Yelp for Prescribers: A Quasi-Experimental Study of Providing Antibiotic Cost Data and Prescription of High-Cost Antibiotics in an Academic and Tertiary Care Hospital.

BACKGROUND: Physicians frequently prescribe antibiotics to inpatients without knowledge of medication cost. It is not well understood whether providing cost data would change prescribing behavior. OBJECTIVE: To evaluate the association between providing cost data alongside culture and antibiotic susceptibility results and prescribing of high-cost antibiotics. DESIGN: Quasi-experimental pre-post analysis. PARTICIPANTS: Inpatients diagnosed with bacteremia or urinary tract infection in two tertiary care hospitals. INTERVENTION: Cost category data for each antibiotic ($, $$, $$$, or $$) were added to culture and susceptibility testing results available to physicians. MAIN MEASURES: Average cost category of antibiotics prescribed to patients after the receipt of susceptibility testing results. KEY RESULTS: There was a significant decrease in the average cost category of antibiotics per patient after the intervention (pre-intervention = 1.9 $ vs. post-intervention = 1.7 $, where 1.5 $ would mean that the average number of dollar signs for antibiotics prescribed was between $ and $$, p = 0.002). After adjusting for age, insurance type, and prior length of stay, the odds ratio (OR) of a patient's average antibiotic being higher cost vs. lower cost after the intervention compared to before the intervention was 0.74 [95% confidence interval (CI) 0.56, 0.98]. The intervention was associated with a 31.3% reduction in the average cost per unit of antibiotics prescribed (p < 0.001). CONCLUSIONS: Providing physicians with cost feedback alongside susceptibility testing data was associated with a significant decrease in prescription of high-cost antibiotics. This intervention is intuitive, low cost, and may shift providers toward lower cost medications when equally acceptable options are available.

Increased cardiovascular disease, resource use, and costs before the clinical diagnosis of diabetes in veterans in the southeastern U.S.

IMPORTANCE: Screening for diabetes might be more widespread if adverse associations with cardiovascular disease (CVD), resource use, and costs were known to occur earlier than conventional clinical diagnosis. OBJECTIVE: The purpose of this study was to determine whether adverse effects associated with diabetes begin prior to clinical diagnosis. DESIGN: Veterans with diabetes were matched 1:2 with controls by follow-up, age, race/ethnicity, gender, and VA facility. CVD was obtained from ICD-9 codes, and resource use and costs from VA datasets. SETTING: VA facilities in SC, GA, and AL. PARTICIPANTS: Patients with and without diagnosed diabetes. MAIN OUTCOME MEASURES: Diagnosed CVD, resource use, and costs. RESULTS: In this study, the 2,062 diabetic patients and 4,124 controls were 63 years old on average, 99 % male, and 29 % black; BMI was 30.8 in diabetic patients vs. 27.8 in controls (p<0.001). CVD prevalence was higher and there were more outpatient visits in Year -4 before diagnosis through Year +4 after diagnosis among diabetic vs. control patients (all p<0.01); in Year -2, CVD prevalence was 31 % vs. 24 %, and outpatient visits were 22 vs. 19 per year, respectively. Total VA costs/year/veteran were higher in diabetic than control patients from Year -4 ($4,083 vs. $2,754) through Year +5 ($8,347 vs. $5,700) (p<0.003) for each, reflecting underlying increases in outpatient, inpatient, and pharmacy costs (p<0.05 for each). Regression analysis showed that diabetes contributed an average of $1,748/year to costs, independent of CVD (p<0.001). CONCLUSIONS AND RELEVANCE: VA costs per veteran are higher--over $1,000/year before and $2,000/year after diagnosis of diabetes--due to underlying increases in outpatient, inpatient, and pharmacy costs, greater number of outpatient visits, and increased CVD. Moreover, adverse associations with veterans' health and the VA healthcare system occur early in the natural history of the disease, several years before diabetes is diagnosed. Since adverse associations begin before diabetes is recognized, greater consideration should be given to systematic screening in order to permit earlier detection and initiation of preventive management. Keeping frequency of CVD and marginal costs in line with those of patients before diabetes is currently diagnosed has the potential to save up to $2 billion a year.

Optic neuropathy, myelopathy, anemia, and neutropenia caused by acquired copper deficiency after gastric bypass surgery.

