University of Kentucky HealthCare

To evaluate diabetic ketoacidosis (DKA) risk among new users of ertugliflozin versus sulfonylureas (SU) or thiazolidinediones (TZD) and incretin-based drugs in patients with type 2 diabetes. We used Medicare and Medicaid fee-for-service adjudicated claims within the Innovation in Medical Evidence and Development Surveillance network to identify three new-user cohorts: (1) ertugliflozin; (2) SU/TZD; and (3) incretin-based drugs. The outcome was a principal hospital discharge diagnosis for DKA. Adjusted hazard ratios (HRs) were estimated after 1:1 propensity score (PS) matching, separately for ertugliflozin vs. SU/TZD and vs. incretin-based drugs. Subgroup analyses were performed based on baseline insulin use. After PS matching, baseline characteristics were similarly distributed in each cohort. For ertugliflozin (n = 42,907) vs. SU/TZD (n = 42,907), the incidence rates of DKA per 1000 person-years (PY) were 2.95 and 1.49, respectively. For ertugliflozin (n = 42,247) vs. incretin-based drugs (n = 42,247), the incidence rates of DKA per 1000 PY were 2.76 and 1.06, respectively. For ertugliflozin vs. SU/TZD, the HR [95% confidence interval (CI)] was 1.88 [1.17-3.02]; in non-insulin users, 2.34 [1.27-4.31]; and in insulin users, 1.17 [0.54-2.52]. For ertugliflozin vs. incretin-based drugs, the HR [95% CI] was 2.40 [1.40-4.11]; in non-insulin users, 2.84 [1.42-5.66]; and in insulin users, 1.87 [0.79-4.46]. Ertugliflozin was associated with a higher risk of DKA relative to comparators. HRs were higher among new users with no-concomitant insulin use than those with concomitant insulin use. Results were consistent with prior SGLT2i data and highlighted the importance of caution by both patients and physicians.

BackgroundGram-negative bacteremia (GNB) in pediatric patients presents a serious clinical challenge, yet comprehensive data on its epidemiology, management, and outcomes in this population are limited. This study aimed to characterize the clinical features, microbiologic profile, and factors associated with mortality in pediatric patients with monomicrobial GNB at a large academic medical center.MethodsA retrospective cohort study was conducted among 970 patients with GNB identified from institutional microbiology records; 62 pediatric patients (< 18 yrs) with monomicrobial GNB were included. Demographics, clinical characteristics, microbiology, time to diagnostics and interventions, and outcomes were analyzed.ResultsOf the 62 pediatric patients, 64.5% of infections were community-acquired. The cohort was predominantly White (75.8%) followed by 9.7% Black, 9.7% Hispanic, and 4.8% other. The most common pathogens were E. coli (51.6%) and Klebsiella spp. (12.9%). Overall mortality was 11.3%, with a 90-day readmission rate of 25.8%. ICU admission occurred in 19.4% of cases. ID consultation was obtained in 58.1% of cases, with a median (IQR) time to consult of 22.2 hrs (6, 43.9). Median hospital LOS was 15.5 days (10, 72); ICU LOS was 10.4 days (6.4, 18.1). Time to ePlex® result and susceptibility data were 15.6 hrs (13.1, 23.5) and 3.6 days (2.6, 5.7), respectively. Median duration of antimicrobial therapy was 10 days (6.9, 13.5). The Charlson Comorbidity Index (CCI) was low in 79%, moderate in 12.9%, and high in 8.1%, with higher CCI significantly associated with mortality (p=0.003). Mortality was highest among patients with P. aeruginosa (100%, N=3) and E. coli (9.4%, N=3) bacteremia. No deaths occurred among patients with Klebsiella spp. or S. marcescens infections.ConclusionAt our institution, pediatric Gram-negative bacteremia was predominantly community-acquired and most frequently caused by E. coli. Although overall mortality was low, it was notably higher in patients with P. aeruginosa infections and elevated CCI scores. Ongoing efforts are needed to enhance risk stratification and optimize management strategies in this high-risk population.DisclosuresAll Authors: No reported disclosures

The role of telehealth use in primary care among rural Medicare Advantage (MA) beneficiaries following Medicare's expanded telehealth coverage during COVID-19 is not well understood. With increasing evidence that provider characteristics influence patient access to telehealth, this study compared receipt of telehealth primary care between rural and nonrural MA beneficiaries by providers' level of telehealth delivery. Using claims for MA beneficiaries from January 2021 to June 2024, we compared the proportion of primary care visits that were delivered via telehealth between rural and nonrural beneficiaries. We then categorized primary care physician (PCP) groups into quartiles based on the provision of telehealth as a share of total primary care visits. We conducted visit-level generalized linear regression analyses to assess whether differences in telehealth primary care receipt between rural and nonrural beneficiaries varied by PCP telehealth quartile. PCPs delivering the highest rates of telehealth were significantly more likely to provide primary care via telehealth to rural MA beneficiaries than nonrural ones (4th quartile odds ratio: 1.12, 95% confidence interval: 1.02, 1.22). This finding differed from the overall disparity in telehealth use between rural and nonrural populations, in which rural beneficiaries used less telehealth. Results showing increased telehealth use among rural MA beneficiaries receiving care from PCPs delivering the highest rates of telehealth may partly stem from unique capabilities among these providers, who are potentially better equipped with tools for implementing telehealth. As such, we provide insight on provider-oriented factors that can bolster telehealth access for rural MA populations.

