Most end‐stage renal disease (ESRD) patients do not have primary‐care providers, and preventive medicine often is provided by their nephrologists. Little has been written about their success in providing this care. We studied all patients on dialysis at our hospital and compared their preventive care to a control group followed in the general medical clinic. The general medical group showed higher compliance with Pap smears (89% vs 48%), mammography (87% vs 62%), fecal occult blood testing (75% vs 50%), and pneumococcal vaccination (55% vs 28%). The ESRD group had better compliance with influenza vaccination (70% vs 55%) and lipid profile (100% vs 75%). When the subgroup of patients on hemodialysis (HD) was compared with patients on peritoneal dialysis (PD), it was shown that HD patients were more likely than PD patients to receive preventive care. We also compared diabetes‐specific care. The ESRD group had a higher rate of HbA 1C (100% vs 78%) and lipid monitoring (100% vs 76%), diabetes education (100% vs 84%), and podiatry visits (70% vs 38%). There was no difference in ophthalmologic examination or influenza vaccination. We found that nephrologists provide preventive care to ESRD patients with success approximately equal to primary‐care physicians in our institution, although in different parameters. Ready access to dialysis patients and their blood and unit‐specific policies contribute to compliance that is above national averages. Further improvements can be made by additional preventative measures policies, by physician and patient education, and by monitoring primary‐care compliance in the chart.
Abstract Background Antibiotic-resistant infections are one of the greatest public health issues with more than 2 million infections and 23,000 deaths per year in the United States. Reducing inappropriate antibiotic use is essential to reduce both antibiotic resistance and adverse events. The most important modifiable risk factor for antibiotic resistance is inappropriate prescribing of antibiotics. At least 30% of outpatient antibiotic prescriptions in the United States are unnecessary. We aimed to pilot our outpatient antimicrobial stewardship initiative to track and reduce antibiotic prescriptions among adult patients presenting with common acute respiratory infections in our hospital’s outpatient primary care settings. Methods A retrospective and prospective cohort study from October, 2017 to March, 2019. Implemented a robust outpatient antimicrobial stewardship initiative with a dedicated team and data analyst based on CDC core elements for outpatient antimicrobial stewardship and a prior UHF initiative. Data of common respiratory tract infections and the respective rates of antibiotic prescriptions from 3 adult primary care sites were collected from the EHR. Serials of educational interventions were performed between June, 2018 to September, 2018. We disseminated resources from the CDC and DOH like brochures, posters, viral prescription pads, pocket guidelines, grand rounds and electronic lectures for providers and periodic provider feedback reports. Results Our findings revealed that the physician compliance rate of antibiotics not prescribed for common respiratory tract infections remarkably improved from 72% to 85% after implementing our interventions (Figure 1). The chi-square test showed 40, and P value is 0.000034 which is less than 0.05. Thus, we are 95% confident that there is a significant association between our interventions and reduction of inappropriate antibiotic use (Figure 2). Conclusion Introduction of a robust and multifaceted Outpatient Antimicrobial Stewardship initiative with a dedicated team can substantially decrease outpatient antibiotic prescription rates for respiratory tract infections in metropolitan community hospital-based primary care settings. Disclosures All authors: No reported disclosures.
Most end-stage renal disease (ESRD) patients do not have primary-care providers, and preventive medicine often is provided by their nephrologists. Little has been written about their success in providing this care. We studied all patients on dialysis at our hospital and compared their preventive care to a control group followed in the general medical clinic. The general medical group showed higher compliance with Pap smears (89% vs 48%), mammography (87% vs 62%), fecal occult blood testing (75% vs 50%), and pneumococcal vaccination (55% vs 28%). The ESRD group had better compliance with influenza vaccination (70% vs 55%) and lipid profile (100% vs 75%). When the subgroup of patients on hemodialysis (HD) was compared with patients on peritoneal dialysis (PD), it was shown that HD patients were more likely than PD patients to receive preventive care. We also compared diabetes-specific care. The ESRD group had a higher rate of HbA 1C (100% vs 78%) and lipid monitoring (100% vs 76%), diabetes education (100% vs 84%), and podiatry visits (70% vs 38%). There was no difference in ophthalmologic examination or influenza vaccination. We found that nephrologists provide preventive care to ESRD patients with success approximately equal to primary-care physicians in our institution, although in different parameters. Ready access to dialysis patients and their blood and unit-specific policies contribute to compliance that is above national averages. Further improvements can be made by additional preventative measures policies, by physician and patient education, and by monitoring primary-care compliance in the chart.
Oral L-carnitine has been reported to lower the elevated serum myoglobin of renal failure in chronic peritoneal dialysis patients, and intravenous L-carnitine can improve muscle fatigue and cramps in chronic hemodialysis patients. In this study oral L-carnitine, 1.98 g/day, was administered to 6 chronic hemodialysis patients for 8 weeks. Serum levels of myoglobin, creatine kinase, and aldolase, as well as skeletal muscle symptoms (cramps during dialysis, fatigue, and weakness) were monitored biweekly for 12 weeks. Mean baseline serum myoglobin level was 337 ± 34 ng/mL. By 6 and 8 weeks mean serum myoglobin was 234 ± 39 and 233 ± 40 ng/mL, significantly lower by the Friedman test (p < 0.05). Four weeks after carnitine was discontinued, mean serum myoglobin had risen to 320 ± 118 ng/mL. Serum creatine kinase and aldolase levels were normal throughout the study. All 6 patients noted improvement in muscular symptoms, with maximal effect at 8 weeks, although 2 patients did not improve until 2 to 4 weeks after carnitine was stopped. We conclude that oral L-carnitine may lower serum myoglobin and improve muscle cramps and weakness in hemodialysis patients. The maximal effect of carnitine on myoglobin occurs 2 weeks before the maximal improvement in muscular symptoms.
The ability to predict outcomes based on admission criteria has important implications, both prognostically and for assessing interventions on comparable groups. Use of severity of disease scoring systems such as the APACHE II score for predicting mortality has become widespread. There is no comparable formula for acute renal failure. We prospectively evaluated 115 consecutive admissions to the medical intensive care unit to define risk for renal failure from admission data and to assess the impact of admission hypoalbuminemia levels on outcome. Diagnosis, age, serum creatinine and albumin levels, urinary electrolyte concentrations and osmolality, daily serum creatinine levels, and urine output were recorded. Admission APACHE II score was calculated. Admission hypoalbuminemia (57% of patients) was associated with both acute renal failure and death (odds ratios, 16.19 and 8.06, respectively). The Glasgow coma score distinguished between patients in whom acute renal failure developed and in those it did not. Low urine osmolality (<400 mOsm/kg) was the most significant factor in predicting mortality (odds ratio, 9.87). Mortality was lowest in the normal albumin group (2%), intermediate in the low albumin/no renal failure group (12%), and highest in the low albumin/acute renal failure group (53%). The APACHE II score was accurate in 3 of 14 deaths in the hypoalbuminemic population and in the one normal albumin patient who died. We conclude that at admission, hypoalbuminemia, urinary hypo-osmolality, and abnormal creatinine levels are predictive of acute renal failure and death, diagnosis, and mental status impact on the risk for acute renal failure. APACHE II lacks predictive value in hypoalbuminemic patients.
