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Guidelines recommend pharmacologic VTE prophylaxis for acutely ill medical patients at acceptable bleeding risk, but only the International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) model has been validated for bleeding risk assessment.

This study of patients with multiple myeloma found care disparities by race, insurance type, and treatment facility.

AbstractObjective:To derive and validate a model for risk of resistance to first-line community-acquired pneumonia (CAP) therapy.Design:We developed a logistic regression prediction model from a large multihospital discharge database and validated it versus the Drug Resistance in Pneumonia (DRIP) score in a holdout sample and another hospital system outside that database. Resistance to first-line CAP therapy (quinolone or third generation cephalosporin plus macrolide) was based on blood or respiratory cultures.Setting:This study was conducted using data from 177 Premier Healthcare database hospitals and 11 Cleveland Clinic hospitals.Participants:Adults hospitalized for CAP.Exposure:Risk factors for resistant infection.Results:Among 138,762 eligible patients in the Premier database, 12,181 (8.8%) had positive cultures and 5,200 (3.8%) had organisms resistant to CAP therapy. Infection with a resistant organism in the previous year was the strongest predictor of resistance; markers of acute illness (eg, receipt of mechanical ventilation or vasopressors) and chronic illness (eg, pressure ulcer, paralysis) were also associated with resistant infections. Our model outperformed the DRIP score with a C-statistic of 0.71 versus 0.63 for the DRIP score (P< .001) in the Premier holdout sample, and 0.65 versus 0.58 (P< .001) in Cleveland Clinic hospitals. Clinicians at Premier facilities used broad-spectrum antibiotics for 20%–30% of patients. In discriminating between patients with and without resistant infections, physician judgment slightly outperformed the DRIP instrument but not our model.Conclusions:Our model predicting infection with a resistant pathogen outperformed both the DRIP score and physician practice in an external validation set. Its integration into practice could reduce unnecessary use of broad-spectrum antibiotics.

IMPORTANCE: The benefits from colorectal cancer (CRC) screening may take 10 to 15 years to accrue. Therefore, screening is recommended for older adults who are in good health. OBJECTIVE: To determine the number of screening colonoscopies done in patients older than 75 years with a life expectancy of fewer than 10 years, diagnostic yield, and associated adverse events within 10 days and 30 days of the procedure. DESIGN: This cross-sectional study with a nested cohort between January 2009 and January 2022 in an integrated health system assessed asymptomatic patients older than 75 years who underwent screening colonoscopy in the outpatient setting. Reports with incomplete data, any indication other than screening, patients who had a colonoscopy within the previous 5 years, and patients with a personal history of inflammatory bowel disease or CRC were excluded. EXPOSURES: Life expectancy based on a prediction model from previous literature. MAIN OUTCOMES AND MEASURES: The primary outcome was the percentage of screened patients who had limited (&lt;10 years) life expectancy. Other outcomes included colonoscopy findings and adverse events that developed within 10 days and 30 days of the procedure. RESULTS: A total of 7067 patients older than 75 years were included. The median (IQR) age was 78 (77-79) years, 3967 (56%) were women, and 5431 (77%) were White with an average of 2 comorbidities (taken from a select group of comorbidities). The proportion of colonoscopies performed on patients with a life expectancy of fewer than 10 years aged 76 to 80 years was 30% in both sexes and increased with age—82% of men and 61% of women aged 81 to 85 years (71% total), and 100% of patients beyond the age of 85 years. Adverse events requiring hospitalizations were common at 10 days (13.58 per 1000) and increased with age, particularly among patients older than 85 years. The detection of advanced neoplasia varied from 5.4% among patients aged 76 to 80 years to 6.2% in those aged 81 to 85 years and 9.5% among patients older than 85 years (P = .02). Of the total population, 15 patients (0.2%) had invasive adenocarcinoma; among patients with a life expectancy of fewer than 10 years, 1 of 9 was treated, whereas 4 of 6 patients with a life expectancy of greater than or equal to 10 years were treated. CONCLUSIONS AND RELEVANCE: In this cross-sectional study with a nested cohort, most screening colonoscopies performed in patients older than 75 years were in patients with limited life expectancy and associated with increased risk of complications. Colorectal cancer was exceedingly rare.

