Publications

OBJECTIVE: We examined Clostridioides difficile infection (CDI) prevention practices and their relationship with hospital-onset healthcare facility-associated CDI rates (CDI rates) in Veterans Affairs (VA) acute-care facilities.

DESIGN: Cross-sectional study.

METHODS: From January 2017 to February 2017, we conducted an electronic survey of CDI prevention practices and hospital characteristics in the VA. We linked survey data with CDI rate data for the period January 2015 to December 2016. We stratified facilities according to whether their overall CDI rate per 10,000 bed days of care was above or below the national VA mean CDI rate. We examined whether specific CDI prevention practices were associated with an increased risk of a CDI rate above the national VA mean CDI rate.

RESULTS: All 126 facilities responded (100% response rate). Since implementing CDI prevention practices in July 2012, 60 of 123 facilities (49%) reported a decrease in CDI rates; 22 of 123 facilities (18%) reported an increase, and 41 of 123 (33%) reported no change. Facilities reporting an increase in the CDI rate (vs those reporting a decrease) after implementing prevention practices were 2.54 times more likely to have CDI rates that were above the national mean CDI rate. Whether a facility's CDI rates were above or below the national mean CDI rate was not associated with self-reported cleaning practices, duration of contact precautions, availability of private rooms, or certification of infection preventionists in infection prevention.

CONCLUSIONS: We found considerable variation in CDI rates. We were unable to identify which particular CDI prevention practices (i.e., bundle components) were associated with lower CDI rates.

INTRODUCTION: Student pharmacists have significant exposure to online learning methods in their pre-pharmacy educational experiences. With decreasing resources and faculty shortages in pharmacy education, online delivery of course content is an efficient way to deliver pharmacy curricula while optimizing classroom time for active learning strategies. The purpose of this study was to assess student preferences associated with the utility of online learning methods such as online platforms, social media, and handheld devices.

METHODS: An anonymous, voluntary 43-question online survey was delivered to students at colleges and schools of pharmacy in the United States (US). Frequency statistics were used to establish prevalence of student preferences.

RESULTS: Overall, 1873 students from 29 schools of pharmacy completed the survey. Of these students, 30% preferred a blended course structure (with online and classroom components) throughout the curriculum, as compared to 47% of students who preferred live lectures exclusively. Approximately 57% of students found smart phones very or extremely valuable for their academic success. Approximately 61% of students reported using their smart phones and 37% reported using their tablets "always" or "often" during the past year for academic activities; however, only 31% of students found paper textbooks very or extremely valuable for their academic success, with approximately 26% using them "always" or "often."

CONCLUSIONS: US pharmacy students prefer a blend of traditional classroom and online learning methods. When updating and revising pharmacy curricula, colleges and schools of pharmacy should consider the inclusion of technology and online learning methodologies.

OBJECTIVE: To characterize antifungal stewardship among antimicrobial stewardship programs (ASPs) at a diverse range of hospitals and to correlate antifungal stewardship with hospital characteristics.

DESIGN: Cross-sectional survey.

PARTICIPANTS: ASP physician and/or pharmacist members at Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN) hospitals.

METHODS: An electronic survey administered August-September 2018 via the SRN to 111 hospitals. The χ2 test was used to test associations between ASP and hospital characteristics and use of antifungal stewardship strategies.

RESULTS: Of 111 hospitals, 45 (41%) responded; most were academic medical centers (65%) caring for stem-cell patients (73.3%) and solid-organ transplant patients (80.0%). Most hospitals have large, well-established ASPs: 60% had >5 team members and 68.9% had a duration ≥6 years. In 43 hospitals (95.6%), ASPs used antifungal stewardship strategies, most commonly prospective audit and feedback (73.3%) by a pharmacist (71.4%). Half of ASPs (51.1%) created guidelines for invasive fungal infection (IFI) management. Most hospitals (71.1%) offered rapid laboratory tests to diagnose IFI, but polymerase chain reaction (PCR) testing and antifungal susceptibility testing varied. Also, 29 ASPs (64.4%) perform surveillance of antifungal utilization, but only 9 (31%) reported to the CDC National Healthcare Safety Network. ASP size, duration, and presence of transplant populations were not associated with a higher likelihood of using antifungal stewardship strategies (P > .05 for all).

