903 results on '"Goetz, Matthew Bidwell"'
Search Results
2. Evaluation of and implications for a novel hepatitis C e-consult direct-to-treatment pilot program
- Author
-
Mohtashemi, Neaka Z, Teng, Crystal Y, Benhammou, Jihane, Dong, Tien, Goetz, Matthew Bidwell, Patel, Arpan, Kawamoto, Jenna, and Bhattacharya, Debika
- Subjects
Health Services and Systems ,Biomedical and Clinical Sciences ,Clinical Sciences ,Health Sciences ,Liver Disease ,Clinical Research ,Hepatitis - C ,Chronic Liver Disease and Cirrhosis ,Infectious Diseases ,HIV/AIDS ,Emerging Infectious Diseases ,Hepatitis ,Digestive Diseases ,Good Health and Well Being - Abstract
A Hepatitis C (HCV) e-Consult Direct-To-Treatment (DTT) program managed by midlevel providers was developed at the Veteran Affairs Greater Los Angeles Healthcare System (VAGLAHS) which provided remote referral and, in some, remote management of HCV. DTT patients were more likely to be initiated on HCV treatment compared to standard of care (SOC), lending support for similar programs of remote engagement in HCV care.
- Published
- 2023
3. Contingency management with stepped care for unhealthy alcohol use among individuals with HIV: Protocol for a randomized controlled trial
- Author
-
Edelman, E Jennifer, Dziura, James, Deng, Yanhong, DePhilippis, Dominick, Fucito, Lisa M, Ferguson, Tekeda, Bedimo, Roger, Brown, Sheldon, Marconi, Vincent C, Goetz, Matthew Bidwell, Rodriguez-Barradas, Maria C, Simberkoff, Michael S, Molina, Patricia E, Weintrob, Amy C, Maisto, Stephen A, Paris, Manuel, Justice, Amy C, Bryant, Kendall J, and Fiellin, David A
- Subjects
Biomedical and Clinical Sciences ,Health Sciences ,Clinical Research ,Behavioral and Social Science ,Alcoholism ,Alcohol Use and Health ,Comparative Effectiveness Research ,Clinical Trials and Supportive Activities ,Prevention ,Substance Misuse ,7.1 Individual care needs ,Management of diseases and conditions ,Good Health and Well Being ,Humans ,Cohort Studies ,Pandemics ,COVID-19 ,Alcohol Drinking ,HIV Infections ,Randomized Controlled Trials as Topic ,Multicenter study ,Randomized controlled trial ,Algorithms ,HIV ,Alcohol ,Contingency management ,Motivational enhancement therapy ,Medical and Health Sciences ,General Clinical Medicine ,Public Health ,Biomedical and clinical sciences ,Health sciences - Abstract
BackgroundAlthough unhealthy alcohol use is associated with increased morbidity and mortality among people with HIV (PWH), many are ambivalent about engaging in treatment and experience variable responses to treatment. We describe the rationale, aims, and study design for the Financial Incentives, Randomization, with Stepped Treatment (FIRST) Trial, a multi-site randomized controlled efficacy trial.MethodsPWH in care recruited from clinics across the United States who reported unhealthy alcohol use, had a phosphatidylethanol (PEth) >20 ng/mL, and were not engaged in formal alcohol treatment were randomized to integrated contingency management with stepped care versus treatment as usual. The intervention involved two steps; Step 1: Contingency management (n = 5 sessions) with potential rewards based on 1) short-term abstinence; 2) longer-term abstinence; and 3) completion of healthy activities to promote progress in addressing alcohol consumption or conditions potentially impacted by alcohol; Step 2: Addiction physician management (n = 6 sessions) plus motivational enhancement therapy (n = 4 sessions). Participants' treatment was stepped up at week 12 if they lacked evidence of longer-term abstinence. Primary outcome was abstinence at week 24. Secondary outcomes included alcohol consumption (assessed by TLFB and PEth) and the Veterans Aging Cohort Study (VACS) Index 2.0 scores; exploratory outcomes included progress in addressing medical conditions potentially impacted by alcohol. Protocol adaptations due to the COVID-19 pandemic are described.ConclusionsThe FIRST Trial is anticipated to yield insights on the feasibility and preliminary efficacy of integrated contingency management with stepped care to address unhealthy alcohol use among PWH.Clinicaltrialsgov identifier: NCT03089320.
- Published
- 2023
4. Performance of infectious diseases specialists, hospitalists, and other internal medicine physicians in antimicrobial case-based scenarios: Potential impact of antimicrobial stewardship programs at 16 Veterans' Affairs medical centers.
- Author
-
Graber, Christopher J, Simon, Alissa R, Zhang, Yue, Goetz, Matthew Bidwell, Jones, Makoto M, Butler, Jorie M, Chou, Ann F, and Glassman, Peter A
- Subjects
Humans ,Communicable Diseases ,Cellulitis ,Bacteriuria ,Anti-Infective Agents ,Hospitalists ,Internal Medicine ,Veterans ,Antimicrobial Stewardship ,Infectious Diseases ,Clinical Research ,Prevention ,Infection ,Good Health and Well Being ,Medical and Health Sciences ,Epidemiology - Abstract
ObjectiveAs part of a project to implement antimicrobial dashboards at select facilities, we assessed physician attitudes and knowledge regarding antibiotic prescribing.DesignAn online survey explored attitudes toward antimicrobial use and assessed respondents' management of four clinical scenarios: cellulitis, community-acquired pneumonia, non-catheter-associated asymptomatic bacteriuria, and catheter-associated asymptomatic bacteriuria.SettingThis study was conducted across 16 Veterans' Affairs (VA) medical centers in 2017.ParticipantsPhysicians working in inpatient settings specializing in infectious diseases (ID), hospital medicine, and non-ID/hospitalist internal medicine.MethodsScenario responses were scored by assigning +1 for answers most consistent with guidelines, 0 for less guideline-concordant but acceptable answers and -1 for guideline-discordant answers. Scores were normalized to 100% guideline concordant to 100% guideline discordant across all questions within a scenario, and mean scores were calculated across respondents by specialty. Differences in mean score per scenario were tested using analysis of variance (ANOVA).ResultsOverall, 139 physicians completed the survey (19 ID physicians, 62 hospitalists, and 58 other internists). Attitudes were similar across the 3 groups. We detected a significant difference in cellulitis scenario scores (concordance: ID physicians, 76%; hospitalists, 58%; other internists, 52%; P = .0087). Scores were numerically but not significantly different across groups for community-acquired pneumonia (concordance: ID physicians, 75%; hospitalists, 60%; other internists, 56%; P = .0914), for non-catheter-associated asymptomatic bacteriuria (concordance: ID physicians, 65%; hospitalists, 55%; other internists, 40%; P = .322), and for catheter-associated asymptomatic bacteriuria (concordance: ID physicians, 27% concordant; hospitalists, 8% discordant; other internists 13% discordant; P = .12).ConclusionsSignificant differences in performance regarding management of cellulitis and low overall performance regarding asymptomatic bacteriuria point to these conditions as being potentially high-yield targets for stewardship interventions.
- Published
- 2023
5. Antimicrobial physician and pharmacist experience and perception of an antimicrobial Self-Stewardship Time-Out Program (SSTOP) intervention at eight Veterans' Affairs medical centers.
- Author
-
Goedken, Cassie Cunningham, Butler, Jorie M, Judd, Joshua, Brown, Nui, Rubin, Michael, and Goetz, Matthew Bidwell
- Subjects
Prevention ,Antimicrobial Resistance ,Infectious Diseases ,Emerging Infectious Diseases ,Clinical Research ,Medical and Health Sciences ,Epidemiology - Abstract
We explored experiences and perceptions surrounding the Self-Stewardship Time-Out Program (SSTOP) intervention across implementation sites to improve antimicrobial use. Semistructured qualitative interviews were conducted with Antibiotic Stewardship physicians and pharmacists, from which 5 key themes emerged. SSTOP may serve to achieve sustainable promotion of antibiotic use improvements.
- Published
- 2023
6. Natural Language Processing and Machine Learning to Identify People Who Inject Drugs in Electronic Health Records
- Author
-
Goodman-Meza, David, Tang, Amber, Aryanfar, Babak, Vazquez, Sergio, Gordon, Adam J, Goto, Michihiko, Goetz, Matthew Bidwell, Shoptaw, Steven, and Bui, Alex AT
- Subjects
Biomedical and Clinical Sciences ,Clinical Sciences ,Infectious Diseases ,Emerging Infectious Diseases ,Clinical Research ,Networking and Information Technology R&D (NITRD) ,7.3 Management and decision making ,Management of diseases and conditions ,Good Health and Well Being ,EHR ,machine learning ,NLP ,PWID ,Clinical sciences ,Medical microbiology - Abstract
BackgroundImproving the identification of people who inject drugs (PWID) in electronic medical records can improve clinical decision making, risk assessment and mitigation, and health service research. Identification of PWID currently consists of heterogeneous, nonspecific International Classification of Diseases (ICD) codes as proxies. Natural language processing (NLP) and machine learning (ML) methods may have better diagnostic metrics than nonspecific ICD codes for identifying PWID.MethodsWe manually reviewed 1000 records of patients diagnosed with Staphylococcus aureus bacteremia admitted to Veterans Health Administration hospitals from 2003 through 2014. The manual review was the reference standard. We developed and trained NLP/ML algorithms with and without regular expression filters for negation (NegEx) and compared these with 11 proxy combinations of ICD codes to identify PWID. Data were split 70% for training and 30% for testing. We calculated diagnostic metrics and estimated 95% confidence intervals (CIs) by bootstrapping the hold-out test set. Best models were determined by best F-score, a summary of sensitivity and positive predictive value.ResultsRandom forest with and without NegEx were the best-performing NLP/ML algorithms in the training set. Random forest with NegEx outperformed all ICD-based algorithms. F-score for the best NLP/ML algorithm was 0.905 (95% CI, .786-.967) and 0.592 (95% CI, .550-.632) for the best ICD-based algorithm. The NLP/ML algorithm had a sensitivity of 92.6% and specificity of 95.4%.ConclusionsNLP/ML outperformed ICD-based coding algorithms at identifying PWID in electronic health records. NLP/ML models should be considered in identifying cohorts of PWID to improve clinical decision making, health services research, and administrative surveillance.
- Published
- 2022
7. Optimal Urine Culture Diagnostic Stewardship Practice-Results from an Expert Modified-Delphi Procedure.
- Author
-
Claeys, Kimberly C, Trautner, Barbara W, Leekha, Surbhi, Coffey, KC, Crnich, Christopher J, Diekema, Dan J, Fakih, Mohamad G, Goetz, Matthew Bidwell, Gupta, Kalpana, Jones, Makoto M, Leykum, Luci, Liang, Stephen Y, Pineles, Lisa, Pleiss, Ashley, Spivak, Emily S, Suda, Katie J, Taylor, Jennifer M, Rhee, Chanu, and Morgan, Daniel J
- Subjects
Humans ,Urinary Tract Infections ,Anti-Bacterial Agents ,Urinalysis ,Delphi Technique ,diagnostic stewardship ,expert consensus ,modified Delphi ,urinary tract infection ,urine cultures ,Infectious Diseases ,Management of diseases and conditions ,7.3 Management and decision making ,Biological Sciences ,Medical and Health Sciences ,Microbiology - Abstract
BackgroundUrine cultures are nonspecific and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. In this study, we aimed to develop expert guidance on best practices for urine culture diagnostic stewardship.MethodsA RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped into three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed during a virtual meeting, then a second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed.ResultsOne hundred and sixty-five questions were reviewed. The panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, sending alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional urine cultures and urine white blood cell count as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions.ConclusionsThese 18 guidance statements can optimize use of urine cultures for better patient outcomes.
- Published
- 2022
8. Frailty, vaccination, and hospitalization following COVID‐19 positivity in older veterans
- Author
-
Seligman, Benjamin, Ikuta, Kevin, Orshansky, Greg, and Goetz, Matthew Bidwell
- Subjects
Biomedical and Clinical Sciences ,Health Sciences ,Psychology ,Aged ,COVID-19 ,Frailty ,Hospitalization ,Humans ,Vaccination ,Veterans ,Medical and Health Sciences ,Geriatrics ,Biomedical and clinical sciences ,Health sciences - Published
- 2022
9. Dexamethasone in hospitalised COVID-19 patients not on intensive respiratory support
- Author
-
Crothers, Kristina, DeFaccio, Rian, Tate, Janet, Alba, Patrick R, Goetz, Matthew Bidwell, Jones, Barbara, King, Joseph T, Marconi, Vincent, Ohl, Michael E, Rentsch, Christopher T, Rodriguez-Barradas, Maria C, Shahrir, Shahida, Justice, Amy C, and Akgün, Kathleen M
- Subjects
Lung ,Good Health and Well Being ,Aged ,Dexamethasone ,Female ,Hospitalization ,Humans ,Male ,SARS-CoV-2 ,COVID-19 Drug Treatment ,Veterans Aging Cohort Study Clinical COVID-19 Working Group ,Medical and Health Sciences ,Respiratory System - Abstract
BackgroundDexamethasone decreases mortality in coronavirus disease 2019 (COVID-19) patients on intensive respiratory support (IRS) but is of uncertain benefit if less severely ill. We determined whether early (within 48 h) dexamethasone was associated with mortality in patients hospitalised with COVID-19 not on IRS.MethodsWe included patients admitted to US Veterans Affairs hospitals between 7 June 2020 and 31 May 2021 within 14 days after a positive test for severe acute respiratory syndrome coronavirus 2. Exclusions included recent prior corticosteroids and IRS within 48 h. We used inverse probability of treatment weighting (IPTW) to balance exposed and unexposed groups, and Cox proportional hazards models to determine 90-day all-cause mortality.ResultsOf 19 973 total patients (95% men, median age 71 years, 27% black), 15 404 (77%) were without IRS within 48 h. Of these, 3514 out of 9450 (34%) patients on no oxygen received dexamethasone and 1042 (11%) died; 4472 out of 5954 (75%) patients on low-flow nasal cannula (NC) only received dexamethasone and 857 (14%) died. In IPTW stratified models, patients on no oxygen who received dexamethasone experienced 76% increased risk for 90-day mortality (hazard ratio (HR) 1.76, 95% CI 1.47-2.12); there was no association with mortality among patients on NC only (HR 1.08, 95% CI 0.86-1.36).ConclusionsIn patients hospitalised with COVID-19, early initiation of dexamethasone was common and was associated with no mortality benefit among those on no oxygen or NC only in the first 48 h; instead, we found evidence of potential harm. These real-world findings do not support the use of early dexamethasone in hospitalised COVID-19 patients without IRS.
