The aim of the present study is to determine similarities between patients with type 2 diabetes not on metformin therapy compared to patients on metformin therapy at a resident-led primary care clinic.
There is a great deal of concern about opioid use in veterans, particularly those who served in Afghanistan (OEF) and Iraq (OIF and OND). The current study provides a detailed pharmacoepidemiologic analysis of opioid use among OEF/OIF/OND veterans from FY09 to FY12. Data from 3 data repositories from the Veterans Health Administration (VHA) were used to describe demographic, clinical, and medication characteristics associated with opioid use among OEF/OIF/OND veterans and among those with TBI. Logistic regression models were used to identify risks associated with chronic opioid use in FY12. Approximately 23% of all OEF/OIF/OND veterans and 35% of those with TBI received any opioid medications. Most received moderate doses ranging from 26 to 30 mg morphine equivalent dose daily. Median days of opioid use for all OEF/OIF/OND veterans were 30 to 40 days. Factors associated with chronic use in both groups included young age, male sex, white race, being married, and living in rural areas. A diagnosis of PTSD (odds ratio [OR] = 1.22, P < 0.0001), major depressive disorder (OR = 1.14, P < 0.0001), and tobacco use disorder (OR = 1.18, P < 0.0001) were strongly associated with chronic opioid use. Back pain was also strongly associated with chronic use (OR = 2.50, P < 0.0001). As pain severity increased the odds of chronic opioid use also increased: mild pain (OR = 3.76, P < 0.0001), moderate pain (OR = 6.80, P < 0.0001), and severe pain (OR = 8.49, P < 0.0001). Opioid use among OEF/OIF/OND veterans is characterized by moderate doses that are used over relatively long periods of time by a minority of veterans.
To provide full potential benefits to patients, behavioral health interventions often require comprehensive and systematic implementation efforts. The costs of these efforts should therefore be included when organizations decide to fund or adopt a new intervention. However, existing guidelines for conducting economic analyses like cost-effectiveness analyses and budget impact analyses are not well-suited to the complexity of the behavioral healthcare pathway and its many stakeholders. Stakeholder engagement, when used effectively with recent innovations in economic analysis, advance more equitable access to interventions for individuals living with behavioral health conditions. But early and ongoing stakeholder engagement has not yet been incorporated into best-practice guidelines for economic evaluation. We discuss our perspective, as researchers and clinicians in a large integrated health system, on how the integration of stakeholder engagement with existing economic analysis methods could improve decision-making about implementation of behavioral health interventions.
Abstract Background Blood cultures (BCx) guide treatment for hospitalized patients, yet contaminated BCx lead to clinical uncertainty, impacting care. The Clinical and Laboratory Standards Institute (CLSI) recommends contamination rates should be <3%, yet our Emergency Department (ED) rate is consistently above this benchmark. Reasons for this are unclear, thus it is imperative to investigate potential risk factors for BCx contamination. Methods We performed a retrospective case–control risk factor analysis of patients with BCx collected in our ED between 2014 and 2018. Contaminated BCx were identified by the microbiology laboratory per American Society of Microbiology recommendations. Demographics, comorbidities, and clinical characteristics were evaluated in patients with false-positive/contaminated BCx (cases) and patients with negative BCx (controls). Potential risk factors identified in univariate analysis were included in a logistic regression model. Unadjusted and adjusted analyses were performed using SAS 9.4. Results 25,668 BCx from 13,782 patients were included in analysis. 20,907 BCx from 11,266 (82%) patients were negative, 2,856 BCx from 1,504 (11%) patients were true positives, and 1,905 BCx from 1,012 (7%) patients were contaminated. Yearly ED contamination rates ranged from 5.0–9.3%. Collector contamination rates varied, though 38 (19%), 75 (35%), and 7 (3%) of 209 collectors had a contamination rate <3%, ≥ 10%, and ≥ 20%, respectively. Significant patient-specific risk factors identified in univariate analysis are listed in the attached table along with adjusted analysis. Conclusion In our analysis, we identified that older age, African American race, higher BMI, COPD, paralysis, and presenting in septic shock independently increases risk of having a contaminated BCx. Difficulty obtaining venipuncture in patients with these risk factors, often requiring multiple collection attempts, likely leads to decreased sterile technique. It is imperative to have a process assuring sterile technique in these high-risk individuals to minimize consequences associated with having a false-positive BCx result in these high-risk patients. Additionally, variable collector contamination rates seen in this study highlight the necessity for frequent technique in-service training. Disclosures All authors: No reported disclosures.
