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Iowa City, IA, United States

Bailey G.,Iowa City Veterans Affairs Health Care System
Antimicrobial Agents and Chemotherapy | Year: 2013

While numerous studies have assessed the outcomes of methicillin-resistant S. aureus (MRSA) colonization over the short term, little is known about longer-term outcomes after discharge. An assessment of long-term outcomes could provide information about the utility of various MRSA prevention approaches. A matched-cohort study was performed among Veterans Affairs (VA) patients screened for MRSA colonization between the years 2007 and 2009 and followed to evaluate outcomes until 2010. Cox proportional-hazard models were used to evaluate the association between MRSA colonization and long-term outcomes, such as infection-related readmission and crude mortality. A total of 404 veterans were included, 206 of whom were MRSA carriers and 198 of whom were noncarriers. There were no culture-proven MRSA infections on readmission among the noncarriers, but 13% of MRSA carriers were readmitted with culture-proven MRSA infections on readmission (P<0.01). MRSA carriers were significantly more likely to be readmitted, to be readmitted more than once due to proven or probable MRSA infections, and to be readmitted within 90 days of discharge than noncarriers (P<0.05). Infection-related readmission (adjusted hazard ratio [HR] = 4.07; 95% confidence interval [CI], 2.16 to 7.67) and mortality (adjusted HR=2.71; 95% CI, 1.87 to 3.91) were significantly higher among MRSA carriers than among noncarriers after statistically adjusting for potential confounders. Among a cohort of VA patients, MRSA carriers are at high risk of infection-related readmission, MRSA infection, and mortality compared to noncarriers. Noncarriers are at very low risk of subsequent MRSA infection. Future studies should address whether interventions such as nasal or skin decolonization could result in improved outcomes for MRSA carriers. Copyright © 2013, American Society for Microbiology.

Comer R.,Shenandoah University | Lizer M.,Iowa City Veterans Affairs Health Care System
Consultant Pharmacist | Year: 2015

A 69-year-old Caucasian male with a 25-year history of paranoid schizophrenia was brought to the emergency department because of violence toward the staff in his nursing facility. He was diagnosed with a urinary tract infection and was admitted to the behavioral health unit for medication stabilization. History included a five-year state psychiatric hospital admission and nursing facility placement. Because of poor cognitive function, the patient was unable to corroborate medication history, so the pharmacy student on rotation performed an in-depth chart review. The review revealed a transcription error in 2003 deleting amantadine 100 mg twice daily and adding amiodarone 100 mg twice daily. Subsequent hospitalization resulted in another transcription error increasing the amiodarone to 200 mg twice daily. All electrocardiograms conducted were negative for atrial fibrillation. Once detected, the consulted cardiologist discontinued the amiodarone, and the primary care provider was notified via letter and discharge papers. An admission four months later revealed that the nursing facility restarted the amiodarone. Amiodarone was discontinued and the facility was again notified. This case reviews how a 10-yearold medication error went undetected in the electronic medical records through numerous medication reconciliations, but was uncovered when a single comprehensive medication review was conducted. © 2015 American Society of Consultant Pharmacists, Inc. All rights reserved.

Nelson R.E.,Veterans Affairs Salt Lake City Health Care System | Nelson R.E.,University of Utah | Nelson S.D.,Veterans Affairs Salt Lake City Health Care System | Nelson S.D.,University of Utah | And 13 more authors.
Infection Control and Hospital Epidemiology | Year: 2015

background. Estimates of the excess length of stay (LOS) attributable to healthcare-associated infections (HAIs) in which total LOS of patients with and without HAIs are biased because of failure to account for the timing of infection. Alternate methods that appropriately treat HAI as a time-varying exposure are multistate models and cohort studies, which match regarding the time of infection. We examined the magnitude of this time-dependent bias in published studies that compared different methodological approaches. methods. We conducted a systematic review of the published literature to identify studies that report attributable LOS estimates using both total LOS (time-fixed) methods and either multistate models or matching patients with and without HAIs using the timing of infection. results. Of the 7 studies that compared time-fixed methods to multistate models, conventional methods resulted in estimates of the LOS to HAIs that were, on average, 9.4 days longer or 238% greater than those generated using multistate models. Of the 5 studies that compared timefixed methods to matching on timing of infection, conventional methods resulted in estimates of the LOS to HAIs that were, on average, 12.6 days longer or 139% greater than those generated by matching on timing of infection. conclusion. Our results suggest that estimates of the attributable LOS due to HAIs depend heavily on the methods used to generate those estimates. Overestimation of this effect can lead to incorrect assumptions of the likely cost savings from HAI prevention measures. © 2015 by The Society for Healthcare Epidemiology of America. All rights reserved.