- Published
- 2022
10. Antibiotic stewardship implementation at hospitals without on-site infectious disease specialists: A qualitative study
- Author
-
Livorsi, Daniel J, Steffensmeier, Kenda R Stewart, Perencevich, Eli N, Goetz, Matthew Bidwell, and Reisinger, Heather Schacht
- Subjects
Health Services and Systems ,Health Sciences ,Clinical Research ,Health Services ,Clinical Trials and Supportive Activities ,8.1 Organisation and delivery of services ,Health and social care services research ,Good Health and Well Being ,Anti-Bacterial Agents ,Antimicrobial Stewardship ,Communicable Diseases ,Hospitals ,Humans ,Physicians ,Medical and Health Sciences ,Epidemiology ,Biomedical and clinical sciences ,Health sciences - Abstract
BackgroundHospitals are required to have antibiotic stewardship programs (ASPs), but there are few models for implementing ASPs without the support of an infectious disease (ID) specialist, defined as an ID physician and/or ID pharmacist.ObjectiveIn this study, we sought to understand ASP implementation at hospitals that lack on-site ID support within the Veterans' Health Administration (VHA).MethodsUsing a mandatory VHA survey, we identified acute-care hospitals that lacked an on-site ID specialist. We conducted semistructured interviews with personnel involved in ASP activities.SettingThe study was conducted across 7 VHA hospitals.ParticipantsIn total, 42 hospital personnel were enrolled in the study.ResultsThe primary responsibility for ASPs fell on the pharmacist champions, who were typically assigned multiple other non-ASP responsibilities. The pharmacist champions were more successful at gaining buy-in when they had established rapport with clinicians, but at some sites, the use of contract physicians and frequent staff turnover were potential barriers. Some sites felt that having access to an off-site ID specialist was important for overcoming institutional barriers and improving the acceptance of their stewardship recommendations. In general, stewardship champions struggled to mobilize institutional resources, which made it difficult to advance their programmatic goals.ConclusionIn this study of 7 hospitals without on-site ID support, we found that ASPs are largely a pharmacy-driven process. Remote ID support, if available, was seen as helpful for implementing stewardship interventions. These findings may inform the future implementation of ASPs in settings lacking local ID expertise.
- Published
- 2022
11. Defining optimal treatment for recurrent Clostridioides difficile infection (OpTION study): A randomized, double-blind comparison of three antibiotic regimens for patients with a first or second recurrence
- Author
-
Johnson, Stuart, Gerding, Dale N, Li, Xue, Reda, Domenic J, Donskey, Curtis J, Gupta, Kalpana, Goetz, Matthew Bidwell, Climo, Michael W, Gordin, Fred M, Ringer, Robert, Johnson, Neil, Johnson, Michelle, Calais, Lawrence A, Goldberg, Alexa M, Ge, Ling, and Haegerich, Tamara
- Subjects
Biomedical and Clinical Sciences ,Clinical Sciences ,Emerging Infectious Diseases ,Clinical Trials and Supportive Activities ,Infectious Diseases ,Clinical Research ,Digestive Diseases ,Evaluation of treatments and therapeutic interventions ,6.1 Pharmaceuticals ,Infection ,Anti-Bacterial Agents ,COVID-19 ,Clostridioides difficile ,Clostridium Infections ,Diarrhea ,Fidaxomicin ,Humans ,Recurrence ,Treatment Outcome ,Vancomycin ,C ,difficile ,Clinical trial ,Study design ,Clinical treatment ,Veterans ,C. difficile ,Medical and Health Sciences ,General Clinical Medicine ,Public Health ,Biomedical and clinical sciences ,Health sciences - Abstract
BackgroundAlthough many large, randomized controlled trials (RCT) have been conducted on antibiotic therapy for patients with primary C. difficile infections (CDI), few RCTs have been performed for patients with recurrent CDI (rCDI). In addition, fecal microbial transplant (FMT) is neither FDA-approved or guideline-recommended for patients with pauci-rCDI (first or second recurrences). Therefore, a rigorous RCT of sufficient size was designed to determine the optimal treatment among three antibiotic regimens in current practice for treatment of pauci-rCDI.MethodsVA Cooperative Studies Program (CSP) #596 is a prospective, double-blind, multi-center clinical trial of veteran patients with pauci-rCDI comparing fidaxomicin (FDX) 200 mg twice daily for 10 days and vancomycin (VAN) 125 mg four times daily for 10 days followed by a 3-week vancomycin taper and pulse (VAN-T/P) regimen to a standard course of VAN 125 mg four times daily for 10 days. The primary endpoint is sustained clinical response at day 59, with sustained response measured as a diarrhea composite outcome (D-COM) that includes symptom resolution during treatment (before day 10) without recurrence of diarrhea or other clinically important outcomes through day 59.DiscussionCSP study 596 is designed to compare three current antibiotic treatments for recurrent CDI that are in clinical practice, but which lack high-quality evidence to support strong guideline recommendations. The design of the study which included a pilot phase initiated at six sites with expansion to 24 sites is described along with protocol modifications based on early trial experience and clinical realities including the COVID-19 pandemic.Trial registrationThis study is registered with clinicaltrials.gov (Identifier: NCT02667418).
- Published
- 2022
12. Using the biomarker cotinine and survey self-report to validate smoking data from United States Veterans Health Administration electronic health records.
- Author
-
McGinnis, Kathleen A, Skanderson, Melissa, Justice, Amy C, Tindle, Hilary A, Akgün, Kathleen M, Wrona, Aleksandra, Freiberg, Matthew S, Goetz, Matthew Bidwell, Rodriguez-Barradas, Maria C, Brown, Sheldon T, and Crothers, Kristina A
- Subjects
Health Services and Systems ,Public Health ,Health Sciences ,Cancer ,Tobacco ,Prevention ,Tobacco Smoke and Health ,Behavioral and Social Science ,Clinical Research ,Respiratory ,Good Health and Well Being ,smoking ,cotinine ,self-reported ,ICD-10 ,Veterans Health Administration ,electronic health record ,Health services and systems - Abstract
ObjectiveTobacco use/smoking for epidemiologic studies is often derived from electronic health record (EHR) data, which may be inaccurate. We previously compared smoking from the United States Veterans Health Administration (VHA) EHR clinical reminder data with survey data and found excellent agreement. However, the smoking clinical reminder items changed October 1, 2018. We sought to use the biomarker salivary cotinine (cotinine ≥30) to validate current smoking from multiple sources.Materials and methodsWe included 323 Veterans Aging Cohort Study participants with cotinine, clinical reminder, and self-administered survey smoking data from October 1, 2018 to September 30, 2019. We included International Classification of Disease (ICD)-10 codes F17.21 and Z72.0. Operating characteristics and kappa statistics were calculated.ResultsParticipants were mostly male (96%), African American (75%) and mean age was 63 years. Of those identified as currently smoking based on cotinine, 86%, 85%, and 51% were identified as currently smoking based on clinical reminder, survey, and ICD-10 codes, respectively. Of those identified as not currently smoking based on cotinine, 95%, 97%, and 97% were identified as not currently smoking based on clinical reminder, survey, and ICD-10 codes. Agreement with cotinine was substantial for clinical reminder (kappa = .81) and survey (kappa = .83), but only moderate for ICD-10 (kappa = .50).DiscussionTo determine current smoking, clinical reminder, and survey agreed well with cotinine, whereas ICD-10 codes did not. Clinical reminders could be used in other health systems to capture more accurate smoking information.ConclusionsClinical reminders are an excellent source for self-reported smoking status and are readily available in the VHA EHR.
- Published
- 2022
13. Acceptability and effectiveness of antimicrobial stewardship implementation strategies on fluoroquinolone prescribing
- Author
-
Suda, Katie J, Clore, Gosia S, Evans, Charlesnika T, Reisinger, Heather Schacht, Kale, Ibuola, Echevarria, Kelly, Sherlock, Stacey Hockett, Perencevich, Eli N, and Goetz, Matthew Bidwell
- Subjects
Biomedical and Clinical Sciences ,Clinical Sciences ,Clinical Research ,Infectious Diseases ,Infection ,Good Health and Well Being ,Anti-Bacterial Agents ,Antimicrobial Stewardship ,Cephalosporins ,Fluoroquinolones ,Hospitals ,Humans ,VA-CDC Practice-Based Research Network ,Medical and Health Sciences ,Epidemiology ,Biomedical and clinical sciences ,Health sciences - Abstract
ObjectiveTo assess the effectiveness and acceptability of antimicrobial stewardship-focused implementation strategies on inpatient fluoroquinolones.MethodsStewardship champions at 15 hospitals were surveyed regarding the use and acceptability of strategies to improve fluoroquinolone prescribing. Antibiotic days of therapy (DOT) per 1,000 days present (DP) for sites with and without prospective audit and feedback (PAF) and/or prior approval were compared.ResultsAmong all of the sites, 60% had PAF or prior approval implemented for fluoroquinolones. Compared to sites using neither strategy (64.2 ± 34.4 DOT/DP), fluoroquinolone prescribing rates were lower for sites that employed PAF and/or prior approval (35.5 ± 9.8; P = .03) and decreased from 2017 to 2018 (P < .001). This decrease occurred without an increase in advanced-generation cephalosporins. Total antibiotic rates were 13% lower for sites with PAF and/or prior approval, but this difference did not reach statistical significance (P = .20). Sites reporting that PAF and/or prior approval were "completely" accepted had lower fluoroquinolone rates than sites where it was "moderately" accepted (34.2 ± 5.7 vs 48.7 ± 4.5; P < .01). Sites reported that clinical pathways and/or local guidelines (93%), prior approval (93%), and order forms (80%) "would" or "may" be effective in improving fluoroquinolone use. Although most sites (73%) indicated that requiring infectious disease consults would or may be effective in improving fluoroquinolones, 87% perceived implementation to be difficult.ConclusionsPAF and prior approval implementation strategies focused on fluoroquinolones were associated with significantly lower fluoroquinolone prescribing rates and nonsignificant decreases in total antibiotic use, suggesting limited evidence for class substitution. The association of acceptability of strategies with lower rates highlights the importance of culture. These results may indicate increased acceptability of implementation strategies and/or sensitivity to FDA warnings.
- Published
- 2021
14. Impact of Implementation of the Core Elements of Outpatient Antibiotic Stewardship within Veterans Health Administration Emergency Department and Primary Care Clinics on Antibiotic Prescribing and Patient Outcomes
- Author
-
Madaras-Kelly, Karl, Hostler, Christopher, Townsend, Mary, Potter, Emily M, Spivak, Emily S, Hall, Sarah K, Goetz, Matthew Bidwell, Nevers, McKenna, Ying, Jian, Haaland, Benjamin, Rovelsky, Suzette A, Pontefract, Benjamin, Fleming-Dutra, Katherine, Hicks, Lauri A, and Samore, Matthew H
- Subjects
Biomedical and Clinical Sciences ,Clinical Sciences ,Health Services ,Infectious Diseases ,Lung ,Clinical Research ,Infection ,Good Health and Well Being ,Anti-Bacterial Agents ,Antimicrobial Stewardship ,Emergency Service ,Hospital ,Humans ,Inappropriate Prescribing ,Outpatients ,Practice Patterns ,Physicians' ,Primary Health Care ,Respiratory Tract Infections ,Veterans Health ,antimicrobial stewardship ,outpatients ,respiratory tract infections ,Biological Sciences ,Medical and Health Sciences ,Microbiology ,Clinical sciences - Abstract
BackgroundThe Core Elements of Outpatient Antibiotic Stewardship provide a framework to improve antibiotic use. We report the impact of core elements implementation within Veterans Health Administration sites.MethodsIn this quasiexperimental controlled study, effects of an intervention targeting antibiotic prescription for uncomplicated acute respiratory tract infections (ARIs) were assessed. Outcomes included per-visit antibiotic prescribing, treatment appropriateness, ARI revisits, hospitalization, and ARI diagnostic changes over a 3-year pre-implementation period and 1-year post-implementation period. Logistic regression adjusted for covariates (odds ratio [OR], 95% confidence interval [CI]) and a difference-in-differences analysis compared outcomes between intervention and control sites.ResultsFrom 2014-2019, there were 16 712 and 51 275 patient visits within 10 intervention and 40 control sites, respectively. Antibiotic prescribing rates pre- and post-implementation within intervention sites were 59.7% and 41.5%, compared to 73.5% and 67.2% within control sites, respectively (difference-in-differences, P < .001). Intervention site pre- and post-implementation OR to receive appropriate therapy increased (OR, 1.67; 95% CI, 1.31-2.14), which remained unchanged within control sites (OR,1.04; 95% CI, .91-1.19). ARI-related return visits post-implementation (-1.3% vs -2.0%; difference-in-differences P = .76) were not different, but all-cause hospitalization was lower within intervention sites (-0.5% vs -0.2%; difference-in-differences P = .02). The OR to diagnose non-specific ARI compared with non-ARI diagnoses increased post-implementation forintervention (OR, 1.27; 95% CI, 1.21 -1.34) but not control (OR, 0.97; 95% CI, .94-1.01) sites.ConclusionsImplementation of the core elements was associated with reduced antibiotic prescribing for RIs and a reduction in hospitalizations. Diagnostic coding changes were observed.
