Developing a quality measure to assess use of antibiotic medications for respiratory conditions.

Objective: Antibiotics are essential medications for treating life-threatening infections. However, incorrect prescribing can lead to adverse events and contribute to antibiotic resistance. We sought to develop a utilization quality measure that could be used by health insurance plans to track overall prescribing for respiratory conditions. Design: A consensus-based process that included evidence review, testing, and stakeholder input was used to develop a measure and assess its usefulness for the Healthcare Effectiveness Data and Information Set (HEDIS), a national quality measurement tool. Methods: Guidelines and literature were reviewed to establish the rationale for the measure. The measure was tested in claims data for commercial, Medicaid and Medicare Advantage enrollees to assess feasibility of collecting and reporting needed information. The measure was vetted with multistakeholder advisory panels and posted for public comment to solicit wide input on relevance and usability. Results: Respiratory conditions are frequent reasons for outpatient care in the data assessed. On average, across all lines of business, the measure revealed that approximately one-third of outpatient visits for respiratory conditions are followed by antibiotics. Stakeholders supported the measure as a tool for monitoring antibiotic prescribing across health plans alongside existing measures that assess inappropriate prescribing for specific conditions. The final measure assesses the number of antibiotic prescriptions dispensed across all outpatient respiratory-related encounters at a health-plan level. Conclusions: The measure on antibiotic prescribing for respiratory conditions was relevant, feasible, and useful. Stakeholders strongly supported the newly developed measure and recommended its integration into HEDIS.

Development of a universal thoracic enhanced recover after surgery protocol for implementation across a diverse multi-hospital health system.

Background: Implementation of enhanced recovery after surgery (ERAS) pathways for patients undergoing anatomic lung resection have been reported at individual institutions. We hypothesized that an ERAS pathway can be successfully implemented across a large healthcare system including different types of hospital settings (academic, academic-affiliated, community). Methods: An expert panel with representation from each hospital within a healthcare system was convened to establish a thoracic ERAS pathway for patients undergoing anatomic lung resection and to develop tools and analytics to ensure consistent application. The protocol was translated into an order set and pathway within the electronic health record (EHR). Iterative implementation was performed with recording of the processes involved. Barriers and facilitators to implementation were recorded. Results: Development and implementation of the protocol took 13 months from conception to rollout. Considerable change management was needed for consensus and incorporation into practice. Facilitators of change included peer accountability, incorporating ERAS care elements into the EHR, and conducting case reviews with timely feedback on protocol deviations. Barriers included institutional cultural differences, agreement in defining mindful deviation from the ERAS protocol, lack of access to specific coded data, and resource scarcity caused by the COVID-19 pandemic. Support from the hospital system's executive leadership and institutional commitment to quality improvement helped overcome barriers and maintain momentum. Conclusions: Development and implementation of a health-system wide thoracic ERAS protocol for anatomic lung resections across a six-hospital health system requires a multidisciplinary team approach. Barriers can be overcome though multidisciplinary team engagement and executive leadership support.

Risk factors for fatigue and impaired function eight months after hospital admission with COVID-19

INTRODUCTION: We aimed to evaluate post-COVID-19 fatigue, change in functional capacity and health-related quality of life (HRQoL) eight months after discharge from hospital due to COVID-19. METHODS: A total of 83 patients (35 women) admitted to the Copenhagen University Hospital - North Zealand Hospital, Denmark, for COVID-19 during the period from March to June 2020 were evaluated eight months after discharge using validated questionnaires quantifying fatigue, HRQoL and post-COVID-19 functional status. Follow-up data were correlated with measures of pre-COVID-19 status (anthropometrics, comorbidities) and measures of severity of the acute infection. RESULTS: A total of 22 (65%) women and 12 (26%) men reported excessive fatigue. In all, 20 women (67%) and 17 men (37%) reported decreased physical function. Female sex was associated with fatigue. Loss of physical function was associated with pre-COVID-19 presence of heart disease and absence of lung disease. Severity of the acute COVID-19 infection was not associated with fatigue or change in functional status. Fatigue and functional status were correlated with both generic HRQoL and lung disease-specific HRQoL. CONCLUSIONS: Female sex was associated with a higher risk of fatigue eight months after hospitalisation with COVID-19 infection. Regarding loss of functional capacity after COVID-19, we found an apparently protective effect of pre-COVID-19 lung disease. Our findings underscore the urgent need for further research and the importance of evaluating those recovering from COVID-19 for symptoms of excessive fatigue and change in functional capacity irrespective of the severity of the initial infection. FUNDING: none. TRIAL REGISTRATION: not relevant.

