Publications (12) View all
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Article: Effect of nonpayment for hospital-acquired, catheter-associated urinary tract infection.
Annals of internal medicine 02/2013; 158(3):222. · 16.73 Impact Factor -
Article: Perceived strength of evidence supporting practices to prevent health care-associated infection: Results from a national survey of infection prevention personnel.
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ABSTRACT: BACKGROUND: Limited data exist describing the perceived strength of evidence behind practices to prevent common health care-associated infections (HAIs). We conducted a national survey of infection prevention personnel to assess perception of the evidence for various preventive practices. We were also curious whether lead infection preventionist certification in infection prevention and control (CIC) correlated with perceptions of the evidence. METHODS: In 2009, we mailed surveys to 703 infection prevention personnel using a national random sample of US hospitals and all Veterans Affairs hospitals; the response rate was 68%. The survey asked the respondent to grade the strength of evidence behind prevention practices. We considered "strong" evidence as being 4 and 5 on a Likert scale. Multivariable logistic regression models assessed associations between CIC status and the perceived strength of the evidence. RESULTS: The following practices were perceived by 90% or more of respondents as having strong evidence: alcohol-based hand rub, aseptic urinary catheter insertion, chlorhexidine for antisepsis prior to central venous catheter insertion, maximum sterile barriers during central venous catheter insertion, avoiding the femoral site for central venous catheter insertion, and semirecumbent positioning of the ventilated patient. CIC status was significantly associated with the perception of the evidence for several practices. CONCLUSION: Successful implementation of evidence-based practices should consider how key individuals in the translational process assess the strength of that evidence.American journal of infection control 02/2013; 41(2):100-106. · 3.01 Impact Factor -
Article: Physician assessments of medication adherence and decisions to intensify medications for patients with uncontrolled blood pressure: still no better than a coin toss.
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ABSTRACT: BACKGROUND: Many patients have uncontrolled blood pressure (BP) because they are not taking medications as prescribed. Providers may have difficulty accurately assessing adherence. Providers need to assess medication adherence to decide whether to address uncontrolled BP by improving adherence to the current prescribed regimen or by intensifying the BP treatment regimen by increasing doses or adding more medications. METHODS: We examined how provider assessments of adherence with antihypertensive medications compared with refill records, and how providers' assessments were associated with decisions to intensify medications for uncontrolled BP. We studied a cross-sectional cohort of 1169 veterans with diabetes presenting with BP [GREATER-THAN OR EQUAL TO]140/90 to 92 primary care providers at 9 Veterans Affairs (VA) facilities from February 2005 to March 2006. Using VA pharmacy records, we utilized a continuous multiple-interval measure of medication gaps (CMG) to assess the proportion of time in prior year that patient did not possess the prescribed medications; CMG [GREATER-THAN OR EQUAL TO]20 % is considered clinically significant non-adherence. Providers answered post-visit Likert-scale questions regarding their assessment of patient adherence to BP medications. The BP regimen was considered intensified if medication was added or increased without stopping or decreasing another medication. RESULTS: 1064 patients were receiving antihypertensive medication regularly from the VA; the mean CMG was 11.3 %. Adherence assessments by providers correlated poorly with refill history. 211 (20 %) patients did not have BP medication available for > =20 % of days; providers characterized 79 (37 %) of these 211 patients as having significant non-adherence, and intensified medications for 97 (46 %). Providers intensified BP medications for 451 (42 %) patients, similarly whether assessed by provider as having significant non-adherence (44 %) or not (43 %). CONCLUSIONS: Providers recognized non-adherence for less than half of patients whose pharmacy records indicated significant refill gaps, and often intensified BP medications even when suspected serious non-adherence. Making an objective measure of adherence such as the CMG available during visits may help providers recognize non-adherence to inform prescribing decisions.BMC Health Services Research 08/2012; 12(1):270. · 1.66 Impact Factor -
Article: Effect of nonpayment for hospital-acquired, catheter-associated urinary tract infection: a statewide analysis.
