Publications

BACKGROUND: Timely primary care follow-up after hospitalization is recommended to monitor recovery and coordinate care. Whether follow-up differs for vulnerable populations, such as those with frailty and those discharged to skilled nursing facilities (SNF) prior to returning home, is not known.

METHODS: Retrospective cohort study using a 100% sample of traditional Medicare beneficiaries discharged from hospital to home or from hospital to SNF and then home, between 2010 and 2022. The primary outcome was the receipt of a primary care visit within 30 days of return to home, measured overall and stratified by disposition (discharged home vs. to SNF then home) and by frailty (defined by a claims-based frailty index). Multivariable logistic regression models were used to estimate changes in outcomes over time, overall and stratified by disposition and frailty.

RESULTS: The cohort included 94,248,326 discharges (80.1% age ≥ 65 years, 55.1% female, 36.7% frail) of which 21.5% were discharged to SNF and then home. Between 2010 and 2022, primary care follow-up increased from 51.5% to 57.5% for patients discharged directly home and from 24.3% to 28.4% for patients discharged to SNF then home. In adjusted analyses, compared to those discharged directly home, patients discharged to SNF and then home had an 8.2% point (pp) (95% CI, -8.5 to -7.9) lower predicted probability of ambulatory follow-up in 2022. Among patients discharged directly home, no difference was evident in follow-up between frail and non-frail patients (54.6% vs. 54.1%); difference 0.4 pp (95% CI, -0.1 to 1.0). In contrast, among patients discharged to SNF then home, frail patients had a lower predicted probability of follow-up (42.8% vs. 48.9%); difference - 6.1 pp (95% CI, -7.0 to -5.2).

CONCLUSIONS: Frail patients and patients requiring a short-term SNF stay after hospitalization are less likely to receive timely follow-up upon return to home than other patient groups.

BACKGROUND: Proton-pump inhibitors (PPIs) are effective in treating peptic ulcer disease (PUD), but they are often prescribed beyond the approved duration. Because PPIs are associated with adverse effects, there is a need for effective stewardship.

OBJECTIVE: To identify the frequency of and healthcare factors associated with PPI prescriptions exceeding the approved eight-week treatment duration for PUD.

METHODS: We conducted a retrospective cohort study of patients diagnosed with acute PUD without other indications for PPI use using data from the Veterans Health Administration in the United States. Exposures were patient, provider, and facility factors that could influence PPI prescribing. The outcome was time to a filled PPI prescription exceeding the approved treatment duration for PUD. Associations were assessed using a multivariable time-to-recurrent-event model to calculate adjusted hazard ratios (aHR) and population-attributable fractions. Patients who developed indications for long-term PPI use were censored.

RESULTS: We identified 7708 patients with PUD who met eligibility criteria and received PUD treatment (median age 79 [IQR 71-85], 7% female). Thirty-five percent had PPI prescriptions exceeding the approved duration for a median of 346 days (IQR 165-643) of overuse. On the patient level, inpatient PUD diagnosis (aHR 1.32, 95% CI 1.25-1.39), use of nonsteroidal anti-inflammatory drugs (NSAIDs) (aHR 1.26, 95% CI 1.18-1.34), use of anticoagulants (aHR 1.25, 95% CI 1.13-1.38), and moderate frailty (1.15, 95% CI 1.06-1.26) had the strongest associations with filled PPI prescriptions exceeding the approved duration. On the health-system level, inpatient PUD diagnosis had the highest peak population attributable fraction at 0.26, followed by NSAIDs and anticoagulants at 0.18.

CONCLUSIONS: Markers of patient complexity and medication use not meeting gastroprotection guidelines are associated with inappropriate PPI persistence among patients with PUD. These data may inform future targeted PPI deprescribing programs.

CONTEXT: Antimicrobial Stewardship Programs (ASPs) are crucial to optimizing antibiotic use. ASPs are implemented in the Veterans Health Administration (VAs), but they do not target the needs of populations at high risk for resistant infections, such as spinal cord injury and disorder (SCI/D).

OBJECTIVE: The goal of this study was to assess key ASP leader and SCI/D clinicians' perceived level of implementation and impact of 33 Antimicrobial Stewardship (AS) strategies.

METHOD: SCI/D clinicians and ASP leaders across 24 VA facilities with SCI/D units were surveyed. Participants rated their perceived level of impact ("high", "mild", "low") and perceived level of implementation ("not", "partially", "fully") for 33 AS strategies in SCI/D units in VAs. Strategies were grouped into core elements which they support. We conducted a Fisher's exact test to assess differences between respondent perceptions based on role (SCI/D clinicians versus ASP leaders).

