Injection drug use (IDU) and IDU-related infections have increased dramatically. However, the incidence of IDU-related infections may be underreported because drug use is not recorded in diagnostic records where associated infections are identified. Our goal was to estimate a more accurate incidence of IDU-related infections by including IDU-related infections not recorded at the time infections are diagnosed.We performed a retrospective cohort study using inpatient and emergency department visits from the Healthcare Cost and Utilization Project for California, Florida, and New York. We identified all patients diagnosed with bacteremia or sepsis, endocarditis, osteomyelitis or septic arthritis, and skin or soft tissue infection. We estimated the incidence of IDU-related infections by identifying cases where drug use was recorded at the time of an infection and cases where drug use was not recorded at the time of infection but within 6 months before or after the infection diagnosis. We also analyzed factors associated with unrecorded IDU.There has been an increasing trend in the number of IDU-related infections. The annual number of IDU-related infections increased between 105% and 218% after incorporating infections in which drug use was unrecorded. Factors associated with drug use being unrecorded included emergency department diagnosis, the level of hospital experience treating drug use, age <18 years, and having Medicare as the primary payer.More than half of all IDU-related infections may be unrecorded in existing surveillance estimates. There may be many missed opportunities to record, diagnose, or treat underlying drug abuse among patients presenting with IDU-related infections.
Abstract Background Delays in diagnosing herpes simplex encephalitis (HSE) are associated with increased morbidity and mortality. The purpose of this paper is to determine the frequency and duration of diagnostic delays for HSE and risk factors for diagnostic delays. Methods Using data from the IBM Marketscan Databases, 2001–2017, we performed a retrospective cohort study of patients with HSE. We estimated the number of visits with HSE-related symptoms before diagnosis that would be expected to occur in the absence of delays and compared this estimate to the observed pattern of visits. Next, we used a simulation-based approach to compute the number of visits representing a delay, the number of missed diagnostic opportunities per case patient, and the duration of delays. We also investigated potential risk factors for delays. Results We identified 2667 patients diagnosed with HSE. We estimated 45.9% (95% confidence interval [CI], 43.6%–48.1%) of patients experienced at least 1 missed opportunity; 21.9% (95% CI, 17.3%–26.3%) of these patients had delays lasting >7 days. Risk factors for delays included being seen only in the emergency department, age <65, or a history of sinusitis or schizophrenia. Conclusions Many patients with HSE experience multiple missed diagnostic opportunities before diagnosis.
In Brief Purpose: We sought to characterize the physical activity, health, and dietary patterns of middle school children and examine associations between these factors. Parent−child relationships also were examined. Methods: Thirty-eight children and parents participated and completed a three-day physical activity recall and 24-hour dietary recall. The Child Health Questionnaire was used to assess child health. Percentage overweight was determined for each participant. Results: Forty-four percent of children did not meet the current recommendation for physical activity. Fat and sodium consumption exceeded recommendations, and intake of key nutrients was inadequate. Youth who spent more time in sedentary activity had poorer general health. There were positive associations between parent and child percentage overweight and physical activity. Parent physical activity explained an additional 46.2% of the variance in child physical activity. Conclusions: Increasing physical activity and reducing sedentary behaviors through strategies that incorporate parents is an important component of a physical therapy program for school children. The authors studied physical activity, health, and dietary patterns of children. They report parent physical activity explained more than 45% of the variance in child physical activity and describe roles for physical therapists in preventing obesity.
Abstract Objectives Fevers have been used as a marker of disease for hundreds of years and are frequently used for disease screening. However, body temperature varies over the course of a day and across individual characteristics; such variation may limit the detection of febrile episodes complicating the diagnostic process. Our objective was to describe individual variation in diurnal temperature patterns during episodes of febrile activity using millions of recorded temperatures and evaluate the probability of recording a fever by sex and for different age groups. Methods We use timestamped deidentified temperature readings from thermometers across the US to construct illness episodes where continuous periods of activity in a single user included a febrile reading. We model the mean temperature recorded and probability of registering a fever across the course of a day using sinusoidal regression models while accounting for user age and sex. We then estimate the probability of recording a fever by time of day for children, working-age adults, and older adults. Results We find wide variation in body temperatures over the course of a day and across individual characteristics. The diurnal temperature pattern differed between men and women, and average temperatures declined for older age groups. The likelihood of detecting a fever varied widely by the time of day and by an individual’s age or sex. Conclusions Time of day and demographics should be considered when using body temperatures for diagnostic or screening purposes. Our results demonstrate the importance of follow-up thermometry readings if infectious diseases are suspected.
