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Background Venous thromboembolism (VTE) causes preventable in-hospital morbidity. Pharmacologic prophylaxis reduces VTE in at-risk patients but also increases bleeding. To increase appropriate prescribing, a risk calculator to guide prophylaxis decisions was developed. Despite efforts to promote its use, providers accessed it infrequently. Objective This study aimed to understand provider perspectives on VTE prophylaxis and facilitators and barriers to using the risk calculator. Design This is a qualitative study exploring provider perspectives on VTE prophylaxis and the VTE risk calculator. Participants We interviewed attending physicians and advanced practice providers who used the calculator, and site champions who promoted calculator use. Providers were categorized by real-world usage over a 3-month period: low (50%). Approach During semistructured interviews, we asked about experiences with VTE, calculator use, perspectives on its implementation, and experiences with other risk assessment tools. Once thematic saturation was reached, transcripts were analyzed using content analysis to identify themes. Results Fourteen providers participated. Five were high utilizers, three were moderate utilizers, and six were low utilizers. Three site champions participated. Eight major themes were identified as follows: (1) ease of use, (2) perception of VTE risk, (3) harms of thromboprophylaxis, (4) overestimation of calculator use, (5) confidence in own ability, (6) underestimation of risk by calculator, (7) variability of trust in calculator, and (8) validation to withhold prophylaxis from low-risk patients. Conclusions While providers found the calculator is easy to use, routine use may be hindered by distrust of its recommendations. Inaccurate perception of VTE and bleeding risk may prevent calculator use.

Priscilla Kim,1 Abhishek Deshpande,2 Michael B Rothberg2 1Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA; 2Center for Value-Based Care Research, Cleveland Clinic, Cleveland, Ohio, USACorrespondence: Michael B Rothberg, Center for Value-Based Care Research, Cleveland Clinic, 9500 Euclid Ave, Mail Code G10, Cleveland, OH, 44195, USA, Tel +1 216-445-5556, Email rothbem@ccf.orgAbstract: Pneumonia is a leading cause of hospitalization and death due to infection worldwide. Streptococcus pneumoniae and Legionella pneumophila remain among the most commonly identified bacterial pathogens. Unfortunately, more than half of all pneumonia cases today lack an etiologic diagnosis due to limitations in traditional microbiological methods like blood and sputum cultures, which are affected by poor sample collection, prior antibiotic administration, and delayed processing. Urinary antigen tests (UATs) for S. pneumoniae and L. pneumophila have emerged as powerful tools for improving the diagnosis of bacterial respiratory infections, enabling physicians to administer early directed therapy and improve antimicrobial stewardship. UATs are simple, rapid, and non-invasive diagnostic tests with high specificity (> 90%) and moderate sensitivity (< 80%). The potential impact of urinary antigen testing is especially significant for respiratory infections caused by Legionella. While all recommended community-acquired pneumonia (CAP) therapies are adequate for treating pneumococcal pneumonia, only certain antibiotics are effective against Legionella. Delayed therapy for Legionella is associated with worse clinical outcomes, which underscores the importance of rapid diagnostic methods like UATs. Despite their potential impact, current American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) guidelines argue against the routine use of urinary antigen testing for S. pneumoniae and L. pneumophila, except in patients with severe CAP and those with epidemiological risk factors for Legionella. Further research is necessary to evaluate the impact of early targeted treatment due to positive UAT results, as well as optimal strategies for UAT utilization. The purpose of this review is to summarize the UATs available for bacterial respiratory infections, describe current guidelines on their usage, and assess their impact on clinical outcomes and targeted therapy.Keywords: urinary antigen test, Streptococcus pneumoniae, Legionella pneumophila, pneumonia, impact

Supplemental material, sj-docx-1-mdm-10.1177_0272989X221121350 for Informed Decision Making for Anticoagulation Therapy for Atrial Fibrillation by Kathryn A. Martinez, Debra T. Linfield, Victoria Shaker and Michael B. Rothberg in Medical Decision Making

Additional file 1.