Malabsorptive bariatric surgery is rapidly becoming a major cause of copper deficiency given the increasing prevalence of these procedures for morbid obesity. Acquired copper deficiency can present with clinically significant hematologic and neurological manifestations. Although hematologic manifestations of copper deficiency are rapidly reversible, significant neurological improvement after copper supplementation therapy is unusual and many patients remain debilitated and may only experience, at best, stabilization of the neurological manifestations. Here we present a case of an undiagnosed copper deficiency several years after bariatric gastric bypass surgery, in a patient who concomitantly used zinc-containing denture cream for several years, associated with anemia, neutropenia, myelopathy, respiratory failure, and bilateral optic neuropathy, which caused major vision loss. This patient was also a heterozygote carrier of the 5,10-methylenetetrahydrofolate reductase A1298C gene polymorphism, which may affect copper metabolism. Intravenous copper repletion resulted in rapid correction of hematologic indices. However, neurological manifestations, including vision loss responded only modestly to copper supplementation, despite achieving normal blood copper concentrations. Clinicians should consider copper deficiency in patients at risk, as in this case, as a delayed diagnosis can lead to irreversible disability due to neurological manifestations.

Severe leptospirosis: treatment with intravenous corticosteroids and supportive care.

Leptospirosis is a common zoonotic infection worldwide and is recognized as an emerging public health problem. Although commonly thought of as a tropical disease, incidence in temperate climates is increasing, with recent outbreaks in the United States and Germany, among other countries. The disease presents with symptoms ranging from fever, headache, nausea, and vomiting to life-threatening multiorgan failure characterized by acute liver failure, nephritis, pulmonary hemorrhage, meningitis, and cardiac arrhythmia. We describe a case of an otherwise healthy 28-year-old man who had just returned from a 2-month trip to Southeast Asia. He presented to our emergency department twice after his return with the complaint of fever and malaise. Initially, he was treated with symptomatic measures and discharged home with malaria smears and blood cultures pending. On his final presentation before admission, he presented with severe fatigue, myalgia, acute renal failure, and marked thrombocytopenia. After several days, inpatient testing revealed the patient's leptospira antibody titer was markedly positive. Given the nonspecificity of patient symptoms, early diagnosis of leptospirosis can be challenging. Diagnostic uncertainty may lead to delay in recommended intravenous antibiotic treatment. We present a case of severe leptospirosis treated exclusively with supportive measures and intravenous corticosteroids.

Development of a patient-centered bilingual prescription drug label.

Research shows that prescription drug labels are often difficult for patients to understand, which contributes to medication errors and nonadherence. In this study, the authors developed and qualitatively evaluated an evidence-based bilingual prescription container label designed to improve understanding. The authors developed several prototypes in English only or in English and Spanish. The labels included an image of the drug, an icon to show its purpose, and plain-language instructions presented in a 4-time-of-day table. In 5 focus groups and interviews that included 57 participants, patients and pharmacists critically reviewed the designs and compared them with traditional medication labels and reformatted labels without illustrations. Patients strongly preferred labels that grouped patient-relevant content, highlighted key information, and included drug indication icons. They also preferred having the 4-time-of-day table and plain-language text instructions as opposed to either one alone. Patients preferred having pertinent warnings on the main label instead of auxiliary labels. Pharmacists and Latino patients valued having Spanish and English instructions on the label, so both parties could understand the content. The final label design adheres to the latest national- and state-level recommendations for label format and incorporates additional improvements on the basis of patient and pharmacist input. This design may serve as a prototype for improving prescription drug labeling.

The health of safety net hospitals following Massachusetts health care reform: changes in volume, revenue, costs, and operating margins from 2006 to 2009.

Massachusetts health care reform, designed to expand coverage and access to care for vulnerable populations, serves as the model for national health reform in the United States that will be implemented in 2014. Yet, little is known about how the reform may have affected the demand for and the financial performance of safety net hospitals (SNH), the primary source of care for such populations before the reform. Using a quasi-experimental design that included all acute care hospitals in the state, we calculated changes in mean inpatient and outpatient volumes, revenue, and operating margins at SNH from the pre-reform (Fiscal Year 2006) to the post-reform (Fiscal Year 2009) period. We contrasted these changes with contemporaneous changes occurring among non-safety net hospitals (NSNH) using a difference-in-differences approach. We found that SNH in Massachusetts continue to play a disproportionately large role in caring for disadvantaged patients after reform, but that their financial performance has declined considerably compared with NSNH. Ongoing reform efforts in the United States should account for continued SNH demand among the most vulnerable patients and should be designed so as not to undermine the financial stability of SNH that meet this demand.

Discovery of imidazopyridine-pyrazoline-hybrid structure as SHP-1 agonist that suppresses phospho-STAT3 signaling in human breast cancer cells.