AbstractObjective:Clostridioides difficileinfection (CDI) is the most common cause of gastroenteritis, and community-acquired pneumonia (CAP) is the most common infection treated in hospitals. American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) CAP guidelines recommend empiric therapy with a respiratory fluoroquinolone or cephalosporin plus macrolide combination, but the CDI risk of these regimens is unknown. We examined the association between each antibiotic regimen and the development of hospital-onset CDI.Methods:We conducted a retrospective cohort study using data from 638 US hospitals contributing administrative including 177 also contributing microbiologic data to Premier, Inc. We included adults admitted with pneumonia and discharged from July 2010 through June 2015 with a pneumonia diagnosis code who received ≥3 days of either empiric regimen. Hospital-onset CDI was defined by a diagnosis code not present on admission and positive laboratory test on day 4 or later or readmission for CDI. Mixed propensity-weighted multiple logistic regression was used to estimate the associations of CDI with antibiotic regimens.Results:Our sample included 58,060 patients treated with either cephalosporin plus macrolide (36,796 patients) or a fluoroquinolone alone (21,264 patients) and with microbiological data; 127 (0.35%) patients who received cephalosporin plus macrolide and 65 (0.31%) who received a fluoroquinolone developed CDI. After adjustment for patient demographics, comorbidities, risk factors for antimicrobial resistance, and hospital characteristics, CDI risks were similar for fluoroquinolones versus cephalosporin plus macrolide (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.70–1.38).Conclusion:Among patients with CAP at US hospitals, CDI was uncommon, occurring in ∼0.33% of patients. We did not detect a significant association between the choice of empiric guideline recommended antibiotic therapy and the development of CDI.

IMPORTANCE: For patients with atrial fibrillation (AF), the decision to initiate anticoagulation involves the choice between warfarin or a direct oral anticoagulant (DOAC). How physicians engage patients in this decision is unknown. OBJECTIVE: To describe the content of discussions between patients with AF and physicians regarding choice of anticoagulation. DESIGN, SETTING, AND PARTICIPANTS: This qualitative content analysis included clinical encounters between physicians and anticoagulation-naive patients discussing anticoagulation initiation between 2014 and 2020. MAIN OUTCOMES AND MEASURES: Themes identified through content analysis. RESULTS: Of 37 encounters, almost all (34 [92%]) resulted in a prescription for a DOAC. Most (25 [68%]) patients were White; 15 (41%) were female and 22 (59%) were male; and 24 (65%) were aged 65 to 84 years. Twenty-one physicians conducted the included encounters, the majority of whom were cardiologists (14 [67%]) and male (19 [90%]). The analysis revealed 4 major categories and associated subcategories of themes associated with physician discussion of anticoagulation with anticoagulation-naive patients: (1) benefit vs risk of taking anticoagulation—in many cases, this involved an imbalance in completeness of discussion of stroke vs bleeding risk, and physicians often used emotional language; (2) tradeoffs between warfarin and DOACs—physicians typically discussed pros and cons, used persuasive language, and provided mixed signals, telling patients that warfarin and DOACs were basically equivalent, while simultaneously saying warfarin is rat poison; (3) medication costs—physicians often attempted to address patients’ questions about out-of-pocket costs but were unable to provide concrete answers, and they often provided free samples or coupons; and (4) DOACs in television commercials—physicians used direct-to-consumer pharmaceutical advertising about DOACs to orient patients to the issue of anticoagulation as well as the advantages of DOACs over warfarin. Patients and physicians also discussed class action lawsuits for DOACs that patients had seen on television. CONCLUSIONS AND RELEVANCE: This qualitative analysis of anticoagulation discussions between physicians and patients during clinical encounters found that physicians engaged in persuasive communication to convince patients to accept anticoagulation with a DOAC, yet they were unable to address questions regarding medication costs. For patients who are ultimately unable to afford DOACs, this may lead to unnecessary financial burden or abandoning prescriptions at the pharmacy, placing them at continued risk of stroke.