Comprehensive medication reviews (CMRs) are a cornerstone of medication therapy management (MTM) for millions of Medicare Part D beneficiaries, designed to optimize medication use and health outcomes. However, uptake is inconsistent, with known disparities affecting groups such as Asian, Black, and Hispanic patients. To evaluate CMR trends from 2013 to 2021, analyzing changes in provider types, delivery methods, and recipients, with a particular focus on variations across Asian, Black, Hispanic, and White beneficiaries. Employing a serial cross-sectional design, we analyzed Part D MTM program data submitted to the Centers for Medicare & Medicaid Services (CMS) from 2013 through 2021, covering all MTM-eligible Medicare beneficiaries. To explore differences based on race and ethnicity, this dataset was linked with a 5% random sample of Medicare fee-for-service beneficiaries. Descriptive statistics were used to evaluate year-over-year trends in CMR provider categories, the methods of service delivery, and the individuals who received the CMR. The volume of completed CMRs expanded more than 4-fold, increasing from 526,150 encounters in 2013 to more than 2 million by 2020, before a slight decrease in 2021. The proportion of CMRs delivered by plan or pharmacy benefit manager pharmacists declined from 40% in 2013 to 29% in 2021, and the share of reviews provided by MTM vendors and other pharmacist categories generally increased over the same period. Telephone consultations, already the primary mode of delivery, increased their share from 86% to 96% of all CMRs, whereas face-to-face services correspondingly decreased from 14% to 4% across all racial groups. The decline in face-to-face services was steepest for Asian (from 18% in 2013 to 7% by 2021) and Hispanic patients (from 18% in 2013 to 3% by 2021). Black individuals consistently had the highest rates of direct beneficiary involvement (88% in 2021) and the lowest caregiver use. The substantial growth in CMR services represents a positive development in patient care. Nevertheless, the marked shifts toward telephonic delivery and changes in the types of providers and recipients engaged highlight a critical need for ongoing assessment.

Background:Asymptomatic bacteriuria (ASB) is often overtreated, risking patient harm through unnecessary antimicrobial use and fostering antimicrobial resistance. Despite this, patients continue to be treated for ASB requiring targeted intervention for antimicrobial stewardship teams across health systems.Objectives:This study assessed the impact of a multistep urinary tract infection (UTI)-focused stewardship initiative by comparing the incidence of asymptomatic urinary presentation (AUP) treatment before and after implementation.Design:Retrospective cohort study.Methods:Patients ⩾18 years at University of Kentucky HealthCare who received antimicrobial therapy with a urinalysis (UA) and/or urine culture (UCx) collected for a presumed UTI between January 2023 and March 2023 (pre-implementation) and January 2024 and March 2024 (post-implementation) were included in the study. Our primary outcome was to compare the frequency of AUP treatment between groups.Results:Overall, 288 patients were included in the study, with 144 patients in both the pre- and post-implementation groups. Treatment of AUPs significantly decreased by 12% after initiative implementation (47% pre-implementation vs 35% post-implementation, p = 0.042). Additionally, we observed a significant difference in guideline-adherent management between the two groups (29% pre-implementation vs 44% post-implementation, p = 0.007). Patients were more likely to receive guideline-adherent UTI treatment durations (38% vs 53%, p = 0.009) and guideline-adherent definitive antibiotics (18% vs 35%, p < 0.001) post-implementation compared to pre-implementation.Conclusion:Our stewardship initiative resulted in reduced treatment of AUPs and improved adherence to UTI management guidelines. Overall, a multifaceted stewardship initiative is a successful intervention to decrease the treatment of AUPs and unnecessary antibiotic utilization. However, additional frontline stewardship initiatives are likely warranted to decrease the unnecessary ordering of UAs.

BackgroundStenotrophomonas maltophilia, a MDR pathogen, causes healthcare-associated infections in critically ill patients. Deep-seated infections pose treatment challenges due to high bacterial inocula and biofilms. Prior studies often include polymicrobial or colonization cases, complicating evaluations. This study compares monotherapy versus combination therapy in deep-seated, monomicrobial infections to clarify optimal treatment.MethodsThis single centre, retrospective study evaluated patients admitted from 2010 to 2023 with deep-seated, monomicrobial S. maltophilia infections receiving in vitro active antimicrobials within 72 h of culture collection. The primary outcome was clinical failure, defined as 30-day all-cause mortality, infection-related readmission, or recurrent infection. Regression models used inverse probability of treatment weighting and time-varying covariates.ResultsAmong 190 patients, 99 (52.1%) received monotherapy and 91 (47.9%) received combination therapy. Clinical failure occurred in 30.3% of monotherapy and 34.1% of combination therapy patients (P = 0.579). In propensity-weighted regression, combination therapy with levofloxacin plus minocycline (adjusted odds ratio [aOR] 0.44, 95% CI 0.17–0.94, P = 0.022) and levofloxacin plus trimethoprim/sulfamethoxazole (aOR 0.19, 95% CI 0.08–0.76, P = 0.035) was associated with reduced odds of clinical failure. Higher SOFA scores (aOR 1.89, 95% CI 1.25–2.12, P = 0.033), prior carbapenem use (aOR 2.02, 95% CI 1.54–2.24, P = 0.014) and empyema (aOR 2.77, 95% CI 2.18–3.96, P = 0.011) increased the odds of clinical failure.ConclusionLevofloxacin-based combination therapies may reduce clinical failure in deep-seated S. maltophilia infections, while SOFA scores, carbapenem use and empyema increase risk. Prospective trials are warranted to confirm the efficacy of levofloxacin-based combinations.