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Adrianne Kehne,1,2 Steven J Bernstein,1– 3 Jennifer Thomas,1 Mark C Bicket,3,4,* Amy SB Bohnert,2– 4,* Erin Fanning Madden,5,* Victoria D Powell,6,7,* Pooja Lagisetty1– 3 1Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA; 2Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; 3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; 4Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA; 5Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, Detroit, MI, USA; 6Palliative Care Program, Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA; 7Geriatrics Research, Education, and Clinical Center, LTC Charles S. Kettles VA Medical Center, Ann Arbor, MI, USA*These authors contributed equally to this workCorrespondence: Adrianne Kehne, Division of General Internal Medicine, University of Michigan, 2800 Plymouth Road, Building 16, Floor 4, Ann Arbor, MI, 48109, USA, Tel +1 301 503 3936, Email adkehne@med.umich.eduPurpose: About 5– 8 million US patients take long-term opioid therapy for chronic pain. In the context of policies and guidelines instituted to reduce inappropriate opioid prescribing, abrupt discontinuations in opioid prescriptions have increased and many primary care clinics will not prescribe opioids for new patients, reducing access to care. This may result in uncontrolled pain and other negative outcomes, such as transition to illicit opioids. The objective of this study was to generate policy, intervention, and research recommendations to improve access to care for these patients.Participants and Methods: We conducted a RAND/UCLA Modified Delphi, consisting of workshops, background videos and reading materials, and moderated web-based panel discussions held September 2020–January 2021. The panel consisted of 24 individuals from across Michigan, identified via expert nomination and snowball recruitment, including clinical providers, health science researchers, state-level policymakers and regulators, care coordination experts, patient advocates, payor representatives, and community and public health experts. The panel proposed intervention, policy, and research recommendations, scored the feasibility, impact, and importance of each on a 9-point scale, and ranked all recommendations by implementation priority.Results: The panel produced 11 final recommendations across three themes: reimbursement reform, provider education, and reducing racial inequities in care. The 3 reimbursement-focused recommendations were highest ranked (theme average = 4.2/11), including the two top-ranked recommendations: increasing reimbursement for time needed to treat complex chronic pain (ranked #1/11) and bundling payment for multimodal pain care (#2/11). Four provider education recommendations ranked slightly lower (theme average = 6.2/11) and included clarifying the spectrum of opioid dependence and training providers on multimodal treatments. Four recommendations addressed racial inequities (theme average = 7.2/11), such as standardizing pain management protocols to reduce treatment disparities.Conclusion: Panelists indicated reimbursement should incentivize traditionally lower-paying evidence-based pain care, but multiple strategies may be needed to meaningfully expand access.Keywords: long-term opioid therapy, pain care access, reimbursement models, expert panel

The purpose was to assess the clinical utility of diagnostic tests for identifying malignancy within a solitary pulmonary nodule (SPN), and to create a nomogram or "look-up" table using clinical data and non-invasive radiology (positive) test results to estimate post-test probability of malignancy. Studies that examined computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) and single photon emission computed tomography (SPECT) for the evaluation of SPN. Two reviewers independently abstracted data and assessed study quality. Study-specific and overall positive likelihood ratios (LRs) for each diagnostic test confirming a diagnosis of malignancy and negative LR for each diagnostic test excluding a diagnosis of malignancy within an SPN were calculated. Forty-four of 242 articles were included. Positive LRs for diagnostic tests were: CT 3.91 (95% confidence interval 2.42, 5.40), MRI 4.57 (3.03, 6.1), PET 5.44 (3.56, 7.32) and SPECT 5.16 (4.03, 6.30). Negative LRs were: CT 0.10 (0.03, 0.16), MRI 0.08 (0.03, 0.12), PET 0.06 (0.02, 0.09) and SPECT 0.06 (0.04, 0.08). Differences in performance for all tests were negligible; therefore, the clinician may confidently use any of the four tests presented in further evaluating an SPN. Given the low cost and prevalence of the technology, SPECT appears to be the leading choice for additional testing in SPN evaluation. [ABSTRACT FROM AUTHOR]

Objective: Optimal blood pressure (BP) control in patients with diabetes poses a challenge in primary care clinics because of the complexity of the disease and competing patient care demands. We used a multidisciplinary team to standardize and improve hypertension care for patients with diabetes by implementing a visual and action-oriented high BP prompt, collaborative practice agreement, medication intensification protocol, and home BP monitoring machine loan program.Design: Prospective, pre-/poststudy.Setting: General medicine clinic affiliated with a large academic healthcare system.Patients: Two hundred sixty-three patients with type 2 diabetes mellitus.Results: Hypertension control (ie, BP < 135/80 mm Hg) in patients with diabetes improved from 53.6% to 69.3% (P < .001) after implementing a standardized BP assessment and treatment process. There was also a significant decrease of 4 mm Hg in both the mean systolic and diastolic BPs after the intervention. The improvement in BP control was associated with an increase in the average number of antihypertensive medications from 1.56 to 1.93.Conclusions: The use of a process-oriented clinical redesign and a multidisciplinary team approach resulted in improved BP management in patients with diabetes in a primary care setting. [ABSTRACT FROM AUTHOR]

Objective: To develop and test a method for comparing the appropriateness of hysterectomy use in different health plans.Design: Retrospective cohort study.Setting: Seven managed care organizations.Patients: Random sample of all nonemergency, non-oncological hysterectomies performed in the seven managed care organizations over a 1-year period. Patients who were not continuously enrolled in a plan for 2 years prior to their hysterectomy were excluded.Main Outcome Measures: Proportion of women undergoing hysterectomy in each plan for inappropriate clinical reasons according to ratings derived from a panel of managed care physicians.Results: Overall, about 16% of women underwent hysterectomy for reasons judged to be clinically inappropriate. Only one plan had significantly more hysterectomies rated inappropriate compared with the group mean (27%, unadjusted). Adjusting for age and race did not affect the rankings of the plans and had little effect on the numeric results.Conclusion: The rates of inappropriate use of hysterectomies are similar to those for other procedures and vary to a small degree among health plans. This information may be useful to purchasers when they consider which health plans to offer their employees. [ABSTRACT FROM AUTHOR]

Background: Quality improvement (QI) programs require significant financial investment. The authors evaluated the cost-effectiveness of a physician-led, performance-incentivized, QI intervention that increased appropriate peripherally inserted central catheter (PICC) use., Methods: The authors used an economic evaluation from a health care sector perspective. Implementation costs included incentive payments to hospitals and costs for data abstractors and the coordinating center. Effectiveness was calculated from propensity score-matched observations across two time periods for complications (venous thromboembolism [VTE], central line-associated bloodstream infection [CLABSI], and catheter occlusion): preintervention period (January 2015 through December 2016) and intervention period (January 2017 through December 2021). Cost-effectiveness was presented as the cost-offset per averted complication, reflecting the health care costs avoided due to having lower complication rates., Results: Across 35 hospitals, this study sampled 17,418 PICCs placed preintervention and 26,004 placed during the intervention period. PICC complications decreased significantly following the intervention. CLABSIs decreased from 2.1% to 1.5%, VTEs from 3.2% to 2.3%, and catheter occlusions from 10.8% to 7.0% (all p < 0.01). Estimated number of complications prevented included 871 CLABSIs, 2,535 VTEs, and 8,743 catheter occlusions. Project implementation costs were $31.8 million, and the cost-offset related to avoided complications was $64.4 million. Each participating hospital averaged $932,073 in cost-offset over seven years, and the average cost-offset per complication averted was $2,614 (95% CI [confidence interval] $2,314-$3,003)., Conclusion: A large-scale, multihospital QI initiative to improve appropriate PICC use yielded substantial return on investment from cost-offset of prevented complications., (Copyright © 2024 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Importance: Acute urinary retention (UR) is common, yet variations in diagnosis and management can lead to inappropriate catheterization and harm., Objective: To develop an algorithm for screening and management of UR among adult inpatients., Design, Setting, and Participants: In this mixed-methods study using the RAND/UCLA Appropriateness Method and qualitative interviews, an 11-member multidisciplinary expert panel of nurses and physicians from across the US used a formal multi-round process from March to May 2015 to rate 107 clinical scenarios involving diagnosis and management of adult UR in postoperative and medical inpatients. The panel ratings informed the first algorithm draft. Semistructured interviews were conducted from October 2020 to May 2021 with 33 frontline clinicians-nurses and surgeons from 5 Michigan hospitals-to gather feedback and inform algorithm refinements., Main Outcomes and Measures: Panelists categorized scenarios assessing when to use bladder scanners, catheterization at various scanned bladder volumes, and choice of catheterization modalities as appropriate, inappropriate, or uncertain. Next, qualitative methods were used to understand the perceived need, usability, and potential algorithm uses., Results: The 11-member expert panel (10 men and 1 woman) used the RAND/UCLA Appropriateness Method to develop a UR algorithm including the following: (1) bladder scanners were preferred over catheterization for UR diagnosis in symptomatic patients or starting as soon as 3 hours since last void if asymptomatic, (2) bladder scanner volumes appropriate to prompt catheterization were 300 mL or greater in symptomatic patients and 500 mL or greater in asymptomatic patients, and (3) intermittent was preferred to indwelling catheterization for managing lower bladder volumes. Interview findings were organized into 3 domains (perceived need, feedback on algorithm, and implementation suggestions). The 33 frontline clinicians (9 men and 24 women) who reviewed the algorithm reported that an evidence-based protocol (1) was needed and could be helpful to clinicians, (2) should be simple and graphically appealing to improve rapid clinician review, and (3) should be integrated within the electronic medical record and prominently displayed in hospital units to increase awareness. The draft algorithm was iteratively refined based on stakeholder feedback., Conclusions and Relevance: In this study using a systematic, multidisciplinary, evidence- and expert opinion-based approach, a UR evaluation and catheterization algorithm was developed to improve patient safety by increasing appropriate use of bladder scanners and catheterization. This algorithm addresses the need for practical guidance to manage UR among adult inpatients.