Our objective was to describe community-acquired pneumonia (CAP) among patients =85 years and compare them to patients aged 65–74. This was a retrospective cohort study. The study setting included 638 hospitals in the USA participating in the Premier database from 2010 to 2015. The study participants were 488,382 adults aged =65 years hospitalized with CAP. Patients =85 years were more likely to be white (79.8% vs 76.2%), female (58.1% vs 48.3%), and admitted with aspiration pneumonia (17.1% vs 7.0%) as compared with those aged 65–75 years. They had higher rates of dementia (30.4% vs 7.8%), but lower rates of diabetes (11.2% vs 17.6%) and chronic obstructive pulmonary disease (25.5% vs 54.7%). While Staphylococcus aureus(33.4%) was the most common pathogen across all age groups, patients aged =85 were more likely to have Escherichia colipneumonia (16.1% vs 10.7%) compared with those aged 65–74. In adjusted models, patients aged =85 had greater in-hospital mortality (OR 1.14, 95% CI 1.11 to 1.18), but were less likely to be admitted to the intensive care unit (OR 0.54, 95% CI 0.53 to 0.55) and receive mechanical ventilation (OR 0.47, 95% CI 0.46 to 0.48). They also had lower rates of acute kidney injury (OR 0.95, 95% CI 0.91 to 1.00) and Clostridium difficileinfection (OR 0.91, 95% CI 0.85 to 0.99), shorter lengths of stay (mean multiplier 0.93, 95% CI 0.92 to 0.93) and lower cost (mean multiplier 0.81, 95% CI 0.80 to 0.81), and were more likely to be discharged to a skilled nursing facility (OR 2.19, 95% CI 2.15 to 2.24) or hospice (OR 2.19, 95% CI 2.11 to 2.27). In conclusion, patients aged =85 have different comorbidities and etiologies of CAP, receive less intense treatment, and have greater mortality than patients between 65 and 75 years.

AbstractBackground:Evidence from pandemics suggests that influenza is often associated with bacterial coinfection. Among patients hospitalized for influenza pneumonia, we report the rate of coinfection and distribution of pathogens, and we compare outcomes of patients with and without bacterial coinfection.Methods:We included adults admitted with community-acquired pneumonia (CAP) and tested for influenza from 2010 to 2015 at 179 US hospitals participating in the Premier database. Pneumonia was identified using an International Classification of Disease, Ninth Revision, Clinical Modification(ICD-9-CM) algorithm. We used multiple logistic and gamma-generalized linear mixed models to assess the relationships between coinfection and inpatient mortality, intensive care unit (ICU) admission, length of stay, and cost.Results:Among 38,665 patients hospitalized with CAP and tested for influenza, 4,313 (11.2%) were positive. In the first 3 hospital days, patients with influenza were less likely than those without to have a positive culture (10.3% vs 16.2%; P< .001), and cultures were more likely to contain Staphylococcus aureus(34.2% vs 28.2%; P= .007) and less likely to contain Streptococcus pneumoniae(24.9% vs 31.0%; P= .008). Of S. aureusisolates, 42.8% were methicillin resistant among influenza patients versus 53.2% among those without influenza (P= .01). After hospital day 3, pathogens for both groups were similar. Bacterial coinfection was associated with increased odds of in-hospital mortality (aOR, 3.00; 95% CI, 2.17–4.16), late ICU transfer (aOR, 2.83; 95% CI, 1.98–4.04), and higher cost (risk-adjusted mean multiplier, 1.77; 95% CI, 1.59–1.96).Conclusions:In a large US inpatient sample hospitalized with influenza and CAP, S. aureuswas the most frequent cause of bacterial coinfection. Coinfection was associated with worse outcomes and higher costs.

