Sarah L Krein’s research while affiliated with Concordia University Ann Arbor and other places

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Publications (342)


Facilitators of antibiotic decision-making in home-based primary care: a qualitative investigation
  • Article

January 2025

Infection Control and Hospital Epidemiology

Rupak Datta

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Eliza Kiwak

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Terri Fried

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Interviews with 22 home-based primary care (HBPC) clinicians revealed that infectious disease physicians and clinical pharmacists facilitate infection management and antibiotic selection, respectively, and that local initiatives within programs support antibiotic prescribing decisions. Interventions that facilitate specialist engagement and tailored approaches that address the unique challenges of HBPC are needed.


Figure 1. Histogram of team familiarity between surgeons, perfusionists, and anesthesiologists.
Figure 2. The interaction between cardiopulmonary bypass time and team familiarity. A, Acuity of procedure. B, Society of Thoracic Surgeons (STS) predicted risk of mortality (PROM). Shaded regions represent the 95% CI. STS MM indicates Society of Thoracic Surgeons' composite major morbidity and operative mortality.
Multicenter Analysis of the Relationship Between Operative Team Familiarity and Safety and Efficiency Outcomes in Cardiac Surgery
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  • Full-text available

December 2024

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27 Reads

Circulation Cardiovascular Quality and Outcomes

BACKGROUND Safety in cardiac surgical procedures is predicated on effective team dynamics. This study associated operative team familiarity (ie, the extent of clinical collaboration among surgical team members) with procedural efficiency and Society of Thoracic Surgeons (STS) adjudicated patient outcomes. METHODS Institutional STS adult cardiac surgery registry and electronic health record data from 2014 to 2021 were evaluated across 3 quaternary hospitals. Team familiarity was defined as the mean number of cardiac operations performed by surgeon-anesthesiologist, surgeon-perfusionist, and anesthesiologist-perfusionist dyads within 1 year of the operation. The primary outcomes were (1) safety, measured by the STS’ composite major morbidity and operative mortality measure, and (2) procedural efficiency, assessed by cardiopulmonary bypass duration. Team familiarity was stratified by terciles (low, moderate, and high) for crude analyses and analyzed continuously for adjusted analyses. Multivariable logistic and linear regression models were used to assess the association between team familiarity and outcomes. RESULTS Team familiarity was calculated for 13 581 operations. The median (interquartile range) patient age was 64 (55–72) years, and 31.9% (4328/13 581) were women. Terciles of team familiarity were defined as low (<6.00 average shared operations), moderate (6.00–9.67), and high (>9.67). Teams in lower terciles had higher observed STS morbidity and mortality rates (low, 17.9%; moderate, 18.0%; high, 16.0%; P =0.02) and longer median cardiopulmonary bypass duration (low, 137 minutes; moderate, 131 minutes; high, 118 minutes; P <0.001). After risk adjustment, team familiarity was not significantly associated with STS morbidity and mortality (estimate, −0.001 [95% CI, −0.998 to 0.997]) but was inversely associated with cardiopulmonary bypass duration (estimate, −2.02 minutes per 1 unit increase in team familiarity [95% CI, −2.30 to −1.75]). CONCLUSIONS Increased team familiarity was not associated with STS morbidity and mortality but was inversely correlated with cardiopulmonary bypass duration, demonstrating potential benefit. Interventions aimed at improving team familiarity among operative teams may increase procedural efficiency.

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Clinician contributions to central nervous system-active polypharmacy among older adults with dementia in the United States