Background: Inappropriate diagnosis of infections results in antibiotic overuse and may delay diagnosis of underlying conditions. Here we describe the development and characteristics of 2 safety measures of inappropriate diagnosis of urinary tract infection (UTI) and community-acquired pneumonia (CAP), the most common inpatient infections on general medicine services., Methods: Measures were developed from guidelines and literature and adapted based on data from patients hospitalized with UTI and CAP in 49 Michigan hospitals and feedback from end-users, a technical expert panel (TEP), and a patient focus group. Each measure was assessed for reliability, validity, feasibility, and usability., Results: Two measures, now endorsed by the National Quality Forum (NQF), were developed. Measure reliability (derived from 24 483 patients) was excellent (0.90 for UTI; 0.91 for CAP). Both measures had strong validity demonstrated through (a) face validity by hospital users, the TEPs, and patient focus group, (b) implicit case review (ĸ 0.72 for UTI; ĸ 0.72 for CAP), and (c) rare case misclassification (4% for UTI; 0% for CAP) due to data errors (<2% for UTI; 6.3% for CAP). Measure implementation through hospital peer comparison in Michigan hospitals (2017 to 2020) demonstrated significant decreases in inappropriate diagnosis of UTI and CAP (37% and 32%, respectively, P < .001), supporting usability., Conclusions: We developed highly reliable, valid, and usable measures of inappropriate diagnosis of UTI and CAP for hospitalized patients. Hospitals seeking to improve diagnostic safety, antibiotic use, and patient care should consider using these measures to reduce inappropriate diagnosis of CAP and UTI., Competing Interests: Potential conflicts of interest. T. C., D. R., J. K. H., and L. A. P. report grants or contracts paid to institution from Blue Cross Blue Shield of Michigan (BCBSM). E. S. M. reports salary support from BCBSM. T. N. G. reports grants or contracts paid to institution from BCBSM and AHRQ. V. V. reports grants or contracts paid to institution from AHRQ, Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), BCBSM. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Despite antibiotic stewardship programs existing in most acute care hospitals, there continues to be variation in appropriate antibiotic use. While existing research examines individual prescriber behavior, contextual reasons for variation are poorly understood., Methods: We conducted an explanatory, sequential mixed-methods study of a purposeful sample of 7 hospitals with varying discharge antibiotic overuse. For each hospital, we conducted surveys, document analysis, and semi-structured interviews with antibiotic stewardship and clinical stakeholders. Data were analyzed separately and mixed during the interpretation phase, where each hospital was examined as a case, with findings organized across cases using a strengths, weaknesses, opportunities, and threats framework to identify factors accounting for differences in antibiotic overuse across hospitals., Results: Surveys included 85 respondents. Interviews included 90 respondents (31 hospitalists, 33 clinical pharmacists, 14 stewardship leaders, 12 hospital leaders). On surveys, clinical pharmacists at hospitals with lower antibiotic overuse were more likely to report feeling: respected by hospitalist colleagues (P = .001), considered valuable team members (P = .001), and comfortable recommending antibiotic changes (P = .02). Based on mixed-methods analysis, hospitals with low antibiotic overuse had 4 distinguishing characteristics: (1) robust knowledge of and access to antibiotic stewardship guidance; (2) high-quality clinical pharmacist-physician relationships; (3) tools and infrastructure to support stewardship; and (4) highly engaged infectious diseases physicians who advocated stewardship principles., Conclusions: This mixed-methods study demonstrates the importance of organizational context for high performance in stewardship and suggests that improving antimicrobial stewardship requires attention to knowledge, interactions, and relationships between clinical teams and infrastructure that supports stewardship and team interactions., Competing Interests: Potential conflicts of interest. S. A. F. reports grants or contracts, paid to institution, from BCBSM and AHRQ, and personal fees from Wiley Publishing. T. N. G. reports grants or contracts paid to institution from BCBSM and AHRQ. L. A. P. reports grants or contracts from BCBSM and AHRQ. W. R. B. reports participation on a data and safety monitoring board or advisory board as scientific advisor for research with The Joint Commission regarding outpatient stewardship. E. S. S. reports grants or contracts with the Centers for Disease Control and Prevention (CDC) Epicenter University of Utah (Matt Samore, principal investigator; author's role is a co-investigator); consulting fees for educational content paid to author from Prime Education LLC; travel expenses paid to the Society for Healthcare Epidemiology of America (SHEA) 2023 and to IDWeek 2022 (speaker). A. H. reports grants or contracts with CDC, AHRQ, and Patient-Centered Outcomes Research Institute, and a leadership or fiduciary role on the Pediatric Infectious Diseases Society Board. A. M. M. has received grant support from and is a physician consultant to the Michigan Department of Health and Human Services, unrelated to the submitted work; has received payment for expert testimony, unrelated to submitted work; was a member of the SHEA Board of Trustees 2020–2022; served as board member of Michigan Infectious Diseases Society; and is a shareholder of Pfizer. V. M. M. reports grants or contracts paid to institution from AHRQ, CDC, National Institutes of Health, and BCBSM. S. L. Z. reports grants or contracts to institution from AHRQ. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Importance: Little is known about incidence of, risk factors for, and harms associated with inappropriate diagnosis of community-acquired pneumonia (CAP)., Objective: To characterize inappropriate diagnosis of CAP in hospitalized patients., Design, Setting, and Participants: This prospective cohort study, including medical record review and patient telephone calls, took place across 48 Michigan hospitals. Trained abstractors retrospectively assessed hospitalized patients treated for CAP between July 1, 2017, and March 31, 2020. Patients were eligible for inclusion if they were adults admitted to general care with a discharge diagnostic code of pneumonia who received antibiotics on day 1 or 2 of hospitalization. Data were analyzed from February to December 2023., Main Outcomes and Measures: Inappropriate diagnosis of CAP was defined using a National Quality Forum-endorsed metric as CAP-directed antibiotic therapy in patients with fewer than 2 signs or symptoms of CAP or negative chest imaging. Risk factors for inappropriate diagnosis were assessed and, for those inappropriately diagnosed, 30-day composite outcomes (mortality, readmission, emergency department visit, Clostridioides difficile infection, and antibiotic-associated adverse events) were documented and stratified by full course (>3 days) vs brief (≤3 days) antibiotic treatment using generalized estimating equation models adjusting for confounders and propensity for treatment., Results: Of the 17 290 hospitalized patients treated for CAP, 2079 (12.0%) met criteria for inappropriate diagnosis (median [IQR] age, 71.8 [60.1-82.8] years; 1045 [50.3%] female), of whom 1821 (87.6%) received full antibiotic courses. Compared with patients with CAP, patients inappropriately diagnosed were older (adjusted odds ratio [AOR], 1.08; 95% CI, 1.05-1.11 per decade) and more likely to have dementia (AOR, 1.79; 95% CI, 1.55-2.08) or altered mental status on presentation (AOR, 1.75; 95% CI, 1.39-2.19). Among those inappropriately diagnosed, 30-day composite outcomes for full vs brief treatment did not differ (25.8% vs 25.6%; AOR, 0.98; 95% CI, 0.79-1.23). Full vs brief duration of antibiotic treatment among patients was associated with antibiotic-associated adverse events (31 of 1821 [2.1%] vs 1 of 258 [0.4%]; P = .03)., Conclusions and Relevance: In this cohort study, inappropriate diagnosis of CAP among hospitalized adults was common, particularly among older adults, those with dementia, and those presenting with altered mental status. Full-course antibiotic treatment of those inappropriately diagnosed with CAP may be harmful.