Our objective was to describe community-acquired pneumonia (CAP) among patients ≥85 years and compare them to patients aged 65–74. This was a retrospective cohort study. The study setting included 638 hospitals in the USA participating in the Premier database from 2010 to 2015. The study participants were 488,382 adults aged ≥65 years hospitalized with CAP. Patients ≥85 years were more likely to be white (79.8% vs 76.2%), female (58.1% vs 48.3%), and admitted with aspiration pneumonia (17.1% vs 7.0%) as compared with those aged 65–75 years. They had higher rates of dementia (30.4% vs 7.8%), but lower rates of diabetes (11.2% vs 17.6%) and chronic obstructive pulmonary disease (25.5% vs 54.7%). While Staphylococcus aureus(33.4%) was the most common pathogen across all age groups, patients aged ≥85 were more likely to have Escherichia colipneumonia (16.1% vs 10.7%) compared with those aged 65–74. In adjusted models, patients aged ≥85 had greater in-hospital mortality (OR 1.14, 95% CI 1.11 to 1.18), but were less likely to be admitted to the intensive care unit (OR 0.54, 95% CI 0.53 to 0.55) and receive mechanical ventilation (OR 0.47, 95% CI 0.46 to 0.48). They also had lower rates of acute kidney injury (OR 0.95, 95% CI 0.91 to 1.00) and Clostridium difficileinfection (OR 0.91, 95% CI 0.85 to 0.99), shorter lengths of stay (mean multiplier 0.93, 95% CI 0.92 to 0.93) and lower cost (mean multiplier 0.81, 95% CI 0.80 to 0.81), and were more likely to be discharged to a skilled nursing facility (OR 2.19, 95% CI 2.15 to 2.24) or hospice (OR 2.19, 95% CI 2.11 to 2.27). In conclusion, patients aged ≥85 have different comorbidities and etiologies of CAP, receive less intense treatment, and have greater mortality than patients between 65 and 75 years.

AbstractObjective:Viruses are more common than bacteria in patients hospitalized with community-acquired pneumonia. Little is known, however, about the frequency of respiratory viral testing and its associations with antimicrobial utilization.Design:Retrospective cohort study.Setting:The study included 179 US hospitals.Patients:Adults admitted with pneumonia between July 2010 and June 2015.Methods:We assessed the frequency of respiratory virus testing and compared antimicrobial utilization, mortality, length of stay, and costs between tested versus untested patients, and between virus-positive versus virus-negative patients.Results:Among 166,273 patients with pneumonia on admission, 40,787 patients (24.5%) were tested for respiratory viruses, 94.8% were tested for influenza, and 20.7% were tested for other viruses. Viral assays were positive in 5,133 of 40,787 tested patients (12.6%), typically for influenza and rhinovirus. Tested patients were younger and had fewer comorbidities than untested patients, but patients with positive viral assays were older and had more comorbidities than those with negative assays. Blood cultures were positive for bacterial pathogens in 2.7% of patients with positive viral assays versus 5.3% of patients with negative viral tests (P< .001). Antibacterial courses were shorter for virus-positive versus -negative patients overall (mean 5.5 vs 6.4 days; P< .001) but varied by bacterial testing: 8.1 versus 8.0 days (P= .60) if bacterial tests were positive; 5.3 versus 6.1 days (P< .001) if bacterial tests were negative; and 3.3 versus 5.2 days (P< .001) if bacterial tests were not obtained (interaction P< .001).Conclusions:A minority of patients hospitalized with pneumonia were tested for respiratory viruses; only a fraction of potential viral pathogens were assayed; and patients with positive viral tests often received long antibacterial courses.