Vaccine perceptions in a free urban clinic for underserved, uninsured adults.

BACKGROUND: Adult vaccine rates remain low despite public health efforts. Despite the likelihood that underserved patients face more barriers to vaccination, little is known on the perceptions underserved patients have about vaccines as a whole. Additional information could guide health care providers in efforts to improve adult vaccination rates in the medically underserved population. OBJECTIVES: The primary objective of this survey was to assess perceived susceptibility to and severity of vaccine-preventable disease (VPD) and perceived safety and effectiveness of vaccines in a medically underserved population. METHODS: This cross-sectional, descriptive study evaluated vaccine perceptions using a self-administered paper survey in a free clinic providing care to uninsured, low-income adults. All patients with scheduled appointments in the clinic were eligible to participate. Two Likert-type items were used to define responses regarding trust and beliefs. Level of trust was defined as "Not at all" (1), "A little" (2), "Not sure" (3), "Some" (4), and "A lot" (5). Responses to vaccine belief items were defined as "Strongly disagree" (1), "Disagree" (2), "Neither agree nor disagree" (3), "Agree" (4), and "Strongly agree" (5). Statistical analyses were descriptive in nature. RESULTS: Final analysis included 131 surveys. Health care providers were the most common patient-reported vaccine information source (73.3%) and the most trusted (median: 5). Despite clear agreement among respondents that vaccines are safe (median: 3.94) and effective (median: 4) in adults, with similar results regarding children, the results regarding personal risk from VPDs were less definitive (median: 3). CONCLUSION: Overall, survey responses in this uninsured, low-income population indicate that vaccines are perceived as safe and effective, but there is less consensus regarding the individual risk patients face from VPD. Focusing patient education on individual risk as much as overall vaccine safety and efficacy may help improve low adult vaccination rates in the medically underserved.

Design in emergency scenario: Project of a hand sanitizer dispenser in public transport using Design Sprint method

In the emergency scenario generated by COVID-19 pandemic, the development of fast solutions to reduce the contagious curve can mean saving lives. Democratic access to prevention methods is essential, especially in places with high exposure to contamination and whose activities have not been interrupted, such as public transportation. This work presents the development of a hand sanitizer dispenser for public transportation and other possible locations in the urban environment, designed during an online marathon. The focus is on the development of the Design Sprint method and its adaptations to fit the remote work and other constraints due social distance. The final product was designed to be produced by 3D printing and open design, to fast distribution and replication. It fits in the bus's handrails, with some positioning possibilities and the use of PET bottles as alcohol containers. As a result, the paper highlights the particularities of agile methods for the design process at a distance and demonstrates that the process used allows for quickly responding to solutions for emerging needs. © 2020 Universidade do Vale do Rio dos Sinos. All rights reserved.

Multiplex Fragment Analysis Identifies SARS-CoV-2 Variants (preprint)

The rapid spread of SARS-CoV-2 variants are of critical concern, necessitating systematic efforts for epidemiological surveillance. The current method for identifying variants is viral genome sequencing. Sequencing has multiple limitations to broad clinical adoption including requirements for technical expertise, expense of equipment and bioinformatics, and time for implementation. Here we describe a scalable non-sequencing-based capillary electrophoresis assay to affordably screen variants of SARS-CoV-2. The assay has targets for N1 (CDC nucleocapsid target, internal control), spike gene 69_70 deletion, spike gene 144 deletion, and ORF1A 3675_3677 deletion, which are all present in the B.1.1.7 (UK) variant. ORF1A deletions alone are also present in the New York, Brazil, and South African variants. 648 specimens have been tested to date and the assay is able to detect the B.1.1.7 variant 32 times (n=23 specimens, n=9 positive control replicates). Additionally, the B.1.429 (California) variant can be detected when a 3bp insertion or drop out of the S144 target is present. 7/23 B.1.1.7 specimens have been confirmed by Whole Genome Sequencing (16 pending confirmation), and demonstrate the ability to rapidly track the progression of COVID-19 variants in the population.