Supplemental material, sj-docx-1-mdm-10.1177_0272989X221121350 for Informed Decision Making for Anticoagulation Therapy for Atrial Fibrillation by Kathryn A. Martinez, Debra T. Linfield, Victoria Shaker and Michael B. Rothberg in Medical Decision Making

Background Infection with SARS-CoV-2 has been shown to be highly protective against reinfection and symptomatic disease. However, effectiveness against the highly transmissible Delta variant and duration of natural immunity remain unknown. Methods This retrospective cohort study included 325,157 patients tested for coronavirus disease 2019 (COVID-19) via polymerase chain reaction (PCR) from 09 March 2020 to 31 December 2020 (Delta variant analysis) and 152,656 patients tested from 09 March 2020 to 30 August 2020 (long-term effectiveness analysis) with subsequent testing through 09 September 2021. The primary outcome was reinfection, defined as a positive PCR test >90 days after initial positive test. Results Among 325,157 patients tested before 31 December 2020, 50,327 (15.5%) tested positive. After 01 July 2021 (Delta dominant period), 40 (0.08%) of the initially positive and 1,494 (0.5%) of the initially negative patients tested positive. Protection of prior infection against reinfection with Delta was 85.4% (95% CI, 80.0-89.3). For the long-term effectiveness analysis, among 152,656 patients tested before 30 August 2020, 11,186 (7.3%) tested positive. After at least 90 days, 81 (0.7%) of the initially positive patients and 7,167 (5.1%) of the initially negative patients tested positive. Overall protection of previous infection was 85.7% (95% CI, 82.2-88.5) and lasted up to 13 months. Patients over age 65 had slightly lower protection. Conclusions SARS-CoV-2 infection is highly protective against reinfection with the Delta variant. Immunity from prior infection lasts for at least 13 months. Countries facing vaccine shortages should consider delaying vaccinations for previously infected patients to increase access.

Acute kidney injury (AKI) is common among hospitalized patients with community-acquired pneumonia (CAP). We aimed to estimate and compare the risk of AKI for various antibiotic combinations in adults hospitalized for CAP. We conducted a retrospective cohort study of the Premier Healthcare Database containing all admissions for 660 US hospitals from 2010 to 2015. We included adults aged ���18 years hospitalized with CAP and considered 6 different antibiotic combinations based on continuous use in the first 3 hospital days. The primary outcome was incident AKI, defined by ICD-9 codes 584.5-584-9. We evaluated associations of AKI with in-hospital mortality and length-of-stay. We excluded patients who were admitted directly to the intensive care unit, had AKI codes present on admission or had dialysis in the first 2 days. We used generalized linear mixed models with the hospital as a random effect and covariate adjustment for patient demographics, comorbidities, other treatments on day 0/1, and hospital characteristics. The total sample included 449,535 patients, 3.15% of whom developed AKI. All other regimens but fluoroquinolones exhibited higher AKI odds than 3rd generation cephalosporin with or without macrolide. The combination of piperacillin/tazobactam and vancomycin with or without other antibiotics was associated with the highest AKI odds (OR = 1.89; 95% CI: 1.73���2.06). Patients with incident AKI had an increased odds of hospital mortality (OR = 6.37; 95% CI: 6.07���6.69) and longer length-of-stay (mean multiplier = 1.84; 95% CI: 1.82, 1.86). Compared to 3rd generation cephalosporin with or without macrolide, piperacillin/tazobactam, vancomycin, and their combination were associated with higher odds of developing AKI, which in turn were associated with worse clinical outcomes.

Nivolumab plus ipilimumab represents an effective combination of checkpoint inhibitors that can lead to a durable response with minimal toxicity in patients with metastatic renal cell carcinoma (mRCC). We present a case of a pathologic complete response to neoadjuvant nivolumab plus ipilimumab in a patient with a 13.9 cm left renal mass and significant retroperitoneal and iliac lymphadenopathy, classified as intermediate-risk mRCC. We discuss and review the literature on complete responses after systemic therapy and the ability to predict who has undergone a complete response in the face of residual radiographic evidence of disease.

Supplemental material, Appendix_MDM-19-501-R1_8-4-2020_online_supp for Opportunities, Pitfalls, and Alternatives in Adapting Electronic Health Records for Health Services Research by Glen B. Taksler, Jarrod E. Dalton, Adam T. Perzynski, Michael B. Rothberg, Alex Milinovich, Nikolas I. Krieger, Neal V. Dawson, Mary J. Roach and Douglas Einstadter in Medical Decision Making