Background: Antibiotic overuse at hospital discharge is common, costly, and harmful. While discharge-specific antibiotic stewardship interventions are effective, they are resource-intensive and often infeasible for hospitals with resource constraints. This weakness impacts generalizability of stewardship interventions and has health equity implications as not all patients have access to the benefits of stewardship based on where they receive care. There may be different pathways to improve discharge antibiotic prescribing that vary widely in feasibility. Supporting hospitals in selecting interventions tailored to their context may be an effective approach to feasibly reduce antibiotic overuse at discharge across diverse hospitals. The objective of this study is to evaluate the effectiveness of the Reducing Overuse of Antibiotics at Discharge Home multicomponent implementation strategy ("ROAD Home") on antibiotic overuse at discharge for community-acquired pneumonia and urinary tract infection., Methods: This 4-year two-arm parallel cluster-randomized trial will include three phases: baseline (23 months), intervention (12 months), and postintervention (12 months). Forty hospitals recruited from the Michigan Hospital Medicine Safety Consortium will undergo covariate-constrained randomization with half randomized to the ROAD Home implementation strategy and half to a "stewardship as usual" control. ROAD Home is informed by the integrated-Promoting Action on Research Implementation in Health Services Framework and includes (1) a baseline needs assessment to create a tailored suite of potential stewardship interventions, (2) supported decision-making in selecting interventions to implement, and (3) external facilitation following an implementation blueprint. The primary outcome is baseline-adjusted days of antibiotic overuse at discharge. Secondary outcomes include 30-day patient outcomes and antibiotic-associated adverse events. A mixed-methods concurrent process evaluation will identify contextual factors influencing the implementation of tailored interventions, and assess implementation outcomes including acceptability, feasibility, fidelity, and sustainment., Discussion: Reducing antibiotic overuse at discharge across hospitals with varied resources requires tailoring of interventions. This trial will assess whether a multicomponent implementation strategy that supports hospitals in selecting evidence-based stewardship interventions tailored to local context leads to reduced overuse of antibiotics at discharge. Knowledge gained during this study could inform future efforts to implement stewardship in diverse hospitals and promote equity in access to the benefits of quality improvement initiatives., Trial Registration: Clinicaltrials.gov NCT06106204 on 10/30/23., (© 2024. The Author(s).)

Background: Midline catheters (midlines) are increasingly used in patients with advanced chronic kidney disease (CKD)., Objective: This study describes current practice and acute complications associated with midlines in CKD patients., Designs, Setting, and Participants: Trained abstractors at 66 hospitals from the Michigan Hospital Medicine Safety (HMS) Consortium collected data on a sample of patients who received a midline during hospitalization. Patients were classified as having advanced CKD if their estimated glomerular filtration rate was <45 mL/min/1.73 m 2 ., Main Outcome and Measures: Midline recipients with advanced CKD were compared to those without advanced CKD by patient, provider, and device characteristics, and by the occurrence of acute complications including major (e.g., upper extremity deep vein thrombosis [UE-DVT] and catheter-related bloodstream infection [CRBSI]) or minor (e.g., catheter occlusion, catheter dislodgement, infiltration, superficial thrombophlebitis, and leaking at insertion site) events. Multivariable mixed effects logistic regression was used to evaluate the association between catheter-related complications and stage of CKD., Results: Of 21,415 midline recipients, 5272 (24.6%) had advanced CKD, while 16,143 (75.4%) did not. Most midlines were single lumen (90.5%) and remained in place for a median of 6 days. A major or minor midline complication occurred in 804 (15.3%) patients with and 2239 (14.4%) patients without advanced CKD (adjusted odds ratios = 1.04; 95% confidence interval: 0.94-1.14). Among patients with advanced CKD, CRBSI occurred in 13 patients (0.2%) and UE-DVT occurred in 65 patients (1.2%). The proportion of advanced CKD among midline recipients and the frequency of midline-related complications varied across hospitals (interquartile range [IQR] = 19.2% to 29.8% [median = 25.0%] and IQR = 11.0%-18.9% [median = 15.4%], respectively)., (© 2023 The Authors. Journal of Hospital Medicine published by Wiley Periodicals LLC on behalf of Society of Hospital Medicine.)

Importance: Hospitalized patients with asymptomatic bacteriuria (ASB) often receive unnecessary antibiotic treatment, which increases antibiotic resistance and adverse events., Objective: To determine whether diagnostic stewardship (avoiding unnecessary urine cultures) or antibiotic stewardship (reducing unnecessary antibiotic treatment after an unnecessary culture) is associated with better outcomes in reducing antibiotic use for ASB., Design, Setting, and Participants: This 3-year, prospective quality improvement study included hospitalized general care medicine patients with a positive urine culture among 46 hospitals participating in a collaborative quality initiative, the Michigan Hospital Medicine Safety Consortium. Data were collected from July 1, 2017, through March 31, 2020, and analyzed from February to October 2022., Exposure: Participation in the Michigan Hospital Medicine Safety Consortium with antibiotic and diagnostic stewardship strategies at hospital discretion., Main Outcomes and Measures: Overall improvement in ASB-related antibiotic use was estimated as change in percentage of patients treated with antibiotics who had ASB. Effect of diagnostic stewardship was estimated as change in percentage of patients with a positive urine culture who had ASB. Effect of antibiotic stewardship was estimated as change in percentage of patients with ASB who received antibiotics and antibiotic duration., Results: Of the 14 572 patients with a positive urine culture included in the study (median [IQR] age, 75.8 [64.2-85.1] years; 70.5% female); 28.4% (n = 4134) had ASB, of whom 76.8% (n = 3175) received antibiotics. Over the study period, the percentage of patients treated with antibiotics who had ASB (overall ASB-related antibiotic use) declined from 29.1% (95% CI, 26.2%-32.2%) to 17.1% (95% CI, 14.3%-20.2%) (adjusted odds ratio [aOR], 0.94 per quarter; 95% CI, 0.92-0.96). The percentage of patients with a positive urine culture who had ASB (diagnostic stewardship metric) declined from 34.1% (95% CI, 31.0%-37.3%) to 22.5% (95% CI, 19.7%-25.6%) (aOR, 0.95 per quarter; 95% CI, 0.93-0.97). The percentage of patients with ASB who received antibiotics (antibiotic stewardship metric) remained stable, from 82.0% (95% CI, 77.7%-85.6%) to 76.3% (95% CI, 68.5%-82.6%) (aOR, 0.97 per quarter; 95% CI, 0.94-1.01), as did adjusted mean antibiotic duration, from 6.38 (95% CI, 6.00-6.78) days to 5.93 (95% CI, 5.54-6.35) days (adjusted incidence rate ratio, 0.99 per quarter; 95% CI, 0.99-1.00)., Conclusions and Relevance: This quality improvement study showed that over 3 years, ASB-related antibiotic use decreased and was associated with a decline in unnecessary urine cultures. Hospitals should prioritize reducing unnecessary urine cultures (ie, diagnostic stewardship) to reduce antibiotic treatment related to ASB.

Rationale: Little is known about the safety of infusing vasopressors through a midline catheter. Objectives: To evaluate safety outcomes after vasopressor administration through a midline. Methods: We conducted a cohort study of adults admitted to 39 hospitals in Michigan (December 2017-March 2022) who received vasopressors while either a midline or peripherally inserted central catheter (PICC) was in place. Patients receiving vasopressors through a midline were compared with those receiving vasopressors through a PICC and, separately, to those with midlines in place but who received vasopressors through a different catheter. We used descriptive statistics to characterize and compare cohort characteristics. Multivariable mixed effects logistic regression models were fit to determine the association between vasopressor administration through a midline with outcomes, primarily catheter-related complications (bloodstream infection, superficial thrombophlebitis, exit site infection, or catheter occlusion). Results: Our cohort included 287 patients with midlines through which vasopressors were administered, 1,660 with PICCs through which vasopressors were administered, and 884 patients with midlines who received vasopressors through a separate catheter. Age (median [interquartile range]: 68.7 [58.6-75.7], 66.6 [57.1-75.0], and 67.6 [58.7-75.8] yr) and gender (percentage female: 50.5%, 47.3%, and 43.8%) were similar in all groups. The frequency of catheter-related complications was lower in patients with midlines used for vasopressors than PICCs used for vasopressors (5.2% vs. 13.4%; P  < 0.001) but similar to midlines with vasopressor administration through a different device (5.2% vs. 6.3%; P  = 0.49). After adjustment, administration of vasopressors through a midline was not associated with catheter-related complications compared with PICCs with vasopressors (adjusted odds ratios [aOR], 0.65 [95% confidence interval, 0.31-1.33]; P  = 0.23) or midlines with vasopressors elsewhere (aOR, 0.85 [0.46-1.58]; P  = 0.59). Midlines used for vasopressors were associated with greater risk of systemic thromboembolism (vs. PICCs with vasopressors: aOR, 2.69 [1.31-5.49]; P  = 0.008; vs. midlines with vasopressors elsewhere: aOR, 2.42 [1.29-4.54]; P  = 0.008) but not thromboses restricted to the ipsilateral upper extremity (vs. PICCs with vasopressors: aOR, 2.35 [0.83-6.63]; P  = 0.10; model did not converge for vs. midlines with vasopressors elsewhere). Conclusions: We found no significant association of vasopressor administration through a midline with catheter-related complications. However, we identified increased odds of systemic (but not ipsilateral upper extremity) venous thromboembolism warranting further evaluation.