November 2024

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4 Reads

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1 Citation

Journal of the American Geriatrics Society

Background Exposure to central nervous system (CNS)‐active polypharmacy—overlapping exposure to three or more CNS‐active medications—is potentially harmful yet common among persons living with dementia (PLWD). The extent to which these medications are prescribed to community‐dwelling PLWD by individual clinicians versus distributed across multiple prescribers is unclear. Methods We identified community‐dwelling Medicare beneficiaries with a dementia diagnosis and Medicare Parts A, B, and D coverage for at least one month in 2019. Using fill date and days' supply for prescriptions filled between January 1, 2019 and December 31, 2019, we identified beneficiaries exposed to CNS‐active polypharmacy (i.e., >30 days of overlapping exposure to three or more antidepressant, antipsychotic, antiseizure, benzodiazepine, opioid, nonbenzodiazepine benzodiazepine receptor agonists, or skeletal muscle relaxant medications). We examined the number and type of clinicians who contributed to polypharmacy person‐days among PLWD. Results The cohort included 955,074 PLWD who were primarily female (64.0%), were White (78.5%), and had a mean age of 83.4 years (standard deviation 8.0). Notably, 14.3% were exposed to CNS‐active polypharmacy. At the person level, 24.6% of PLWD experienced polypharmacy prescribed by a single clinician. Considering total days of exposure, 45.3% of polypharmacy person‐days were prescribed by a single clinician. Primary care physicians prescribed 63.0% of polypharmacy person‐days and accounted for the plurality of days for all seven medication classes, followed by psychiatrists for antipsychotics and benzodiazepines and primary care advanced practice providers (APPs) for antidepressants and antiseizure medications. Conclusion In this cross‐sectional analysis of Medicare claims data, primary care clinicians (both physicians and APPs) prescribed the majority of medications that contributed to CNS‐active polypharmacy for PLWD. Future research is needed to identify strategies to support primary care clinicians in appropriate prescribing of CNS‐active medications to PLWD.





Fig 1 | Percentage of patients receiving proton pump inhibitor (PPI) prescriptions (top) and percentage of time with co-prescribed PPI in patients appropriate for gastroprotection (bottom) per 6 month period before and after implementation for Veterans Integrated Service Network 17 (VISN 17) and all other Veterans Affairs (VA) sites (controls), with fitted lines showing predicted percentages based on difference-in-difference regression models. For both outcomes, fitted lines were generated using predicted values for each time interval and site using difference-in-difference regression models after exclusion of data from 1 year implementation period (2013-14). Table 2 shows significant absolute changes associated with VISN 17 intervention in two outcomes based on models and their 95% confidence intervals, which exclude zero. Predictors included time (centered at implementation period), post-implementation period indicator, VISN 17 indicator (intervention), and interaction of VISN 17 by postimplementation. Robust standard errors were used to account for heteroscedasticity. For top panel, patients were included in numerator if they had received any PPI prescription dispensed by VA health system. Denominator included all patients who had ≥2 primary care visits during 2 years before interval. For bottom panel, patients were considered appropriate for gastroprotection during time that they had medication possession of ≥2 antithrombotic drugs with at least daily dosing (including anticoagulants, aspirin, and P2Y12 inhibitors) or an antithrombotic drug together with a non-steroidal anti-inflammatory drug with at least daily dosing. Patients were considered to have gastroprotection during time in which they had medication possession of a PPI with at least daily dosing. Only medications dispensed by VA were included
Impact of large scale, multicomponent intervention to reduce proton pump inhibitor overuse in integrated healthcare system: difference-in-difference study

April 2024

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41 Reads

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3 Citations

The BMJ

Objective To determine how a large scale, multicomponent, pharmacy based intervention to reduce proton pump inhibitor (PPI) overuse affected prescribing patterns, healthcare utilization, and clinical outcomes. Design Difference-in-difference study. Setting US Veterans Affairs Healthcare System, in which one regional network implemented the overuse intervention and all 17 others served as controls. Participants All individuals receiving primary care from 2009 to 2019. Intervention Limits on PPI refills for patients without a documented indication for long term use, voiding of PPI prescriptions not recently filled, facilitated electronic prescribing of H2 receptor antagonists, and education for patients and clinicians. Main outcome measures The primary outcome was the percentage of patients who filled a PPI prescription per 6 months. Secondary outcomes included percentage of days PPI gastroprotection was prescribed in patients at high risk for upper gastrointestinal bleeding, percentage of patients who filled either a PPI or H2 receptor antagonist prescription, hospital admission for acid peptic disease in older adults appropriate for PPI gastroprotection, primary care visits for an upper gastrointestinal diagnosis, upper endoscopies, and PPI associated clinical conditions. Results The number of patients analyzed per interval ranged from 192 607 to 250 349 in intervention sites and from 3 775 953 to 4 360 868 in control sites, with 26% of patients receiving PPIs before the intervention. The intervention was associated with an absolute reduction of 7.3% (95% confidence interval −7.6% to −7.0%) in patients who filled PPI prescriptions, an absolute reduction of 11.3% (−12.0% to −10.5%) in PPI use among patients appropriate for gastroprotection, and an absolute reduction of 5.72% (−6.08% to −5.36%) in patients who filled a PPI or H2 receptor antagonist prescription. No increases were seen in primary care visits for upper gastrointestinal diagnoses, upper endoscopies, or hospital admissions for acid peptic disease in older patients appropriate for gastroprotection. No clinically significant changes were seen in any PPI associated clinical conditions. Conclusions The multicomponent intervention was associated with reduced PPI use overall but also in patients appropriate for gastroprotection, with minimal evidence of either clinical benefits or harms.


