How can artificial intelligence decrease cognitive and work burden for front line practitioners?

Artificial intelligence (AI) has tremendous potential to improve the cognitive and work burden of clinicians across a range of clinical activities, which could lead to reduced burnout and better clinical care. The recent explosion of generative AI nicely illustrates this potential. Developers and organizations deploying AI have a responsibility to ensure AI is designed and implemented with end-user input, has mechanisms to identify and potentially reduce bias, and that the impact on cognitive and work burden is measured, monitored, and improved. This article focuses specifically on the role AI can play in reducing cognitive and work burden, outlines the critical issues associated with the use of AI, and serves as a call to action for vendors and users to work together to develop functionality that addresses these challenges.

Leveraging technology in public-private partnerships: a model to address public health inequities.

Long-standing inequities in healthcare access and outcomes exist for underserved populations. Public-private partnerships (PPPs) are where the government and a private entity jointly invest in the provision of public services. Using examples from the Health Equity Consortium (HEC), we describe how technology was used to facilitate collaborations between public and private entities to address health misinformation, reduce vaccine hesitancy, and increase access to primary care services across various underserved communities during the COVID-19 pandemic. We call out four enablers of effective collaboration within the HEC-led PPP model, including: 1. Establishing trust in the population to be served 2. Enabling bidirectional flow of data and information 3. Mutual value creation and 4. Applying analytics and AI to help solve complex problems. Continued evaluation and improvements to the HEC-led PPP model are needed to address post-COVID-19 sustainability.

The Essential Role of Technology in the Public Health Battle Against COVID-19.

Technology has played an important role in responding to the novel coronavirus (SARS-CoV-2) and subsequent COVID-19 pandemic. The virus's blend of lethality and transmissibility have challenged officials and exposed critical limitations of the traditional public health apparatus. However, throughout this pandemic, technology has answered the call for a new form of public health that illustrates opportunities for enhanced agility, scale, and responsiveness. The authors share the Microsoft perspective and illustrate how technology has helped transform the public health landscape with new and refined capabilities - the efficacy and impact of which will be determined by history. Technologies like chatbot and virtualized patient care offer a mechanism to triage and distribute care at scale. Artificial intelligence and high-performance computing have accelerated research into understanding the virus and developing targeted therapeutics to treat infection and prevent transmission. New mobile contact tracing protocols that preserve patient privacy and civil liberties were developed in response to public concerns, creating new opportunities for privacy-sensitive technologies that aid efforts to prevent and control outbreaks. While much progress is still needed, the COVID-19 pandemic has highlighted technology's importance to public health security and pandemic preparedness. Future multi-stakeholder collaborations, including those with technology organizations, are needed to facilitate progress in overcoming the current pandemic, setting the stage for improved pandemic preparedness in the future. As lessons are assessed from the current pandemic, public officials should consider technology's role and continue to seek opportunities to supplement and improve on traditional approaches.

Relationship between organizational factors and performance among pay-for-performance hospitals.

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS)/Premier Hospital Quality Incentive Demonstration (HQID) project aims to improve clinical performance through a pay-for-performance program. We conducted this study to identify the key organizational factors associated with higher performance. METHODS: An investigator-blinded, structured telephone survey of eligible hospitals' (N = 92) quality improvement (QI) leaders was conducted among HQID hospitals in the top 2 or bottom 2 deciles submitting performance measure data from October 2004 to September 2005. The survey covered topics such as QI interventions, data feedback, physician leadership, support for QI efforts, and organizational culture. RESULTS: More top performing hospitals used clinical pathways for the treatment of AMI (49% vs. 15%, p < 0.01), HF (44% vs. 18%, p < 0.01), PN (38% vs. 13%, p < 0.01) and THR/TKR (56% vs. 23%, p < 0.01); organized into multidisciplinary teams to manage patients with AMI (93% vs. 77%, p < 0.05) and HF (93% vs. 69%, p < 0.01); used order sets for the treatment of THR/TKR (91% vs. 64%, p < 0.01); and implemented computerized physician order entry in the hospital (24.4% vs. 7.9%, p < 0.05). Finally, more top performers reported having adequate human resources for QI projects (p < 0.01); support of the nursing staff to increase adherence to quality indicators (p < 0.01); and an organizational culture that supported coordination of care (p < 0.01), pace of change (p < 0.01), willingness to try new projects (p < 0.01), and a focus on identifying system errors rather than blaming individuals (p < 0.05). CONCLUSIONS: Organizational structure, support, and culture are associated with high performance among hospitals participating in a pay-for-performance demonstration project. Multiple organizational factors remain important in optimizing clinical care.

In-hospital observation after antibiotic switch in pneumonia: a national evaluation.