IMPORTANCE: Despite high prevalence of elevated blood pressure (BP) among medical inpatients, BP management guidelines are lacking for this population. The outcomes associated with intensifying BP treatment in the hospital are poorly studied. OBJECTIVES: To characterize clinician response to BP in the hospital and at discharge and to compare short- and long-term outcomes associated with antihypertensive treatment intensification. DESIGN, SETTING, AND PARTICIPANTS: This cohort study took place from January 1 to December 31, 2017, with 1 year of follow-up at 10 hospitals within the Cleveland Clinic Hospitals health care system. All adults admitted to a medicine service in 2017 were evaluated for inclusion. Patients with cardiovascular diagnoses were excluded. Demographic and BP characteristics were used for propensity matching. EXPOSURES: Acute hypertension treatment, defined as administration of an intravenous antihypertensive medication or a new class of an oral antihypertensive treatment. MAIN OUTCOMES AND MEASURES: The association between acute hypertension treatment and subsequent inpatient acute kidney injury, myocardial injury, and stroke was measured. Postdischarge outcomes included stroke and myocardial infarction within 30 days and BP control up to 1 year. RESULTS: Among 22 834 adults hospitalized for noncardiovascular diagnoses (mean [SD] age, 65.6 [17.9] years; 12 993 women [56.9%]; 15 963 White patients [69.9%]), 17 821 (78%) had at least 1 hypertensive BP recorded during their admission. Of these patients, 5904 (33.1%) were treated. A total of 8692 of 106 097 cases (8.2%) of hypertensive systolic BPs were treated; of these, 5747 (66%) were treated with oral medications. In a propensity-matched sample controlling for patient and BP characteristics, treated patients had higher rates of subsequent acute kidney injury (466 of 4520 [10.3%] vs 357 of 4520 [7.9%]; P &lt; .001) and myocardial injury (53 of 4520 [1.2%] vs 26 of 4520 [0.6%]; P = .003). There was no BP interval in which treated patients had better outcomes than untreated patients. A total of 1645 of 17 821 patients (9%) with hypertension were discharged with an intensified antihypertensive regimen. Medication intensification at discharge was not associated with better BP control in the following year. CONCLUSIONS AND RELEVANCE: In this cohort study, hypertension was common among medical inpatients, but antihypertensive treatment intensification was not. Intensification of therapy without signs of end-organ damage was associated with worse outcomes.

Physicians play a crucial role in providing smoking cessation counseling and medications. However, it is unknown whether individual physicians’ approaches affect whether patients quit.

ABSTRACTBackground: We aimed to estimate population-based trends in the prevalence of coexisting type 2 diabetes (T2D) and suspected nonalcoholic fatty liver disease (NAFLD) and pioglitazone use among U.S. adults.Research design and methods: We conducted a cross-sectional analysis of the National Health and Nutrition Examination Survey from 2003 to 2016. We included people aged ≥18 years who had HbA1C >6.4%, fasting plasma glucose >125 mg/dL, or were told they had diabetes by a doctor. Suspected NAFLD was defined using a hepatic steatosis index of >36. Prevalence was estimated for each 2-year survey cycle. Trends were analyzed using logistic regression, accounting for the complex survey design.Results: Total sample size was 40,323 U.S. adults, of which 5690 had T2D. Age-adjusted prevalence of T2D with NAFLD increased from 5.6% in 2003–2004 to 6.8% in 2015–2016 (p-value <0.001). Pioglitazone use peaked at 20% in 2005–2006 and then declined to 4.1% in 2013–2014. Patients with suspected NAFLD were not more likely to receive pioglitazone; 3.8% of patients received the drug in 2015–2016.Conclusions: The prevalence of T2D with suspected NALFD increased among U.S. adults, but pioglitazone use decreased significantly over 2003–2016. Our study suggested a missed opportunity to prevent a future epidemic of cirrhosis due to NAFLD in patients with T2D.

Hospitalized patients are exposed to more than 1 medication error per day, but there are limited data concerning the factors associated with medication order errors made by general surgery residents. The objective of this study was to identify patterns in medication order errors amongst general surgery residents, which may provide educational targets to reduce medication errors by this population of providers.

The “burden” of atrial fibrillation (AF) detected by screening likely influences stroke risk, but the distribution of burden is not well described.

Background:Studies reporting disparities inmultiple myeloma (MM) care patterns are mostly limited to Medicare Parts A & B beneficiaries. Moreover, little is known about access to triplet regimens and expensive prescription oral medications such as lenalidomide.