Nelson R.E.,Veterans Affairs Salt Lake City Health Care System | Nelson R.E.,University of Utah | Stevens V.W.,Veterans Affairs Salt Lake City Health Care System | Stevens V.W.,University of Utah | And 16 more authors.
American Journal of Preventive Medicine | Year: 2016

Introduction In an effort to reduce methicillin-resistant Staphylococcus aureus (MRSA) transmission through universal screening and isolation, the Department of Veterans Affairs (VA) launched the National MRSA Prevention Initiative in October 2007. The objective of this analysis was to quantify the budget impact and cost effectiveness of this initiative. Methods An economic model was developed using published data on MRSA hospital-acquired infection (HAI) rates in the VA from October 2007 to September 2010; estimates of the costs of MRSA HAIs in the VA; and estimates of the intervention costs, including salaries of staff members hired to support the initiative at each VA facility. To estimate the rate of MRSA HAIs that would have occurred if the initiative had not been implemented, two different assumptions were made: no change and a downward temporal trend. Effectiveness was measured in life-years gained. Results The initiative resulted in an estimated 1,466-2,176 fewer MRSA HAIs. The initiative itself was estimated to cost $207 million during this 3-year period, while the cost savings from prevented MRSA HAIs ranged from $27 million to $75 million. The incremental cost-effectiveness ratios ranged from $28,048 to $56,944/life-years. The overall impact on the VA's budget was $131-$179 million. Conclusions Wide-scale implementation of a national MRSA surveillance and prevention strategy in VA inpatient settings may have prevented a substantial number of MRSA HAIs. Although the savings associated with prevented infections helped offset some but not all of the cost of the initiative, this model indicated that the initiative would be considered cost effective. © 2016 American Journal of Preventive Medicine.

Skoff R.A.,Iowa City Veterans Affairs Health Care System | Waterbury N.V.,Iowa City Veterans Affairs Health Care System | Shaw R.F.,Iowa City Veterans Affairs Health Care System | Egge J.A.,University of Iowa | Cantrell M.,University of Iowa
Journal of Managed Care Pharmacy | Year: 2011

Background: In 2009, the Veterans Health Administration (VHA) released a national bulletin regarding the risk of hypoglycemia associated with the use of glyburide in elderly patients with renal dysfunction. Providers were encouraged to avoid glyburide and use glipizide in patients with a calculated creatinine clearance (CrCl) of less than 50 mL per minute. Since this initiative, many veterans were converted by their providers from glyburide to glipizide regardless of renal impairment. Objectives: To (a) identify whether hemoglobin A1c remained equivalent in patients converted from glyburide to glipizide, (b) evaluate the prevalence of hypoglycemia during treatment with glyburide or glipizide, © compare change in glycemic control for renally impaired versus nonimpaired patients, and (d) analyze dosage conversion ratios selected by providers and measures of patient follow-up after conversion including time until A1c measurement and number of glipizide dose titrations. Methods: This was a single-center, retrospective analysis of veterans converted from glyburide to glipizide from January 1, 2008, through May 31, 2010, who had documented A1c values concurrent with glyburide and glipizide use. A 2-sided equivalence analysis was used for the primary outcome. Equivalence was defined as a change in mean A1c of ± 0.2. Hypoglycemia was defined as blood glucose of less than 70 mg per dL, symptoms of hypoglycemia, or hypoglycemia that led to a fall, loss of consciousness, emergency room visit, hospitalization, or death. The pre- to post-conversion change in rates of hypoglycemia was tested for significance using a McNemar's test. Results: In the 141 (99.3% male, 53.9% CrCl < 50 mL per minute, mean age = 74.0 years) patients meeting inclusion criteria between 2008-2010, the average change in A1c (+ 0.34) was nonequivalent after conversion from glyburide to glipizide (7.08% vs. 7.42%, respectively). Hypoglycemia occurred more frequently during treatment with glyburide than glipizide (31.2% vs. 12.8%, respectively, P < 0.001). Mean dose conversion ratios were consistent with VHA recommendations (1 mg per day glyburide = 1.26-1.55 mg per day glipizide). Conclusions: Conversion from glyburide to glipizide was associated with an increase in A1c, but the incidence of hypoglycemia was reduced. Results of this study are consistent with the recommendation of the American Diabetes Association and European Association for the Study of Diabetes to use second-generation sulfonylureas other than glyburide. Patients converted to glipizide should be monitored closely to adjust therapy as appropriate to maintain glycemic control. © 2011, Academy of Managed Care Pharmacy.

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