Signal transducer and activator of transcription 3 (STAT3) promotes breast cancer malignancy and controls key processes including proliferation, differentiation, and survival in breast cancer cells. Although many methods for treating breast cancer have been improved, there is still a need to discover and develop new methods for breast cancer treatment. Therefore, we synthesized a new compound 2-(4-(2,3-dichlorophenyl)piperazin-1-yl)-1-(3-(2,6-dimethylimidazo[1,2-a]pyridin-3-yl)-5-(3-nitrophenyl)-4,5-dihydro-1H-pyrazol-1-yl)ethanone (DIP). We aimed to evaluate the anti-cancer effect of DIP in breast cancer cells and clarify its mode of action. We noted that DIP abrogated STAT3 activation and STAT3 upstream kinases janus-activated kinase (JAK) and Src kinases. In addition, DIP promoted the levels of SHP-1 protein and acts as SHP-1 agonist. Further, silencing of SHP-1 gene reversed the DIP-induced attenuation of STAT3 activation and apoptosis. DIP also induced apoptosis through modulating PARP cleavage and oncogenic proteins. Moreover, DIP also significantly enhanced the apoptotic effects of docetaxel through the suppression of STAT3 activation in breast cancer cells. Overall, our data indicated that DIP may act as a suppressor of STAT3 cascade, and it could be a new therapeutic strategy in breast cancer cells.

Morphological Study of Hashimoto Thyroiditis in Fine Needle Aspiration Cytology Specimens.

Background: Hashimoto thyroiditis is an autoimmune disease which is diagnosed based on well-defined clinical and cytological criteria. Purpose: The objective of this research is to study cytomorphological features in patients of Hashimoto thyroiditis and compare the findings with other studies. Literature on morphology of multinucleated giant cells was found to be lacking, and this study has focused on the number and morphology of these cells in this study. Material and Methods: FNAC was done in patients who met the clinical diagnostic criteria of Hashimoto thyroiditis formulated by "Japan Thyroid Association" and smears were analyzed by light microscopy. Data analysis was done by XLSTAT in Microsoft Excel 2010. The Wilcoxon Signed Rank Test was done to analyze the data on multinucleated giant cells. The null hypothesis was that the median of the population of differences between the paired data of small and large giant cells is zero. Results: A total of 26 patients were included in a period of one year. Contrary to observations in other studies, multinucleated giant cells were found in most participants. The Wilcoxon Signed Rank Test proved that small multinucleated giant cells were significantly more common than large multinucleated giant cells in Hashimoto thyroiditis; P value (two-tailed) being <0.0001 at significance alpha of 0.05. This study has also revealed that a few patients with Hashimoto thyroiditis can have large and very large multinucleated giant cells in a small number. Data on other cytomorphological features were no different than in other studies. Conclusion: The presence of multinucleated giant cells in 92.3% of patients in this study is far higher than in other studies which can have important diagnostic implications. Few large multinucleated giant cells can be present in a small number in a few patients as in Hashimoto thyroiditis.

PictureRx: Illustrated medication instructions for patients with limited health literacy.

OBJECTIVES: To describe the role of illustrated medication instructions in pharmacy practice, the evidence for their use, and our experience with their implementation. PRACTICE DESCRIPTION: PictureRx is applicable to all pharmacy practice settings. PRACTICE INNOVATION: PictureRx enables pharmacists to rapidly produce evidence-based, illustrated medication instructions that are well understood by patients of all health literacy levels. RESULTS: PictureRx has been studied in a number of settings. The tool was successfully deployed at a busy outpatient pharmacy and in a medical clinic for the underserved and was pilot tested among elderly community-dwelling Medicare recipients. In each of these settings, PictureRx was received favorably by patients, pharmacists, and other health care providers. It improved patients' satisfaction with the pharmacy and knowledge about their medications. Ongoing research is assessing whether PictureRx enhances medication management among Latinos. CONCLUSION: PictureRx helps pharmacists address challenges related to low health literacy and can be implemented in a broad range of practice environments. Ongoing research will delineate the extent to which PictureRx reduces health disparities.

Life and health insurance industry investments in fast food.

Previous research on health and life insurers' financial investments has highlighted the tension between profit maximization and the public good. We ascertained health and life insurance firms' holdings in the fast food industry, an industry that is increasingly understood to negatively impact public health. Insurers own $1.88 billion of stock in the 5 leading fast food companies. We argue that insurers ought to be held to a higher standard of corporate responsibility, and we offer potential solutions.

Site-controlled InGaAs quantum dots with tunable emission energy.

Semiconductor quantum-dot (QD) systems offering perfect site control and tunable emission energy are essential for numerous nanophotonic device applications involving spatial and spectral matching of dots with optical cavities. Herein, the properties of ordered InGaAs/GaAs QDs grown by organometallic chemical vapor deposition on substrates patterned with pyramidal recesses are reported. The seeded growth of a single QD inside each pyramid results in near-perfect (<10 nm) control of the QD position. Moreover, efficient and uniform photoluminescence (inhomogeneous broadening <10 meV) is observed from ordered arrays of such dots. The QD emission energy can be finely tuned by varying 1) the pyramid size and 2) its position within specific patterns. This tunability is brought about by the patterning of both the chemical properties and the surface curvature features of the substrate, which allows local control of the adatom fluxes that determine the QD thickness and composition.