Background: The RAND/UCLA Appropriateness Method (RAM), a variant of the Delphi Method, was developed to synthesize existing evidence and elicit the clinical judgement of medical experts on the appropriate treatment of specific clinical presentations. Technological advances now allow researchers to conduct expert panels on the internet, offering a cost-effective and convenient alternative to the traditional RAM. For example, the Department of Veterans Affairs recently used a web-based RAM to validate clinical recommendations for de-intensifying routine primary care services. A substantial literature describes and tests various aspects of the traditional RAM in health research; yet we know comparatively less about how researchers implement web-based expert panels., Objective: The objectives of this study are twofold: (1) to understand how the web-based RAM process is currently used and reported in health research and (2) to provide preliminary reporting guidance for researchers to improve the transparency and reproducibility of reporting practices., Methods: The PubMed database was searched to identify studies published between 2009 and 2019 that used a web-based RAM to measure the appropriateness of medical care. Methodological data from each article were abstracted. The following categories were assessed: composition and characteristics of the web-based expert panels, characteristics of panel procedures, results, and panel satisfaction and engagement., Results: Of the 12 studies meeting the eligibility criteria and reviewed, only 42% (5/12) implemented the full RAM process with the remaining studies opting for a partial approach. Among those studies reporting, the median number of participants at first rating was 42. While 92% (11/12) of studies involved clinicians, 50% (6/12) involved multiple stakeholder types. Our review revealed that the studies failed to report on critical aspects of the RAM process. For example, no studies reported response rates with the denominator of previous rounds, 42% (5/12) did not provide panelists with feedback between rating periods, 50% (6/12) either did not have or did not report on the panel discussion period, and 25% (3/12) did not report on quality measures to assess aspects of the panel process (eg, satisfaction with the process)., Conclusions: Conducting web-based RAM panels will continue to be an appealing option for researchers seeking a safe, efficient, and democratic process of expert agreement. Our literature review uncovered inconsistent reporting frameworks and insufficient detail to evaluate study outcomes. We provide preliminary recommendations for reporting that are both timely and important for producing replicable, high-quality findings. The need for reporting standards is especially critical given that more people may prefer to participate in web-based rather than in-person panels due to the ongoing COVID-19 pandemic., (©Jordan B Sparks, Mandi L Klamerus, Tanner J Caverly, Sarah E Skurla, Timothy P Hofer, Eve A Kerr, Steven J Bernstein, Laura J Damschroder. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 26.08.2022.)

Background: The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) provides evidence-based criteria for peripherally inserted central catheter (PICC) use. Whether implementing MAGIC improves PICC appropriateness and reduces complications is unknown., Methods: A quasiexperimental study design to implement MAGIC in 52 Michigan hospitals was used. Data were collected from medical records by trained abstractors. Hospital performance on three appropriateness criteria was measured: short-term PICC use (≤5 days), use of multilumen PICCs and PICC placement in patients with chronic kidney disease. PICC appropriateness and device complications preintervention (January 2013 to December 2016) versus postintervention (January 2017 to January 2020) were compared. Change-point analysis was used to evaluate the effect of the intervention on device appropriateness. Logistic regression and Poisson models were fit to assess the association between appropriateness and complications (composite of catheter occlusion, venous thromboembolism (VTE) and central line-associated bloodstream infection (CLABSI))., Results: Among 38 592 PICCs, median catheter dwell ranged from 8 to 56 days. During the preintervention period, the mean frequency of appropriate PICC use was 31.9% and the mean frequency of complications was 14.7%. Following the intervention, PICC appropriateness increased to 49.0% (absolute difference 17.1%, p<0.001) while complications decreased to 10.7% (absolute difference 4.0%, p=0.001). Compared with patients with inappropriate PICC placement, appropriate PICC use was associated with a significantly lower odds of complications (OR 0.29, 95% CI 0.25 to 0.34), including decreases in occlusion (OR 0.25, 95% CI 0.21 to 0.29), CLABSI (OR 0.61, 95% CI 0.46 to 0.81) and VTE (OR 0.40, 95% CI 0.33 to 0.47, all p<0.01). Patients with appropriate PICC placement had lower rate of complications than those with inappropriate PICC use (incidence rate ratio 0.987, 95% CI 0.98 to 0.99, p<0.001)., Conclusions: Implementation of MAGIC in Michigan hospitals was associated with improved PICC appropriateness and fewer complications. These findings have important quality, safety and policy implications for hospitals, patients and payors., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Antibiotics are commonly prescribed to patients as they leave the hospital. We aimed to create a comprehensive metric to characterize antibiotic overuse after discharge among hospitalized patients treated for pneumonia or urinary tract infection (UTI), and to determine whether overuse varied across hospitals and conditions., Methods: In a retrospective cohort study of hospitalized patients treated for pneumonia or UTI in 46 hospitals between 1 July 2017-30 July 2019, we quantified the proportion of patients discharged with antibiotic overuse, defined as unnecessary antibiotic use, excess antibiotic duration, or suboptimal fluoroquinolone use. Using linear regression, we assessed hospital-level associations between antibiotic overuse after discharge in patients treated for pneumonia versus a UTI., Results: Of 21 825 patients treated for infection (12 445 with pneumonia; 9380 with a UTI), nearly half (49.1%) had antibiotic overuse after discharge (56.9% with pneumonia; 38.7% with a UTI). For pneumonia, 63.1% of overuse days after discharge were due to excess duration; for UTIs, 43.9% were due to treatment of asymptomatic bacteriuria. The percentage of patients discharged with antibiotic overuse varied 5-fold among hospitals (from 15.9% [95% confidence interval, 8.7%-24.6%] to 80.6% [95% confidence interval, 69.4%-88.1%]) and was strongly correlated between conditions (regression coefficient = 0.85; P < .001)., Conclusions: Antibiotic overuse after discharge was common and varied widely between hospitals. Antibiotic overuse after discharge was associated between conditions, suggesting that the prescribing culture, physician behavior, or organizational processes contribute to overprescribing at discharge. Multifaceted efforts focusing on all 3 types of overuse and multiple conditions should be considered to improve antibiotic prescribing at discharge., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America.)

