Consumption of Mother's Own Milk by Infants Born Extremely Preterm Following Implementation of a Donor Human Milk Program: A Retrospective Cohort Study.

OBJECTIVE: To compare mothers' own milk (MOM) consumption by infants born extremely preterm before and after implementation of a donor human milk (DHM) program and determine healthcare provider's knowledge and practices regarding DHM. STUDY DESIGN: One hundred fifty-seven infants born at <30 weeks of gestation were enrolled during 3 time-periods. Group 1: before DHM program implementation, Group 2: the year following implementation, and Group 3: the second year after implementation. The proportion of feeds consisting of MOM for 6 weeks following birth was analyzed using a generalized linear mixed model. The study's second phase surveyed healthcare providers regarding knowledge and practices concerning DHM. RESULTS: Group 1 consumed feeds with a greater proportion of MOM than Group 3 during weeks 1 (P < .001) and 3 (P = .007) and more than both Group 2 (P = .033) and 3 (P = .021) in week 4. During the first 14 days, Group 1 consumed feeds with 23.6% more MOM than Group 3 (P = .002) and had a greater odds of consuming feeds with > 90% MOM (P < .001) than Group 3. During days 1-28, Group 1 consumed feeds with 22% more MOM than Group 3 (P = .003) and had greater odds of consuming feeds with >90% MOM than Group 2 (P = .020) and 3 (P = .004). Knowledge regarding DHM was inconsistent among providers and they were unlikely to communicate potential risks and benefits of DHM to mothers. CONCLUSIONS: Following implementation of a DHM program, MOM consumption decreased over 2 years. Strategies focused on lactation success are necessary to increase MOM consumption.

Trends in Warfarin Monitoring Practices Among New York Medicare Beneficiaries, 2006-2011.

Anticoagulation with warfarin requires frequent evaluation of the international normalized ratio (INR), and less invasive testing devices are available for use by clinicians at the point-of-care (POC) and by patients who self-test (PST). Despite commercial availability and positive results of published studies, evidence suggests that adoption of less invasive (POC/PST) testing in the United States is slow. Considering the equivalence of results and logistical advantages of POC/PST testing, slow uptake may indicate a gap in quality of care warranting evaluation and possibly intervention. This study used Medicare fee for service claims data to explore the uptake of POC/PST INR monitoring across New York State over a 6 year time frame (2006-11), with additional analyses based on beneficiary age, sex, race and ethnicity and income by county. In 2006, only 28.3% of 103,410 analyzable beneficiaries presumed to be chronic warfarin users based on INR testing patterns were monitored by POC/PST, and increased to only 37.6% by 2011. Utilization of POC/PST testing varied widely by county (baseline range 1.2-89.4%), and uptake of these testing modalities in New York State was significantly lower among the very elderly, women, and ethnic minorities. We hypothesize that poor penetration of these less invasive INR testing modalities into highly populated New York City and barriers to POC utilization in long term care facilities may account for a portion of the variability in INR testing patterns observed in this study. However, additional research is needed to further explore whether disparities in warfarin monitoring practices exist.

Improving warfarin safety in long-term care.

OBJECTIVE: To assess the impact of a multidisciplinary warfarin safety intervention on objective quality measurements. DESIGN: A pre-post comparison of aggregate performance following 12 months of intervention activities. SETTING: Long-term care facilities. PATIENTS, PARTICIPANTS: Twelve long-term care facilities in New York state. INTERVENTIONS: Interventions included serial data reports, pharmacy alerts, quality improvement meetings, and Webinars. MAIN OUTCOME MEASURES: The primary outcome was the proportion of residents receiving anticoagulation therapy and who were receiving timely International Normalized Ratio (INR) testing following initiation of an interacting antibiotic. Secondary outcomes included: time in therapeutic range (TTR), mean INR, mean time between INRs, proportion of INR values between 2.3 and 2.7, and the frequency of INR "excursions." RESULTS: Baseline analysis of the three-month preintervention period identified 207 warfarin-antibiotic coprescribing events, with only 70% being followed by a timely INR test. The baseline TTR was 45.49%, and the mean INR was 2.32. Baseline evaluations of facility policies and procedures identified process gaps in dosing and monitoring of warfarin. Intervention significantly improved the timeliness of INR monitoring (79.6%; P=0.03), but secondary measures were not measurably improved. Facility adherence to intervention implementation was poor, diminishing study impact. CONCLUSION: Anticoagulation management was suboptimal at baseline, and improvements were not seen despite repeated attempts to implement a structured, sequential intervention. Long-term care facilities may be unwilling or unable to voluntarily implement known best practices for anticoagulation management, suggesting that changes to regulations and reimbursement systems may be warranted.