PURPOSE: To evaluate the clinical benefit of in-hospital observation after the switch from intravenous (IV) to oral antibiotics in a large Medicare population. Retrospective studies of relatively small size indicate that the practice of in-hospital observation after the switch from IV to oral antibiotics for patients hospitalized with community-acquired pneumonia (CAP) is unnecessary. METHODS: We performed a retrospective examination of the US Medicare National Pneumonia Project database. Eligible patients were discharged with an ICD-9-CM diagnosis consistent with community-acquired pneumonia and divided into 2 groups: 1) a "not observed" cohort, in which patients were discharged on the same day as the switch from IV to oral antibiotics and 2) an "observed for 1 day" cohort, in which patients remained hospitalized for 1 day after the switch from IV to oral antibiotics. We compared clinical outcomes between these 2 cohorts. RESULTS: A total of 39,242 cases were sampled, representing 4341 hospitals in all 50 states and the District of Columbia. There were 5248 elderly patients who fulfilled eligibility criteria involving a length of stay of no more than 7 hospital days (2536 "not observed" and 2712 "observed for 1 day" patients). Mean length of stay was 3.8 days for the "not observed" cohort and 4.5 days for the "observed for 1 day" cohort (P <.0001). There was no significant difference in 14-day hospital readmission rate (7.8% in the "not observed" cohort vs 7.2% "observed for 1 day" cohort, odds ratio 0.91; 95% confidence interval [CI] 0.74-1.12; P =.367) and 30-day mortality rate (5.1% "not observed" cohort vs 4.4% in the "observed for 1 day" cohort, odds ratio 0.86; 95% CI, 0.67-1.11; P =.258) between the "not observed" and "observed for 1 day" cohorts. CONCLUSIONS: Our analysis of the US Medicare Pneumonia Project database provides further evidence that the routine practice of in-hospital observation after the switch from IV to oral antibiotics for patients with CAP may be avoided in patients who are clinically stable although these findings should be verified in a large randomized controlled trial.

Extramammary Paget's disease resistant to surgery and imiquimod monotherapy but responsive to imiquimod combination topical chemotherapy with 5-fluorouracil and retinoic acid: a case report.

Extramammary Paget's disease (EMPD) is an uncommon skin neoplasm that usually affects the elderly population and occurs in the genital, anorectal, or axillary areas. The recommended treatment of EMPD involves surgical excision, including Mohs micrographic surgery; however, surgery is associated with a high rate of recurrence. There have been reports of successful treatment of recurrence with monochemotherapy involving topical imiquimod 5% cream. We report a case of EMPD recurrence after surgery that was resistant to imiquimod monotherapy but that completely resolved after imiquimod was combined with topical 5-fluorouracil (5-FU) and retinoic acid. To our knowledge, this is the first reported case of imiquimod combination therapy with 5-FU and retinoic acid for the treatment of recurrent EMPD.

Meta-analysis: angiotensin-receptor blockers in chronic heart failure and high-risk acute myocardial infarction.

BACKGROUND: The role of angiotensin-receptor blockers (ARBs) in treating patients with chronic heart failure and high-risk acute myocardial infarction (MI) has been controversial, and recent clinical trials provide more information on this topic. PURPOSE: To quantify the effect of ARBs when compared with placebo (with and without background angiotensin-converting enzyme [ACE] inhibitors) and ACE inhibitors on all-cause mortality and heart failure hospitalizations in patients with chronic heart failure and high-risk acute MI. DATA SOURCES: Data from original research published through 13 November 2003. STUDY SELECTION: Predefined criteria were used to identify 24 trials. DATA EXTRACTION: 2 reviewers independently collected information on study characteristics and data on all-cause mortality and heart failure hospitalization. DATA SYNTHESIS: 24 trials involving 38 080 patients were included. Analysis of chronic heart failure trials revealed that 1) ARBs were associated with reduced all-cause mortality (odds ratio [OR], 0.83 [95% CI, 0.69 to 1.00]) and heart failure hospitalizations (OR, 0.64 [CI, 0.53 to 0.78]) as compared with placebo; 2) for ARBs versus ACE inhibitors, all-cause mortality (OR, 1.06 [CI, 0.90 to 1.26]) and heart failure hospitalization (OR, 0.95 [CI, 0.80 to 1.13]) did not differ; 3) and for combinations of ARBs plus ACE inhibitors versus ACE inhibitors alone, all-cause mortality was not reduced (OR, 0.97 [CI, 0.87 to 1.08]) but heart failure hospitalizations were reduced (OR, 0.77 [CI, 0.69 to 0.87]). For patients with high-risk acute MI, 2 randomized trials compared ARBs with ACE inhibitors but did not reveal differences in all-cause mortality or heart failure hospitalization. LIMITATIONS: Comparative economic data between ARBs and ACE inhibitors are lacking. CONCLUSIONS: Because ACE inhibitors and ARBs do not differ in efficacy for reducing all-cause mortality and heart failure hospitalizations in patients with chronic heart failure and in patients with high-risk acute MI, ARBs should be regarded as suitable alternatives to ACE inhibitors.