- Published
- 2021
15. Using Serologic Testing to Assess the Effectiveness of Outbreak Control Efforts, Serial Polymerase Chain Reaction Testing, and Cohorting of Positive Severe Acute Respiratory Syndrome Coronavirus 2 Patients in a Skilled Nursing Facility
- Author
-
Dora, Amy V, Winnett, Alexander, Fulcher, Jennifer A, Sohn, Linda, Calub, Feliza, Lee-Chang, Ian, Ghadishah, Elham, Schwartzman, William A, Beenhouwer, David O, Vallone, John, Graber, Christopher J, Goetz, Matthew Bidwell, and Bhattacharya, Debika
- Subjects
Clinical Research ,Pneumonia ,Infectious Diseases ,Lung ,Pneumonia & Influenza ,Health Services ,Prevention ,Emerging Infectious Diseases ,Good Health and Well Being ,COVID-19 ,Disease Outbreaks ,Humans ,Polymerase Chain Reaction ,SARS-CoV-2 ,Skilled Nursing Facilities ,SARS-CoV-2 serology ,long-term care facility ,infection control ,Biological Sciences ,Medical and Health Sciences ,Microbiology - Abstract
We characterized serology following a nursing home outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) where residents were serially tested by reverse-transcription polymerase chain reaction (RT-PCR) and positive residents were cohorted. When tested 46-76 days later, 24 of 26 RT-PCR-positive residents were seropositive; none of the 124 RT-PCR-negative residents had confirmed seropositivity, supporting serial SARS-CoV-2 RT-PCR testing and cohorting in nursing homes.
- Published
- 2021
16. Risks of Opportunistic Infections in People Living with HIV with Cancers Treated with Chemotherapy
- Author
-
Makinson, Alain, Park, Lesley S, Stone, Kimberly, Tate, Janet, Rodriguez-Barradas, Maria C, Brown, Sheldon T, Wadia, Roxanne, Crothers, Kristina, Bedimo, Roger, Goetz, Matthew Bidwell, Shebl, Fatma, Reynes, Jacques, Le Moing, Vincent, and Sigel, Keith M
- Subjects
Medical Microbiology ,Biomedical and Clinical Sciences ,Clinical Sciences ,Immunology ,Cancer ,Infectious Diseases ,Rare Diseases ,Prevention ,HIV/AIDS ,Infection ,Good Health and Well Being ,chemotherapy ,opportunistic infections ,Pneumocystis jirovecii pneumonia ,prophylaxis ,Clinical sciences ,Medical microbiology - Abstract
BackgroundWe ascertained incidence of opportunistic infections (OIs) in people with human immunodeficiency virus (PWH) with cancer undergoing chemotherapy with non-human immunodeficiency virus (HIV) comparators.MethodsWe identified 2106 PWH and 2981 uninfected Veterans with cancer who received at least 1 dose of chemotherapy between 1996 and 2017 from the Veterans Aging Cohort Study. We ascertained incident OIs within 6 months of chemotherapy amongst zoster, cytomegalovirus, tuberculosis, Candida esophagitis, Pneumocystis jirovecii pneumonia (PCP), toxoplasmosis, Cryptococcosis, atypical Mycobacterium infection, Salmonella bacteremia, histoplasmosis, coccidioidomycosis, or progressive multifocal leukoencephalopathy. We used Poisson methods to calculate OI incidence rates by HIV status, stratifying for hematological and nonhematological tumors. We compared OI rates by HIV status, using inverse probability weights of HIV status, further adjusting for PCP prophylaxis.ResultsWe confirmed 106 OIs in 101 persons. Adjusted OI incidence rate ratios (IRRs) indicated higher risk in PWH for all cancers (IRR, 4.8; 95% confidence interval [CI], 2.8-8.2), hematological cancers (IRR, 8.2; 95% CI, 2.4-27.3), and nonhematological cancers (IRR, 3.9; 95% CI, 2.1-7.2). Incidence rate ratios were not significantly higher in those with CD4 >200 cells/mm3 and viral load 200/mm3.ConclusionsVeterans with HIV undergoing chemotherapy had higher rates of OIs than uninfected Veterans, particularly those with hematological cancers, but not in PWH with HIV controlled disease. Our study does not support systematic PCP prophylaxis in solid tumors in PWH with HIV controlled disease.
- Published
- 2021
17. The feasibility of implementing antibiotic restrictions for fluoroquinolones and cephalosporins: a mixed-methods study across 15 Veterans Health Administration hospitals
- Author
-
Livorsi, Daniel J, Suda, Katie J, Goedken, Cassie Cunningham, Sherlock, Stacey Hockett, Balkenende, Erin, Chasco, Emily E, Scherer, Aaron M, Goto, Michihiko, Perencevich, Eli N, Goetz, Matthew Bidwell, Reisinger, Heather Schacht, and Network, Veterans Affairs-Centers for Disease Control and Prevention Practice-Based Research
- Subjects
Infectious Diseases ,Clinical Research ,Infection ,Good Health and Well Being ,Anti-Bacterial Agents ,Cephalosporins ,Feasibility Studies ,Fluoroquinolones ,Hospitals ,Humans ,Veterans Health ,Veterans Affairs-Centers for Disease Control and Prevention Practice-Based Research Network ,Microbiology ,Medical Microbiology ,Pharmacology and Pharmaceutical Sciences - Abstract
IntroductionThe optimal method for implementing hospital-level restrictions for antibiotics that carry a high risk of Clostridioides difficile infection has not been identified. We aimed to explore barriers and facilitators to implementing restrictions for fluoroquinolones and third/fourth-generation cephalosporins.MethodsThis mixed-methods study across a purposeful sample of 15 acute-care, geographically dispersed Veterans Health Administration hospitals included electronic surveys and semi-structured interviews (September 2018 to May 2019). Surveys on stewardship strategies were administered at each hospital and summarized with descriptive statistics. Interviews were performed with 30 antibiotic stewardship programme (ASP) champions across all 15 sites and 19 additional stakeholders at a subset of 5 sites; transcripts were analysed using thematic content analysis.ResultsThe most restricted agent was moxifloxacin, which was restricted at 12 (80%) sites. None of the 15 hospitals restricted ceftriaxone. Interviews identified differing opinions on the feasibility of restricting third/fourth-generation cephalosporins and fluoroquinolones. Some participants felt that restrictions could be implemented in a way that was not burdensome to clinicians and did not interfere with timely antibiotic administration. Others expressed concerns about restricting these agents, particularly through prior approval, given their frequent use, the difficulty of enforcing restrictions and potential unintended consequences of steering clinicians towards non-restricted antibiotics. A variety of stewardship strategies were perceived to be effective at reducing the use of these agents.ConclusionsAcross 15 hospitals, there were differing opinions on the feasibility of implementing antibiotic restrictions for third/fourth-generation cephalosporins and fluoroquinolones. While the perceived barrier to implementing restrictions was frequently high, many hospitals were effectively using restrictions and reported few barriers to their use.
- Published
- 2021
18. Social dynamics of a population-level dashboard for antimicrobial stewardship: A qualitative analysis.
- Author
-
Taber, Peter, Weir, Charlene, Butler, Jorie M, Graber, Christopher J, Jones, Makoto M, Madaras-Kelly, Karl, Zhang, Yue, Chou, Ann F, Samore, Matthew H, Goetz, Matthew Bidwell, and Glassman, Peter A
- Subjects
Humans ,Anti-Bacterial Agents ,Pharmacists ,Physicians ,Quality Improvement ,Antimicrobial Stewardship ,Antibiotics ,Cognitive support ,Decision support ,Informatics ,Learning health system ,Social motivation ,Clinical Research ,Prevention ,Infectious Diseases ,Epidemiology ,Nursing ,Public Health and Health Services - Abstract
ObjectiveTo evaluate antimicrobial stewards' experiences of using a dashboard display integrating local and national antibiotic use data implemented in the U.S. Department of Veterans Affairs (VA). This paper reports early formative evaluation.DesignQualitative interviewing.SettingEight VA hospitals participated with established antimicrobial stewardship (AS) programs participated in the pilot.ParticipantsSix infectious disease physicians and eight clinical pharmacists agreed to be interviewed (n = 14).MethodsA 3-part qualitative interview script was used involving a description of local stewardship activities, a Critical Incident description of dashboard use, and general questions regarding attitudes towards the tool. An inductive open coding approach was used for analysis.ResultsWe found 4 themes showing the complexities of using stewardship tools: (1) Data validity is socially negotiated; (2) Performance feedback motivates and persuades social goals when situated in an empirical distribution; (3) Shared problem awareness is aided by authoritative data; and (4) The AS dashboard encourages connections with local quality improvement culture.ConclusionsSocial dimensions of AS tool use emerged as distinct from, and equally important as decision support provided by the dashboard. Successful stewardship tools should be designed to support both the social and cognitive needs of users.
- Published
- 2021
19. Safety of vaccines used for routine immunization in the United States: An updated systematic review and meta-analysis
- Author
-
Gidengil, Courtney, Goetz, Matthew Bidwell, Newberry, Sydne, Maglione, Margaret, Hall, Owen, Larkin, Jody, Motala, Aneesa, and Hempel, Susanne
- Subjects
Health Services and Systems ,Biomedical and Clinical Sciences ,Health Sciences ,Prevention ,Immunization ,Infectious Diseases ,Emerging Infectious Diseases ,Patient Safety ,Vaccine Related ,Pediatric ,3.4 Vaccines ,Prevention of disease and conditions ,and promotion of well-being ,Infection ,Good Health and Well Being ,Adult ,Child ,Diphtheria ,Female ,Humans ,Infant ,Measles ,Measles-Mumps-Rubella Vaccine ,Mumps ,Pregnancy ,United States ,Vaccination ,Vaccine safety ,Meta-analysis ,Systematic review ,Childhood vaccines ,Biological Sciences ,Agricultural and Veterinary Sciences ,Medical and Health Sciences ,Virology ,Biomedical and clinical sciences ,Health sciences - Abstract
BackgroundUnderstanding the safety of vaccines is critical to inform decisions about vaccination. Our objective was to conduct a systematic review of the safety of vaccines recommended for children, adults, and pregnant women in the United States.MethodsWe searched the literature in November 2020 to update a 2014 Agency for Healthcare Research and Quality review by integrating newly available data. Studies of vaccines that used a comparator and reported the presence or absence of key adverse events were eligible. Adhering to Evidence-based Practice Center methodology, we assessed the strength of evidence (SoE) for all evidence statements. The systematic review is registered in PROSPERO (CRD42020180089).ResultsOf 56,603 reviewed citations, 338 studies reported in 518 publications met inclusion criteria. For children, SoE was high for no increased risk of autism following measles, mumps, and rubella (MMR) vaccine. SoE was high for increased risk of febrile seizures with MMR. There was no evidence of increased risk of intussusception with rotavirus vaccine at the latest follow-up (moderate SoE), nor of diabetes (high SoE). There was no evidence of increased risk or insufficient evidence for key adverse events for newer vaccines such as 9-valent human papillomavirus and meningococcal B vaccines. For adults, there was no evidence of increased risk (varied SoE) or insufficient evidence for key adverse events for the new adjuvanted inactivated influenza vaccine and recombinant adjuvanted zoster vaccine. We found no evidence of increased risk (varied SoE) for key adverse events among pregnant women following tetanus, diphtheria, and acellular pertussis vaccine, including stillbirth (moderate SoE).ConclusionsAcross a large body of research we found few associations of vaccines and serious key adverse events; however, rare events are challenging to study. Any adverse events should be weighed against the protective benefits that vaccines provide.
- Published
- 2021
20. Coordinated outreach for veterans in long-term care facilities by an integrated Veterans Affairs healthcare system during the COVID-19 pandemic.
- Author
-
Winnett, Alexander, Jatt, Lauren P, Sohn, Linda, Lysaght, Marcia, Yoshikawa, Thomas, Simon, Steven R, Graber, Christopher J, and Goetz, Matthew Bidwell
- Subjects
Epidemiology ,Medical and Health Sciences - Published
- 2021
21. Inpatient antibiotic utilization in the Veterans' Health Administration during the coronavirus disease 2019 (COVID-19) pandemic.