Feasibility and acceptability of patient- and clinician-level antithrombotic stewardship interventions to reduce gastrointestinal bleeding risk in patients using warfarin (AEGIS): a factorial randomized controlled pilot trial

April 2024

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17 Reads

Research and Practice in Thrombosis and Haemostasis

Background Overuse of antiplatelet therapy and underuse of gastroprotection contribute to preventable bleeding in patients taking anticoagulants. Objectives (1) Determine the feasibility of a factorial trial testing patient activation and clinician outreach to reduce gastrointestinal (GI) bleeding risk in patients prescribed warfarin–antiplatelet therapy without proton pump inhibitor gastroprotection and (2) assess intervention acceptability. Methods Pragmatic 2 × 2 factorial cluster-randomized controlled pilot comparing (1) a patient activation booklet vs usual care and (2) clinician notification vs clinician notification plus nurse facilitation was performed. The primary feasibility outcome was percentage of patients completing a structured telephone assessment after 5 weeks. Exploratory outcomes, including effectiveness, were evaluated using chart review, surveys, and semistructured interviews. Results Among 47 eligible patients, 35/47 (74.5%; 95% CI, 58.6%-85.7%) met the feasibility outcome. In the subset confirmed to be high risk for upper GI bleeding, 11/29 (37.9%; 95% CI, 16.9%-64.7%) made a medication change, without differences between intervention arms. In interviews, few patients reported reviewing the activation booklet; barriers included underestimating GI bleeding risk, misunderstanding the booklet’s purpose, and receiving excessive health communication materials. Clinicians responded to notification messages for 24/47 patients (51.1%; 95% CI, 26.4%-75.4%), which was lower for surgeons than nonsurgeons (22.7% vs 76.0%). Medical specialists but not surgeons viewed clinician notification as acceptable. Conclusion The proposed trial design and outcome ascertainment strategy were feasible, but the patient activation intervention is unlikely to be effective as designed. While clinician notification appears promising, it may not be acceptable to surgeons, findings which support further refinement and testing of a clinician notification intervention.


Diagnostic uncertainty and decision-making in home-based primary care: A qualitative study of antibiotic prescribing

January 2024

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13 Reads

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2 Citations

Journal of the American Geriatrics Society

Background Evaluating infection in home‐based primary care is challenging, and these challenges may impact antibiotic prescribing. A refined understanding of antibiotic decision‐making in this setting can inform strategies to promote antibiotic stewardship. This study investigated antibiotic decision‐making by exploring the perspectives of clinicians in home‐based primary care. Methods Clinicians from the Department of Veterans Affairs Home‐Based Primary Care Program were recruited. Semi‐structured interviews were conducted from June 2022 through September 2022 using a discussion guide. Transcripts were analyzed using grounded theory. The constant comparative method was used to develop a coding structure and to identify themes. Results Theoretical saturation was reached after 22 clinicians (physicians, n = 7; physician assistants, n = 2, advanced practice registered nurses, n = 13) from 19 programs were interviewed. Mean age was 48.5 ± 9.3 years, 91% were female, and 59% had ≥6 years of experience in home‐based primary care. Participants reported uncertainty about the diagnosis of infection due to the characteristics of homebound patients (atypical presentations of disease, presence of multiple chronic conditions, presence of cognitive impairment) and the challenges of delivering medical care in the home (limited access to diagnostic testing, suboptimal quality of microbiological specimens, barriers to establishing remote access to the electronic health record). When faced with diagnostic uncertainty about infection, participants described many factors that influenced the decision to prescribe antibiotics, including those that promoted prescribing (desire to avoid hospitalization, pressure from caregivers, unreliable plans for follow‐up) and those that inhibited prescribing (perceptions of antibiotic‐associated harms, willingness to trial non‐pharmacological interventions first, presence of caregivers who were trusted by clinicians to monitor symptoms). Conclusions Clinicians face the difficult task of balancing diagnostic uncertainty with many competing considerations during the treatment of infection in home‐based primary care. Recognizing these issues provides insight into strategies to promote antibiotic stewardship in home care settings.