Prevalence and outcomes of anemia in individuals with human immunodeficiency virus: a systematic review of the literature.

In patients with human immunodeficiency virus (HIV), anemia is a commonly encountered hematologic abnormality that has a significant impact on clinical outcomes and quality of life (QOL). This review describes the prevalence of anemia in several populations of patients with HIV and the effects of anemia on survival, morbidity, disease progression, transfusion requirements, and QOL. The prevalence of anemia in HIV disease varies considerably, ranging from 1.3% to 95%: it depends on several factors, including the stage of HIV disease, sex, age, pregnancy status, and injection-drug use as well as the definition of anemia used. In general, as HIV disease progresses, the prevalence and severity of anemia increase. Anemia is also more prevalent in HIV-positive women, children, and injection-drug users than in HIV-negative women, children, and injection-drug users. Anemia has been shown to be a statistically significant predictor of progression to the acquired immunodeficiency syndrome and is independently associated with an increased risk of death in patients with HIV. Treatment of anemia with epoetin-alpha has resulted in significantly fewer patients requiring transfusion as well as decreases in the mean number of units of blood transfused. Resolution of HIV-related anemia has been shown to improve QOL, physical functioning, energy, and fatigue in individuals with HIV. More recently, the use of highly active antiretroviral therapy has also been associated with a significant increase in hemoglobin concentrations and a decrease in the prevalence of anemia.

Early switch and early discharge opportunities in intravenous vancomycin treatment of suspected methicillin-resistant staphylococcal species infections.

BACKGROUND: Patients with methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant coagulase negative staphylococci (MR-CoNS) infections are usually treated with intravenous (IV) vancomycin and remain hospitalized for the duration of IV therapy. Oral linezolid has excellent bioavailability and activity against MRSA and MR-CoNS and offers the potential for outpatient treatment of MRSA and MR-CoNS infections. OBJECTIVE: To determine the potential for early switch (ES) from IV vancomycin to oral linezolid and subsequent early discharge (ED) in hospitalized, adult patients treated for an MRSA or MR-CoNS infection. METHODS: We conducted a retrospective cohort study at the Veterans Administration Greater Los Angeles Healthcare System from January 1 through December 31, 2000. Potential reductions in vancomycin use, hospital length of stay (LOS), and economic savings were determined. RESULTS: A total of 103 of 177 (58%) treatment courses for MRSA or MR-CoNS infections were potentially eligible for ES, with annual and mean decreases in vancomycin use of 535 defined daily doses and 5.2 days per event. Of the ES cohort, 55 of 103 (53%) courses were potentially eligible for ED, with an annual and mean reduction in LOS of 181 days and 3.3 days per event. The total potential savings was $220,181, at an average of $3,478 per event. CONCLUSION: Early switch to oral linezolid for treatment of MRSA or MR-CoNS infections could reduce vancomycin use, hospital length of stay, and economic costs.

Association between protease inhibitor use and increased cardiovascular risk in patients infected with human immunodeficiency virus: a systematic review.

Some studies have shown that currently available protease inhibitors (PIs) are associated with an increased risk of cardiovascular disease. We have systematically reviewed the published literature and conference abstracts for studies evaluating cardiovascular risk factors and events in patients receiving highly active antiretroviral therapy, with and without PIs. The majority of studies showed that the use of PIs was associated with increased levels of total cholesterol (36 [75%] of 48 studies), triglycerides (35 [73%] of 48 studies), and low-density lipoprotein (12 [100%] of 12 studies). PI use was often associated with morphological signs of cardiovascular disease, such as increased carotid intima thickness or atherosclerotic lesions (7 [88%] of 8 studies). Finally, 2 (67%) of 3 long-term observational studies that met our inclusion criteria demonstrated an association between use of PIs and subsequent myocardial infarction. The benefits of the currently available PIs should be balanced against the long-term risk of cardiovascular disease.

Azithromycin monotherapy for patients hospitalized with community-acquired pneumonia: a 31/2-year experience from a veterans affairs hospital.