- Author
-
Dieringer, Thomas D, Furukawa, Daisuke, Graber, Christopher J, Stevens, Vanessa W, Jones, Makoto M, Rubin, Michael A, and Goetz, Matthew Bidwell
- Subjects
Epidemiology ,Medical and Health Sciences - Abstract
Antibiotic prescribing practices across the Veterans' Health Administration (VA) experienced significant shifts during the coronavirus disease 2019 (COVID-19) pandemic. From 2015 to 2019, antibiotic use between January and May decreased from 638 to 602 days of therapy (DOT) per 1,000 days present (DP), while the corresponding months in 2020 saw antibiotic utilization rise to 628 DOT per 1,000 DP.
- Published
- 2021
22. Antibiotic stewardship implementation at hospitals without on-site infectious disease specialists: A qualitative study.
- Author
-
Livorsi, Daniel J, Stewart Steffensmeier, Kenda R, Perencevich, Eli N, Goetz, Matthew Bidwell, and Schacht Reisinger, Heather
- Subjects
Epidemiology ,Medical and Health Sciences - Abstract
BackgroundHospitals are required to have antibiotic stewardship programs (ASPs), but there are few models for implementing ASPs without the support of an infectious disease (ID) specialist, defined as an ID physician and/or ID pharmacist.ObjectiveIn this study, we sought to understand ASP implementation at hospitals that lack on-site ID support within the Veterans' Health Administration (VHA).MethodsUsing a mandatory VHA survey, we identified acute-care hospitals that lacked an on-site ID specialist. We conducted semistructured interviews with personnel involved in ASP activities.SettingThe study was conducted across 7 VHA hospitals.ParticipantsIn total, 42 hospital personnel were enrolled in the study.ResultsThe primary responsibility for ASPs fell on the pharmacist champions, who were typically assigned multiple other non-ASP responsibilities. The pharmacist champions were more successful at gaining buy-in when they had established rapport with clinicians, but at some sites, the use of contract physicians and frequent staff turnover were potential barriers. Some sites felt that having access to an off-site ID specialist was important for overcoming institutional barriers and improving the acceptance of their stewardship recommendations. In general, stewardship champions struggled to mobilize institutional resources, which made it difficult to advance their programmatic goals.ConclusionIn this study of 7 hospitals without on-site ID support, we found that ASPs are largely a pharmacy-driven process. Remote ID support, if available, was seen as helpful for implementing stewardship interventions. These findings may inform the future implementation of ASPs in settings lacking local ID expertise.
- Published
- 2021
23. Statin exposure and risk of cancer in people with and without HIV infection.
- Author
-
Bedimo, Roger J, Park, Lesley S, Shebl, Fatima M, Sigel, Keith, Rentsch, Christopher T, Crothers, Kristina, Rodriguez-Barradas, Maria C, Goetz, Matthew Bidwell, Butt, Adeel A, Brown, Sheldon T, Gibert, Cynthia, Justice, Amy C, and Tate, Janet P
- Subjects
Clinical Research ,HIV/AIDS ,Prevention ,Cancer ,Infectious Diseases ,2.2 Factors relating to the physical environment ,2.1 Biological and endogenous factors ,Aetiology ,Infection ,Good Health and Well Being ,Cohort Studies ,Female ,HIV Infections ,Humans ,Hydroxymethylglutaryl-CoA Reductase Inhibitors ,Male ,Neoplasms ,Proportional Hazards Models ,cancer ,HIV ,hypolipidemic agents ,neoplasms ,Biological Sciences ,Medical and Health Sciences ,Psychology and Cognitive Sciences ,Virology - Abstract
ObjectiveTo determine whether statin exposure is associated with decreased cancer and mortality risk among persons with HIV (PWH) and uninfected persons. Statins appear to have immunomodulatory and anti-inflammatory effects and may reduce cancer risk, particularly among PWH as they experience chronic inflammation and immune activation.DesignPropensity score-matched cohort of statin-exposed and unexposed patients from 2002 to 2017 in the Veterans Aging Cohort Study (VACS), a large cohort with cancer registry linkage and detailed pharmacy data.MethodsWe calculated Cox regression hazard ratios (HRs) and 95% confidence intervals (CI) associated with statin use for all cancers, microbial cancers (associated with bacterial or oncovirus coinfection), nonmicrobial cancers, and mortality.Results:The propensity score-matched sample (N = 47 940) included 23 970 statin initiators (31% PWH). Incident cancers were diagnosed in 1160 PWH and 2116 uninfected patients. Death was reported in 1667 (7.0%) statin-exposed, and 2215 (9.2%) unexposed patients. Statin use was associated with 24% decreased risk of microbial-associated cancers (hazard ratio 0.76; 95% CI 0.69-0.85), but was not associated with nonmicrobial cancer risk (hazard ratio 1.00; 95% CI 0.92-1.09). Statin use was associated with 33% lower risk of death overall (hazard ratio 0.67; 95% CI 0.63-0.72). Results were similar in analyses stratified by HIV status, except for non-Hodgkin lymphoma where statin use was associated with reduced risk (hazard ratio 0.56; 95% CI 0.38-0.83) for PWH, but not for uninfected (P interaction = 0.012).ConclusionIn both PWH and uninfected, statin exposure was associated with lower risk of microbial, but not nonmicrobial cancer incidence, and with decreased mortality.
- Published
- 2021
24. Simulated Adoption of 2019 Community-Acquired Pneumonia Guidelines Across 114 Veterans Affairs Medical Centers: Estimated Impact on Culturing and Antibiotic Selection in Hospitalized Patients
- Author
-
Christensen, Matthew A, Nevers, McKenna, Ying, Jian, Haroldsen, Candace, Stevens, Vanessa, Jones, Makoto M, Yarbrough, Peter M, Goetz, Matthew Bidwell, Restrepo, Marcos I, Madaras-Kelly, Karl, Samore, Matthew H, and Jones, Barbara Ellen
- Subjects
Biomedical and Clinical Sciences ,Clinical Sciences ,Oncology and Carcinogenesis ,Antimicrobial Resistance ,Infectious Diseases ,Clinical Research ,Lung ,Prevention ,Pneumonia ,Pneumonia & Influenza ,Rare Diseases ,Emerging Infectious Diseases ,Infection ,Good Health and Well Being ,Anti-Bacterial Agents ,Community-Acquired Infections ,Humans ,Methicillin-Resistant Staphylococcus aureus ,Veterans ,pneumonia ,guideline ,empiric therapy ,Biological Sciences ,Medical and Health Sciences ,Microbiology ,Clinical sciences - Abstract
BackgroundThe 2019 American Thoracic Society/Infectious Diseases Society of America guidelines for community-acquired pneumonia (CAP) revised recommendations for culturing and empiric broad-spectrum antibiotics. We simulated guideline adoption in Veterans Affairs (VA) inpatients.MethodsFor all VA acute hospitalizations for CAP from 2006-2016 nationwide, we compared observed with guideline-expected proportions of hospitalizations with initial blood and respiratory cultures obtained, empiric antibiotic therapy with activity against methicillin-resistant Staphylococcus aureus (anti-MRSA) or Pseudomonas aeruginosa (antipseudomonal), empiric "overcoverage" (receipt of anti-MRSA/antipseudomonal therapy without eventual detection of MRSA/P. aeruginosa on culture), and empiric "undercoverage" (lack of anti-MRSA/antipseudomonal therapy with eventual detection on culture).ResultsOf 115 036 CAP hospitalizations over 11 years, 17 877 (16%) were admitted to an intensive care unit (ICU). Guideline adoption would slightly increase respiratory culture (30% to 36%) and decrease blood culture proportions (93% to 36%) in hospital wards and increase both respiratory (40% to 100%) and blood (95% to 100%) cultures in ICUs. Adoption would decrease empiric selection of anti-MRSA (ward: 27% to 1%; ICU: 61% to 8%) and antipseudomonal (ward: 25% to 1%; ICU: 54% to 9%) therapies. This would correspond to greatly decreased MRSA overcoverage (ward: 27% to 1%; ICU: 56% to 8%), slightly increased MRSA undercoverage (ward: 0.6% to 1.3%; ICU: 0.5% to 3.3%), with similar findings for P. aeruginosa. For all comparisons, P
- Published
- 2021
25. Survey of physician and pharmacist steward perceptions of their antibiotic stewardship programs
- Author
-
Burrowes, Shana AB, Drainoni, Mari-Lynn, Tjilos, Maria, Butler, Jorie M, Damschroder, Laura J, Goetz, Matthew Bidwell, Madaras-Kelly, Karl, Reardon, Caitlin M, Samore, Matthew H, Shen, Jincheng, Stenehjem, Edward, Zhang, Yue, and Barlam, Tamar F
- Subjects
Health Services and Systems ,Health Sciences ,Clinical Research ,Good Health and Well Being ,antbiotic stewardship ,pharmacist stewards ,volunteer stewards - Abstract
ObjectiveTo examine how individual steward characteristics (eg, steward role, sex, and specialized training) are associated with their views of antimicrobial stewardship program (ASP) implementation at their institution.DesignDescriptive survey from a mixed-methods study.SettingTwo large national healthcare systems; the Veterans' Health Administration (VA) (n = 134 hospitals) and Intermountain Healthcare (IHC; n = 20 hospitals).ParticipantsWe sent the survey to 329 antibiotic stewards serving in 154 hospitals; 152 were physicians and 177 were pharmacists. In total, 118 pharmacists and 64 physicians from 126 hospitals responded.MethodsThe survey was grounded in constructs of the Consolidated Framework for Implementation Research, and it assessed stewards' views on the development and implementation of antibiotic stewardship programs (ASPs) at their institutions We then examined differences in stewards' views by demographic factors.ResultsRegardless of individual factors, stewards agreed that the ASP added value to their institution and was advantageous to patient care. Stewards also reported high levels of collegiality and self-efficacy. Stewards who had specialized training or those volunteered for the role were less likely to think that the ASP was implemented due to a mandate. Similarly volunteers and those with specialized training felt that they had authority in the antibiotic decisions made in their facility.ConclusionsGiven the importance of ASPs, it may be beneficial for healthcare institutions to recruit and train individuals with a true interest in stewardship.
- Published
- 2021
26. Contingency management with stepped care for unhealthy alcohol use among individuals with HIV: Protocol for a randomized controlled trial
- Author
-
Edelman, E. Jennifer, Dziura, James, Deng, Yanhong, DePhilippis, Dominick, Fucito, Lisa M., Ferguson, Tekeda, Bedimo, Roger, Brown, Sheldon, Marconi, Vincent C., Goetz, Matthew Bidwell, Rodriguez-Barradas, Maria C., Simberkoff, Michael S., Molina, Patricia E., Weintrob, Amy C., Maisto, Stephen A., Paris, Manuel, Justice, Amy C., Bryant, Kendall J., and Fiellin, David A.
- Published
- 2023
- Full Text
- View/download PDF
27. Brief Report: Accuracy of FIB-4 for Cirrhosis in People Living With HIV and Hepatocellular Carcinoma.
- Author
-
Torgersen, Jessie, Kallan, Michael J, Carbonari, Dena M, Park, Lesley S, Mehta, Rajni L, D'Addeo, Kathryn, Tate, Janet P, Lim, Joseph K, Goetz, Matthew Bidwell, Rodriguez-Barradas, Maria C, Bräu, Norbert, Brown, Sheldon T, Taddei, Tamar H, Justice, Amy C, and Lo Re, Vincent
- Subjects
Biomedical and Clinical Sciences ,Public Health ,Health Sciences ,Liver Cancer ,HIV/AIDS ,Rare Diseases ,Chronic Liver Disease and Cirrhosis ,Prevention ,Cancer ,Liver Disease ,Digestive Diseases ,4.2 Evaluation of markers and technologies ,Detection ,screening and diagnosis ,Age Factors ,Alanine Transaminase ,Aspartate Aminotransferases ,Carcinoma ,Hepatocellular ,Clinical Decision Rules ,Cross-Sectional Studies ,Female ,HIV Infections ,Humans ,Liver Cirrhosis ,Liver Neoplasms ,Male ,Middle Aged ,Platelet Count ,Registries ,Virginia ,FIB-4 ,cirrhosis ,HIV ,hepatocellular carcinoma ,Clinical Sciences ,Public Health and Health Services ,Virology ,Clinical sciences ,Epidemiology ,Public health - Abstract
BackgroundHepatocellular carcinoma (HCC) may develop in the absence of cirrhosis in HIV, and determining how often this occurs can provide insights into mechanisms of carcinogenesis. Studies evaluating the prevalence of cirrhosis in the setting of HCC among people living with HIV (PLWH) often rely on noninvasive markers, such as the Fibrosis-4 Index for Hepatic Fibrosis (FIB-4). However, the accuracy of FIB-4 for cirrhosis in the setting of HCC has not been determined among PLWH.MethodsWe conducted a cross-sectional study among PLWH in the Veterans Aging Cohort Study with VA cancer registry-confirmed HCC diagnosed between 1999 and 2015. FIB-4 was calculated using the age, alanine aminotransferase, aspartate aminotransferase, and platelet count obtained closest to, but within 1 year before, HCC diagnosis. Medical records were reviewed within 1 year before HCC diagnosis to determine the cirrhosis status. We evaluated the area under the receiver-operating characteristic curve and performance characteristics of FIB-4 for confirmed cirrhosis.ResultsIncident HCC was diagnosed in 302 PLWH. After medical record review, 203 (67.2%, 95% confidence interval: 61.6% to 72.5%) had evidence of cirrhosis. FIB-4 identified patients with cirrhosis with an area under the receiver-operating characteristic curve of 0.67 (95% confidence interval: 0.60 to 0.73). FIB-4 scores >5.0 had a positive predictive value >80% and specificity of >77%, negative predictive value of
- Published
- 2020
28. Serious cardiovascular adverse events with fluoroquinolones versus other antibiotics: A self-controlled case series analysis.