Objective: To describe MiPATH (the Michigan Plan for Appropriate Tailored Healthcare in pregnancy) panel process and key recommendations for prenatal care delivery., Methods: We conducted an appropriateness study using the RAND Corporation and University of California Los Angeles Appropriateness Method, a modified e-Delphi process, to develop MiPATH recommendations using sequential steps: 1) definition and scope of key terms, 2) literature review and data synthesis, 3) case scenario development, 4) panel selection and scenario revisions, and 5) two rounds of panel appropriateness ratings with deliberation. Recommendations were developed for average-risk pregnant individuals (eg, individuals not requiring care by maternal-fetal medicine specialists). Because prenatal services (eg, laboratory tests, vaccinations) have robust evidence, panelists considered only how services are delivered (eg, visit frequency, telemedicine)., Results: The appropriateness of key aspects of prenatal care delivery across individuals with and without common medical and pregnancy complications, as well as social and structural determinants of health, was determined by the panel. Panelists agreed that a risk assessment for medical, social, and structural determinants of health should be completed as soon as individuals present for care. Additionally, the panel provided recommendations for: 1) prenatal visit schedules (care initiation, visit timing and frequency, routine pregnancy assessments), 2) integration of telemedicine (virtual visits and home devices), and 3) care individualization. Panelists recognized significant gaps in existing evidence and the need for policy changes to support equitable care with changing practices., Conclusion: The MiPATH recommendations offer more flexible prenatal care delivery for average-risk individuals., Competing Interests: Financial Disclosure Steven J. Bernstein reports money was paid to his institution from the Blue Cross Blue Shield of Michigan/Blue Care Network, the U.S. Department of Veterans Affairs, and the U.S. Agency for Healthcare Research and Quality. He also served and currently serves as an external physician on the Utilization Management and Clinical Quality Committees for Blue Cross Blue Shield of Michigan and Blue Care Network. He received an honorarium for each committee meeting. The other authors did not report any potential conflicts of interest., (Copyright © 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Much of health care involves established, routine use of medical services for chronic conditions or prevention. Stopping these services when the evidence changes or if the benefits no longer outweigh the risks is essential. Yet, most guidelines focus on escalating care and provide few explicit recommendations to stop or scale back (ie, deintensify) treatment and testing., Objective: To develop a systematic, transparent, and reproducible approach for identifying, specifying, and validating deintensification recommendations associated with routine adult primary care., Design, Setting, and Participants: A focused review of existing guidelines and recommendations was completed to identify and prioritize potential deintensification indications. Then, 2 modified virtual Delphi expert panels examined the synthesized evidence, suggested ways that the candidate recommendations could be improved, and assessed the validity of the recommendations using the RAND/UCLA Appropriateness Method. Twenty-five physicians from Veterans Affairs and US academic institutions with knowledge in relevant clinical areas (eg, geriatrics, primary care, women's health, cardiology, and endocrinology) served as panel members., Main Outcomes and Measures: Validity of the recommendations, defined as high-quality evidence that deintensification is likely to improve patient outcomes, evidence that intense testing and/or treatment could cause harm in some patients, absence of evidence on the benefit of continued or repeated intense treatment or testing, and evidence that deintensification is consistent with high-quality care., Results: A total of 409 individual recommendations were identified representing 178 unique opportunities to stop or scale back routine services (eg, stopping population-based screening for vitamin D deficiency and decreasing concurrent use of opioids and benzodiazepines). Thirty-seven recommendations were prioritized and forwarded to the expert panels. Panelists reviewed the evidence and suggested modifications, resulting in 44 recommendations being rated. Overall, 37 recommendations (84%) were considered to be valid, as assessed by the RAND/UCLA Appropriateness Method., Conclusions and Relevance: In this study, a total of 178 unique opportunities to deintensify routine primary care services were identified, and 37 of these were validated as high-priority deintensification recommendations. To date, this is the first study to develop a model for identifying, specifying, and validating deintensification recommendations that can be implemented and tracked in clinical practice.

Objectives: Vascular access device decision-making for pediatric patients remains a complex, highly variable process. To date, evidence-based criteria to inform these choices do not exist. The objective of the Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC) was to provide guidance on device selection, device characteristics, and insertion technique for clinicians, balancing and contextualizing evidence with current practice through a multidisciplinary panel of experts., Methods: The RAND Corporation and University of California, Los Angeles Appropriateness Method was used to develop miniMAGIC, which included the following sequential phases: definition of scope and key terms, information synthesis and literature review, expert multidisciplinary panel selection and engagement, case scenario development, and appropriateness ratings by an expert panel via 2 rounds., Results: The appropriateness of the selection, characteristics, and insertion technique of intravenous catheters commonly used in pediatric health care across age populations (neonates, infants, children, and adolescents), settings, diagnoses, clinical indications, insertion locations, and vessel visualization devices and techniques was defined. Core concepts including vessel preservation, insertion and postinsertion harm minimization (eg, infection, thrombosis), undisrupted treatment provision, and inclusion of patient preferences were emphasized., Conclusions: In this study, we provide evidence-based criteria for intravenous catheter selection (from umbilical catheters to totally implanted venous devices) in pediatric patients across a range of clinical indications. miniMAGIC also highlights core vascular access practices in need of collaborative research and innovation., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Ullman reports investigator-initiated research grants and speaker fees provided to Griffith University from vascular access product manufacturers (3M Medical, AngioDynamics, Becton Dickinson, Cardinal Health) unrelated to the current project. Dr Bernstein reports grants from the Agency for Healthcare Research and Quality and the US Department of Veterans Affairs. Dr Doellman reports honoraria from Genentech and Lineus Medical and consulting with Teleflex Medical unrelated to this project. Dr Gore reports honoraria for invited talks in patient safety and patient advocacy. Ms Kleidon reports investigator-initiated research grants and speaker fees provided to Griffith University from 3M Medical, AngioDynamics, Baxter, BD-Bard, Centurion, Cook Medical, Medical Specialties Australia, and Vygon (unrelated to the current project). Dr Wolf reports participation in research sponsored by Astellas Inc, Cempra Pharmaceuticals Inc, and Merck Inc and in-kind research support from Karius Inc and Carefusion Inc. Ms Pitts reports employment by B. Braun Medical and St Joseph’s Children’s Hospital, Tampa, Florida, previous employment and stockholder status with AngioDynamics, and board membership of Navi Medical Technologies. Dr Cooke reports investigator-initiated research grants and speaker fees provided to Griffith University by vascular access product manufacturers (Baxter, Becton Dickinson, Entrotech Life Sciences) unrelated to this project. Dr Rickard reports investigator-initiated research grants and speaker fees provided to Griffith University from vascular access product manufacturers (3M, AngioDynamics, Baxter, B. Braun Medical, BD-Bard; Medtronic, ResQDevices, Smiths Medical) unrelated to this project. Dr Chopra reports grants from the Agency for Healthcare Research and Quality and American Hospital Association, book royalties from Oxford University Press for The Saint-Chopra Guide to Inpatient Medicine, and honoraria for invited external talks as a visiting professor; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Objective: To critically review the evidence for the selection and insertion of pediatric vascular access devices (VADs)., Data Sources: Data were sourced from the US National Library of Medicine, Cumulative Index to Nursing and Allied Health, the Cochrane Library databases, Embase, and international clinical trial databases., Study Selection: Clinical practice guidelines, systematic reviews, cohort designs, randomized control trials (RCTs), quasi RCTs, before-after trials, or case-control studies that reported on complications and/or risk as well as reliability of VADs in patients aged 0 to 18 years were included., Data Extraction: Articles were independently reviewed to extract and summarize details on the number of patients and catheters, population, age of participants, VAD type, study method, indication, comparators, and the frequency of VAD failure or complications., Results: VAD selection and insertion decision-making in general hospitalized and some specialized patient populations were well evidenced. The use of single-lumen devices and ultrasound-guided techniques was also broadly supported. There was a lack of RCTs, and for neonates, cardiac patients, patients with difficult venous access, midline catheters, catheter-to-vein ratio, and near-infrared devices, the lack of evidence necessitated broadening the review scope., Limitations: Limitations include the lack of formal assessment of the quality of evidence and the lack of RCTs and systematic reviews. Consequently, clinical decision-making in certain pediatric populations is not guided by strong, evidence-based recommendations., Conclusions: This is the first synthesis of available evidence for the selection and insertion of VADs in pediatric patients and is important for determining the appropriateness of VADs in pediatric patients., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Chopra reports grants from the Agency for Healthcare Research and Quality, American Hospital Association; book royalties from Oxford University Publishing for The Saint-Chopra Guide to Inpatient Medicine; and honoraria for invited external talks as visiting professor. Ms Kleidon reports investigator-initiated research grants and speaker fees provided to Griffith University from 3M Medical; AngioDynamics; Baxter; BD-Bard; Centurion Medical; Cook Medical; Medical Specialties Australasia; and Vygon (unrelated to the current project). Prof Cooke reports investigator-initiated research grants and speaker fees provided to Griffith University by vascular access product manufacturers (Baxter, BD, Entrotech Life Sciences) unrelated to this project. Prof Rickard reports investigator-initiated research grants and speaker fees provided to Griffith University from vascular access product manufacturers (3M Medical; AngioDynamics; Baxter; B. Braun; BD-Bard; Medtronic; ResQDevices; Smiths Medical) unrelated to this project. Dr Bernstein reports grants from the Agency for Healthcare Research and Quality and the US Department of Veterans Affairs. Dr Ullman reports investigator-initiated research grants and speaker fees provided to Griffith University from vascular access product manufacturers (3M Medical, AngioDynamics, and BD) unrelated to the current project. Drs Paterson and Brown have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Objectives: To describe the methodology undertaken to provide guidance on the appropriateness, as well as inappropriateness, of vascular access device selection, characteristics, and insertion technique for pediatric patients., Methods: The RAND Corporation-University of California, Los Angeles Appropriateness Method was used. After definition of key terms and scope, a systematic review of the pediatric vascular access literature was undertaken. Clinical scenarios were developed to reflect the common indications for vascular access across pediatric health care. These were sectioned according to (1) device selection, (2) device characteristics, and (3) insertion technique. An interdisciplinary panel of experts ( N = 14) consisting of leading experts representing diverse pediatric clinical disciplines including anesthesiology, cardiology and cardiac surgery, critical care and emergency, general surgery, hematology and oncology, hospital medicine, infectious disease, interventional radiology, pharmacology, regional pediatric hospitalist, and vascular access nursing specialties was convened. The scenarios were rated for appropriateness by the panel over 2 rounds (1 [highly inappropriate] to 9 [highly appropriate]). Round 1 ratings were completed anonymously and independently by panel members and classified into 3 levels of appropriateness: appropriate, uncertain, and inappropriate, or disagreement. For round 2, panelists met in-person to discuss the round 1 ratings and independently rerated the indications. All indications were reclassified into 3 levels of appropriateness or disagreement., Conclusions: The RAND Corporation-University of California, Los Angeles Appropriateness Method provides a rigorous, in-depth and transparent methodology to develop the first appropriateness criteria for the selection of pediatric vascular access devices in a range of patient groups., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Ullman reports investigator-initiated research grants and speaker fees provided to Griffith University from vascular access product manufacturers (3M Medical, AngioDynamics, and Becton, Dickinson, and Company [BD]) unrelated to the current project. Dr Chopra reports grants from the Agency for Healthcare Research and Quality, American Hospital Association; book royalties from Oxford University Publishing for The Saint-Chopra Guide to Inpatient Medicine; and honoraria for invited external talks as visiting professor. Ms Kleidon reports investigator-initiated research grants and speaker fees provided to Griffith University from vascular access product manufacturers (3M, AngioDynamics; Baxter; BD-Bard; Centurion Medical; Cook Medical; and Medical Specialties Australasia) unrelated to this project. Prof Cooke reports investigator-initiated research grants and speaker fees provided to Griffith University by vascular access product manufacturers (Baxter, BD, Entrotech Life Sciences) unrelated to this project. Prof Rickard reports investigator-initiated research grants and speaker fees provided to Griffith University from vascular access product manufacturers (3M, AngioDynamics; Baxter; B. Braun Medical; BD-Bard; Medtronic; ResQDevices; Smiths Medical) unrelated to this project. Prof Bernstein reports grants from the Agency for Healthcare Research and Quality and the US Department of Veterans Affairs; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