CONCLUSIONS: The use of antifungal stewardship strategies was high at SRN hospitals, but they mainly involved audit and feedback. ASPs should be encouraged (1) to disseminate guidelines for IFI management, (2) to promote access to laboratory tests for rapid and accurate IFI diagnosis, and (3) to perform surveillance for antifungal utilization with reporting to the CDC.

STUDY DESIGN: Retrospective cohort study.

OBJECTIVES: The goal of this study was to assess the impact of multidrug resistant gram-negative organisms (MDRGNOs) on outcomes in those with SCI/D.

SETTING: VA SCI System of Care, Department of Veterans Affairs, United States.

METHODS: Multidrug resistance (MDR) was defined as being non-susceptible to ≥1 antibiotic in ≥3 antibiotic classes. Multivariable cluster-adjusted regression models were fit to assess the association of MDRGNOs with 1-year mortality, 30-day readmission, and postculture length of stay (LOS) stratified by case setting patients. Only the first culture per patient during the study period was included.

RESULTS: A total of 8,681 individuals with SCI/D had a culture with gram-negative bacteria during the study period, of which 33.0% had a MDRGNO. Overall, 954 (10.9%) died within 1 year of culture date. Poisson regression showed that MDR was associated with 1-year mortality among outpatients (IRR: 1.28, 95% CI, 1.06-1.54) and long-term care patients (OR: 2.06, 95% CI, 1.28-3.31). MDR significantly impacted postculture LOS in inpatients, as evidenced by a 10% longer LOS in MDR vs. non-MDR (IRR: 1.10, 95% CI, 1.02-1.19). MDR was not associated with increased 30-day readmission.

CONCLUSIONS: MDRGNOs are prevalent in SCI/D and MDR may result in poor outcomes. Further attention to prevention of infections, antibiotic stewardship, and management are warranted in this population.

INTRODUCTION: Dentists prescribe 1 in 10 opioid prescriptions in the U.S. When opioids are necessary, national guidelines recommend the prescription of low-dose opioids for a short duration. This study assesses the appropriate prescribing of opioids by dentists before guideline implementation.

METHODS: The authors performed a cross-sectional analysis of a population-based sample of 542,958 U.S. commercial dental patient visits between 2011 and 2015 within the Truven Health MarketScan Research Databases (data analysis October 2018‒April 2019). Patients with recent hospitalization, active cancer treatment, or chronic pain conditions were excluded. Prescription opioids were ascertained using pharmacy claims data with standardized morphine equivalents and recorded days' supply. Appropriate prescribing was determined from the 2016 Centers for Disease Control and Prevention guidelines for pain management based on a recommended 3 days' supply of opioid medication and anticipated post-procedural pain.

RESULTS: Twenty-nine percent of prescribed opioids exceeded the recommended morphine equivalents for appropriate management of acute pain. Approximately half (53%) exceeded the recommended days' supply. Patients aged 18-34 years, men, patients residing in the Southern U.S., and those receiving oxycodone were most likely to have opioids prescribed inappropriately. The proportion of opioids that exceed the recommended morphine equivalents increased over the study period, whereas opioids exceeding the recommended days' supply remained unchanged.

CONCLUSIONS: Between 1 in 4 and 1 in 2 opioids prescribed to adult dental patients are overprescribed. Judicious opioid-prescribing interventions should be tailored to oral health conditions and dentists.

IMPORTANCE: Conflicting evidence exists on the association between azithromycin use and cardiac events.

