrests (codes) and fatal codes remains unclear and widely debated. OBJECTIVE: To describe the implementation of a hospitalist-led MET and compare the number of code calls and code deaths before and after implementation. DESIGN: Interrupted time series. SETTING: Tertiary care academic medical center. PATIENTS: All hospitalized patients. INTERVENTION: Implementation of an MET, consisting of a critical care nurse, respiratory therapist, intravenous therapist, and the patient's physician. MEASUREMENTS: Number of MET calls, code calls, cardiac arrests and other medical crises, and code deaths per 1000 admissions, stratified by location (inside vs outside critical care). RESULTS: From implementation in March 2006 through December 2009, the MET logged 2717 calls, most commonly for respiratory distress (33%), cardiovascular instability (25%), and neurological abnormality (20%). Overall code calls declined significantly between pre-implementation and post-implementation of the MET from 7.30 (95% confidence interval [CI] 5.81, 9.16) to 4.21 (95% CI 3.42, 5.18) code calls per 1000 admissions. Outside of critical care, code calls declined from 4.70 (95% CI 3.92, 5.63) before the MET was implemented to 3.11 (95% CI 2.44, 3.97) afterwards, primarily due to a decrease in medical crises, which averaged 3.29 events per 1000 admissions (95% CI 2.70, 4.02) before implementation and decreased to 1.72 (95% CI 1.28, 2.31) afterwards. Code calls within critical care also declined. The rate of fatal codes was not affected. CONCLUSIONS: A hospitalist-led MET decreased code call rates but did not affect mortality rates.

A simulation-based program to train medical residents to lead and perform advanced cardiovascular life support.

BACKGROUND: Medical residents are often responsible for leading and performing cardiopulmonary resuscitation; however, their levels of expertise and comfort as leaders of advanced cardiovascular life support (ACLS) teams vary widely. While the current American Heart Association ACLS course provides education in recommended resuscitative protocols, training in leadership skills is insufficient. In this article, we describe the design and implementation in our institution of a formative curriculum aimed at improving residents' readiness for being leaders of ACLS teams using human patient simulation. Human patient simulation refers to a variety of technologies using mannequins with realistic features, which allows learners to practice through scenarios without putting patients at risk. We discuss the limitations of the program and the challenges encountered in implementation. We also provide a description of the initiation and organization of the program. Case scenarios and assessment tools are provided. DESCRIPTION OF THE INSTITUTIONAL TRAINING PROGRAM: Our simulation-based training curriculum consists of 8 simulated patient scenarios during four 1-hour sessions. Postgraduate year-2 and 3 internal medicine residents participate in this program in teams of 4. Assessment tools are utilized only for formative evaluation. Debriefing is used as a teaching strategy for the individual resident leader of the ACLS team to facilitate learning and improve performance. To evaluate the impact of the curriculum, we administered a survey before and after the intervention. The survey consisted of 10 questions answered on a 5-point Likert scale, which addressed residents' confidence in leading ACLS teams, management of the equipment, and management of cardiac rhythms. Respondents' mean presimulation (ie, baseline) and postsimulation (ie, outcome) scores were compared using a 2-sample t test. Residents' overall confidence score improved from 2.8 to 3.9 (P < 0.001; mean improvement, 1.1; 95% confidence interval, 0.7-1.6). The average score for performing and leading ACLS teams improved from 2.8 to 4 (P < 0.001; mean difference, 1.2; 95% confidence interval, 0.7-1.7). There was a uniform increase in the residents' self-confidence in their role as effective leaders of ACLS teams, and residents valued this simulation-based training program.

International outsourcing of medical research by high-income countries: changes from 1995 to 2005.

BACKGROUND: Medical research outsourcing provides a financial benefit to those conducting research and financial incentives to the developing countries hosting the research. Little is known about how frequently outsourcing occurs or the type of research that is outsourced. METHODS: To document changes in medical research outsourcing over a 10-year period, we conducted a cross-sectional comparison of 3 medical journals: Lancet, The New England Journal of Medicine, and JAMA: The Journal of the American Medical Association in the last 6 months of 1995 and 2005. The main outcome measure was the 10-year change in proportion of studies including patients from low-income countries. FINDINGS: We reviewed 598 articles. During the 10-year period, the proportion of first authors from low-income countries increased from 3% to 6% (P = 0.21), whereas studies with participants from low-income countries increased from 8% to 22% (P = < 0.001). In 2005, compared with studies conducted exclusively in high-income countries, those including participants from low-income countries were more likely to be randomized trials (55% vs 35%, P = 0.004), to study medications (65% vs 34%, P < 0.001), to be funded by pharmaceutical companies (33% vs 21%, P = 0.05), and to involve pediatric populations (29% vs 8%, P < 0.001). INTERPRETATION: Outsourcing of medical research seems to be increasing. Additional studies are required to know if subjects from low-income countries are being adequately protected.