- Author
-
Aspinall, Sherrie L, Sylvain, Nathan P, Zhao, Xinhua, Zhang, Rongping, Dong, Diane, Echevarria, Kelly, Glassman, Peter A, Goetz, Matthew Bidwell, Miller, Donald R, and Cunningham, Francesca E
- Subjects
Humans ,Cardiovascular Diseases ,Fluoroquinolones ,Anti-Bacterial Agents ,Risk Factors ,Aged ,Middle Aged ,Female ,Male ,Veterans ,adverse drug reactions ,fluoroquinolones ,Cardiovascular ,Prevention ,Clinical Research ,Infection ,Good Health and Well Being ,Medicinal and Biomolecular Chemistry ,Pharmacology and Pharmaceutical Sciences - Abstract
The objective of this study was to evaluate the association between fluoroquinolone (FQ) use and the occurrence of aortic aneurysm/dissection (AA/AD), acute myocardial infarction (AMI), ventricular arrhythmias (VenA), and all-cause mortality vs other commonly used antibiotics. We conducted a self-controlled case series analysis of patients who experienced the outcomes of AA/AD, AMI, and VenA, based on diagnosis codes from emergency department visits and hospitalizations within Veterans Health Administration, and death in FY2014-FY2018. These Veterans also received outpatient prescriptions for FQs. Conditional Poisson regression models were used to estimate the association between FQs and each of the outcomes vs antibiotics of interest (ie amoxicillin or amoxicillin/clavulanate, azithromycin, doxycycline, cefuroxime or cephalexin, or sulfamethoxazole-trimethoprim), adjusted for time-varying covariates. Using a 30-day risk period after each antibiotic prescription, adjusted incidence rate ratios (aIRRs) for FQs vs each comparator antibiotic were not statistically different for outcomes of VenA or AMI. For AA/AD, incidence was higher during FQ risk periods vs amoxicillin [aIRR 1.50 (95% CI 1.01, 2.25)] and azithromycin [aIRR 2.15 (95% CI 1.27, 3.64)] risk periods. A significantly increased risk of mortality was observed with FQs vs each antibiotic of interest. FQs were associated with an increased risk of AA/AD vs amoxicillin and azithromycin and an increased risk of all-cause mortality vs multiple antibiotics commonly used for outpatient infections. Although the differences in event rates are small, FQ use should be limited to serious infections without appropriate alternatives.
- Published
- 2020
29. Validation for using electronic health records to identify community acquired pneumonia hospitalization among people with and without HIV
- Author
-
Rodriguez-Barradas, Maria C, McGinnis, Kathleen A, Akgün, Kathleen, Tate, Janet P, Brown, Sheldon T, Butt, Adeel A, Fine, Michael, Goetz, Matthew Bidwell, Graber, Christopher J, Huang, Laurence, Rimland, David, Justice, Amy, and Crothers, Kristina
- Subjects
Biomedical and Clinical Sciences ,Clinical Sciences ,Lung ,Patient Safety ,Infectious Diseases ,Pneumonia ,Clinical Research ,Pneumonia & Influenza ,Respiratory ,Infection ,Good Health and Well Being ,Community-acquired pneumonia ,HIV ,Electronic health records ,Other Medical and Health Sciences ,Clinical sciences - Abstract
BackgroundCohort studies identifying the incidence, complications and co-morbidities associated with community acquired pneumonia (CAP) are largely based on administrative datasets and rely on International Classification of Diseases (ICD) codes; however, the reliability of ICD codes for hospital admissions for CAP in people with HIV (PWH) has not been systematically assessed.MethodsWe used data from the Veterans Aging Cohort Study survey sample (N = 6824; 3410 PWH and 3414 uninfected) to validate the use of electronic health records (EHR) data to identify CAP hospitalizations when compared to chart review and to compare the performance in PWH vs. uninfected patients. We used different EHR algorithms that included a broad set of CAP ICD-9 codes, a set restricted to bacterial and viral CAP codes, and algorithms that included pharmacy data and/or other ICD-9 diagnoses frequently associated with CAP. We also compared microbiologic workup and etiologic diagnosis by HIV status among those with CAP.ResultsFive hundred forty-nine patients were identified as having an ICD-9 code compatible with a CAP diagnosis (13% of PWH and 4% of the uninfected, p
- Published
- 2020
30. Widespread severe acute respiratory coronavirus virus 2 (SARS-CoV-2) laboratory surveillance program to minimize asymptomatic transmission in high-risk inpatient and congregate living settings
- Author
-
Jatt, Lauren P, Winnett, Alexander, Graber, Christopher J, Vallone, John, Beenhouwer, David O, and Goetz, Matthew Bidwell
- Subjects
Biomedical and Clinical Sciences ,Clinical Sciences ,Pneumonia & Influenza ,Prevention ,Lung ,Infectious Diseases ,Biodefense ,Emerging Infectious Diseases ,Pneumonia ,Clinical Research ,Vaccine Related ,Infection ,Good Health and Well Being ,Adult ,Aged ,Aged ,80 and over ,Asymptomatic Infections ,Betacoronavirus ,COVID-19 ,COVID-19 Testing ,California ,Clinical Laboratory Techniques ,Coronavirus Infections ,Delivery of Health Care ,Integrated ,Female ,Hospitalization ,Humans ,Infection Control ,Laboratories ,Hospital ,Male ,Middle Aged ,Pandemics ,Pneumonia ,Viral ,SARS-CoV-2 ,Medical and Health Sciences ,Epidemiology ,Biomedical and clinical sciences ,Health sciences - Abstract
We describe a widespread laboratory surveillance program for severe acute respiratory coronavirus virus 2 (SARS-CoV-2) at an integrated medical campus that includes a tertiary-care center, a skilled nursing facility, a rehabilitation treatment center, and temporary shelter units. We identified 22 asymptomatic cases of SARS-CoV-2 and implemented infection control measures to prevent SARS-CoV-2 transmission in congregate settings.
- Published
- 2020
31. Decreases in antimicrobial use associated with multihospital implementation of electronic antimicrobial stewardship tools
- Author
-
Graber, Christopher J, Jones, Makoto M, Goetz, Matthew Bidwell, Madaras-Kelly, Karl, Zhang, Yue, Butler, Jorie M, Weir, Charlene, Chou, Ann F, Youn, Sarah Y, Samore, Matthew H, and Glassman, Peter A
- Subjects
Emerging Infectious Diseases ,Clinical Research ,Infectious Diseases ,Antimicrobial Resistance ,Anti-Bacterial Agents ,Anti-Infective Agents ,Antimicrobial Stewardship ,Electronics ,Humans ,Methicillin-Resistant Staphylococcus aureus ,antimicrobial stewardship ,antibiotic utilization ,data visualization ,Biological Sciences ,Medical and Health Sciences ,Microbiology - Abstract
BackgroundAntimicrobial stewards may benefit from comparative data to inform interventions that promote optimal inpatient antimicrobial use.MethodsAntimicrobial stewards from 8 geographically dispersed Veterans Affairs (VA) inpatient facilities participated in the development of antimicrobial use visualization tools that allowed for comparison to facilities of similar complexity. The visualization tools consisted of an interactive web-based antimicrobial dashboard and, later, a standardized antimicrobial usage report updated at user-selected intervals. Stewards participated in monthly learning collaboratives. The percent change in average monthly antimicrobial use (all antimicrobial agents, anti-methicillin-resistant Staphylococcus aureus [anti-MRSA] agents, and antipseudomonal agents) was analyzed using a pre-post (January 2014-January 2016 vs July 2016-January 2018) design with segmented regression and external comparison with uninvolved control facilities (n = 118).ResultsIntervention sites demonstrated a 2.1% decrease (95% confidence interval [CI], -5.7% to 1.6%) in total antimicrobial use pre-post intervention vs a 2.5% increase (95% CI, 0.8% to 4.1%) in nonintervention sites (absolute difference, 4.6%; P = .025). Anti-MRSA antimicrobial use decreased 11.3% (95% CI, -16.0% to -6.3%) at intervention sites vs a 6.6% decrease (95% CI, -9.1% to -3.9%) at nonintervention sites (absolute difference, 4.7%; P = .092). Antipseudomonal antimicrobial use decreased 3.4% (95% CI, -8.2% to 1.7%) at intervention sites vs a 3.6% increase (95% CI, 0.8% to 6.5%) at nonintervention sites (absolute difference, 7.0%; P = .018).ConclusionsComparative data visualization tool use by stewards at 8 VA facilities was associated with significant reductions in overall antimicrobial and antipseudomonal use relative to uninvolved facilities.
- Published
- 2020
32. Myocardial Steatosis Among Antiretroviral Therapy–Treated People With Human Immunodeficiency Virus Participating in the REPRIEVE Trial
- Author
-
Neilan, Tomas G, Nguyen, Kim-Lien, Zaha, Vlad G, Chew, Kara W, Morrison, Leavitt, Ntusi, Ntobeko AB, Toribio, Mabel, Awadalla, Magid, Drobni, Zsofia D, Nelson, Michael D, Burdo, Tricia H, Van Schalkwyk, Marije, Sax, Paul E, Skiest, Daniel J, Tashima, Karen, Landovitz, Raphael J, Daar, Eric, Wurcel, Alysse G, Robbins, Gregory K, Bolan, Robert K, Fitch, Kathleen V, Currier, Judith S, Bloomfield, Gerald S, Desvigne-Nickens, Patrice, Douglas, Pamela S, Hoffmann, Udo, Grinspoon, Steven K, Ribaudo, Heather, Dawson, Rodney, Goetz, Matthew Bidwell, Jain, Mamta K, Warner, Alberta, Szczepaniak, Lidia S, and Zanni, Markella V
- Subjects
Cardiovascular ,Clinical Research ,Prevention ,Clinical Trials and Supportive Activities ,Heart Disease ,6.1 Pharmaceuticals ,Evaluation of treatments and therapeutic interventions ,Good Health and Well Being ,Adipose Tissue ,Anti-Retroviral Agents ,Body Mass Index ,CD4 Lymphocyte Count ,Cardiomyopathies ,Female ,HIV Infections ,Heart Disease Risk Factors ,Humans ,Magnetic Resonance Imaging ,Magnetic Resonance Spectroscopy ,Male ,Middle Aged ,Triglycerides ,HIV ,myocardial steatosis ,intramyocardial triglyceride content ,cardiovascular magnetic resonance spectroscopy ,MRS ,cardiometabolic risk ,heart failure ,Biological Sciences ,Medical and Health Sciences ,Microbiology - Abstract
BackgroundPeople with human immunodeficiency virus (PWH) face increased risks for heart failure and adverse heart failure outcomes. Myocardial steatosis predisposes to diastolic dysfunction, a heart failure precursor. We aimed to characterize myocardial steatosis and associated potential risk factors among a subset of the Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE) participants.MethodsEighty-two PWH without known heart failure successfully underwent cardiovascular magnetic resonance spectroscopy, yielding data on intramyocardial triglyceride (IMTG) content (a continuous marker for myocardial steatosis extent). Logistic regression models were applied to investigate associations between select clinical characteristics and odds of increased or markedly increased IMTG content.ResultsMedian (Q1, Q3) IMTG content was 0.59% (0.28%, 1.15%). IMTG content was increased (> 0.5%) among 52% and markedly increased (> 1.5%) among 22% of participants. Parameters associated with increased IMTG content included age (P = .013), body mass index (BMI) ≥ 25 kg/m2 (P = .055), history of intravenous drug use (IVDU) (P = .033), and nadir CD4 count
- Published
- 2020
33. Perspectives of Physician and Pharmacist Stewards on Successful Antibiotic Stewardship Program Implementation: A Qualitative Study
- Author
-
Barlam, Tamar F, Childs, Ellen, Zieminski, Sarah A, Meshesha, Tsega M, Jones, Kathryn E, Butler, Jorie M, Damschroder, Laura J, Goetz, Matthew Bidwell, Madaras-Kelly, Karl, Reardon, Caitlin M, Samore, Matthew H, Shen, Jincheng, Stenehjem, Edward, Zhang, Yue, and Drainoni, Mari-Lynn
- Subjects
Medical Microbiology ,Biomedical and Clinical Sciences ,Clinical Sciences ,Clinical Research ,antibiotic resistance ,antibiotic stewardship ,infectious diseases ,infection prevention ,Clinical sciences ,Medical microbiology - Abstract
BackgroundAntibiotic stewardship programs (ASPs) are required at every hospital regardless of size. We conducted a qualitative study across different hospital settings to examine perspectives of physician and pharmacist stewards about the dynamics within their team and contextual factors that facilitate the success of their programs.MethodsSemistructured interviews were conducted in March-November 2018 with 46 ASP stewards, 30 pharmacists, and 16 physicians, from 39 hospitals within 2 large hospital systems.ResultsWe identified 5 major themes: antibiotic stewards were enthusiastic about their role, committed to the goals of stewardship for their patients and as a public-health imperative, and energized by successful interventions; responsibilities of pharmacist and physician stewards are markedly different, and pharmacy stewards performed the majority of the day-to-day stewardship work; collaborative teamwork is important to improving care, the pharmacists and physicians supported each other, and pharmacists believed that having a strong physician leader was essential; provider engagement strategies are a critical component of stewardship, and recommendations must be communicated in a collegial manner that did not judge the provider competence, preferably through face-to-face interactions; and hospital leadership support for ASP goals and for protected time for ASP activities is critical for success.ConclusionsThe physician-pharmacist team is essential for ASPs; most have pharmacists leading and performing day-to-day activities with physician support. Collaborative, persuasive approaches for ASP interventions were the norm. Stewards were careful not to criticize or judge inappropriate antibiotic prescribing. Further research should examine whether this persuasive approach undercuts provider appreciation of stewardship as a public health mandate.