HealthSTAT: a student approach to building skills needed to serve poor communities.

The HealthSTAT model of professional development uses team-based leadership and peer-to-peer learning to cultivate inter-professional collaboration and community partnership in service to the poor and underserved of Georgia.

Successful reimplantation of extruded long bone segments in open fractures of lower limb--a report of 3 cases.

Extruded bone segments are rare complication of high energy open fractures. Routinely these fractures are treated by debridement followed by bone loss management in the form of either bone transport or free fibula transfer. There are very few reports in the literature about reimplantation of extruded segments of bone and there are no clear guidelines regarding timing of reimplantation, bone stabilisation and sterilisation techniques. Reimplantation of extruded bone is a risky procedure due to high chances of infection which determines the final outcome and can result in secondary amputations. We present two cases of successful reimplantation of extruded diaphyseal segment of femur and one case of reimplantation of extruded segment of tibia.

Improving medication understanding among Latinos through illustrated medication lists.

OBJECTIVES: Strategies are needed to improve medication management among vulnerable populations. We tested the effect of providing illustrated, plain-language medication lists on medication understanding, adherence, and satisfaction among Latino patients with diabetes in a safety net clinic. STUDY DESIGN: Randomized controlled trial. METHODS: Intervention patients received a PictureRx illustrated medication list that depicted the medication, indication, and dosing instructions, accompanied by plain language bilingual text. Usual care patients received a written list of their medications in their preferred language, with indication but no images. Outcomes were assessed by telephone approximately 1 week later. The Medication Understanding Questionnaire measured patients' ability to report the indication, strength, dosing, and frequency for their medication regimen. Self-reported adherence and satisfaction were secondary outcomes. Analysis was performed by intention to treat. RESULTS: Of 200 enrolled participants, 197 (98.5%) completed follow-up. Most (71%) had not graduated high school, and 59% had low health literacy. Patients randomized to illustrated medication instructions had better overall understanding of their medications (P<.001), including greater ability to report the drug indication (P<.01), strength (P<.05), dosing (P<.01), and frequency of administration (P<.001). Self-reported adherence did not differ significantly between study groups. Patients who received illustrated medication lists were very satisfied with them. CONCLUSIONS: In this randomized controlled trial, patients who received illustrated, plain-language medication lists demonstrated significantly greater understanding of their medication regimen. Such tools have the potential to improve medication use and chronic disease control, as well as reduce health disparities-although this requires further study.

Changes in geographic variation in the use of percutaneous coronary intervention for stable ischemic heart disease after publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial.

BACKGROUND: Clinical uncertainty is cited as a cause of geographic variation. However, little is known about the effect of comparative effectiveness research on variation. We examined whether geographic variation in the use of percutaneous coronary intervention (PCI) for stable ischemic heart disease (SIHD) declined after publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial. METHODS AND RESULTS: We examined changes in utilization and geographic variation in 67 hospital referral regions using the State Inpatient Databases. We compared age- and sex-adjusted rates of PCI for SIHD before (2006) and after (2008) publication of the COURAGE trial and compared those with contemporaneous changes in PCI volume for acute coronary syndrome. A total of 272,659 PCIs for SIHD from 526 hospitals were included in the analysis. After the publication of the COURAGE trial, PCI volume for SIHD declined by 25% (P<0.001) and decreased by 12% for acute coronary syndrome (P<0.001). This was predominantly attributable to changes in hospital referral regions with the highest levels of utilization pre-COURAGE trial (35% decline in the highest tertile versus 18% in the lowest). As measured by the systematic component of variation, there was substantial geographic variation in the use of PCI for SIHD preceding the publication of the COURAGE trial. Variation declined by 28% (0.53 versus 0.40) after publication, but geographic variation remained higher for SIHD than acute coronary syndrome (0.40 versus 0.17). CONCLUSIONS: There was a substantial decline in the use of and geographic variation in PCI for SIHD after the publication of the COURAGE trial. However, geographic variation in the use of PCI for SIHD remained high.

Illustrated medication instructions as a strategy to improve medication management among Latinos: a qualitative analysis.

Although illustrated medication instructions may improve medication management among vulnerable populations, little prior research has evaluated their use among Latinos. We conducted focus groups and interviews with Latino patients with diabetes at two safety net clinics in Tennessee to understand medication taking practices and perceptions of illustrated medication instructions. Patients reported confidence in being able to take medications, but demonstrated a lack of understanding of medication instructions. On further probing, they described several barriers to effective medication management rooted in poor communication. Patients expressed preference for illustrated medication instructions which could address several of the challenges raised by patients.