In a 2016 survey of 46 Michigan hospitals, we identified four key needs for antibiotic stewardship: clinically-relevant antibiotic data, monitoring compliance, syndrome-specific interventions, and discharge stewardship. A stewardship initiative now addresses these needs within the Michigan Hospital Medicine Safety Consortium., (© The Author(s) 2020. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Objectives: To formally assess the appropriateness of different timings of urethral catheter removal after transurethral prostate resection or ablation. Although urethral catheter placement is routine after this common treatment for benign prostatic hyperplasia (BPH), no guidelines inform duration of catheter use., Study Design: RAND/UCLA Appropriateness Methodology., Methods: Using a standardized, multiround rating process (ie, the RAND/UCLA Appropriateness Methodology), an 11-member multidisciplinary panel reviewed a literature summary and rated clinical scenarios for urethral catheter duration after transurethral prostate surgery for BPH as appropriate (ie, benefits outweigh risks), inappropriate, or of uncertain appropriateness. We examined appropriateness across 4 clinical scenarios (no preexisting catheter, preexisting catheter [including intermittent], difficult catheter placement, significant perforation) and 5 durations (postoperative day [POD] 0, 1, 2, 3-6, or ≥7)., Results: Urethral catheter removal and first trial of void on POD 1 was rated appropriate for all scenarios except clinically significant perforations. In this case, waiting until POD 3 was deemed the earliest appropriate timing. Waiting 3 or more days to remove the catheter for patients with or without preexisting catheter needs, or for those with difficult catheter placement in the operating room, was rated as inappropriate., Conclusions: We defined clinically relevant guidance statements for the appropriateness of urethral catheter duration after transurethral prostate surgery. Given the lack of guidelines and this robust expert panel approach, these ratings may help clinicians and healthcare systems improve the consistency and quality of care for patients undergoing transurethral surgery for BPH.

Background: While midline vascular catheters are gaining popularity in clinical practice, patterns of use and outcomes related to these devices are not well known., Methods: Trained abstractors collected data from medical records of hospitalised patients who received midline catheters in 12 hospitals. Device characteristics, patterns of use and outcomes were assessed at device removal or at 30 days. Rates of major (upper-extremity deep vein thrombosis [DVT], bloodstream infection [BSI] and catheter occlusion) and minor complications were assessed. χ 2 tests were used to examine differences in rates of complication by number of lumens, reasons for catheter removal l, and hospital-level differences in rates of midline use., Results: Complete data on 1161 midlines representing 5%-72% of all midlines placed in participating hospitals between 1 January 2017 and 1 March 2018 were available. Most (70.8%) midlines were placed in general ward settings for difficult intravenous access (61.4%). The median dwell time of midlines across hospitals was 6 days; almost half (49%) were removed within 5 days of insertion. A major or minor complication occurred in 10.3% of midlines, with minor complications such as dislodgement, leaking and infiltration accounting for 71% of all adverse events. While rates of major complications including occlusion, upper-extremity DVT and BSI were low (2.2%, 1.4% and 0.3%, respectively), they were just as likely to lead to midline removal as minor complications (53.8% vs 52.5%, p=0.90). Across hospitals, absolute volume of midlines placed varied from 100 to 1837 devices, with corresponding utilisation rates of 0.97%-12.92% (p<0.001)., Conclusion: Midline use and outcomes vary widely across hospitals. Although rates of major complications are low, device removal as a result of adverse events is common., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Existing guidelines, including Choosing Wisely recommendations, endorse avoiding placement of peripherally inserted central catheters (PICCs) in patients with chronic kidney disease (CKD)., Objective: To describe the frequency of and characteristics associated with PICC use in hospitalized patients with stage 3b or greater CKD (glomerular filtration rate [GFR] <45 mL/min/1.73 m2)., Design: Prospective cohort study., Setting: 52 hospitals participating in the Michigan Hospital Medicine Safety Consortium., Participants: Hospitalized medical patients who received a PICC between November 2013 and September 2016., Measurements: Percentage of patients receiving PICCs who had CKD, frequency of PICC-related complications, and variation in the proportion of PICCs placed in patients with CKD., Results: Of 20 545 patients who had PICCs placed, 4743 (23.1% [95% CI, 20.9% to 25.3%]) had an estimated GFR (eGFR) less than 45 mL/min/1.73 m2 and 699 (3.4%) were receiving hemodialysis. In the intensive care unit (ICU), 30.9% (CI, 29.7% to 32.2%) of patients receiving PICCs had an eGFR less than 45 mL/min/1.73 m2; the corresponding percentage in wards was 19.3% (CI, 18.8% to 19.9%). Among patients with an eGFR less than 45 mL/min/1.73 m2, multilumen PICCs were placed more frequently than single-lumen PICCs. In wards, PICC-related complications occurred in 15.3% of patients with an eGFR less than 45 mL/min/1.73 m2 and in 15.2% of those with an eGFR of 45 mL/min/1.73 m2 or higher. The corresponding percentages in ICU settings were 22.4% and 23.9%. In patients with an eGFR less than 45 mL/min/1.73 m2, PICC placement varied widely across hospitals (interquartile range, 23.7% to 37.8% in ICUs and 12.8% to 23.7% in wards)., Limitation: Nephrologist approval for placement could not be determined, and 2.7% of eGFR values were unknown and excluded., Conclusion: In this sample of hospitalized patients who received PICCs, placement in those with CKD was common and not concordant with clinical guidelines., Primary Funding Source: Blue Cross Blue Shield of Michigan and Blue Care Network.

