bluuebunny/crossref_metadata_2025_split huggingface dataset:
603. Evaluating the Effects of Centers for Medicare & Medicaid Services Sepsis Core Measure in a Community Hospital
Authors: Kim So , Ty Peter 
Published: January 2021

Abstract

Background
Sepsis is the leading cause of morbidity and mortality in hospitals, accounting for 30% of deaths in the emergency department. In 2001, Rivers et al. found that early goal-directed therapy (EGDT) led to significant mortality benefits, which ultimately prompted United States Centers for Medicare and Medicaid Services (CMS) to mandate EGDT in hospitals through its implementation of sepsis core measures. CMS core measures are intended to facilitate the broad implementation of evidence-based treatment standards, and while voluntary, non-compliance is associated with negative consequences to both quality and financial metrics for participating hospitals. However, while quality measures are implemented to ultimately improve patient care, its effects on the healthcare system can also include negative unanticipated consequences. This study seeks to characterize the effect of the CMS sepsis core measure on sepsis identification, antimicrobial utilization, and nd specific prescribing patterns.

Methods
This is a retrospective cohort review of 175 randomly selected patients greater than and equal to 18 years of age with admitting diagnosis of sepsis, severe sepsis, and septic shock from January 2013 to December 2018. Medical charts were reviewed for relevant data.

Results
Comparing ED antibiotic prescribing patterns between pre-and post-Sepsis CMS Core Measures, there was no statistical difference in total antibiotics usage and the initiation of broad antibiotics. There was a decreased time to the first antibiotic, an increase in receiving Normal Saline boluses post-Sepsis CMS Core Measures.

Conclusion
1. No significant changes were seen in ED antibiotic prescribing behaviors with regard to volume and spectrum
2. ED time to antibiotic administration was significantly faster after the implementation of CMS Core Measures. Also, there was a significant positive shift in time to fluid bolus, fluid selection, and fluid volume
3. Significantly decreased ICU length of stay after implementation of CMS Core Measures possibly associated with above behavior changes
4. No outcomes benefits (mortality, hospital length of stay) realized after implementation of CMS Core Measures

Disclosures
All Authors: No reported disclosures
604. Factors Associated with Adverse Drug Reactions Leading to Discontinuation of Vancomycin in Outpatient Parenteral Antimicrobial Therapy
Authors: McDonald Josh , Benefield Russell J , Certain Laura 
Published: January 2021

Abstract

Background
Over 250,000 patients receive outpatient parenteral antimicrobial therapy (OPAT) in the United States each year. Vancomycin is commonly used in OPAT but has a high rate of discontinuations due to adverse drug reactions (ADRs). Being able to predict the occurrence of these ADRs and assess their impact could improve the overall quality of OPAT services when utilizing vancomycin.

Methods
This was a retrospective chart review of all adult University of Utah Health (UUH) patients who received vancomycin OPAT and had planned follow-up with UUH infectious disease (ID) providers between October 25, 2018 and July 31, 2019. Patients were excluded if they were less than 18 years of age, pregnant, did not have planned follow up with UUH ID physicians, or were on any form of renal replacement therapy. The primary outcome assessed was discontinuation of vancomycin due to ADR, as documented by the ID provider. Type of ADR leading to discontinuation and 30-day unplanned readmission were also assessed.

Results
One hundred fifty-eight patients met inclusion criteria (n=158). The mean age of patients was 55 years with a median Charlson comorbidity score of 3. Most patients utilized a non-UUH infusion service (116, 73% vs 42, 27%) and utilized vancomycin as their sole antibiotic (83, 53%). The majority of patients were being treated for orthopedic infections (78, 49%). Twenty-eight patients discontinued vancomycin OPAT due to an ADR (18%). The most common ADR leading to discontinuation was acute kidney injury (10, 36%). Variables associated with ADRs leading to discontinuation included utilization of UUH home infusion services (54% vs 21%, P &lt; 0.001) and initial vancomycin plasma concentrations obtained less than 7 days after discharge (92% vs 71%, P &lt; 0.001). The overall 30 day readmission rate was 10% and the rate among patients who experienced an ADR leading to discontinuation was higher than those who did not (25% vs 8%, P &lt; 0.001).

Conclusion
The overall rate of discontinuation of vancomycin OPAT due to ADR in the UUH population is similar to what has been described in previous literature. The higher rate of unplanned readmission in the population of patients who experienced ADRs warrants further study. The results of this study will be utilized for future quality improvement interventions at our institution.