BACKGROUND: Compared with medical therapy, percutaneous coronary intervention (PCI) does not reduce mortality or myocardial infarction in patients with stable angina. Therefore, PCI should be guided by refractory anginal symptoms and not just lesion characteristics. HYPOTHESIS: We hypothesized that angiographic lesion characteristics and stress test results would have a greater role in the decision to proceed with PCI than would symptom severity. METHODS: We performed a retrospective cohort study of patients undergoing elective cardiac catheterization and possible PCI at an academic medical center. Anginal symptoms, optimal medical therapy, antianginal therapy, stress test results, and angiographic lesions (including American College of Cardiology/American Heart Association [ACC/AHA] lesion type) were analyzed. Logistic regression was used to determine predictors of medical management among patients not referred for coronary artery bypass surgery. RESULTS: Of the 207 patients with obstructive lesions amenable to PCI, 163 underwent PCI and 44 were referred to medical therapy. In the multivariable logistic model, the following variables were associated with medical management: advancing age (odds ratio [OR] per 1 year: 0.94, 95% confidence interval [CI]: 0.91‐0.98), chronic kidney disease (OR: 0.23, 95% CI: 0.06‐0.95), distal location (OR: 0.21, 95% CI: 0.09‐0.48), and ACC/AHA type C lesion (OR: 0.08, 95% CI: 0.03‐0.22). There was no association with sex, race, symptoms, optimal medical therapy, maximal antianginal therapy, referral status, or type of interventional cardiologist (academic vs private practice). CONCLUSIONS: For patients undergoing cardiac catheterization for stable angina, the decision to proceed to PCI vs medical management appears to depend largely on patient and angiographic characteristics, but not on symptoms or ischemia. Distal and high‐risk lesions (ACC/AHA type C) are more often referred for medical therapy.

Despite influenza vaccination being an integral part of prenatal care, vaccination rates remain low. To evaluate the impact of pre-visit video education on patients' vaccination health beliefs and vaccination rate.From November 2013-January 2014 unvaccinated patients seen for routine prenatal carewere randomized into 2 study groups: pre-visit vaccination video education or control. Pre- and post-video health beliefs were assessed on a 5-point scale, and unvaccinated participants were subsequently interviewed by phone.In 105 randomized participants, intervention positively influenced health beliefs, as demonstrated by differences in mean pre- versus post-video scores for intervention versus control: vaccination may harm mother (difference = -0.05, p = 0.009) and baby (difference = -0.44, p = 0.015), and vaccination can protect mother (difference = 0.49, p = 0.003) and baby (difference = 0.59, p = 0.001). Vaccination rates were 28% intervention and 25% control (p = 0.70). Provider recommendation was associated with vaccination (47% if recommended vs. 12% if not, p0.001). Phone interviews revealed susceptibility, to influenza and vaccine safety as primary reasons for remaining unvaccinated.Video education positively influenced vaccination health beliefs without impacting vaccination rates. Physician's recommendation was strongly associated with participant's decision to become vaccinated and may be most effective when emphasizing influenza vaccination's protective impact on the newborn,.

Supplemental material, Appendix_1_online_supp for Assessing Patient Interest in Individualized Preventive Care Recommendations by Glen B. Taksler, Mary Beth Mercer, Angela Fagerlin and Michael B. Rothberg in MDM Policy & Practice

Supplemental material, Appendix_4_online_supp for Assessing Patient Interest in Individualized Preventive Care Recommendations by Glen B. Taksler, Mary Beth Mercer, Angela Fagerlin and Michael B. Rothberg in MDM Policy & Practice

Supplemental material, Appendix_3_online_supp for Assessing Patient Interest in Individualized Preventive Care Recommendations by Glen B. Taksler, Mary Beth Mercer, Angela Fagerlin and Michael B. Rothberg in MDM Policy & Practice

Supplemental material, Appendix_2_online_supp for Assessing Patient Interest in Individualized Preventive Care Recommendations by Glen B. Taksler, Mary Beth Mercer, Angela Fagerlin and Michael B. Rothberg in MDM Policy & Practice

Supplemental material, Appendix_1_online_supp for Assessing Patient Interest in Individualized Preventive Care Recommendations by Glen B. Taksler, Mary Beth Mercer, Angela Fagerlin and Michael B. Rothberg in MDM Policy & Practice

Supplemental material, Appendix_4_online_supp for Assessing Patient Interest in Individualized Preventive Care Recommendations by Glen B. Taksler, Mary Beth Mercer, Angela Fagerlin and Michael B. Rothberg in MDM Policy & Practice

Supplemental material, Appendix_3_online_supp for Assessing Patient Interest in Individualized Preventive Care Recommendations by Glen B. Taksler, Mary Beth Mercer, Angela Fagerlin and Michael B. Rothberg in MDM Policy & Practice

Supplemental material, Appendix_2_online_supp for Assessing Patient Interest in Individualized Preventive Care Recommendations by Glen B. Taksler, Mary Beth Mercer, Angela Fagerlin and Michael B. Rothberg in MDM Policy & Practice