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In Data We Trust? Comparison of Electronic Versus Manual Abstraction of Antimicrobial Prescribing Quality Metrics for Hospitalized Veterans With Pneumonia.

ABSTRACT: BACKGROUND:Electronic health records provide the opportunity to assess system-wide quality measures. Veterans Affairs Pharmacy Benefits Management Center for Medication Safety uses medication use evaluation (MUE) through manual review of the electronic health records. OBJECTIVE:To compare an electronic MUE approach versus human/manual review for extraction of antibiotic use (choice and duration) and severity metrics. RESEARCH DESIGN:Retrospective. SUBJECTS:Hospitalizations for uncomplicated pneumonia occurring during 2013 at 30 Veterans Affairs facilities. MEASURES:We compared summary statistics, individual hospitalization-level agreement, facility-level consistency, and patterns of variation between electronic and manual MUE for initial severity, antibiotic choice, daily clinical stability, and antibiotic duration. RESULTS:Among 2004 hospitalizations, electronic and manual abstraction methods showed high individual hospitalization-level agreement for initial severity measures (agreement=86%-98%, ?=0.5-0.82), antibiotic choice (agreement=89%-100%, ?=0.70-0.94), and facility-level consistency for empiric antibiotic choice (anti-MRSA r=0.97, P<0.001; antipseudomonal r=0.95, P<0.001) and therapy duration (r=0.77, P<0.001) but lower facility-level consistency for days to clinical stability (r=0.52, P=0.006) or excessive duration of therapy (r=0.55, P=0.005). Both methods identified widespread facility-level variation in antibiotic choice, but we found additional variation in manual estimation of excessive antibiotic duration and initial illness severity. CONCLUSIONS:Electronic and manual MUE agreed well for illness severity, antibiotic choice, and duration of therapy in pneumonia at both the individual and facility levels. Manual MUE showed additional reviewer-level variation in estimation of initial illness severity and excessive antibiotic use. Electronic MUE allows for reliable, scalable tracking of national patterns of antimicrobial use, enabling the examination of system-wide interventions to improve quality.

SUBMITTER: Jones BE

PROVIDER: S-EPMC6002916 | biostudies-literature | 2018 Jul

REPOSITORIES: biostudies-literature

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In Data We Trust? Comparison of Electronic Versus Manual Abstraction of Antimicrobial Prescribing Quality Metrics for Hospitalized Veterans With Pneumonia.

Jones Barbara E BE Haroldsen Candace C Madaras-Kelly Karl K Goetz Matthew B MB Ying Jian J Sauer Brian B Jones Makoto M MM Leecaster Molly M Greene Tom T Fridkin Scott K SK Neuhauser Melinda M MM Samore Matthew H MH

Medical care 20180701 7

<h4>Background</h4>Electronic health records provide the opportunity to assess system-wide quality measures. Veterans Affairs Pharmacy Benefits Management Center for Medication Safety uses medication use evaluation (MUE) through manual review of the electronic health records.<h4>Objective</h4>To compare an electronic MUE approach versus human/manual review for extraction of antibiotic use (choice and duration) and severity metrics.<h4>Research design</h4>Retrospective.<h4>Subjects</h4>Hospitaliz ...[more]

