Reply to Bodi et al.
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Anti-Bacterial Agents↗
Biomedical subjects
Jacqueline Pugh
Publications and source records attributed to Jacqueline Pugh.
Cost utility of substituting enoxaparin for unfractionated heparin for prophylaxis of venous thrombosis in the hospitalized medical patient.
BACKGROUND: Both heparin and enoxaparin are effective for the prevention of venous thromboembolism (VTE) in medical patients. On the basis of price, heparin appears preferable because it is less expensive. However, choosing enoxaparin may have greater cost utility when the outcomes of heparin-induced thrombocytopenia (HIT) and heparin-induced thrombocytopenia with thrombosis (HITT) are considered. OBJECTIVE: To determine the cost utility of substituting enoxaparin for heparin from payer and institutional perspectives. DESIGN: A decision analysis model was used. Cost data were based on Medicare reimbursement and the medication and laboratory costs for a multi-institutional healthcare system. Quality-adjusted life years (QALYs) saved by preventing HIT/HITT through the use of enoxaparin were based on published data. Costs are expressed on a per-day basis, and the incremental cost of enoxaparin over that of heparin was used in the calculation of cost/QALY. A sensitivity analysis also was performed. SETTING: Inpatient medicine. PATIENTS: All medical patients for whom VTE prophylaxis was appropriate. INTERVENTIONS: Substitution of enoxaparin for heparin. MEASUREMENT: Cost/QALY. RESULTS: From a payer perspective, using enoxaparin resulted in a decrease in cost of 28.61 dollars over that of heparin and saved 0.00629 QALYs in the base case, resulting in a savings of 4550.17 dollars/QALY. The sensitivity analysis showed this finding of decreased cost and increased effectiveness to be consistent. From an institutional perspective, the use of heparin generally appeared less costly but was dependent on medication price, length of stay required, and bed utilization. CONCLUSIONS: From a payer and, by extrapolation, a societal perspective, cost-utility analysis supports the use of enoxaparin in place of heparin for the prevention of VTE in medical inpatients. From an institutional perspective, the decision is more complicated, but in most cases, the use of enoxaparin also is supported.
Costs and Cost Analysis↗
Strategies for promoting organizational and practice change by advancing implementation research.
BACKGROUND: The persistence of a large quality gap between what we know about how to produce high quality clinical care and what the public receives has prompted interest in developing more effective methods to get evidence into practice. Implementation research aims to supply such methods. PURPOSE: This article proposes a set of recommendations aimed at establishing a common understanding of what implementation research is, and how to foster its development. METHODS: We developed the recommendations in the context of a translation research conference hosted by the VA for VA and non-VA health services researchers. IMPACTS: Health care organizations, journals, researchers and academic institutions can use these recommendations to advance the field of implementation science and thus increase the impact of clinical and health services research on the health and health care of the public.
Evidence-Based Medicine↗
The impact of empiric antimicrobial therapy with a β-lactam and fluoroquinolone on mortality for patients hospitalized with severe pneumonia.
INTRODUCTION: National clinical practice guidelines have recommended specific empiric antimicrobial regimes for patients with severe community-acquired pneumonia. However, evidence confirming improved mortality with many of these regimes is lacking. Our aim was to determine the association between the empiric use of a β-lactam with fluoroquinolone, compared with other recommended antimicrobial therapies, and mortality in patients hospitalized with severe community-acquired pneumonia. METHODS: A retrospective observational study was conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of community-acquired pneumonia and had a chest X-ray and a discharge ICD-9 diagnosis consistent with this. Subjects were excluded if they received 'comfort measures only' during the admission, had been transferred from another acute care hospital, did not meet criteria for severe pneumonia, or were treated with non-guideline-concordant antibiotics. A multivariable logistic regression model was used to assess the association between 30-day mortality and the use of a β-lactam antibiotic with a fluoroquinolone compared with other guideline-concordant therapies, after adjustment for potential confounders including a propensity score. RESULTS: Data were abstracted on 172 subjects at the two hospitals. The mean age was 63.5 years (SD 15.0). The population was 88% male; 91% were admitted through the emergency department and 62% were admitted to the intensive care unit within the first 24 hours after admission. Mortality was 19.8% at 30 days. After adjustment for potential confounders the use of a β-lactam with a fluoroquinolone (odds ratio 2.71, 95% confidence interval 1.2 to 6.1) was associated with increased mortality. CONCLUSION: The use of initial empiric antimicrobial therapy with a β-lactam and a fluoroquinolone was associated with increased short-term mortality for patients with severe pneumonia in comparison with other guideline-concordant antimicrobial regimes. Further research is needed to determine the range of appropriate empiric antimicrobial therapies for patients with severe community-acquired pneumonia.