OBJECTIVE: To compare the odds of cardiac events among new users of azithromycin relative to new users of amoxicillin using real-world data.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used data from Truven Health Analytics MarketScan database from January 1, 2009, to June 30, 2015. Patients receiving either amoxicillin or azithromycin and enrolled in a health care plan 365 days before (baseline period) the dispensing date (index date) were included in the study. Patients were matched 1:1 on high-dimensional propensity scores. Data were analyzed from October 1, 2018, to December 31, 2019.

EXPOSURES: New use of azithromycin compared with new use of amoxicillin.

MAIN OUTCOMES AND MEASURES: The primary outcome consisted of cardiac events, including syncope, palpitations, ventricular arrhythmias, cardiac arrest, or death as a primary diagnosis for hospitalization at 5, 10, and 30 days from the index date. Logistic regression models were used to estimate odds ratios (ORs) with 95% CIs.

RESULTS: After matching, the final cohort included 2 141 285 episodes of each index therapy (N = 4 282 570) (mean [SD] age of patients, 35.7 [22.3] years; 52.6% female). Within 5 days after therapy initiation, 1474 cardiac events (0.03%) occurred (708 in the amoxicillin cohort and 766 in the azithromycin cohort). The 2 most frequent events were syncope (1032 [70.0%]) and palpitations (331 [22.5%]). The odds of cardiac events with azithromycin compared with amoxicillin were not significantly higher at 5 days (OR, 1.08; 95% CI, 0.98-1.20), 10 days (OR, 1.05; 95% CI, 0.97-1.15), and 30 days (OR, 0.98; 95% CI, 0.92-1.04). Among patients receiving any concurrent QT-prolonging drug, the odds of cardiac events with azithromycin were 1.40 (95% CI, 1.04-1.87) greater compared with amoxicillin. Among patients 65 years or older and those with a history of cardiovascular disease and other risk factors, no increased risk of cardiac events with azithromycin was noted.

CONCLUSIONS AND RELEVANCE: This study found no association of cardiac events with azithromycin compared with amoxicillin except among patients using other QT-prolonging drugs concurrently. Although azithromycin is a safe therapy, clinicians should carefully consider its use among patients concurrently using other QT-prolonging drugs.

PURPOSE: To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2020 in the United States, with a focus on the nonfederal hospital and clinic sectors.

METHODS: Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2020 were reviewed, including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for specialty drugs, biosimilars, and diabetes medications. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2020 were based on a combination of quantitative analyses and expert opinion.

RESULTS: In 2019, overall US pharmaceutical expenditures grew 5.4% compared to 2018, for a total of $507.9 billion. This increase was driven to similar degrees by prices, utilization, and new drugs. Adalimumab was the top drug in US expenditures in 2019, followed by apixaban and insulin glargine. Drug expenditures were $36.9 billion (a 1.5% increase from 2018) and $90.3 billion (an 11.8% increase from 2018) in nonfederal hospitals and clinics, respectively. In clinics, growth was driven by new products and increased utilization, whereas in hospitals growth was driven by new products and price increases. Several new drugs that will likely influence spending are expected to be approved in 2020. Specialty and cancer drugs will continue to drive expenditures.

CONCLUSION: For 2020 we expect overall prescription drug spending to rise by 4.0% to 6.0%, whereas in clinics and hospitals we anticipate increases of 9.0% to 11.0% and 2.0% to 4.0%, respectively, compared to 2019. These national estimates of future pharmaceutical expenditure growth may not be representative of any particular health system because of the myriad of local factors that influence actual spending.

OBJECTIVE: To investigate the proportions and trends in gender ratios of journal editorial boards in medicine, nursing, and pharmacy from 1995 to 2016.

DESIGN: This was a pooled cross-sectional evaluation of 21 high-impact medical, nursing, and pharmacy journals.

SETTING AND PARTICIPANTS: The gender composition of editorial boards for each discipline was obtained. Gender expression was based on the person's name or other information available on the Internet.

OUTCOME MEASURES: The proportion of all editorial board member positions, including editorial leadership positions, occupied by the underrepresented gender, and trends over time were measured.