- Published
- 2020
34. HIV RNA, CD4+ Percentage, and Risk of Hepatocellular Carcinoma by Cirrhosis Status.
- Author
-
Torgersen, Jessie, Kallan, Michael J, Carbonari, Dena M, Park, Lesley S, Mehta, Rajni L, D’Addeo, Kathryn, Tate, Janet P, Lim, Joseph K, Goetz, Matthew Bidwell, Rodriguez-Barradas, Maria C, Gibert, Cynthia L, Bräu, Norbert, Brown, Sheldon T, Roy, Jason A, Taddei, Tamar H, Justice, Amy C, and Lo Re, Vincent
- Subjects
Medical Microbiology ,Biomedical and Clinical Sciences ,Immunology ,Digestive Diseases ,Cancer ,Prevention ,Hepatitis ,Infectious Diseases ,Rare Diseases ,Chronic Liver Disease and Cirrhosis ,Clinical Research ,HIV/AIDS ,Liver Disease ,Liver Cancer ,Infection ,Good Health and Well Being ,Adult ,CD4-Positive T-Lymphocytes ,CD8-Positive T-Lymphocytes ,Carcinoma ,Hepatocellular ,Cohort Studies ,Female ,HIV ,HIV Infections ,Humans ,Liver Cirrhosis ,Liver Neoplasms ,Male ,Middle Aged ,RNA ,Viral ,Retrospective Studies ,United States ,United States Department of Veterans Affairs ,Veterans ,Viremia ,Oncology and Carcinogenesis ,Oncology & Carcinogenesis ,Oncology and carcinogenesis - Abstract
BackgroundDespite increasing incidence of hepatocellular carcinoma (HCC) among HIV-infected patients, it remains unclear if HIV-related factors contribute to development of HCC. We examined if higher or prolonged HIV viremia and lower CD4+ cell percentage were associated with HCC.MethodsWe conducted a cohort study of HIV-infected individuals who had HIV RNA, CD4+, and CD8+ cell counts and percentages assessed in the Veterans Aging Cohort Study (1999-2015). HCC was ascertained using Veterans Health Administration cancer registries and electronic records. Cox regression was used to determine hazard ratios (HR, 95% confidence interval [CI]) of HCC associated with higher current HIV RNA, longer duration of detectable HIV viremia (≥500 copies/mL), and current CD4+ cell percentage less than 14%, adjusting for traditional HCC risk factors. Analyses were stratified by previously validated diagnoses of cirrhosis prior to start of follow-up.ResultsAmong 35 659 HIV-infected patients, 302 (0.8%) developed HCC over 281 441 person-years (incidence rate = 107.3 per 100 000 person-years). Among patients without baseline cirrhosis, higher HIV RNA (HR = 1.25, 95% CI = 1.12 to 1.40, per 1.0 log10 copies/mL) and 12 or more months of detectable HIV (HR = 1.47, 95% CI = 1.02 to 2.11) were independently associated with higher risk of HCC. CD4+ percentage less than 14% was not associated with HCC in any model. Hepatitis C coinfection was a statistically significant predictor of HCC regardless of baseline cirrhosis status.ConclusionAmong HIV-infected patients without baseline cirrhosis, higher HIV RNA and longer duration of HIV viremia increased risk of HCC, independent of traditional HCC risk factors. This is the strongest evidence to date that HIV viremia contributes to risk of HCC in this group.
- Published
- 2020
35. Empirical Anti-MRSA vs Standard Antibiotic Therapy and Risk of 30-Day Mortality in Patients Hospitalized for Pneumonia
- Author
-
Jones, Barbara Ellen, Ying, Jian, Stevens, Vanessa, Haroldsen, Candace, He, Tao, Nevers, McKenna, Christensen, Matthew A, Nelson, Richard E, Stoddard, Gregory J, Sauer, Brian C, Yarbrough, Peter M, Jones, Makoto M, Goetz, Matthew Bidwell, Greene, Tom, and Samore, Matthew H
- Subjects
Biomedical and Clinical Sciences ,Clinical Sciences ,Oncology and Carcinogenesis ,Lung ,Prevention ,Pneumonia & Influenza ,Infectious Diseases ,Antimicrobial Resistance ,Clinical Research ,Pneumonia ,Emerging Infectious Diseases ,Infection ,Good Health and Well Being ,Aged ,Aged ,80 and over ,Anti-Bacterial Agents ,Female ,Hospital Mortality ,Humans ,Male ,Methicillin-Resistant Staphylococcus aureus ,Middle Aged ,Pneumonia ,Bacterial ,Pneumonia ,Staphylococcal ,Retrospective Studies ,Opthalmology and Optometry ,Public Health and Health Services ,Clinical sciences ,Health services and systems - Abstract
ImportanceUse of empirical broad-spectrum antibiotics for pneumonia has increased owing to concern for resistant organisms, including methicillin-resistant Staphylococcus aureus (MRSA). The association of empirical anti-MRSA therapy with outcomes among patients with pneumonia is unknown, even for high-risk patients.ObjectiveTo compare 30-day mortality among patients hospitalized for pneumonia receiving empirical anti-MRSA therapy vs standard empirical antibiotic regimens.Design, setting, and participantsRetrospective multicenter cohort study was conducted of all hospitalizations in which patients received either anti-MRSA or standard therapy for community-onset pneumonia in the Veterans Health Administration health care system from January 1, 2008, to December 31, 2013. Subgroups of patients analyzed were those with initial intensive care unit admission, MRSA risk factors, positive results of a MRSA surveillance test, and positive results of a MRSA admission culture. Primary analysis was an inverse probability of treatment-weighted propensity score analysis using generalized estimating equation regression; secondary analyses included an instrumental variable analysis. Statistical analysis was conducted from June 14 to November 20, 2019.ExposuresEmpirical anti-MRSA therapy plus standard pneumonia therapy vs standard therapy alone within the first day of hospitalization.Main outcomes and measuresRisk of 30-day all-cause mortality after adjustment for patient comorbidities, vital signs, and laboratory results. Secondary outcomes included the development of kidney injury and secondary infections with Clostridioides difficile, vancomycin-resistant Enterococcus species, or gram-negative bacilli.ResultsAmong 88 605 hospitalized patients (86 851 men; median age, 70 years [interquartile range, 62-81 years]), empirical anti-MRSA therapy was administered to 33 632 (38%); 8929 patients (10%) died within 30 days. Compared with standard therapy alone, in weighted propensity score analysis, empirical anti-MRSA therapy plus standard therapy was significantly associated with an increased adjusted risk of death (adjusted risk ratio [aRR], 1.4 [95% CI, 1.3-1.5]), kidney injury (aRR, 1.4 [95% CI, 1.3-1.5]), and secondary C difficile infections (aRR, 1.6 [95% CI, 1.3-1.9]), vancomycin-resistant Enterococcus spp infections (aRR, 1.6 [95% CI, 1.0-2.3]), and secondary gram-negative rod infections (aRR, 1.5 [95% CI, 1.2-1.8]). Similar associations between anti-MRSA therapy use and 30-day mortality were found by instrumental variable analysis (aRR, 1.6 [95% CI, 1.4-1.9]) and among patients admitted to the intensive care unit (aRR, 1.3 [95% CI, 1.2-1.5]), those with a high risk for MRSA (aRR, 1.2 [95% CI, 1.1-1.4]), and those with MRSA detected on surveillance testing (aRR, 1.6 [95% CI, 1.3-1.9]). No significant favorable association was found between empirical anti-MRSA therapy and death among patients with MRSA detected on culture (aRR, 1.1 [95% CI, 0.8-1.4]).Conclusions and relevanceThis study suggests that empirical anti-MRSA therapy was not associated with reduced mortality for any group of patients hospitalized for pneumonia. These results contribute to a growing body of evidence that questions the value of empirical use of anti-MRSA therapy using existing risk approaches.
- Published
- 2020
36. FIB-4 stage of liver fibrosis is associated with incident heart failure with preserved, but not reduced, ejection fraction among people with and without HIV or hepatitis C.
- Author
-
So-Armah, Kaku A, Lim, Joseph K, Lo Re, Vincent, Tate, Janet P, Chang, Chung-Chou H, Butt, Adeel A, Gibert, Cynthia L, Rimland, David, Marconi, Vincent C, Goetz, Matthew Bidwell, Ramachandran, Vasan, Brittain, Evan, Long, Michelle, Nguyen, Kim-Lien, Rodriguez-Barradas, Maria C, Budoff, Matthew J, Tindle, Hilary A, Samet, Jeffrey H, Justice, Amy C, Freiberg, Matthew S, and VACS Project Team
- Subjects
VACS Project Team ,Humans ,Hepatitis C ,HIV Infections ,Liver Cirrhosis ,Anti-HIV Agents ,Stroke Volume ,Prognosis ,Viral Load ,Severity of Illness Index ,Incidence ,Risk Assessment ,Risk Factors ,Health Status ,Ventricular Function ,Left ,Time Factors ,Adult ,Middle Aged ,HIV Long-Term Survivors ,United States ,Female ,Male ,Heart Failure ,Veterans Health ,Cohort ,Ejection fraction ,HIV ,Heart failure ,Hepatitis ,Liver fibrosis ,Clinical Research ,Heart Disease ,Chronic Liver Disease and Cirrhosis ,Liver Disease ,Cardiovascular ,Digestive Diseases ,Cardiovascular System & Hematology ,Cardiorespiratory Medicine and Haematology - Abstract
BackgroundLiver fibrosis, is independently associated with incident heart failure (HF). Investigating the association between liver fibrosis and type of HF, specifically HF with reduced ejection fraction (EF; HFrEF) or HF with preserved ejection fraction (HFpEF), may provide mechanistic insight into this association. We sought to determine the association between liver fibrosis score (FIB-4) and type of HF, and to assess whether HIV or hepatitis C status modified this association.MethodsWe included patients alive on or after 4/1/2003 from the Veterans Aging Cohort Study. We followed patients without prevalent cardiovascular disease until their first HF event, death, last clinic visit, or 9/30/2015. We defined liver fibrosis as: likely advanced fibrosis (FIB-4 > 3.25), indeterminate (FIB-4 range 1.45-3.25), unlikely advanced fibrosis (FIB-4
- Published
- 2020
37. Inpatient Management of Uncomplicated Skin and Soft Tissue Infections in 34 Veterans Affairs Medical Centers: A Medication Use Evaluation.
- Author
-
Sutton, Jesse D, Carico, Ronald, Burk, Muriel, Jones, Makoto M, Wei, XiangMing, Neuhauser, Melinda M, Goetz, Matthew Bidwell, Echevarria, Kelly L, Spivak, Emily S, Cunningham, Francesca E, and Skin and Soft Tissue Infection Medication Use Evaluation Group
- Subjects
Skin and Soft Tissue Infection Medication Use Evaluation Group ,abscess ,antibiotic stewardship ,cellulitis ,skin and soft tissue infections ,Skin and Soft Tissue Infection Medication Use Evaluation Group ,Antimicrobial Resistance ,Emerging Infectious Diseases ,Infectious Diseases ,7.3 Management and decision making ,Infection - Abstract
Background:Skin and soft tissue infections (SSTIs) are a key antimicrobial stewardship target because they are a common infection in hospitalized patients, and non-guideline-concordant antibiotic use is frequent. To inform antimicrobial stewardship interventions, we evaluated the proportion of veterans hospitalized with SSTIs who received guideline-concordant empiric antibiotics or an appropriate total duration of antibiotics. Methods:A retrospective medication use evaluation was performed in 34 Veterans Affairs Medical Centers between 2016 and 2017. Hospitalized patients who received antibiotics for uncomplicated SSTI were included. Exclusion criteria were complicated SSTI, severe immunosuppression, and antibiotics for any non-SSTI indication. Data were collected by manual chart review. The primary outcome was the proportion of patients receiving both guideline-concordant empiric antibiotics and appropriate treatment duration, defined as 5-10 days of antibiotics. Data were analyzed and reported using descriptive statistics. Results:Of the 3890 patients manually evaluated for inclusion, 1828 patients met inclusion criteria. There were 1299 nonpurulent (71%) and 529 purulent SSTIs (29%). Overall, 250 patients (14%) received guideline-concordant empiric therapy and an appropriate duration. The most common reason for non-guideline-concordance was receipt of antibiotics targeting methicillin-resistant Staphylococcus aureus (MRSA) in 906 patients (70%) with a nonpurulent SSTI. Additionally, 819 patients (45%) received broad-spectrum Gram-negative coverage, and 860 patients (48%) received an antibiotic duration >10 days. Conclusions:We identified 3 common opportunities to improve antibiotic use for patients hospitalized with uncomplicated SSTIs: use of anti-MRSA antibiotics in patients with nonpurulent SSTIs, use of broad-spectrum Gram-negative antibiotics, and prolonged durations of therapy.