Aged↗
The impact of prior outpatient ACE inhibitor use on 30-day mortality for patients hospitalized with community-acquired pneumonia.
BACKGROUND: Recent studies suggest that angiotensin-converting enzyme (ACE) inhibitors may have beneficial effects for patients at risk for some types of infections. We examined the effect of prior outpatient use of ACE inhibitors on mortality for patients hospitalized with community-acquired pneumonia. METHODS: A retrospective cohort study conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of, had a chest x-ray consistent with, and had a discharge ICD-9 diagnosis of pneumonia. Subjects were excluded if they were "comfort measures only" or transferred from another acute care hospital. Subjects were considered to be on a medication if they were taking it at the time of presentation. RESULTS: Data was abstracted on 787 subjects at the two hospitals. Mortality was 9.2% at 30-days and 13.6% at 90-days. At presentation 52% of subjects were low risk, 34% were moderate risk, and 14% were high risk. In the multivariable conditional logistic regression analysis, after adjusting for potential confounders, the use of ACE inhibitors at presentation (odds ratio 0.44, 95% confidence interval 0.22-0.89) was significantly associated with 30-day mortality. CONCLUSION: Prior outpatient use of an ACE inhibitor was associated with decreased mortality in patients hospitalized with community-acquired pneumonia despite their use being associated with comorbid illnesses likely to contribute to increased mortality. Confirmatory studies are needed, as well as research to determine the mechanism(s) of this protective effect.
Adult↗
The effect of prior statin use on 30-day mortality for patients hospitalized with community-acquired pneumonia.
BACKGROUND: Recent studies suggest that HMG-CoA reductase inhibitors ("statins") may have beneficial effects for patients at risk for some types of infections. We examined the effect of prior outpatient use of statins on mortality for patients hospitalized with community-acquired pneumonia. METHODS: A retrospective cohort study conducted at two tertiary teaching hospitals. Eligible subjects were admitted with a diagnosis of, had a chest x-ray consistent with, and had a discharge ICD-9 diagnosis of pneumonia. Subjects were excluded if they were "comfort measures only" or transferred from another acute care hospital. Subjects were considered to be on a medication if they were taking it at the time of presentation. RESULTS: Data was abstracted on 787 subjects at the two hospitals. Mortality was 9.2% at 30-days and 13.6% at 90-days. At presentation 52% of subjects were low risk, 34% were moderate risk, and 14% were high risk based on the pneumonia severity index. In the multivariable regression analysis, after adjusting for potential confounders including a propensity score, the use of statins at presentation (odds ratio 0.36, 95% confidence interval 0.14-0.92) was associated with decreased 30-day mortality. DISCUSSION: Prior outpatient statin use was associated with decreased mortality in patients hospitalized with community-acquired pneumonia despite their use being associated with comorbid illnesses likely to contribute to increased mortality. Confirmatory studies are needed, as well as research to determine the mechanism(s) of this protective effect.
Cohort Studies↗
Effects of guideline-concordant antimicrobial therapy on mortality among patients with community-acquired pneumonia.
PURPOSE: National practice guidelines have recommended specific initial empiric antimicrobial regimens for patients with community-acquired pneumonia. Our aim was to determine the association between the use of guideline-concordant antimicrobial therapy and 30-day mortality in patients with pneumonia. METHODS: We conducted a retrospective cohort study at two tertiary teaching hospitals. Eligible patients were admitted with a diagnosis of community-acquired pneumonia, had a chest radiograph consistent with pneumonia, and had a discharge diagnosis of pneumonia. All eligible patients were identified and a random sample was abstracted. We determined whether the use of guideline-concordant antibiotics was associated with 30-day mortality in an analysis that adjusted for potential confounders using propensity scores. RESULTS: Information was obtained on 420 patients with pneumonia. The mean (+/- SD) age was 63 +/- 16 years, 355 were men, and 82 patients were initially admitted to the intensive care unit. At 30 days after presentation, 41 patients (9.8%) had died: 21 of 97 (21.7%) in the non-guideline-concordant group and 20 of 323 (6.2%) in the guideline-concordant group. Antibiotics were concordant with national guidelines in 323 patients. In the regression analysis, after adjustment for the propensity score, failure to comply with antimicrobial therapy guidelines was associated with increased 30-day mortality (odds ratio = 5.7; 95% confidence interval: 2.0 to 16.0). CONCLUSION: Receipt of antimicrobial regimens concordant with national published guidelines may reduce 30-day mortality among patients hospitalized with pneumonia.
Aged↗
A nurse-facilitator intervention improved the use of beta-blockers in outpatients with stable congestive heart failure.
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Comment↗