Background: Indwelling urinary catheters are commonly used for patients undergoing general and orthopaedic surgery. Despite infectious and non-infectious harms of urinary catheters, there is limited guidance available to surgery teams regarding appropriate perioperative catheter use., Objective: Using the RAND Corporation/University of California Los Angeles (RAND/UCLA) Appropriateness Method, we assessed the appropriateness of indwelling urinary catheter placement and different timings of catheter removal for routine general and orthopaedic surgery procedures., Methods: Two multidisciplinary panels consisting of 13 and 11 members (physicians and nurses) for general and orthopaedic surgery, respectively, reviewed the available literature regarding the impact of different perioperative catheter use strategies. Using a standardised, multiround rating process, the panels independently rated clinical scenarios (91 general surgery, 36 orthopaedic surgery) for urinary catheter placement and postoperative duration of use as appropriate (ie, benefits outweigh risks), inappropriate or of uncertain appropriateness., Results: Appropriateness of catheter use varied by procedure, accounting for procedure-specific risks as well as expected procedure time and intravenous fluids. Procedural appropriateness ratings for catheters were summarised for clinical use into three groups: (1) can perform surgery without catheter; (2) use intraoperatively only, ideally remove before leaving the operating room; and (3) use intraoperatively and keep catheter until postoperative days 1-4. Specific recommendations were provided by procedure, with postoperative day 1 being appropriate for catheter removal for first voiding trial for many procedures., Conclusion: We defined the appropriateness of indwelling urinary catheter use during and after common general and orthopaedic surgical procedures. These ratings may help reduce catheter-associated complications for patients undergoing these procedures., Competing Interests: Competing interests: JM has reported receiving honoraria for lectures and teaching related to prevention and value-based purchasing policies involving catheter-associated urinary tract infection and hospital-acquired pressure ulcers. SS has reported receiving honoraria for lectures and teaching related to prevention of catheter-associated urinary tract infection, and is on the medical advisory boards of Doximity and Jvion., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To switch patients with ulcerative colitis (UC) from costlier 5-aminosalicylic acid compounds to sulfasalazine and assess (1) the cost savings, (2) the barriers to switching, and (3) adverse events (AEs) and adherence at 3 months after the drug switch., Study Design: An open-label, pharmacist-administered drug switch program coordinated at an academic inflammatory bowel disease center., Methods: A clinical pharmacist contacted patients with UC who were prescreened by physicians and covered by specific insurers to enroll them in the drug switch program. Enrolled patients were followed for 3 months to assess AEs and medication adherence. Reasons for declining to participate were recorded., Results: A total of 205 eligible patients were identified; only 14 enrolled, and 10 remained on sulfasalazine for the entire 3-month follow-up period. The enrollment rate was only 4.9%, yet a net cost savings of $22,828/3-month to the insurer was achieved (including program administration costs but excluding AE costs), with co-pays reduced by approximately $25 per month per patient. The rate of AEs on sulfasalazine (28.6%) was similar to that found in previous reports. Significant unanticipated barriers to switching were encountered, namely patient desire to not alter an existing effective drug regimen., Conclusions: A pharmacist-administered drug switch program in patients with UC was significantly more difficult than anticipated, with questionable achievement of cost savings. This experience suggests that future drug switches and studies should focus on patient preferences for drug switching, as this may have implications for switching from brand name to biosimilar drugs.

Background: Catheter exchange over a guidewire is frequently performed for malfunctioning peripherally inserted central catheters (PICCs). Whether such exchanges are associated with venous thromboembolism is not known., Methods: We performed a retrospective cohort study to assess the association between PICC exchange and risk of thromboembolism. Adult hospitalized patients that received a PICC during clinical care at one of 51 hospitals participating in the Michigan Hospital Medicine Safety consortium were included. The primary outcome was hazard of symptomatic venous thromboembolism (radiographically confirmed upper-extremity deep vein thrombosis and pulmonary embolism) in those that underwent PICC exchange vs those that did not., Results: Of 23,010 patients that underwent PICC insertion in the study, 589 patients (2.6%) experienced a PICC exchange. Almost half of all exchanges were performed for catheter dislodgement or occlusion. A total of 480 patients (2.1%) experienced PICC-associated deep vein thrombosis. The incidence of deep vein thrombosis was greater in those that underwent PICC exchange vs those that did not (3.6% vs 2.0%, P < .001). Median time to thrombosis was shorter among those that underwent exchange vs those that did not (5 vs 11 days, P = .02). Following adjustment, PICC exchange was independently associated with twofold greater risk of thrombosis (hazard ratio [HR] 1.98; 95% confidence interval [CI], 1.37-2.85) vs no exchange. The effect size of PICC exchange on thrombosis was second in magnitude to device lumens (HR 2.06; 95% CI, 1.59-2.66 and HR 2.31; 95% CI, 1.6-3.33 for double- and triple-lumen devices, respectively)., Conclusion: Guidewire exchange of PICCs may be associated with increased risk of thrombosis. As some exchanges may be preventable, consideration of risks and benefits of exchanges in clinical practice is needed., (Published by Elsevier Inc.)

Background: The guidelines for peripherally inserted central catheters (PICCs) recommend avoiding insertion if the anticipated duration of use is =5 days. However, short-term PICC use is common in hospitals. We sought to identify patient, provider, and device characteristics and the clinical outcomes associated with short-term PICCs., Methods: Between January 2014 and June 2016, trained abstractors at 52 Michigan Hospital Medicine Safety (HMS) Consortium sites collected data from medical records of adults that received PICCs during hospitalization. Patients were prospectively followed until PICC removal, death, or 70 days after insertion. Multivariable logistic regression models were fit to identify factors associated with short-term PICCs, defined as dwell time of =5 days. Complications associated with short-term use, including major (eg, venous thromboembolism [VTE] or central lineassociated bloodstream infection [CLABSI]) or minor (eg, catheter occlusion, tip migration) events were assessed., Results: Of the 15,397 PICCs placed, 3902 (25.3%) had a dwell time of =5 days. Most (95.5%) short-term PICCs were removed during hospitalization. Compared to PICCs placed for >5 days, variables associated with short-term PICCs included difficult venous access (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.40-1.69), multilumen devices (OR, 1.53; 95% CI, 1.39-1.69), and teaching hospitals (OR, 1.25; 95% CI, 1.04-1.52). Among those with short-term PICCs, 374 (9.6%) experienced a complication, including 99 (2.5%) experiencing VTE and 17 (0.4%) experiencing CLABSI events. The most common minor complications were catheter occlusion (4%) and tip migration (2.2%)., Conclusion: Short-term use of PICCs is common and associated with patient, provider, and device factors. As PICC placement, even for brief periods, is associated with complications, efforts targeted at factors underlying such use appear necessary., (© 2018 Society of Hospital Medicine)

Objectives: In 2009 and 2010, 17 primary care sites within 1 healthcare system became patient-centered medical homes (PCMHs), but the sites trained different personnel (pharmacists vs nurses) to improve diabetes care using self-management support (SMS). We report the challenges and successes of our efforts to: 1) assemble a new multipayer (Medicare, Medicaid, commercial) claims dataset linked to a clinical registry and 2) use the new dataset to perform comparative effectiveness research on implementation of the 2 SMS models., Study Design: Longitudinal cohort study., Methods: We lost permission to use private-payer data. Therefore, we used claims from Medicare fee-for-service and Medicare/Medicaid dual-eligible patients merged with chronic disease registry data. We studied 2008 to 2010, which included 1 year pre- and 1 year post the 2009 implementation time period. Outcomes were outpatient and emergency department visits, hospitalizations, care process (use of statin), and 3 intermediate outcomes (glycemic control, blood pressure [BP], and low-density lipoprotein cholesterol [LDL-C])., Results: In our sample of 2826 patients, quality of care improved and utilization decreased over the 2.5 years. Both approaches improved lipid control (LDL-C decreased by an average of 4 mg/dL for pharmacy-SMS and 5.6 mg/dL for nurse-SMS) and diastolic BP (-1.5 mm Hg for pharmacy-SMS and -1.3 mm Hg for nurse-SMS), whereas only the pharmacy-led approach decreased primary care visits (by 0.8 visits). The groups differed slightly on 2 measures (glycated hemoglobin, systolic BP) with respect to the trajectory of improvement over time, but performance was similar by 2.5 years., Conclusions: Diabetes care improved during PCMH implementation systemwide, supporting both nurse-led and pharmacist-led SMS models.

Essentials How best to quantify thrombosis risk with peripherally inserted central catheters (PICC) is unknown. Data from a registry were used to develop the Michigan Risk Score (MRS) for PICC thrombosis. Five risk factors were associated with PICC thrombosis and used to develop a risk score. MRS was predictive of the risk of PICC thrombosis and can be useful in clinical practice., Summary: Background Peripherally inserted central catheters (PICCs) are associated with upper extremity deep vein thrombosis (DVT). We developed a score to predict risk of PICC-related thrombosis. Methods Using data from the Michigan Hospital Medicine Safety Consortium, image-confirmed upper-extremity DVT cases were identified. A logistic, mixed-effects model with hospital-specific random intercepts was used to identify factors associated with PICC-DVT. Points were assigned to each predictor, stratifying patients into four classes of risk. Internal validation was performed by bootstrapping with assessment of calibration and discrimination of the model. Results Of 23 010 patients who received PICCs, 475 (2.1%) developed symptomatic PICC-DVT. Risk factors associated with PICC-DVT included: history of DVT; multi-lumen PICC; active cancer; presence of another CVC when the PICC was placed; and white blood cell count greater than 12 000. Four risk classes were created based on thrombosis risk. Thrombosis rates were 0.9% for class I, 1.6% for class II, 2.7% for class III and 4.7% for class IV, with marginal predicted probabilities of 0.9% (0.7, 1.2), 1.5% (1.2, 1.9), 2.6% (2.2, 3.0) and 4.5% (3.7, 5.4) for classes I, II, III, and IV, respectively. The risk classification rule was strongly associated with PICC-DVT, with odds ratios of 1.68 (95% CI, 1.19, 2.37), 2.90 (95% CI, 2.09, 4.01) and 5.20 (95% CI, 3.65, 7.42) for risk classes II, III and IV vs. risk class I, respectively. Conclusion The Michigan PICC-DVT Risk Score offers a novel way to estimate risk of DVT associated with PICCs and can help inform appropriateness of PICC insertion., (© 2017 International Society on Thrombosis and Haemostasis.)