RESULTS: A total of 5309 editorial board members and 312 editorial leadership positions were identified. From 1995 to 2016, women remained underrepresented across medicine and pharmacy journal editorial boards, whereas men remained underrepresented across nursing journal editorial boards. However, there were statistically significant increases in the representation of the underrepresented gender on editorial boards across all disciplines. Medicine was the only discipline to experience a statistically significant increase in the underrepresented gender of the editorial board being appointed to a leadership position; the proportion of women increased from 3% in 1995 to 35% in 2016.

CONCLUSION: The gender gap in medicine and pharmacy journals appears to be narrowing. Although men continue to lag behind women in nursing journals, they are and have been overrepresented when considering the proportion of men practicing in the field. Overall, continued efforts are needed to resolve gender inequities in academic health sciences.

Previous studies have suggested an increased risk of cardiac events with azithromycin, but the predictors of such events are unknown. We sought to develop and validate two prediction models to identify such predictors. We used data from Truven Marketscan Database (01/2009 to 06/2015). Using a split-sample approach, we developed two prediction models, which included baseline demographics, clinical conditions (Model 1), concurrent use of any drug (Model 1) and therapeutic class (Model 2) with a risk of QT-prolongation (CQT-Rx). Patients enrolled in a health plan for 365 days before and five days after dispensing of azithromycin (episodes). Cardiac events included syncope, palpitations, ventricular arrhythmias, cardiac arrest as a primary diagnosis for hospitalization including death. For each model, a backward elimination of predictors using logistic regression was applied to identify predictors in 100 random samples of the training cohort. Predictors prevalent in >50% of the models were included in the final model. A score for the Assessment of Cardiac Risk with Azithromycin (ACRA) was generated using the training cohort then tested in the validation cohort. A cohort of 20,134,659 episodes with 0.03% cardiac events were included. Over 60% included females with mean age of 40.1±21.3 years. Age, sex, history of syncope, cardiac dysrhythmias, non-specific chest pain, and presence of a CQT-Rx were included as predictors for Model-1 (c-statistic = 0.68). For Model-2 (c-statistic = 0.64), predictors included age, sex, anti-arrhythmic agents, anti-emetics, antidepressants, loop diuretics, and ACE inhibitors. ACRA score is available online (bit.ly/ACRA_2020). The ACRA score may help identify patients who are at higher risk of cardiac events following treatment with azithromycin. Providers should assess the risk-benefit of using azithromycin and consider alternative antibiotics among high-risk patients.

BACKGROUND: Opioid prescribing by dentists for older patients receiving medications with potential contraindications and the subsequent impact on acute care outcomes is not well described.

OBJECTIVES: Our objective of this paper was to evaluate the use of potentially inappropriate medication combinations (PIMCs) involving opioids prescribed by dentists according to the Beers Criteria and risks of 30-day emergency department (ED) visits and all-cause hospitalization among commercially insured dental patients ages 65 years and older.

METHODS: We conducted a retrospective cohort study of 40,800 older dental patient visits in which opioids were prescribed between 2011 and 2015 using the IBM MarketScan databases. Data collection from dental, medical, and pharmacy claims included information on the concurrent use of PIMCs and outcomes of all-cause acute care utilization over the 30-day period after dental encounters.

RESULTS: For the overall cohort, the median age was 69 years, and 45% were women. The prevalence of PIMCs per Beers Criteria was 10.4%. A total of 947 all-cause acute care events were observed in the 30 days post-dental visit. Patients with PIMCs involving opioids prescribed by dentists according to the Beers Criteria had higher rates of acute care use (3.3% vs 2.2%, p<0.001), which were associated with an increased risk of all-cause acute care utilization (adjusted risk ratio [RR] 1.23, 95% confidence interval [CI] 1.02-1.48). A dose-response relationship was seen with increasing oral morphine equivalents prescribed and increased acute care utilization (p<0.001).

CONCLUSION: A significant proportion of older patients receiving opioids at dental visits use psychotropic medications that in combination should be avoided according to the American Geriatric Society Beers Criteria.