Disclosures
Russell J. Benefield, PharmD, Merck and Co (Grant/Research Support)Paratek Pharmaceuticals (Grant/Research Support)Rempex Pharmaceuticals (Grant/Research Support)
606. HIV Homecare: Understanding its Impact for Lost-to-Follow-Up Populations
Authors: Bonadonna Lily , Guerrero Esther , McClendon Tammie , Union Sheronda , Kabbani Dana , Veltman Jennifer 
Published: January 2021

Abstract

Background
Maintaining people living with HIV (PLWH) in clinical care is a global priority. In the metro-Detroit area of Michigan, approximately 30% of PLWH are out of care. To re-engage lost-to-follow-up patients, the Wayne State University Physician Group – Infectious Disease clinic launched an innovative Homecare program in 2017. In addition to home healthcare delivery, the program included links to community resources and quarterly community meetings. In the first year of Homecare, 28 of 34 participants became virally suppressed at least once. We aimed to understand reasons why people who left clinic-based treatment were able to become virally suppressed in this program. We included data from PLWH and their healthcare workers.

Methods
We used a mixed-methods design, including (1) semi-structured interviews with PLWH and healthcare workers, and (2) a validated Likert scale questionnaire rating illness perception before and after Homecare. Data were collected from 15 PLWH in metro-Detroit and two healthcare workers responsible for program delivery. Semi-structured interviews focused on obstacles to clinic-based care, support networks, and illness perceptions. Interview data were transcribed and analyzed using a grounded theory approach. A fully coded analysis was used to create a conceptual framework of factors contributing to Homecare’s success. Means in eight categories of the brief illness perception questionnaire (BIPQ) were compared using paired T-tests.

Results
The Homecare program offered (1) social support and stigma reduction through strong relationships with healthcare workers; (2) removal of physical and resource barriers such as transportation; and (3) positive changes in illness perceptions. PLWH worked towards functional coping strategies, including improvements in emotional regulation, acceptance of their diagnosis, and more positive perspectives of control. BIPQ showed significant changes in six domains before and after Homecare.
Homecare Conceptual Framework

General

Joint Display: Brief Illness Perception Questionnaire

Conclusion
Homecare offers an innovative system for successfully re-engaging and maintaining lost-to-follow-up PLWH in care. These findings have implications for HIV control efforts and could inform the development of future programs for difficult to reach populations.

Disclosures
All Authors: No reported disclosures
607. Identifying Intervention Opportunities to Prevent Readmissions during OPAT
Authors: Swartwood Michael J , Farel Claire E , Mavrogiorgos Nikolaos , Boerneke Renae A , Marx Ashley , Ciccone Emily J , Schranz Asher J , Kinlaw Alan C 
Published: January 2021

Abstract

Background
Patients receiving outpatient parenteral antimicrobial therapy (OPAT) experience high rates of unplanned readmissions. To inform interventions that may reduce risk of unplanned readmissions during OPAT, we examined the frequency and reasons for readmission in a large cohort of OPAT patients.

Methods
We analyzed data on all patients enrolled in UNC’s OPAT program from February 2015-February 2020. Patients were evaluated by an infectious diseases (ID) physician prior to OPAT enrollment, discharged with &gt;14 remaining days of prescribed therapy, and received care coordination and systematic monitoring by an ID pharmacist. We abstracted EHR data into a REDCap database to ascertain information on each patient’s OPAT course and readmission details: length of stay, primary ICD-9-CM/ICD-10-CM diagnosis code associated with readmission, and reason for readmission from clinical notes. Diagnosis codes and notes were adjudicated and summarized by a multidisciplinary team.

Results
Among 1,165 OPAT courses, 19% resulted in at least one readmission during therapy, lasting for a median length of stay of 5 days. Among those patients who were readmitted during OPAT, the median time from OPAT start to readmission was 17 days (interquartile range, IQR: 8-29 days). 66% of readmissions preceded the scheduled follow-up appointment during OPAT (median time to scheduled follow-up was 27 days, IQR: 15-35 days). 55% of readmissions were unrelated to OPAT diagnosis. Based on ICD-9-CM/ICD-10-CM code classifications, the most common infectious diseases-related reasons for readmission were worsening OPAT infection (18%), OPAT-related adverse drug reaction (12%), and new infection (11%).