Herpes simplex encephalitis (HSE) is a severe, and often fatal, condition requiring timely diagnosis and treatment. Little is known about the frequency and factors associated with diagnostic delays. We conducted a retrospective cohort study using the Truven Health Analytics Commercial Claims and Encounters Database from 2011 to 2016. We identified case visits where patients were first diagnosed with HSE. We analyzed visits prior to the index HSE diagnosis for HSE-related symptoms, including fever, headache, seizure, neurologic disorder, or impaired consciousness. We utilized a time-series change-point analysis and simulation models to identify the window before an HSE diagnosis where diagnostic opportunities began to appear and to estimate the likelihood of actual diagnostic delays. Our study cohort included 3,390 cases of HSE. There is a dramatic spike in visits with HSE-related symptoms that occurs just prior to the index HSE diagnosis (see figure). Prior to the index diagnosis we identified 2,459 visits, from 938 patients, that contained possible symptoms of HSE. We estimated that approximately 1,355 (CI 1,195–1,490) visits represented likely diagnostic delays with around 20% (CI 18.8–21.0) of patients experiencing at least one missed opportunity. The median duration of diagnostic delays, from first symptoms to diagnosis, was 6 days. Most diagnostic opportunities occurred in outpatient settings, 835 delays (CI 739–944), followed by emergency departments, 313 delays (CI 252–354), and inpatient settings, 259 (CI 226–291). Diagnostic opportunities involving seizures tended to occur earliest (median 7 days before HSE diagnosis), followed by headaches, neurologic symptoms, or changes in mental status (5 days), and finally fever (3 days). Patients with a history of three or more visits for chronic migraines, 90 days before HSE, were more likely to experience a diagnostic delay, OR 2.5 (CI 1.4–3.1), and experienced more diagnostic delays 0.8 vs. 1.5 delays (P < 0.001). There may be many missed diagnostic opportunities in both inpatient and ambulatory settings. Diagnostic opportunities tended to present with neurologic conditions before fever. Most opportunities occur in outpatient and emergency settings. Patients with a history of migraines may be more at risk for experiencing a delay. All authors: No reported disclosures.
Previous studies have suggested that a hospital patient's risk of developing healthcare facility-onset (HCFO) Clostridioides difficile infections (CDIs) increases with the number of concurrent spatially proximate patients with CDI, termed CDI pressure. However, these studies were performed either in a single institution or in a single state with a very coarse measure of concurrence. We conducted a retrospective case-control study involving over 17.5 million inpatient visits across 700 hospitals in eight US states. We built a weighted, directed network connecting overlapping inpatient visits to measure facility-level CDI pressure. We then matched HCFO-CDIs with non-CDI controls on facility, comorbidities and demographics and performed a conditional logistic regression to determine the odds of developing HCFO-CDI given the number of coincident patient visits with CDI. On average, cases' visits coincided with 9.2 CDI cases, which for an individual with an average length of stay corresponded to an estimated 17.7% (95% CI 12.9-22.7%) increase in the odds of acquiring HCFO-CDI compared to an inpatient visit without concurrent CDI cases or fully isolated from both direct and indirect risks from concurrent CDI cases. These results suggest that, either directly or indirectly, hospital patients with CDI lead to CDIs in non-infected patients with temporally overlapping visits.
Background Early detection of diabetic foot ulcers can improve outcomes. However, patients do not always monitor their feet or seek medical attention when ulcers worsen. New approaches for diabetic-foot surveillance are needed. The goal of this study was to determine if patients would be willing and able to regularly photograph their feet; evaluate different foot-imaging approaches; and determine clinical adequacy of the resulting pictures. Methods We recruited adults with diabetes and assigned them to Self Photo (SP), Assistive Device (AD), or Other Party (OP) groups. The SP group photographed their own feet, while the AD group used a selfie stick; the OP group required another adult to photograph the patient's foot. For 8 weeks, we texted all patients requesting that they text us a photo of each foot. The collected images were evaluated for clinical adequacy. Numbers of (i) submitted and (ii) clinically useful images were compared among groups using generalized linear models and generalized linear mixed models. Results A total of 96 patients consented and 88 participated. There were 30 patients in SP, 29 in AD, and 29 in OP. The completion rate was 77%, with no significant differences among groups. However, 74.1% of photographs in SC, 83.7% in AD, 92.6% in OP were determined to be clinically adequate, and these differed statistically significantly. Conclusions Patients with diabetes are willing and able to take photographs of their feet, but using selfie sticks or having another adult take the photographs increases the clinical adequacy of the photographs.Level of Evidence: II.