BACKGROUND: Current American Thoracic Society (ATS) community-acquired pneumonia treatment guidelines recommend azithromycin monotherapy for a limited subset of hospitalized patients. We evaluated the effectiveness of azithromycin monotherapy in a more generalized population of patients hospitalized with mild-to-moderate community-acquired pneumonia. METHODS: We reviewed medical records from a Veterans Affairs facility for patients admitted with community-acquired pneumonia between December 1, 1997, and June 30, 2001, comparing those receiving azithromycin monotherapy, other ATS-recommended antibiotics, and non-ATS-recommended antibiotics. We excluded patients with immunosuppression, metastatic cancer, or hospital-acquired pneumonia. Outcome measures included times to stability, meeting criteria for change to oral therapy, and eligibility for discharge; length of stay; intensive care unit transfer; and mortality. Outcomes were adjusted for pneumonia severity, skilled nursing facility status, and processes of care. RESULTS: A total of 442 patients were eligible for the study (221 in the azithromycin monotherapy group, 129 in the ATS group, and 92 in the non-ATS group). Times to clinical stability and to fulfilling early switch criteria were not statistically significantly different among the 3 groups. Mean time to fulfilling early discharge criteria was 2.48 days for patients receiving azithromycin monotherapy vs 2.84 days for those receiving ATS antibiotics (P =.008) and 2.58 days for those receiving non-ATS antibiotics (P =.64). Overall mean length of stay was shorter in the azithromycin monotherapy group (4.35 days) vs the ATS (5.73 days) (P =.002) and non-ATS (6.21 days) (P<.001) groups. Mortality, intensive care unit transfer, and readmission rates were similar across the groups. CONCLUSION: Azithromycin monotherapy is equally as efficacious as other ATS-recommended regimens for treating hospitalized patients with mild-to-moderate community-acquired pneumonia.

Cost analysis of switching from i.v. vancomycin to p.o. linezolid for the management of methicillin-resistant Staphylococcus species.

BACKGROUND: Infections with methicillin-resistant Staphylococcus species (MRSS) are associated with higher treatment costs than infections with methicillin-sensitive Staphylococcus species in the United States--partly because of an increased length of hospital stay (LOS). OBJECTIVE: This study used pharmacoeconomic modeling to evaluate the costs and outcomes associated with the use of i.v. vancomycin compared with p.o. linezolid in the treatment of MRSS-infected patients. METHODS: A retrospective chart review was used to determine the number of cases with confirmed or presumed MRSS infections treated with i.v. vancomycin during calendar-year 2000 at the Veterans Affairs Greater Los Angeles Healthcare System inpatient facility. Patients who were eligible for a switch to p.o. linezolid with or without early discharge to home were identified. Cost differences associated with conversion from i.v. to p.o. therapy (compared with continued i.v. therapy) were estimated based on a mean decreased LOS and a decrease in the costs associated with catheter-related adverse events. Rates and costs of catheter-related adverse events were based on estimates from the literature. Sensitivity analyses were performed by variation of the estimated mean LOS decrease in the SD and by variation of the estimates for incidence and costs related to catheter complications. Costs were measured in year 2000 US dollars, and differences were not assessed for statistical significance. RESULTS: Of 177 patients treated with i.v. vancomycin, 103 (58%) were eligible for conversion to p.o. linezolid and 55 (31%) were eligible for early discharge from the hospital with continuation of p.o. therapy. Early discharge was associated with a mean (SD) LOS decrease of 3.3 (2.9) days. Annual mean total cost savings in patients eligible for conversion from i.v. vancomycin to p.o. linezolid with early discharge were $294,750 (range, $35,730-$553,790). For cases eligible for inpatient conversion from i.v. vancomycin to p.o. linezolid therapy (n=48), the mean total annual cost difference was an increase of $6340 for p.o. linezolid (range, -$12,910 to $11,900). CONCLUSION: These results--although partly based on estimates from the literature, rather than direct measurements--support the use of p.o. linezolid with or without early discharge as a potential cost-savings alternative for eligible patients treated with a full course of i.v. vancomycin for suspected or confirmed MRSS infection.

Comparing quality of care for sexually transmitted diseases in specialized and general clinics.

OBJECTIVE: The objective of this study was to compare quality of care for patients with sexually transmitted diseases (STDs) in specialized vs. general clinics. METHODS: The authors conducted a retrospective chart review evaluating compliance with a set of STD-related process of care quality indicators for adult patients seen in six Los Angeles County clinics (two STD specialized clinics and four general medical clinics). RESULTS: Thirty-two quality indicators were selected using a modified Delphi process. From March 1, 1996, to June 31, 1996, there were 205 STD-related visits to the two specialized STD clinics and 373 STD-related visits to the four general medical clinics. For patients with "classic" STDs (those for which sexual contact is the primary means of transmission), STD clinics achieved greater compliance than general medical clinics on 14 quality indicators, while general medical clinics achieved greater compliance on 4 indicators. CONCLUSION: STD clinics provide better overall STD care than general medical clinics. Possible explanations include differences in clinician experience with STD patients and greater use of standardized protocol sheets.