Conclusion
One-fifth of OPAT courses resulted in readmission during therapy. Half of readmissions were associated with OPAT or other infection, and half were for other reasons. Earlier post-discharge follow-up by a multidisciplinary team (including primary care providers, case management, and OPAT) might prevent infection-related readmissions for OPAT patients. Future work should also address the need for enhanced care coordination with non-infectious disease providers to manage OPAT patients.

Disclosures
All Authors: No reported disclosures
609. Implementation and Post-implementation Analysis of a Pilot Program for Inpatient Review of Outpatient Parenteral Antimicrobial Therapy Prior to Discharge
Authors: Hart Delaney , McCoy Hailey , Gens Krista , Wankum Michael , Tarleton Andrew 
Published: January 2021

Abstract

Background
The Infectious Diseases Society of America OPAT (outpatient parenteral antimicrobial therapy) guidelines state that effective OPAT programs require a multidisciplinary team1. Currently within the health system, there is no formal OPAT program in place, and OPAT prescribing is not limited to any specialty. This project aimed to pilot a pharmacist-driven program across five hospitals.

Methods
Adult patients with OPAT ordered between February 1 and May 1, 2020 were included. Patients were excluded if the OPAT was prescribed by infectious diseases (ID) providers or if patients were on OPAT prior to hospital admission. An alert was generated in the electronic health record (EHR) when an order for an intravenous catheter was placed for patients with concomitant antimicrobials. Follow up was performed and documented via a progress note in the EHR as appropriate. Data was collected via retrospective chart review and statistical analysis was performed using Chi-squared test with Yates’ correction.

Results
101 pre- and 7 patients post-implementation were included in this study. There were a total of 51 patients pre-implementation that received inappropriate OPAT care per the IDSA OPAT guidelines, and post-implementation 2 patients (50.5% vs 28.6%, p=0.47). The secondary outcomes of 30-day readmission rates were 17% and 0% (p=0.52); and complications related to OPAT (e.g. central-line associated blood stream infections) were 12% and 0% (p=0.73), respectively. 2 midline catheters were recommended by the OPAT team, and a cost savings of up to $6,796 was calculated.

Conclusion
This pilot showed a trend towards decreased inappropriate OPAT prescribing and cost avoidance of an ID pharmacist-driven review of OPAT prior to patient hospital discharge. Limitations to this pilot included being underpowered due to the limited time-frame of the post-implementation period, and an inability for follow up with patients discharged utilizing an alternative home infusion service.

Disclosures
All Authors: No reported disclosures
614. Long-Acting Lipoglycopeptides for the Treatment of Bone and Joint Infections and Bacteremia in Infectious Disease Outpatient Infusion Clinics
Authors: Metzger Brian S , Prokesch Richard C , Bernett Jorge R , Mandel Richard M , Nathan Ramesh V , Nathan Ramesh V , Stock Kent , Hardin Thomas C , Schroeder Claudia P , Van Anglen Lucinda J 
Published: January 2021

Abstract

Background
Long-acting lipoglycopeptides (LGPs) are approved for the treatment of acute bacterial skin and skin-structure infections. Broad Gram-positive coverage and weekly dosing regimens are useful for other diagnoses, but real-world data supporting such use are sparse. We review our experience of dalbavancin and oritavancin for the treatment of bone and joint infection (BJI) and bacteremia (BAC) in outpatient infusion clinics (OICs).

Methods
We conducted a multicenter, retrospective, observational cohort study of patients (pts) receiving long-acting LGPs in OICs over 2 yrs from 2018-2019 for BJI and BAC. Data collected included demographics, diagnosis, dosing regimen, microbiology, clinical outcomes, and adverse events (AEs). Clinical success, defined as resolution of infection with continued oral antibiotics allowed, was assessed at the next follow-up visit. Worsening infection, the need for additional intravenous therapy, and discontinuations during therapy were deemed non-successful.

Results
We identified 70 pts (mean age: 64±16 years, 53% male) from 25 OICs, who received dalbavancin (n=50), oritavancin (n=19) and both (n=1). BJI accounted for 55 (79%) with 31 osteomyelitis, 9 bursitis, 7 prosthetic joint, 7 septic arthritis and 1 tenosynovitis. BAC was the primary diagnosis in 15 (21%) and sources were 6 device, 2 lower respiratory tract, 2 urinary tract and 5 unknown. 46% of pts were treated in the OIC without prior hospitalization. 72 Gram-positive isolates were obtained from 67 pts, with Staphylococcus aureus predominant (42/72, 58%), including methicillin-resistant (26/72, 36%) and methicillin-susceptible isolates (16/72, 22%). Median number of doses administered were 2 [IQR 1-2] in BJI and 1 in BAC [IQR 1-2]. Overall clinical success was 86% (57/66), with 4 non-evaluable. BJI had 85% success (44/52), with 90% in osteomyelitis (28/31), 50% in prosthetic joint (3/6) and 87% (13/15) in the others. Clinical success was 93% (13/14) in BAC. Three pts (4%) on dalbavancin experienced mild AEs, none resulting in discontinuation of therapy.