RESULTS: AS strategy implementation varied across VA facilities. Of the AS strategies, pre-authorization was perceived to be highly impactful (78%) and fully implemented (82%). SCI/D clinicians and ASP leaders rated AS strategies differently such that SCI/D clinicians were less aware of implementation of AS strategies related to reporting requirements; further, SCI/D clinicians rated strategies which guide treatment duration and which limit C. difficile antibiotic exposure as more impactful than ASP leaders. Ratings for facility-wide and SCI/D unit ratings did not significantly differ for impact or implementation.

CONCLUSION: Implementation practices varied across VA facilities. Future work should implement highly impactful AS strategies according to facility and unit needs.

OBJECTIVE: Many post-acute and long-term care settings (PALTCs) struggle to measure antibiotic use via the standard metric, days of therapy (DOT) per 1000 days of care (DOC). Our objective was to develop antibiotic use metrics more tailored to PALTCs.

DESIGN: Retrospective cohort study with a validation cohort.

SETTING: PALTC settings within the same network.

METHODS: We obtained census data and pharmacy dispensing data for 13 community PALTCs (January 2020-December 2023). We calculated antibiotic DOT/1000 DOC, DOT per unique residents, and antibiotic starts per unique residents, at monthly intervals for community PALTCs. The validation cohort was 135 Veterans Affairs Community Living Centers (VA CLCs). For community PALTCs only, we determined the DOT and antibiotics starts per unique residents cared for by individual prescribers.

RESULTS: For community PALTCs, the correlation between facility-level antibiotic DOT/1000 DOC and antibiotic DOT/unique residents and antibiotic courses/unique residents was 0.97 (P < 0.0001) and 0.84 (P < 0.0001), respectively. For VA CLCs, those values were 0.96 (P < 0.0001) and 0.85 (P < 0.0001), respectively. At community PALTCs, both novel metrics permitted assessment and comparison of antibiotic prescribing among practitioners.

CONCLUSION: At the facility level, the novel metric antibiotic DOT/unique residents demonstrated strong correlation with the standard metric. In addition to supporting tracking and reporting of antibiotic use among PALTCs, antibiotic DOT/unique residents permits visualization of the antibiotic prescribing rates among individual practitioners, and thus peer comparison, which in turn can lead to actionable feedback that helps improve antibiotic use in the care of PALTC residents.

BACKGROUND: Urinary tract infections (UTI) are common complications in people with neurogenic bladder (NB). Limited data exist on UTI-related knowledge, experiences, and quality of life (QoL) impacts in this population.

METHODS: We mailed surveys to 289 Veterans with NB due to spinal cord injury/disorder (SCI/D), multiple sclerosis, or Parkinson's Disease who had a UTI diagnosis at four Veterans Affairs Medical Centers between May 2022-May 2023. The survey was adapted from existing instruments and previously collected qualitative data and assessed patient knowledge and experiences with UTI and QoL impacts. Descriptive statistics summarized responses and scaled QoL scores were calculated, with higher scores indicating greater negative impact.

RESULTS: Most respondents (n = 71) were older (mean age = 69), had SCI/D (77%), and used urinary catheters (77%). Over a third had misperceptions about antibiotic risks and the significance of a positive urine culture or bacteriuria for diagnosing UTI. 18% wanted more information about UTIs, with most preferring written materials (77%) or information at healthcare provider visits (62%). The strongest QoL impacts were on daily activities, with many respondents indicating UTIs affect diet (50%), travel (53%), and sex life (60%). Mean [standard deviation (SD)] scaled QoL score was 40.8 (15.3) out of a maximum of 75, with ≥ 3 UTIs in the prior year associated with higher scores (p = 0.02).

CONCLUSIONS: People with NB may have misperceptions about UTI diagnosis and antibiotic risks, and experience substantial QoL impacts from UTIs. Provider encounters for suspected UTI may be good opportunities for delivering written education and assessing QoL impacts.

BACKGROUND: One of the largest-ever retail drug shortages began in 2018 when several angiotensin II receptor blockers (ARBs) for treating hypertension, heart failure, and chronic kidney disease-valsartan, losartan, and irbesartan-were recalled for carcinogenic impurities. The long-term consequences of the ARB shortages and whether certain groups experienced more adverse outcomes is unknown.

OBJECTIVE: To evaluate changes in adherence and health outcomes after ARB recalls and to identify patients who experienced greater changes in access and adverse clinical outcomes.

METHODS: Using an integrated claims and electronic health record dataset and a difference-in-differences design, we evaluated changes in the proportion of days covered (PDC) for ARBs and similar drugs (angiotensin-converting enzyme inhibitors [ACE-Is]), uncontrolled blood pressure, major cardiovascular event (MACE)-related acute care visits, and all-cause ambulatory care visits in the 12 months before vs 18 months after recalls for valsartan, losartan, and irbesartan users vs patients taking similar, nonrecalled drugs (ACE-Is, nonrecalled ARBs). Triple-difference models characterized heterogeneous associations by pre-recall patient demographic (race, ethnicity, age), clinical (baseline indication, mental health conditions), and adherence variables.