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ABSTRACT: Most (59% to 86%) hospital-acquired urinary tract infections (UTIs) are catheter-associated urinary tract infections (CAUTIs). As of 2008, claims data are used to deny payment for certain hospital-acquired conditions, including CAUTIs, and publicly report hospital performance. To examine rates of UTIs in adults that are coded in claims data as hospital-acquired and catheter-associated events and evaluate how often nonpayment for CAUTI lowers hospital payment. Before-and-after study of all-payer cross-sectional claims data. 96 nonfederal acute care Michigan hospitals. Nonobstetric adults discharged in 2007 (n = 767 531) and 2009 (n = 781 343). Hospital rates of UTIs (categorized as catheter-associated or hospital-acquired) and frequency of reduced payment for hospital-acquired CAUTIs. Hospitals frequently requested payment for non-CAUTIs as secondary diagnoses: 10.0% (95% CI, 9.5% to 10.5%) of discharges in 2007 and 10.3% (CI, 9.8% to 10.9%) in 2009. Hospital rates of CAUTI were very low: 0.09% (CI, 0.06% to 0.12%) in 2007 and 0.14% (CI, 0.11% to 0.17%) in 2009. In 2009, 2.6% (CI, 1.6% to 3.6%) of hospital-acquired UTIs were described as CAUTIs. Nonpayment for hospital-acquired CAUTIs reduced payment for 25 of 781 343 (0.003%) hospitalizations in 2009. Data are from only 1 state and involved only 1 year before and after nonpayment for complications. Hospital prevention practices were not examined. Catheter-associated UTI rates determined by claims data seem to be inaccurate and are much lower than expected from epidemiologic surveillance data. The financial impact of current nonpayment policy for hospital-acquired CAUTI is low. Claims data are currently not valid data sets for comparing hospital-acquired CAUTI rates for the purpose of public reporting or imposing financial incentives or penalties. Blue Cross Blue Shield of Michigan Foundation.Annals of internal medicine 09/2012; 157(5):305-12. · 16.73 Impact Factor -
Article: Does Nonpayment for Hospital-Acquired Catheter-Associated Urinary Tract Infections Lead to Overtesting and Increased Antimicrobial Prescribing?
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ABSTRACT: Background. On 1 October 2008, in an effort to stimulate efforts to prevent catheter-associated urinary tract infection (CAUTI), the Centers for Medicare & Medicaid Services (CMS) implemented a policy of not reimbursing hospitals for hospital-acquired CAUTI. Since any urinary tract infection present on admission would not fall under this initiative, concerns have been raised that the policy may encourage more testing for and treatment of asymptomatic bacteriuria. Methods. We conducted a retrospective multicenter cohort study with time series analysis of all adults admitted to the hospital 16 months before and 16 months after policy implementation among participating Society for Healthcare Epidemiology of America Research Network hospitals. Our outcomes were frequency of urine culture on admission and antimicrobial use. Results. A total of 39 hospitals from 22 states submitted data on 2 362 742 admissions. In 35 hospitals affected by the CMS policy, the median frequency of urine culture performance did not change after CMS policy implementation (19.2% during the prepolicy period vs 19.3% during the postpolicy period). The rate of change in urine culture performance increased minimally during the prepolicy period (0.5% per month) and decreased slightly during the postpolicy period (-0.25% per month; P < .001). In the subset of 10 hospitals providing antimicrobial use data, the median frequency of fluoroquinolone antimicrobial use did not change substantially (14.6% during the prepolicy period vs 14.0% during the postpolicy period). The rate of change in fluoroquinolone use increased during the prepolicy period (1.26% per month) and decreased during the postpolicy period (-0.60% per month; P < .001). Conclusions. We found no evidence that CMS nonpayment policy resulted in overtesting to screen for and document a diagnosis of urinary tract infection as present on admission.Clinical Infectious Diseases 06/2012; 55(7):923-929. · 9.15 Impact Factor