- Published
- 2020
38. Trends in Incidence of Norovirus-associated Acute Gastroenteritis in Four Veterans Affairs Medical Center Populations in the United States, 2011–2015
- Author
-
Grytdal, Scott, Browne, Hannah, Collins, Nikail, Vargas, Blanca, Rodriguez-Barradas, Maria C, Rimland, David, Beenhouwer, David O, Brown, Sheldon T, Goetz, Matthew Bidwell, Lucero-Obusan, Cynthia, Holodniy, Mark, Kambhampati, Anita, Parashar, Umesh, Vinjé, Jan, Lopman, Ben, Hall, Aron J, and Cardemil, Cristina V
- Subjects
Prevention ,Infectious Diseases ,Digestive Diseases ,Foodborne Illness ,Emerging Infectious Diseases ,Clinical Research ,Good Health and Well Being ,Adult ,Caliciviridae Infections ,Feces ,Gastroenteritis ,Genotype ,Georgia ,Humans ,Incidence ,Infant ,Los Angeles ,New York ,Norovirus ,Phylogeny ,Texas ,United States ,Veterans ,norovirus ,gastroenteritis ,veterans ,outpatients ,inpatients ,Biological Sciences ,Medical and Health Sciences ,Microbiology - Abstract
BackgroundNorovirus is an important cause of epidemic acute gastroenteritis (AGE), yet the burden of endemic disease in adults has not been well documented. We estimated the prevalence and incidence of outpatient and community-acquired inpatient norovirus AGE at 4 Veterans Affairs Medical Centers (VAMC) (Atlanta, Georgia; Bronx, New York; Houston, Texas; and Los Angeles, California) and examined trends over 4 surveillance years.MethodsFrom November 2011 to September 2015, stool specimens collected within 7 days of AGE symptom onset for clinician-requested diagnostic testing were tested for norovirus, and positive samples were genotyped. Incidence was calculated by multiplying norovirus prevalence among tested specimens by AGE-coded outpatient encounters and inpatient discharges, and dividing by the number of unique patients served.ResultsOf 1603 stool specimens, 6% tested were positive for norovirus; GII.4 viruses (GII.4 New Orleans [17%] and GII.4 Sydney [47%]) were the most common genotypes. Overall prevalence and outpatient and inpatient community-acquired incidence followed a seasonal pattern, with higher median rates during November-April (9.2%, 376/100 000, and 45/100 000, respectively) compared to May-October (3.0%, 131/100 000, and 13/100 000, respectively). An alternate-year pattern was also detected, with highest peak prevalence and outpatient and inpatient community-acquired norovirus incidence rates in the first and third years of surveillance (14%-25%, 349-613/100 000, and 43-46/100 000, respectively).ConclusionsThis multiyear analysis of laboratory-confirmed AGE surveillance from 4 VAMCs demonstrates dynamic intra- and interannual variability in prevalence and incidence of outpatient and inpatient community-acquired norovirus in US Veterans, highlighting the burden of norovirus disease in this adult population.
- Published
- 2020
39. Trends in Incidence of Norovirus-associated Acute Gastroenteritis in 4 Veterans Affairs Medical Center Populations in the United States, 2011-2015.
- Author
-
Grytdal, Scott, Browne, Hannah, Collins, Nikail, Vargas, Blanca, Rodriguez-Barradas, Maria C, Rimland, David, Beenhouwer, David O, Brown, Sheldon T, Goetz, Matthew Bidwell, Lucero-Obusan, Cynthia, Holodniy, Mark, Kambhampati, Anita, Parashar, Umesh, Vinjé, Jan, Lopman, Ben, Hall, Aron J, and Cardemil, Cristina V
- Subjects
gastroenteritis ,inpatients ,norovirus ,outpatients ,veterans ,Microbiology ,Biological Sciences ,Medical and Health Sciences - Abstract
BackgroundNorovirus is an important cause of epidemic acute gastroenteritis (AGE), yet the burden of endemic disease in adults has not been well documented. We estimated the prevalence and incidence of outpatient and community-acquired inpatient norovirus AGE at 4 Veterans Affairs Medical Centers (VAMC) (Atlanta, Georgia; Bronx, New York; Houston, Texas; and Los Angeles, California) and examined trends over 4 surveillance years.MethodsFrom November 2011 to September 2015, stool specimens collected within 7 days of AGE symptom onset for clinician-requested diagnostic testing were tested for norovirus, and positive samples were genotyped. Incidence was calculated by multiplying norovirus prevalence among tested specimens by AGE-coded outpatient encounters and inpatient discharges, and dividing by the number of unique patients served.ResultsOf 1603 stool specimens, 6% tested were positive for norovirus; GII.4 viruses (GII.4 New Orleans [17%] and GII.4 Sydney [47%]) were the most common genotypes. Overall prevalence and outpatient and inpatient community-acquired incidence followed a seasonal pattern, with higher median rates during November-April (9.2%, 376/100 000, and 45/100 000, respectively) compared to May-October (3.0%, 131/100 000, and 13/100 000, respectively). An alternate-year pattern was also detected, with highest peak prevalence and outpatient and inpatient community-acquired norovirus incidence rates in the first and third years of surveillance (14%-25%, 349-613/100 000, and 43-46/100 000, respectively).ConclusionsThis multiyear analysis of laboratory-confirmed AGE surveillance from 4 VAMCs demonstrates dynamic intra- and interannual variability in prevalence and incidence of outpatient and inpatient community-acquired norovirus in US Veterans, highlighting the burden of norovirus disease in this adult population.
- Published
- 2020
40. Sodium Content of Intravenous Antibiotic Preparations.
- Author
-
Wang, Nina, Nguyen, Phuong Khanh, Pham, Christine U, Smith, Ethan A, Kim, Brian, Goetz, Matthew Bidwell, and Graber, Christopher J
- Published
- 2019
41. Potential Impact of Hospital-acquired Pneumonia Guidelines on Empiric Antibiotics. An Evaluation of 113 Veterans Affairs Medical Centers
- Author
-
Bostwick, A Doran, Jones, Barbara E, Paine, Robert, Goetz, Matthew Bidwell, Samore, Matthew, and Jones, Makoto
- Subjects
Biomedical and Clinical Sciences ,Clinical Sciences ,Infectious Diseases ,Antimicrobial Resistance ,Lung ,Pneumonia ,Prevention ,Emerging Infectious Diseases ,Clinical Research ,Infection ,Aged ,Anti-Bacterial Agents ,Community-Acquired Infections ,Cross Infection ,Female ,Hospitalization ,Hospitals ,Veterans ,Humans ,Male ,Methicillin-Resistant Staphylococcus aureus ,Middle Aged ,Multivariate Analysis ,Pneumonia ,Bacterial ,Regression Analysis ,Retrospective Studies ,United States ,hospital-acquired pneumonia ,antibiograms ,resistance ,Cardiovascular medicine and haematology ,Clinical sciences - Abstract
Rationale: The 2016 guidelines for hospital-acquired pneumonia (HAP) suggest applying a universal antibiogram resistance threshold in addition to patient criteria to determine empiric coverage. The impact of these recommendations is unknown.Objectives: 1) Describe national antibiotic use and microbiology patterns for HAP among patients with noninfectious admissions, 2) measure the predictive performance of the antibiogram threshold and risk factors, and 3) estimate the change in practice with guideline implementation.Methods: We conducted a retrospective analysis of all hospitalizations without initial infection but with secondary pneumonia diagnoses at Veterans Affairs Medical Centers between October 1, 2012, and September 30, 2015. For each hospitalization we extracted: presence of methicillin-resistant Staphylococcus aureus (MRSA) and resistant gram-negative rods (R-GNR) in cultures, anti-MRSA and antipseudomonal antimicrobial administration, and facility-level prevalence of MRSA and R-GNR. We calculated the percentage of hospitalizations with resistant organisms, broad-spectrum antibiotics, and the predictive performance of patient characteristics and prevalence thresholds for MRSA.Results: Among 3,562 cases, 5.17% were positive for MRSA and 2.30% for R-GNR. The recommended MRSA prevalence threshold was 100.00% sensitive (95% confidence interval [CI], 98.02-100.00%) and 0.03% specific (95% CI, 0.00-0.16%) for MRSA-positive culture, leading to overtreatment of 94.81% (95% CI, 94.02-95.50%) of patients. Pressor order (odds ratio [OR], 3.89; 95% CI, 1.17-12.91) and intravenous antibiotics within the past 90 days (OR, 1.98; 95% CI, 1.03-3.81) were associated with MRSA. Mechanical ventilation was associated with R-GNR (OR, 4.37; 95% CI, 1.52-12.57).Conclusions: The guideline-recommended antibiogram threshold and characteristics did not improve prediction of MRSA or R-GNR and would have led to an increase in MRSA treatment.
- Published
- 2019
42. A novel risk-adjusted metric to compare hospitals on their antibiotic-prescribing at hospital discharge
- Author
-
Livorsi, Daniel J, primary, Merchant, James A, additional, Cho, Hyunkeun, additional, Goetz, Matthew Bidwell, additional, Alexander, Bruce, additional, Beck, Brice, additional, and Goto, Michihiko, additional
- Published
- 2024
- Full Text
- View/download PDF
43. Evaluation of uncomplicated acute respiratory tract infection management in veterans: A national utilization review
- Author
-
Bohan, Jefferson G, Madaras-Kelly, Karl, Pontefract, Benjamin, Jones, Makoto, Neuhauser, Melinda M, Goetz, Matthew Bidwell, Burk, Muriel, and Cunningham, Francesca
- Subjects
Infectious Diseases ,Emerging Infectious Diseases ,Patient Safety ,Health Services ,Lung ,Clinical Research ,Management of diseases and conditions ,7.3 Management and decision making ,Infection ,Adult ,Aged ,Anti-Bacterial Agents ,Female ,Guideline Adherence ,Hospitals ,Veterans ,Humans ,Inappropriate Prescribing ,Male ,Middle Aged ,Practice Guidelines as Topic ,Practice Patterns ,Physicians' ,Quality Improvement ,Respiratory Tract Infections ,United States ,Utilization Review ,Veterans ,ARI Management Improvement Group ,Medical and Health Sciences ,Epidemiology - Abstract
BackgroundAntibiotics are overprescribed for acute respiratory tract infections (ARIs). Guidelines provide criteria to determine which patients should receive antibiotics. We assessed congruence between documentation of ARI diagnostic and treatment practices with guideline recommendations, treatment appropriateness, and outcomes.MethodsA multicenter quality improvement evaluation was conducted in 28 Veterans Affairs facilities. We included visits for pharyngitis, rhinosinusitis, bronchitis, and upper respiratory tract infections (URI-NOS) that occurred during the 2015-2016 winter season. A manual record review identified complicated cases, which were excluded. Data were extracted for visits meeting criteria, followed by analysis of practice patterns, guideline congruence, and outcomes.ResultsOf 5,740 visits, 4,305 met our inclusion criteria: pharyngitis (n = 558), rhinosinusitis (n = 715), bronchitis (n = 1,155), URI-NOS (n = 1,475), or mixed diagnoses (>1 ARI diagnosis) (n = 402). Antibiotics were prescribed in 68% of visits: pharyngitis (69%), rhinosinusitis (89%), bronchitis (86%), URI-NOS (37%), and mixed diagnosis (86%). Streptococcal diagnostic testing was performed in 33% of pharyngitis visits; group A Streptococcus was identified in 3% of visits. Streptococcal tests were ordered less frequently for patients who received antibiotics (28%) than those who did not receive antibiotics 44%; P < .01). Although 68% of visits for rhinosinusitis had documentation of symptoms, only 32% met diagnostic criteria for antibiotics. Overall, 39% of patients with uncomplicated ARIs received appropriate antibiotic management. The proportion of 30-day return visits for ARI care was similar for appropriate (11%) or inappropriate (10%) antibiotic management (P = .22).ConclusionsAntibiotics were prescribed in most uncomplicated ARI visits, indicating substantial overuse. Practice was frequently discordant with guideline diagnostic and treatment recommendations.
- Published
- 2019
44. Provider verification of electronic health record receipt and nonreceipt of direct-acting antivirals for the treatment of hepatitis C virus infection
- Author
-
Rentsch, Christopher T, Cartwright, Emily J, Gandhi, Neel R, Brown, Sheldon T, Rodriguez-Barradas, Maria C, Goetz, Matthew Bidwell, Marconi, Vincent C, Gibert, Cynthia L, Re, Vincent Lo, Fiellin, David A, Justice, Amy C, and Tate, Janet P
- Subjects
Biomedical and Clinical Sciences ,Clinical Sciences ,Health Sciences ,Digestive Diseases ,Chronic Liver Disease and Cirrhosis ,Emerging Infectious Diseases ,Infectious Diseases ,Clinical Research ,Hepatitis ,Hepatitis - C ,Liver Disease ,Infection ,Good Health and Well Being ,Aged ,Antiviral Agents ,Drug Prescriptions ,Electronic Health Records ,Female ,Hepatitis C ,Chronic ,Humans ,Male ,Middle Aged ,Pharmacoepidemiology ,Pharmacy ,United States ,United States Department of Veterans Affairs ,Veterans ,Veterans Health ,Antivirals ,Direct-acting antiviral ,Hepatitis C ,Observational data ,Validation ,Medical and Health Sciences ,Epidemiology ,Biomedical and clinical sciences ,Health sciences - Abstract
PurposePharmacoepidemiologic studies using electronic health record data could serve an important role in assessing safety and effectiveness of direct-acting antiviral therapy for chronic hepatitis C virus (HCV) infection, but the validity of these data needs to be determined. We evaluated the accuracy of pharmacy fill records in the national Veterans Health Administration (VA) Corporate Data Warehouse (CDW) as compared to facility-level electronic health record.MethodsPatients prescribed a direct-acting antiviral regimen at five VA sites between 2014 and 2016 were randomly selected and reviewed. A random sample of patients with chronic HCV infection without evidence of HCV treatment during the study period also underwent chart review. We calculated positive predictive value and negative predictive value overall and by site.ResultsOf the 501 patients who received a total of 2416 prescriptions, 494 were validated using data extracted from CDW 6 months after the study period, yielding a positive predictive value of 98.6% (95% confidence interval, 97.6%-99.6%). Of the 100 patients with chronic HCV infection without prescriptions for HCV treatment, 99 were confirmed not to have received antiviral treatment (negative predictive value, 99.0%; 95% confidence interval, 97.1%-100%).ConclusionsThese findings provide assurance to researchers who use national VA CDW data for retrospective cohort studies that the CDW contains accurate information on HCV therapies in the modern treatment era.