RESULTS: Adjusting for pre-recall patient characteristics, we observed no significant changes in PDC for ARBs and ACE-Is (combined), uncontrolled blood pressure, or ambulatory care visits among 86,507 recalled ARB users vs 123,583 comparison drug users in the 18 months after the recalls. Following the recalls, medication switches increased on average by an additional 2.08 percentage points (p.p.) per quarter (95% CI = 2.01-2.15) for recalled ARB vs comparison drug users, a 195.9% relative increase. We observed the most switches in the 90-day period immediately after valsartan's recall (difference-in-difference: 9.48 p.p.; 95% CI = 9.36-9.59; relative change = 892%). Cumulatively, 55.2% of valsartan, 7.6% of losartan, and 18.9% of irbesartan users switched medications after 18 months. We observed an increase in the proportion of recalled ARB vs comparison patients who experienced medication gaps exceeding 30 days (1.13 p.p. per quarter on average; 95% CI = 0.97-1.30), which was most apparent after approximately 15 months (5 quarters). Although MACE-related acute care visits did not change in the quarter (90 days) immediately after valsartan's recall, we observed an increase of 1.40 additional visits per 1,000 recalled ARB vs comparison drug patients in each subsequent quarter, a 9.3% relative increase. Results were similar across most subgroups.

CONCLUSIONS: The 2018 ARB recalls were associated with immediate changes in antihypertension medication use. Many patients transitioned to alternative medications. Although overall impacts on clinical outcomes were minimal and not statistically significant, small increases in medication gaps and MACE-related acute care visits among some patients occurred after more than 1 year. The ARB recalls may have been associated with fewer adverse events than other recent shortages owing to the widespread availability of alternative treatments in the same or similar drug class.

PURPOSE: We compare trends in gabapentinoid and opioid utilization overall and by economic development category. We also sought to predict future trends and assess correlations in gabapentinoid and opioid utilization.

METHODS: We conducted a repeated cross-sectional analysis of retail prescriptions for 72 countries from Q1 2012 to Q3 2023. We measured standardized units/1000 population for gabapentinoid and opioid sales, stratified by development category, and used time-series models to predict trends for the following 3 years. Granger causality tests examined predictive relationships between gabapentinoid and opioid sales.

RESULTS: Global gabapentinoid annual sales rose by 114.5% from 2012 to 2022, with a higher increase in developing (180.9%) than developed economies (110.0%). In contrast, annual opioid sales declined globally by 25.4%, with a 27.9% decrease in developed and a 16.8% increase in developing economies. Assuming current trends persist over the following 3 years, gabapentinoid quarterly sales are forecasted to rise by 7.7% in developed and 18.6% in developing economies, while opioid quarterly sales are expected to decrease by 9.5% and increase by 15.1%, respectively. Granger causality tests indicated that gabapentinoids may predict opioid sales globally for the following year, but opioids did not predict gabapentinoid sales.

CONCLUSION: We evaluated the global trends in gabapentinoid and opioid sales, suggesting important differences in pain management practices across developed and developing economies. Our findings highlight the need to ensure the safe use of gabapentinoids and opioids while balancing proper pain management.

Predicting major bleeding in nonvalvular atrial fibrillation (AF) patients on direct oral anticoagulants (DOACs) is crucial for personalized care. Alternatives like left atrial appendage closure devices lower stroke risk with fewer nonprocedural bleeds. This study compares machine learning (ML) models with conventional bleeding risk scores (HAS-BLED, ORBIT, and ATRIA) for predicting bleeding events requiring hospitalization in AF patients on DOACs at their index cardiologist visit. This retrospective cohort study used electronic health records from 2010 to 2022 at the University of Pittsburgh Medical Center. It included 24,468 nonvalvular AF patients (age ≥18) on DOACs, excluding those with prior significant bleeding or warfarin use. The primary outcome was hospitalization for bleeding within one year, with follow-up at one, two, and five years. ML algorithms (logistic regression, classification trees, random forest, XGBoost, k-nearest neighbor, naïve Bayes) were compared for performance. Of 24,468 patients, 553 (2.3%) had bleeding within one year, 829 (3.5%) within two years, and 1,292 (5.8%) within five years. ML models outperformed HAS-BLED, ATRIA, and ORBIT in 1-year predictions. The random forest model achieved an AUC of 0.76 (0.70 to 0.81), G-Mean of 0.67, and net reclassification index of 0.14 compared to HAS-BLED's AUC of 0.57 (p < 0.001). ML models showed superior results across all timepoints and for hemorrhagic stroke. SHAP analysis identified new risk factors, including BMI, cholesterol profile, and insurance type. In conclusion, ML models demonstrated improved performance to conventional bleeding risk scores and uncovered novel risk factors, offering potential for more personalized bleeding risk assessment in AF patients on DOACs.