IMPORTANCE: Research demonstrates adenoma detection rate (ADR) and proximal sessile serrated polyp detection rate (pSSPDR) are associated with endoscopist characteristics including sex, specialty, and years in practice. However, many studies have not adjusted for other risk factors associated with colonic neoplasia. OBJECTIVE: To assess the association between endoscopist characteristics and polyp detection after adjusting the factors included in previous studies as well as other factors. DESIGN, SETTING, AND PARTICIPANTS: This cohort study was conducted in the Cleveland Clinic health system with data from individuals undergoing screening colonoscopies between January 2015 and June 2017. The study analyzed data using methods from previous studies that have demonstrated significant associations between endoscopist characteristics and ADR or pSSPDR. Multilevel mixed-effects logistic regression was performed to examine 7 endoscopist characteristics associated with ADRs and pSSPDRs after controlling for patient demographic, clinical, and colonoscopy-associated factors. EXPOSURES: Seven characteristics of endoscopists performing colonoscopy. MAIN OUTCOMES AND MEASURES: The ADR and pSSPDR, with a hypothesis created after data collection began. RESULTS: A total of 16 089 colonoscopies were performed in 16 089 patients by 56 clinicians. Of these, 8339 patients were male (51.8%), and the median (range) age of the cohort was 59 (52-66) years. Analyzing the data by the methods used in 4 previous studies yielded an association between endoscopist and polyp detection; surgeons (OR, 0.49 [95% CI, 0.28-0.83]) and nongastroenterologists (OR, 0.50 [95% CI 0.29-0.85]) had reduced odds of pSSPDR, which was similar to results in previous studies. In a multilevel mixed-effects logistic regression analysis, ADR was not significantly associated with any endoscopist characteristic, and pSSPDR was only associated with years in practice (odds ratio, 0.86 [95% CI, 0.83-0.89] per increment of 10 years; P &lt; .001) and number of annual colonoscopies performed (odds ratio, 1.05 [95% CI, 1.01-1.09] per 50 colonoscopies/year; P = .02). CONCLUSIONS AND RELEVANCE: The differences in ADRs that were associated with 7 of 7 endoscopist characteristics and differences in pSSPDRs that were associated with 5 of 7 endoscopist characteristics in previous studies may have been associated with residual confounding, because they were not replicated in this analysis. Therefore, these characteristics should not influence the choice of endoscopist for colorectal cancer screening. However, clinicians further from their training and those with lower colonoscopy volumes have lower adjusted pSSPDRs and may need additional training to help increase pSSPDRs.

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IMPORTANCE: The live attenuated herpes zoster vaccine (ZVL) is recommended for immunocompetent adults 60 years or older, but the efficacy wanes with age and over time. A new adjuvanted herpes zoster subunit vaccine (HZ/su) has higher efficacy but might be more expensive. The choice of vaccines depends on their relative values. OBJECTIVE: To assess the cost-effectiveness of HZ/su. DESIGN, SETTING, AND PARTICIPANTS: Markov decision model with transition probabilities based on the US medical literature. Participants were immunocompetent adults 60 years or older. Data were derived from participant groups ranging in number from less than 100 to more than 30 000 depending on the variable assessed. The study dates were July 1 to 31, 2017. EXPOSURES: No vaccination, ZVL (single dose), and HZ/su (2-dose series) vaccine administered at different ages. MAIN OUTCOMES AND MEASURES: Total costs and quality-adjusted life-years (QALYs) were estimated. RESULTS: Based on randomized clinical trial data, at a price of $280 per series ($140 per dose), HZ/su was more effective and less expensive than ZVL at all ages. The incremental cost-effectiveness ratios compared with no vaccination ranged from $20 038 to $30 084 per QALY, depending on vaccination age. The finding was insensitive to variations in most model inputs other than the vaccine price and certain combinations of low adherence rate with a second dose and low efficacy of a single dose of HZ/su. At the current ZVL price ($213 per dose), HZ/su had lower overall costs than ZVL up to a price of $350 per 2-dose series. In probabilistic sensitivity analysis, HZ/su had 73% probability of being cost-effective for 60-year-olds at $50 000 per QALY. CONCLUSIONS AND RELEVANCE: Under conservative assumptions, at a price of $280 per series ($140 per dose), HZ/su would cost less than ZVL and has a high probability of offering good value.