Factors affecting ACOs’ decisions to remain in or exit the Medicare Shared Savings Program following Pathways to Success

January 2024

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11 Reads

Health Affairs Scholar

The Medicare Shared Savings Program (MSSP) is an alternative payment model launched in 2012, creating accountable care organizations (ACOs) to improve quality and lower costs for Traditional Medicare patients. Most MSSP participants were expected to shift from bearing no financial risk to a two-sided risk model (i.e., bonus if spending reduced below historical benchmarks, penalty if not), yet fewer than 20% did. Therefore, in 2019 the Centers for Medicare and Medicaid Services (CMS) launched the Pathways to Success program, which required shifting to a two-sided model within 12 months. For the first time, more ACOs exited than entered the MSSP. To understand these participation decisions, we conducted qualitative interviews with ACO leaders. Pathways caused ACOs to: reassess their potential shared savings versus losses, particularly in light of benchmarking methodology changes, reconsider perceived non-revenue benefits, and reassess participation in the MSSP vs. other programs. As ACOs, particularly those assuming downside risk, have contained costs and enhanced care quality, policymakers should strive to improve MSSP enrollment rates in downside-risk models through strategies that allow ACOs to achieve shared-savings and deliver accountable care.


Citations (68)


... The acidic environment prompts the transformation of PPI prodrugs into active metabolites, which can irreversibly block the hydrogen-potassium (H + -K + ) ATPase activity of parietal cells, thus preventing gastric acid secretion and increasing the pH, in turn promoting tissue repair [3]. Approximately one-quarter of the adult population is prescribed PPIs, with an estimated 25-70% of these prescriptions considered inappropriate [4]. Recent research has shed light on the potential health risks associated with the prolonged and excessive prescription of PPIs, leading to growing concerns about their overutilization [1,5,6]. ...

Reference:

Proton Pump Inhibitors and Oral–Gut Microbiota: From Mechanism to Clinical Significance
Impact of large scale, multicomponent intervention to reduce proton pump inhibitor overuse in integrated healthcare system: difference-in-difference study

The BMJ

... 21 Vascular access teams led by nurses are prevalent in the United States, with reported percentages exceeding 77%. 22 This implies that PICC nursing teams are widely common, yet they are in the early stages of development in Asia and some Western countries. 23 In Saudi Arabia, the responsibility of performing PICC insertion is primarily handled by interventional radiologists (IRs) or other medical physicians; nevertheless, only one study 24 has explored the intra-cavitary electrocardiogram (IC-ECG) guided PICC insertion by nurses in Saudi Arabia, which revealed a high success rate, with 96% of the PICCs inserted being successfully placed within the superior vena cava (SVC) or cavoatrial junction (CAJ). ...

The role of hospital‐based vascular access teams and implications for patient safety: A multi‐methods study
  • Citing Article
  • December 2023

Journal of Hospital Medicine

... However, these approaches are resource-intensive and often infeasible or unsustainable at hospitals with limited resources (e.g., those without ID pharmacists) or shifting priorities. This limitation impacts the generalizability of successful stewardship interventions; though nearly all US hospitals have antimicrobial stewardship programs (ASPs), they vary considerably in their capacity to implement evidence-based but resource-intensive interventions [21,22]. ...