Conclusion
This multicenter real-world study of long-acting LGPs demonstrates safety and high clinical success rates in BJI and BAC. Our experience suggests a role for use of these agents in treatment of BJI and BAC in the outpatient setting.

Disclosures
Brian S. Metzger, MD, MPH, Allergan (Speaker’s Bureau)Cumberland (Speaker’s Bureau)Melinta (Speaker’s Bureau) Ramesh V. Nathan, MD, FIDSA, Merck & Co. (Other Financial or Material Support, Grant Steering Committee Member) Lucinda J. Van Anglen, PharmD, Merck & Co. (Grant/Research Support)
617. Physician Perspective: Utilization of Advanced Practice Providers (APPs) in the ID Workforce
Authors: Beieler Alison M , Beieler Alison M , Yoke Leah H , Yoke Leah H , Liu Catherine , Pergam Steven A , Wald Anna , Wald Anna , Dhanireddy Shireesha , Dhanireddy Shireesha 
Published: January 2021

Abstract

Background
Applicants entering Infectious Disease (ID) fellowships are declining and shortages of ID physicians is a challenge recognized by the clinical workforce and Infectious Diseases Society of America (IDSA). There is increased awareness of more Advanced Practice Providers (APPs) being used within ID to expand and extend existing practices. However, little is known about APP utilization, APP clinical scope of practice, specific roles, and opportunities for education.

Methods
To evaluate physician perspectives on APP utilization in ID, we created an anonymous and voluntary survey using the REDCap data tool that was distributed by social media, key stakeholder emails, and IDSA online community forum between 12/1/2019-1/31/2020. In addition to collecting geographic information and the type of ID practice, participants were also surveyed about the use of APPs and any perceived barriers that may limit their use.

Results
218 practicing ID physicians responded to the survey (Figure 1). 155 (71%) physicians work with APPs in their current practice (Figure 2); specifically, 56 (27%) with 1 APP, 62 (30%) with 2-4 APPs, 28 (13%) with 5-9 APPs, and 11 (5%) with &gt; 10 APPs. Of respondents, 104 (48%) practiced at University/Medical schools, 80 (37%) in hospitals/clinics, and 28 (13%) in private practice (Table 1); most work in adult inpatient/outpatient ID. The main reasons selected by respondents for not using APPs in their practice included concerns around a lack of formal ID training 22 (15%), lack of time/lack of ability to assist with APP training 29 (20%), practice is already sufficiently staffed 19 (13%), and concern for physician revenue loss 16 (11%) (Table 1).
Figure 1. Physician Responses by Region, n = 218

Figure 2. Physicians Utilizing APPs in Practice, n = 210 (*no response, 8)

Table 1. Physician ID Practice Type, Setting, and Concerns

Conclusion
Results suggest that while collaboration between ID physicians and APPs exists to meet current needs, a lack of ID training is a limiting factor. Our findings demonstrate there is an opportunity for formal ID education and resource development both to enhance APPs clinical skills and address perceived knowledge gaps. Inclusion of APPs in the ID workforce may allow physicians to expand ID care into more resource limited areas to continue to provide high quality patient care.

Disclosures
Steven A. Pergam, MD, MPH, Chimerix, Inc (Scientific Research Study Investigator)Global Life Technologies, Inc. (Research Grant or Support)Merck & Co. (Scientific Research Study Investigator)Sanofi-Aventis (Other Financial or Material Support, Participate in clinical trial sponsored by NIAID (U01-AI132004); vaccines for this trial are provided by Sanofi-Aventis)
619. Quantifying the non-billable workload of Outpatient Parenteral Antibiotic Therapy (OPAT) services in a University Infectious Diseases (ID) Clinic
Authors: Burgoyne Colleen , Calisir Nurhan , Munsiff Sonal 
Published: January 2021

Abstract

Background
OPAT service has health and economic benefits for the patient, health care facility and the general community. Management of patients receiving OPAT requires an interdisciplinary team approach and complex care coordination and has been shown to decrease adverse reaction, and rehospitalizations. Much of the work involved in caring for patients on OPAT occurs outside of a billable office visit. Describing and quantifying this workload is important to justify staffing and to advocate for change in reimbursement structure.