Background:Although randomized trials demonstrate the noninferiority of rivaroxaban compared with warfarin in the context of nonvalvular atrial fibrillation (AF), little is known about how these drugs compare in practice. Objective:To assess the relative effectiveness and safety of rivaroxaban versus warfarin in a large health system and to evaluate this association by time in therapeutic range (TTR). Methods:We conducted a retrospective cohort study with propensity matching in the Cleveland Clinic Health System. The study included patients initiated on warfarin or rivaroxaban for thromboembolic prevention in nonvalvular AF between January 2012 and July 2016. The main outcomes were thromboembolic events and major bleeds. Analyses were stratified by warfarin patients’ TTR. Results:The cohort consisted of 472 propensity-matched pairs. The mean age was 73.6 years (SD = 11.7), and the mean CHADS2score was 1.8. The median TTR for warfarin patients was 64%. In the propensity-matched analysis, there was no significant difference in thromboembolic or major bleeding events between groups. Among warfarin patients with a TTR <64% and their matched rivaroxaban pairs, there was also no significant difference in thromboembolic or major bleeding events. Conclusions:Under real-world conditions, warfarin and rivaroxaban were associated with similar safety and effectiveness, even among those with suboptimal therapeutic control. Individualized decision making, taking into account the nontherapeutic tradeoffs associated with these medications (eg, monitoring, half-life, cost) is warranted.

•Patients with systolic heart failure admitted for pneumonia had worse in-hospital outcomes compared to patients with diastolic heart failure.•There were no substantial differences in cost or length of stay between systolic and diastolic HF patients admitted for pneumonia.•Patients with systolic heart failure were frequently not prescribed heart failure treatments during hospitalization, even when they became hemodynamically stable enough to discharge home.•Among patients hospitalized for pneumonia, there is a need to optimize guideline-directed medications in systolic HF prior to discharge.

OBJECTIVETo compare the rates of and reasons for presenteeism associated with influenza-like illness (ILI) among healthcare professionals (HCPs) caring for hospitalized inpatient transplant recipients and internal medicine patients.DESIGNWe designed a 10-question anonymous survey in which ILI was defined as fever (>37.8°C) and cough and/or sore throat and ILI B was defined as fever (>37.8°C) or cough or sore throat; both definitions were considered in the absence of another known cause.SETTINGTertiary-care center.PARTICIPANTSPhysicians, advanced practice providers (APPs) and nurses.INTERVENTIONSurvey deployed at peak of influenza activity in 2016.MEASUREMENTSRates of ILI, presenteeism, wearing masks, and time away due to ILI.RESULTSOf 707 HCPs surveyed, 286 (40%) responded; 15 (5.2%) reported having ILI, and 73 (25.5%) reported having ILI B in the preceding 2 weeks. Presenteeism rates were 92% in both groups of HCPs and were higher among women (adjusted odds ratio [AOR], 2.64; 95% CI, 1.23–5.71; P=.01) and those ≤40 years old (AOR, 1.92; 95% CI, 1.03–3.68; P=.04). Healthcare professionals who cared for transplant recipients and female HCPs were more likely to wear masks (AOR, 2.13; 95% CI, 1.05–3.40; P=.04 for transplant recipients and AOR, 3.96; 95% CI, 1.35–11.63; P=.01 for female HCPs). Nurses were more likely than physicians and APPs to take time off (AOR, 3.33; 95% CI, 1.10–10.09; P=.03.)CONCLUSIONSPresenteeism among HCPs with ILI is common, including among those caring for transplant recipients. Nonpunitive systems should encourage HCPs not to work with ILI and to wear masks to prevent spread of infections.Infect Control Hosp Epidemiol2017;38:966–969