Abstract Objectives Diagnostic delays are a major source of morbidity and mortality. Despite the adverse outcomes associated with diagnostic delays, few studies have examined the incidence and factors that influence diagnostic delays for different infectious diseases. The objective of this study was to understand the relative frequency of diagnostic delays for six infectious diseases commonly seen by infectious diseases (ID) consultants and to examine contributing factors for these delays. Methods A 25-item survey to examine diagnostic delays in six infectious diseases was sent to all infectious diseases physicians in the Emerging Infections Network (EIN) who provide care to adult patients. Diseases included (1) tuberculosis, (2) non-tuberculous mycobacterial infections, (3) syphilis, (4) epidural abscess, (5) infective endocarditis, and (6) endemic fungal infections (e.g., histoplasmosis, blastomycosis). Results A total of 533 of 1,323 (40%) EIN members responded to the survey. Respondents perceived the diagnosis not being considered initially and the appropriate test not being ordered as the two most important contributors to diagnostic delays. Unusual clinical presentations and not consulting ID physicians early enough were also reported as a contributing factor to delays. Responses recorded in open-text fields also indicated errors related to testing as a likely cause of delays; specifically, test-related errors included ordering the wrong laboratory test, laboratory delays (specialized labs not available at the facility), and lab processing delays. Conclusions Diagnostic delays commonly occur for the infectious diseases we considered. The contributing factors we identified are potential targets for future interventions to decrease diagnostic delays.
Prior studies have used International Classification of Disease (ICD) diagnosis codes in administrative data to identify patients with infective endocarditis (IE) associated with intravenous drug use (IVDU). Little is known about the accuracy of ICD codes for IVDU-IE.We used 2 previously described algorithms to identify patients with potential IVDU-IE admitted to 125 Veterans Administration hospitals from January 2010 through December 2018. Algorithm A identified patients with concurrent ICD-9/10 codes for IE and drug use during the same admission. Algorithm B identified patients with drug use coded either during the IE admission or during outpatient or other visits within 6 months of admission. We reviewed 400 randomly selected patient charts to determine the positive predictive value (PPV) of each algorithm for clinical documentation of IE, any drug use, IVDU, and IVDU-IE, respectively.Algorithm A identified 788 patients, and B identified 1314 patients, a 68% increase. PPVs were high for clinical documentation of diagnoses of IE (86.5% for A and 82.6% for B) and any drug use (99.0% and 96.3%). PPVs were lower for documented IVDU (74.5% and 64.1%) and combined diagnoses of IVDU-IE (65.0% and 55.2%), partly because of a lack of ICD codes specific to IVDU. Among patients identified by algorithm B but not A, 72% had clinical documentation of drug use during the IE admission, indicating a failure of algorithm A to capture cases due to incomplete recording of inpatient ICD codes for drug use.There is need for improved algorithms for IVDU-IE surveillance during the ongoing opioid epidemic.
Background. Delayed diagnosis of tuberculosis (TB) may lead to worse outcomes and additional TB exposures. Methods. To estimate the potential number of misdiagnosed TB cases, we linked all hospital and emergency department (ED) visits in California's Healthcare Cost and Utilization Project (HCUP) databases (2005-2011). We defined a potential misdiagnosis as a visit with a new, primary diagnosis of TB preceded by a recent respiratory-related hospitalization or ED visit. Next, we calculated the prevalence of potential missed TB diagnoses for different time windows. We also computed odds ratios (OR) comparing the likelihood of a previous respiratory diagnosis in patients with and without a TB diagnosis, controlling for patient and hospital characteristics. Finally, we determined the correlation between a hospital's TB volume and the prevalence of potential TB misdiagnoses. Results. Within 30 days before an initial TB diagnosis, 15.9% of patients (25.7% for 90 days) had a respiratory-related hospitalization or ED visit. Also, within 30 days, prior respiratory-related visits were more common in patients with TB than other patients (OR = 3.83; P < .01), controlling for patient and hospital characteristics. Respiratory diagnosis-related visits were increasingly common until approximately 90 days before the TB diagnosis. Finally, potential misdiagnoses were more common in hospitals with fewer TB cases (ρ = -0.845; P < .01). Conclusions. Missed opportunities to diagnose TB are common and correlate inversely with the number of TB cases diagnosed at a hospital. Thus, as TB becomes infrequent, delayed diagnoses may increase, initiating outbreaks in communities and hospitals.