Purpose: To evaluate patterns and predictors of peripherally inserted central catheter (PICC)-related occlusion., Materials and Methods: Data from a multihospital study were used to examine factors associated with PICC occlusion. Occlusion was defined if documented in the medical record or when tissue plasminogen activator was administered for occlusion-related concerns. Mixed-effects logistic regression was used to predict occlusion, controlling for patient-, provider-, device-, and hospital-level characteristics., Results: A total of 14,278 PICCs placed in 13,408 patients were included. Of these, occlusion developed in 1,716 PICCs (12%) in 1,684 patients. The most common indications for PICC insertion were intravenous antibiotic therapy (32.7%), difficult intravenous access (21.5%), and central access (13.7%). PICCs placed in the right arm had decreased odds of occlusion compared with those in the left arm (odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.72-0.94). Verification of catheter tip position following insertion was associated with reduction in occlusion (OR = 0.75; 95% CI = 0.61-0.92). Although normal saline solution or heparin flushes did not reduce occlusion, PICCs flushed with normal saline solution and "locked" with heparin were less likely to become occluded (OR = 0.54; 95% CI = 0.33-0.88). Compared with single-lumen devices, double- and triple-lumen PICCs were associated with greater incidences of occlusion (double, OR = 3.07; 95% CI = 2.56-3.67; triple, OR = 3.72; 95% CI = 2.92-4.74). Catheter tip malposition was also associated with occlusion (OR = 1.46; 95% CI = 1.14-1.87)., Conclusions: Several patient, provider, and device characteristics appear associated with PICC occlusion. Interventions targeting these factors may prove valuable in reducing this complication., (Published by Elsevier Inc.)

Background: While some research has examined general attitudes about efforts to reduce overutilization of services, such as the Choosing Wisely ® (CW) initiative, little data exists regarding primary care providers' attitudes regarding individual recommendations., Objective: We sought to identify whether particular CW recommendations were perceived by primary care providers as difficult to follow, difficult for patients to accept, or both., Design: Two national surveys, one by mail to a random sample of 2000 U.S. primary care physicians in November 2013, and the second electronically to a random sample of 2500 VA primary care providers (PCPs) in October-December 2014., Participants: A total of 603 U.S. primary care physicians and 1173 VA primary care providers. Response rates were 34 and 48 %, respectively., Main Measures: PCP ratings of whether 12 CW recommendations for screening, testing and treatments applicable to adult primary care were difficult to follow and difficult for patients to accept; and ratings of potential barriers to reducing overutilization., Key Results: For four recommendations regarding not screening or testing in asymptomatic patients, less than 20 % of PCPs found the CW recommendations difficult to accept (range 7.2-16.6 %) or difficult for patients to follow (12.2-19.3 %). For five recommendations regarding testing or treatment for symptomatic conditions, however, there was both variation in reported difficulty to follow (9.8-32 %) and a high level of reported difficulty for patients to accept (35.7-87.1 %). The most frequently reported barriers to reducing overuse included malpractice concern, patient requests for services, lack of time for shared decision making, and the number of tests recommended by specialists., Conclusions: While PCPs found many CW recommendations easy to follow, they felt that some, especially those for symptomatic conditions, would be difficult for patients to accept. Overcoming PCPs' perceptions of patient acceptability will require approaches beyond routine physician education, feedback and financial incentives., Competing Interests: Compliance with Ethical Standards Funders Partial funding for data collection expenses related to this research was provided by the Center for Healthcare Research and Transformation (CHRT), a non-profit partnership between the University of Michigan and Blue Cross Blue Shield of Michigan. Additionally, partial funding for the VA survey was provided by the Veterans Health Administration’s Patient Aligned Care Team (PACT) Demonstration Laboratory Coordinating Center (DLCC). Support was also provided by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service. Dr. Kullgren is a VA HSR&D Career Development awardee at the Ann Arbor VA. The views expressed herein are those of the authors and do not necessarily represent the U.S. Department of Veterans Affairs or the University of Michigan. Conflict of Interest All authors state that there are no conflicts of interest to report.

Purpose: The adoption of active surveillance varies widely across urological communities, which suggests a need for more consistency in the counseling of patients. To address this need we used the RAND/UCLA Appropriateness Method to develop appropriateness criteria and counseling statements for active surveillance., Materials and Methods: Panelists were recruited from MUSIC urology practices. Combinations of parameters thought to influence decision making were used to create and score 160 theoretical clinical scenarios for appropriateness of active surveillance. Recent rates of active surveillance among real patients across the state were assessed using the MUSIC registry., Results: Low volume Gleason 6 was deemed highly appropriate for active surveillance whereas high volume Gleason 6 and low volume Gleason 3+4 were deemed appropriate to uncertain. No scenario was deemed inappropriate or highly inappropriate. Prostate specific antigen density, race and life expectancy impacted scores for intermediate and high volume Gleason 6 and low volume Gleason 3+4. The greatest degree of score dispersion (disagreement) occurred in scenarios with long life expectancy, high volume Gleason 6 and low volume Gleason 3+4. Recent rates of active surveillance use among real patients ranged from 0% to 100% at the provider level for low or intermediate biopsy volume Gleason 6, demonstrating a clear opportunity for quality improvement., Conclusions: By virtue of this work urologists have the opportunity to present specific recommendations from the panel to their individual patients. Community-wide efforts aimed at increasing rates of active surveillance and reducing practice and physician level variation in the choice of active surveillance vs treatment are warranted., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Mechanisms of red blood cell delivery and their contribution to the incidence of venous thromboembolism are not well understood in the clinical setting. We assessed whether red blood cell transfusion through peripherally inserted central catheters (PICCs) affects the risk of venous thromboembolism compared with transfusion through non-PICC devices., Methods: We implemented a prospective study between Jan 1, 2013, and Sept 12, 2015, in patients (age ≥18 years) admitted to a general medicine ward or intensive care unit who received a PICC for any reason during clinical care in 47 hospitals in Michigan, USA, with a maximum follow-up of 70 days. The exposure of interest was route of red blood cell transfusion. The primary outcome was symptomatic, radiographically confirmed, deep-vein thrombosis in the arm or leg or pulmonary embolism. We used Cox proportional hazards regression for analyses., Findings: Venous thromboembolism developed in 482 (5%) of 10 604 patients with PICCs. Of 788 patients who received a red blood cell transfusion through a multi-lumen PICC, 61 had venous thromboembolism. The adjusted hazard ratio (HR) for venous thromboembolism in all patients whose transfusions were administered through a multi-lumen PICC was 1·96 (95% CI 1·47-2·61; p<0·0001) compared with patients not receiving a transfusion, and was 1·79 (1·09-2·95; p=0·022) compared with patients transfused through a peripheral intravenous line. Compared with delivery through a peripheral intravenous line, venous thromboembolism risk was not elevated if transfusions were delivered through a single-lumen PICC (HR 0·98, 95% CI 0·44-2·14; p=0·95) or central venous catheter (1·50, 0·77-2·91; p=0·23). For every red blood cell unit transfused through a PICC, there was a significantly increased risk of venous thromboembolism (adjusted HR 1·24, 95% CI 1·01-1·52; p=0·037). Patients who received a transfusion through a PICC in the left arm were significantly more likely to develop a deep-vein thrombosis in the ipsilateral arm compared with the contralateral side (HR 23·44, 95% CI 2·96-185·83; p=0·0028). Similarly, patients transfused through a right-sided PICC were more likely to develop deep-vein thrombosis in the ipsilateral arm (HR 3·37, 95% CI 1·02-11·14; p=0·047)., Interpretation: Red blood cell delivery through a multi-lumen PICC is associated with a greater risk of thrombosis than transfusion through a peripheral intravenous catheter. Careful monitoring for venous thromboembolism when transfusing red blood cells through multi-lumen PICCs seems necessary., Funding: Blue Cross Blue Shield of Michigan and Blue Care Network, as part of the BCBSM Value Partnerships program., (Copyright © 2016 Elsevier Ltd. All rights reserved.)