- Published
- 2018
45. Specifying an implementation framework for Veterans Affairs antimicrobial stewardship programmes: using a factor analysis approach.
- Author
-
Chou, Ann F, Graber, Christopher J, Zhang, Yue, Jones, Makoto, Goetz, Matthew Bidwell, Madaras-Kelly, Karl, Samore, Matthew, and Glassman, Peter A
- Subjects
Humans ,Factor Analysis ,Statistical ,United States Department of Veterans Affairs ,Veterans ,Health Facilities ,Emergency Medical Services ,United States ,Antimicrobial Stewardship ,Prevention ,Clinical Research ,Microbiology ,Medical Microbiology ,Pharmacology and Pharmaceutical Sciences - Abstract
Objectives:Inappropriate antibiotic use poses a serious threat to patient safety. Antimicrobial stewardship programmes (ASPs) may optimize antimicrobial use and improve patient outcomes, but their implementation remains an organizational challenge. Using the Promoting Action on Research Implementation in Health Services (PARiHS) framework, this study aimed to identify organizational factors that may facilitate ASP design, development and implementation. Methods:Among 130 Veterans Affairs facilities that offered acute care, we classified organizational variables supporting antimicrobial stewardship activities into three PARiHS domains: evidence to encompass sources of knowledge; contexts to translate evidence into practice; and facilitation to enhance the implementation process. We conducted a series of exploratory factor analyses to identify conceptually linked factor scales. Cronbach's alphas were calculated. Variables with large uniqueness values were left as single factors. Results:We identified 32 factors, including six constructs derived from factor analyses under the three PARiHS domains. In the evidence domain, four factors described guidelines and clinical pathways. The context domain was broken into three main categories: (i) receptive context (15 factors describing resources, affiliations/networks, formalized policies/practices, decision-making, receptiveness to change); (ii) team functioning (1 factor); and (iii) evaluation/feedback (5 factors). Within facilitation, two factors described facilitator roles and tasks and five captured skills and training. Conclusions:We mapped survey data onto PARiHS domains to identify factors that may be adapted to facilitate ASP uptake. Our model encompasses mostly mutable factors whose relationships with performance outcomes may be explored to optimize antimicrobial use. Our framework also provides an analytical model for determining whether leveraging existing organizational processes can potentially optimize ASP performance.
- Published
- 2018
46. A Randomized Trial of Off‐Site Collaborative Care for Depression in Chronic Hepatitis C Virus
- Author
-
Kanwal, Fasiha, Pyne, Jeffrey M, Tavakoli‐Tabasi, Shahriar, Nicholson, Susan, Dieckgraefe, Brian, Storay, Erma, Goetz, Matthew Bidwell, Kramer, Jennifer R, Smith, Donna, Sansgiry, Shubhada, Tansel, Aylin, Gifford, Allen L, and Asch, Steven M
- Subjects
Health Services and Systems ,Health Sciences ,Health Services ,Chronic Liver Disease and Cirrhosis ,Hepatitis - C ,Hepatitis ,Liver Disease ,Clinical Trials and Supportive Activities ,Mental Health ,Prevention ,Brain Disorders ,Depression ,Clinical Research ,Infectious Diseases ,Emerging Infectious Diseases ,Behavioral and Social Science ,Digestive Diseases ,Prevention of disease and conditions ,and promotion of well-being ,3.1 Primary prevention interventions to modify behaviours or promote wellbeing ,Infection ,Mental health ,Good Health and Well Being ,Female ,Hepacivirus ,Hepatitis C ,Chronic ,Hospitals ,Veterans ,Humans ,Male ,Mass Screening ,Middle Aged ,Referral and Consultation ,Self Report ,Surveys and Questionnaires ,Physical health ,depression ,hepatitis C ,Public Health and Health Services ,Policy and Administration ,Health Policy & Services ,Health services and systems ,Policy and administration - Abstract
ObjectiveTo test the effectiveness of a collaborative depression care model in improving depression and hepatitis C virus (HCV) care.Data sources/study settingHepatitis C virus clinic patients who screened positive for depression at four Veterans Affairs Hospitals.Study designWe compared off-site depression collaborative care (delivered by depression care manager, pharmacist, and psychiatrist) with usual care in a randomized trial. Primary depression outcomes were treatment response (≥50 percent decrease in 20-item Hopkins Symptoms Checklist [SCL-20] score), remission (mean SCL-20 score,
- Published
- 2018
47. Association of Human Immunodeficiency Virus Infection and Risk of Peripheral Artery Disease
- Author
-
Beckman, Joshua A, Duncan, Meredith S, Alcorn, Charles W, So-Armah, Kaku, Butt, Adeel A, Goetz, Matthew Bidwell, Tindle, Hilary A, Sico, Jason J, Tracy, Russel P, Justice, Amy C, and Freiberg, Matthew S
- Subjects
Clinical Research ,Heart Disease ,HIV/AIDS ,Prevention ,Cardiovascular ,Infectious Diseases ,Infection ,Good Health and Well Being ,Adult ,CD4 Lymphocyte Count ,Cohort Studies ,Female ,Follow-Up Studies ,HIV Infections ,HIV-1 ,Humans ,Male ,Middle Aged ,Peripheral Arterial Disease ,Prognosis ,Risk ,Survival Analysis ,United States ,Veterans ,amputation ,antiretroviral therapy ,CD4 cells ,human immunodeficiency virus ,mortality ,peripheral artery disease ,Cardiorespiratory Medicine and Haematology ,Clinical Sciences ,Public Health and Health Services ,Cardiovascular System & Hematology - Abstract
BACKGROUND:The effect of human immunodeficiency virus (HIV) on the development of peripheral artery disease (PAD) remains unclear. We investigated whether HIV infection is associated with an increased risk of PAD after adjustment for traditional atherosclerotic risk factors in a large cohort of HIV-infected (HIV+) and demographically similar HIV-uninfected veterans. METHODS:We studied participants in the Veterans Aging Cohort Study from April 1, 2003 through December 31, 2014. We excluded participants with known prior PAD or prevalent cardiovascular disease (myocardial infarction, stroke, coronary heart disease, and congestive heart failure) and analyzed the effect of HIV status on the risk of incident PAD events after adjusting for demographics, PAD risk factors, substance use, CD4 cell count, HIV-1 ribonucleic acid, and antiretroviral therapy. The primary outcome is incident peripheral artery disease events. Secondary outcomes include mortality and amputation in subjects with incident PAD events by HIV infection status, viral load, and CD4 count. RESULTS:Among 91 953 participants, over a median follow up of 9.0 years, there were 7708 incident PAD events. Rates of incident PAD events per 1000 person-years were higher among HIV+ (11.9; 95% confidence interval [CI], 11.5-12.4) than uninfected veterans (9.9; 95% CI, 9.6-10.1). After adjustment for demographics, PAD risk factors, and other covariates, HIV+ veterans had an increased risk of incident PAD events compared with uninfected veterans (hazard ratio [HR], 1.19; 95% CI, 1.13-1.25). This risk was highest among those with time-updated HIV viral load >500 copies/mL (HR, 1.51; 95% CI, 1.38-1.65) and CD4 cell counts
- Published
- 2018
48. Association of Viral Suppression With Lower AIDS-Defining and Non-AIDS-Defining Cancer Incidence in HIV-Infected Veterans: A Prospective Cohort Study.
- Author
-
Park, Lesley S, Tate, Janet P, Sigel, Keith, Brown, Sheldon T, Crothers, Kristina, Gibert, Cynthia, Goetz, Matthew Bidwell, Rimland, David, Rodriguez-Barradas, Maria C, Bedimo, Roger J, Justice, Amy C, and Dubrow, Robert
- Subjects
Clinical Research ,Infectious Diseases ,HIV/AIDS ,Cancer ,Prevention ,Infection ,Good Health and Well Being ,Adult ,Aged ,Anti-HIV Agents ,Case-Control Studies ,Female ,HIV Infections ,Humans ,Incidence ,Male ,Middle Aged ,Neoplasms ,Poisson Distribution ,Prospective Studies ,Risk Factors ,United States ,Veterans ,Viral Load ,Young Adult ,Clinical Sciences ,Public Health and Health Services - Abstract
BackgroundViral suppression is a primary marker of HIV treatment success. Persons with HIV are at increased risk for AIDS-defining cancer (ADC) and several types of non-AIDS-defining cancer (NADC), some of which are caused by oncogenic viruses.ObjectiveTo determine whether viral suppression is associated with decreased cancer risk.DesignProspective cohort.SettingDepartment of Veterans Affairs.ParticipantsHIV-positive veterans (n = 42 441) and demographically matched uninfected veterans (n = 104 712) from 1999 to 2015.MeasurementsStandardized cancer incidence rates and Poisson regression rate ratios (RRs; HIV-positive vs. uninfected persons) by viral suppression status (unsuppressed: person-time with HIV RNA levels ≥500 copies/mL; early suppression: initial 2 years with HIV RNA levels
- Published
- 2018
49. Reply to Johnson.
- Author
-
Spivak, Emily S, Neuhauser, Melinda M, Zhang, Rongping, Goetz, Matthew Bidwell, and Cunningham, Francesca E
- Subjects
Biomedical and Clinical Sciences ,Clinical Sciences ,Bacteriuria ,Hospitals ,Veterans ,Humans ,Stevens-Johnson Syndrome ,United States ,Veterans ,Biological Sciences ,Medical and Health Sciences ,Microbiology ,Clinical sciences - Published
- 2018
50. Bilirubin Is Inversely Associated With Cardiovascular Disease Among HIV‐Positive and HIV‐Negative Individuals in VACS (Veterans Aging Cohort Study)
- Author
-
Marconi, Vincent C, Duncan, Meredith S, So‐Armah, Kaku, Re, Vincent Lo, Lim, Joseph K, Butt, Adeel A, Goetz, Matthew Bidwell, Rodriguez‐Barradas, Maria C, Alcorn, Charles W, Lennox, Jeffrey, Beckman, Joshua A, Justice, Amy, and Freiberg, Matthew
- Subjects
Heart Disease - Coronary Heart Disease ,Clinical Research ,Cardiovascular ,Prevention ,Heart Disease ,Aging ,Good Health and Well Being ,Adult ,Age Factors ,Bilirubin ,Biomarkers ,Cardiovascular Diseases ,Female ,HIV Infections ,Humans ,Incidence ,Male ,Middle Aged ,Prognosis ,Prospective Studies ,Protective Factors ,Risk Assessment ,Risk Factors ,Time Factors ,United States ,Up-Regulation ,Veterans Health ,cardiovascular disease ,bilirubin ,HIV ,stroke ,myocardial infarction ,heart failure ,HIV ,Cardiorespiratory Medicine and Haematology - Abstract
Bilirubin may protect against cardiovascular disease (CVD) by reducing oxidative stress. Whether elevated bilirubin reduces the risk of CVD events among HIV+ individuals and if this differs from uninfected individuals remain unclear. We assessed whether bilirubin independently predicted the risk of CVD events among HIV+ and uninfected participants in VACS (Veterans Aging Cohort Study). We conducted a prospective cohort study using VACS participants free of baseline CVD. Total bilirubin was categorized by quartiles. CVD as well as acute myocardial infarction, heart failure, and ischemic stroke events were assessed. Cox regression was used to evaluate hazard ratios of outcomes associated with quartiles of total bilirubin in HIV+ and uninfected people after adjusting for multiple risk factors. There were 96 381 participants (30 427 HIV+); mean age was 48 years, 48% were black, and 97% were men. There were 6603 total incident CVD events over a mean of 5.7 years. In adjusted models, increasing quartiles of baseline total bilirubin were associated with decreased hazards of all outcomes (hazard ratio, 0.86; 95% confidence interval, 0.80-0.91). Among HIV+ participants, results persisted for heart failure, ischemic stroke, and total CVD, but nonsignificant associations were observed for acute myocardial infarction. VACS participants (regardless of HIV status) with elevated bilirubin levels had a lower risk of incident total CVD, acute myocardial infarction, heart failure, and ischemic stroke events after adjusting for known risk factors. Future studies should investigate how this apparently protective effect of elevated bilirubin could be harnessed to reduce CVD risk or improve risk estimation among HIV+ individuals.
- Published
- 2018
Catalog
Discovery Service for Jio Institute Digital Library
For full access to our library's resources, please sign in.