Excellence in Antibiotic Stewardship: A Mixed-Methods Study Comparing High-, Medium-, and Low-Performing Hospitals
  • Citing Article
  • December 2023

Clinical Infectious Diseases

... For example, in the USA national reporting of UTI rates plays a significant role in driving system-wide improvements in care. 71 Studies undertaken in the UK and Europe were focused primarily on interventions to reduce antimicrobial resistance through stewardship but had significant learning that was transferable to the prevention and recognition of UTI. Our synthesis tried to take account of these differences, but we are aware that we may not have reflected all realities. ...

Characterizing infection prevention programs and urinary tract infection prevention practices in nursing homes: A mixed-methods study

Infection Control and Hospital Epidemiology

... 13,14 Recent data have shown that the guidelines alone have not substantially decreased rates of preoperative urine culture. [15][16][17] The Dual Process Model of Cognition (DPM) has been used to better understand clinician decision-making processes. 18 Helfrich et al.'s de-implementation model, which is based on the DPM, states that clinician decision-making is at least in part reactive to new information, which could result in rejection of new interventions if information is not viewed as coming from a familiar or reputable source, or if they feel their decision-making ability and professional authority has been curtailed. ...

Implementing diagnostic stewardship to improve diagnosis of urinary tract infections across three medical centers: A qualitative assessment
  • Citing Article
  • July 2023

Infection Control and Hospital Epidemiology

... For example, an educational intervention using a case-based format with in-person, real-time feedback from facilitators focused on reducing inappropriate testing for and treatment of ASB; the intervention resulted in reduced urine cultures and lower antibiotic use [31]. The authors found that the minutes that each site spent in delivery of education was significantly associated with antibiotic reductions [32]. ...

Quantifying the Implementation and Cost of a Multisite Antibiotic Stewardship Intervention for Asymptomatic Bacteriuria

Antimicrobial Stewardship & Healthcare Epidemiology

... First, we observed that many of the technical practices known to reduce rates of CLABSI remained in high use at most hospitals. 15 In view of the pandemic and disruption to healthcare delivery, infection prevention and patient safety-this is good news. However, gaps in some evidence-based practices which are known to reduce the risk of CLABSI-such as chlorhexidine bathing-were observed. ...

What US hospitals are doing to prevent common device-associated infections during the coronavirus disease 2019 (COVID-19) pandemic: Results from a national survey in the United States

Infection Control and Hospital Epidemiology

... In different countries, the competencies of first responders include cardiopulmonary resuscitation; automatic external defibrillation; immobilization of the limbs and pelvis; stopping bleeding; oxygen therapy; registration and interpretation of ECG in myocardial infarction. 4,5 Medical technicians are also licensed to use certain medications for shock, myocardial infarction, hypoglycemia, or drug poisoning. Their minimum course duration is from 40 to 84 hours, depending on the number of skills acquired. ...

Factors Impacting Treatment of Out-of-Hospital Cardiac Arrest: A Qualitative Study of Emergency Responders

Journal of the American Heart Association

... This targeted approach can reduce molecular test overuse as has been demonstrated in Clostridioides difficile PCR testing (17,36). Educational efforts range from issuing mass communications such as laboratory bulletins, maintaining an informational test catalog, providing virtual or in-person didactic or in-service sessions to providers, embedding education within interpretative comments of test results, and implementing clinical decision support or electronic advisories at the point of test order (37,38). Other resources for educating stakeholders include vendor-provided seminars, published society guidelines, and laboratory test directory for local or reference laboratories. ...

Diagnostic stewardship to support optimal use of multiplex molecular respiratory panels: A survey from the Society for Healthcare Epidemiology of America Research Network
  • Citing Article
  • May 2023

Infection Control and Hospital Epidemiology

... Formal training on various aspects of team science has been implemented in resuscitation and surgical teams as "non-technical skills", however, no formal training in NCC exists to date [12,13]. Furthermore, there is no formal consensus on how best to implement team science education in NCC. ...

Nontechnical Skills for Intraoperative Team Members
  • Citing Article
  • April 2023

Anesthesiology Clinics