Methods
Patients enrolled in OPAT program at our clinic in 2019 were identified from the electronic medical record (EMR) and information was extracted on all EMR encounters by ID faculty and staff occurring from the start of OPAT monitoring until 14 days after OPAT ended, or until March 31, 2020 for patients still on OPAT on that date.

Results
During 2019, 835 unique OPAT courses were monitored for 767 patients. Activities include a sign-on process, monitoring labs, drug levels, coordinating care, weekly review by OPAT team (Medical Director or an ID attending, nurse practitioner (NP), nurse (RN) and ID pharmacist). We identified 7,640 encounters; 1,072 were office visits. Thus, 86% (N=6569) of encounters were for managing and coordinating care. The OPAT RN created 3435 of 6568 (52%) encounters, 2034 (31%) were by physicians and nurse practitioners, 500 by other clinic RNs and 599 were by administrative staff

Conclusion
Our results quantify the immense care for OPAT patients that is not compensated by insurance. However, this work contributes to patient safety and satisfaction. Our data does not account for time spent by the multidisciplinary team on weekly review of all active OPAT patients which lasts about 3 hours and is essential to ensuring patient safety. This data also does not quantify the contribution of the ID pharmacist who is consulted by OPAT team for multiple issues but whose recommendations are documented by the providers. The total time involved in all this work could not be determined. The quantification of the uncompensated workload of such monitoring is important as it can be justification for modernization of reimbursement for OPAT patient care, making the establishment and maintenance of such programs more financially solvent for health care organizations.

Disclosures
All Authors: No reported disclosures
620. Real-World Insights on HIV Treatment Decision-Making in Federal and Public Healthcare Settings
Authors: Okulicz Jason F , Zawitz Chad J , Blaylock Jason M , Taneva Ekaterina S , Simone Laura , Carter Jeffrey , Sapir Tamar 
Published: January 2021

Abstract

Background
Evidence-based guidelines and novel antiretroviral therapies (ART) for people living with HIV (PLHIV) are quickly evolving. Understanding the practice patterns, gaps, and needs of healthcare professionals (HCPs) who care for PLHIV in specific settings, such as those in the federal and public healthcare sector, can inform education and improvement strategies.

Methods
Surveys were administered before and after a series of 1.5 hour continuing education programs (n=20) on HIV treatment conducted live in various US cities between April 2019 and March 2020. These programs were designed for HCPs in federal and public healthcare systems, such as the Veterans Affairs Medical Centers, Military Medical Treatment Facilities, and Federally Qualified Health Centers.

Results
Survey respondents (n=655) were mostly physicians (35%) or nurse practitioners/physician assistants (25%) practicing in federal healthcare settings (Table 1). Respondents reported a mean patient volume of 1,893 (±240) PLHIV monthly.
Before and after the education, only 34% and 61% of HCPs, respectively, correctly identified recommended first-line ART for most PLHIV. Only 19% and 38% of HCPs reported high levels of confidence in selecting ART for rapid ART initiation before and after the education.
A case-based survey item showed that 35% (pre-education) and 45% (post-education) of HCPs would recommend switching a virologically suppressed patient over age 50 with comorbidities from a boosted protease inhibitor-based regimen to an integrase inhibitor-based regimen. Only 13% and 33% of HCPs reported high confidence in switching ART for older patients with comorbidities before and after the education, respectively.
The biggest challenges identified by HCPs were related to ART selection and patient management (Table 1). After the education, HCPs reported needs and intention to improve their team-based processes to: 1) facilitate rapid ART initiation; 2) optimize ART for patients with comorbidities; 3) optimize treatment for patients with virologic failure.

Conclusion
This educational program improved knowledge and competency in evidence-based HIV treatment and supported team-based action planning. The findings also inform persistent challenges and needs among HCPs in federal settings.

Disclosures
Chad J. Zawitz, MD, Gilead Sciences (Speaker’s Bureau)ViiV (Advisor or Review Panel member) Tamar Sapir, PhD, Gilead Sciences, Inc. (Other Financial or Material Support, Independent medical education grant)ViiV Healthcare (Other Financial or Material Support, Independent medical education grant)