ABSTRACT Introduction The completion rate of Advance Directive (ADs) in the Veterans Health Administration (VHA) is unknown. There is substantial literature on the need for effective Advance Care Planning (ACP) that leads to an AD to ensure that health care preferences for patients are known. Advance Directive are essential to consider since ACP, which explains and plans Advance Directive, does not reach all individuals. Health inequities, such as those experienced in rural areas, continue to exist. While ACP may disproportionately affect rural-residing veterans and their providers, a VHA program was specifically designed to increase ACP engagement with rural veterans and to address several systemic barriers to ACP. Materials and Methods This descriptive analysis seeks to identify patient, provider, and geographic characteristics associated with higher rates of ACP participation in VHA. An observational examination of the profile of veterans and the types of ACP (e.g., individual or in groups) using administrative data for all beneficiaries receiving VHA health care services in federal fiscal year (FY) 2020 was conducted as part of a national program evaluation. The measures include patient-level data on demographics (e.g., race, ethnicity, gender), unique patient identifiers (e.g., name, social security number), geographic characteristics of patient’s location (e.g., rurality defined as Rural–Urban Commuting Areas [RUCA]), VHA priority group; provider-level data (e.g., type of document definition, clinic stop codes, visit date used to verify Advance Care Planning via Group Visits [ACP-GV] attendance; data not shown), and electronic health record note titles that indicated the presence of ACP in VHA (e.g., “Advance Directive [AD] Discussion” note title, “ACP-GV CHAR 4 code”). Pearson’s chi-square statistics were used for between-group comparisons based on a two-sided test with a significance level of 0.05. Results The overall rate of AD discussions among unique VHA users in FY2020 was 5.2% (95% CI: 5.2%—5.2%) and for Advance Care Planning via Group Visits, which targets rural veterans using groups, it was 1.8% (95% CI: 1.8%—1.9%). Advance Directive discussions in VHA are more successful at reaching middle age (M = 64; SD = 16), African Americans, males, veterans living in urban areas, and veterans with a VA disability (Priority Group 1-4). Advance Care Planning delivered in groups is reaching slightly younger veterans under the age of 75 years (M = 62; SD = 15), African Americans, females, disabled veterans (e.g., Priority Group 1-4), and more veterans residing in rural communities compared to the national population of VHA users. Conclusion Advance Directive discussion rates are low across VHA, yet intentional efforts with ACP via group visits are reaching veterans who are considered underserved owing to residing in rural areas. Advance Care Planning needs to be a well-informed clinical priority for VHA to engage with the entire veteran population and to support the completion of ADs.
The potential association between serotonin syndrome and tapentadol is not well described in the literature. This study aimed to review the literature and identify methodological issues that could lead to inaccurately reported rates of serotonin syndrome associated with tapentadol use. A systematic review of English articles using MEDLINE, Cochrane Controlled Trials Register, and Scopus was performed. Additional studies were identified by cross-referencing article bibliographies. Original research that examined the safety of tapentadol in patients with nonconfounding indications were examined. In total, 22 studies met inclusion criteria. There were 13 randomized clinical trials, 7 open-label trials, and 2 observational studies. All studies either did not mention whether serotonergic medication use was prohibited or disallowed use. Frequently reported adverse events were nausea, diarrhea, constipation, fatigue, vomiting, and somnolence. No studies reported serotonin syndrome development. No included trials differentiated between the development of adverse events in patients taking serotonergic drugs and those who were not. This differentiation is necessary to evaluate the increased risk of adverse events in patients prescribed tapentadol concomitantly with other serotonergic medications. Therefore, the current tapentadol literature has important limitations that prevent the adequate characterization of the potential association between tapentadol and serotonin syndrome.
Purpose: Medication cost is frequently overlooked when treating critically ill patients. Stewardship of health care resources in high-utilization settings is imperative. This study was conducted to determine nonpharmacist health care providers' knowledge and perceptions of medication costs in a medical intensive care unit (MICU). Methods: Nonpharmacist health care providers in a MICU completed a 27-item survey. The survey queried perceptions regarding medication cost, cost-limiting strategies, and most/least expensive medications in 8 classes, medication price ranges, and intravenous-to-oral comparisons for commonly prescribed medications. Responses were analyzed using descriptive statistics and compared between providers using Fisher exact tests. Results: Among 98 health care providers (76 medical trainees, 5 attending physicians, 17 nurses), when ordering a medication, 49% consider its cost. Few (15%) providers considered themselves knowledgeable regarding medication costs with no difference between providers (P = .174). Attending physicians were more aware of the most/least expensive medications than residents (correct out of 16: 9.6 vs 8.5, P = .044). The correct price ranges for select medications (11%-36%, P = .373) and intravenous-to-oral relative costs (3%-49%, P = .596) were similarly low. Most (59%) believed pharmacists limit expensive medication use, particularly senior physicians (58% resident vs 100% attending, P = .007). Conclusion: In spite of a goal of cost consideration, most nonpharmacist health care providers are unaware of medication costs and fail to include them in decision making. These knowledge gaps and perceptions should inform future efforts to improve knowledge and attitudes regarding medication costs.
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