PMID: 29668648

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Project description:BackgroundCommunity-acquired pneumonia (CAP) 2007 guidelines from the Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) recommend a respiratory fluoroquinolone or beta-lactam plus macrolide as first-line antibiotics for adults hospitalized with CAP. Few studies have assessed guideline-concordant antibiotic use for patients hospitalized with CAP after the 2007 IDSA/ATS guidelines. We examine antibiotics prescribed and associated factors in adults hospitalized with CAP.MethodsFrom January 2010 to June 2012, adults hospitalized with clinical and radiographic CAP were enrolled in a prospective Etiology of Pneumonia in the Community study across 5 US hospitals. Patients were interviewed using a standardized questionnaire, and medical charts were reviewed. Antibiotics prescribed were classified according to defined nonrecommended CAP antibiotics. We assessed factors associated with nonrecommended CAP antibiotics using logistic regression.ResultsAmong enrollees, 1843 of 1874 (98%) ward and 440 of 446 (99%) ICU patients received ≥1 antibiotic ≤24 hours after admission. Ward patients were prescribed a respiratory fluoroquinolone alone (n = 613; 33%), or beta-lactam plus macrolide (n = 365; 19%), beta-lactam alone (n = 240; 13%), among other antibiotics, including vancomycin (n = 235; 13%) or piperacillin/tazobactam (n = 157; 8%) ≤24 hours after admission. Ward patients with known risk for healthcare-associated pneumonia (HCAP), recent outpatient antibiotic use, and in-hospital antibiotic use <6 hours after admission were significantly more likely to receive nonrecommended CAP antibiotics.ConclusionsAlthough more than half of ward patients received antibiotics concordant with IDSA/ATS guidelines, a number received nonrecommended CAP antibiotics, including vancomycin and piperacillin/tazobactam; risk factors for HCAP, recent outpatient antibiotic, and rapid inpatient antibiotic use contributed to this. This hypothesis-generating descriptive epidemiology analysis could help inform antibiotic stewardship efforts, reinforces the need to harmonize guidelines for CAP and HCAP, and highlights the need for improved diagnostics to better equip clinicians.

Project description:ImportancePrior studies have reported declines in mortality for patients admitted to Veterans Health Administration (VA) and non-VA hospitals using claims-based risk adjustment. These apparent mortality reductions may be influenced by changes in coding practices.ObjectiveTo compare trends in the VA for 30-day mortality following hospitalization for heart failure (HF) and pneumonia using claims-based and clinical risk-adjustment models.Design, setting, and participantsThis observational time-trend study analyzed admissions to a VA Medical Center with a principal diagnosis of HF, pneumonia, or sepsis/respiratory failure (RF) with a secondary diagnosis of pneumonia. Exclusion criteria included having less than 12 months of VA enrollment, being discharged alive within 24 hours, leaving against medical advice, and hospice utilization.ExposuresAdmission to a VA hospital from January 2009 through September 2015.Main outcomes and measuresThe primary outcome was 30-day, all-cause mortality. All models included age and sex. Claims-based covariates included 22 (30) comorbidities for HF (pneumonia). Clinical covariates included vital signs, laboratory values, and ejection fraction.ResultsAmong the 146 924 HF admissions, the mean (SD) age was 71.6 (11.4) years and 144 502 (98.4%) were men; among the 131 325 admissions for pneumonia, the mean (SD) age was 70.8 (12.3) years and 127 491 (97.1%) were men. Unadjusted 30-day mortality rates were 6.45% (HF) and 11.22% (pneumonia). Claims-based models showed an increased predicted risk of 30-day mortality over time (0.019 percentage points per quarter for HF [95% CI, 0.015 to 0.023]; 0.053 percentage points per quarter for pneumonia [95% CI, 0.043 to 0.063]). Clinical models showed declines or no change in predicted risk (-0.014 percentage points per quarter for HF [95% CI, -0.020 to -0.008]; -0.004 percentage points per quarter for pneumonia [95% CI, -0.017 to 0.008]). Claims-based risk adjustment yielded declines in 30-day mortality of 0.051 percentage points per quarter for HF (95% CI, -0.074 to -0.027) and 0.084 percentage points per quarter for pneumonia (95% CI, -0.111 to -0.056). Models adjusting for clinical covariates attenuated or eliminated these changes for HF (-0.017 percentage points per quarter; 95% CI, -0.039 to 0.006) and for pneumonia (-0.026 percentage points per quarter; 95% CI, -0.052 to 0.001). Compared with the claims-based models, the clinical models for HF and pneumonia more accurately differentiated between patients who died after 30 days and those who did not.Conclusions and relevanceAmong HF and pneumonia hospitalizations, adjusting for clinical covariates attenuated declines in mortality rates identified using claims-based models. Assessments of temporal trends in 30-day mortality using claims-based risk adjustment should be interpreted with caution.

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In Data We Trust? Comparison of Electronic Versus Manual Abstraction of Antimicrobial Prescribing Quality Metrics for Hospitalized Veterans With Pneumonia.

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In Data We Trust? Comparison of Electronic Versus Manual Abstraction of Antimicrobial Prescribing Quality Metrics for Hospitalized Veterans With Pneumonia.

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