Veterans Health Care System of the Ozarks

The Food and Drug Administration's warning that transmucosal buprenorphine, a partial opioid agonist used to treat opioid use disorder and chronic pain, may cause dental disease opens questions about potential class-wide adverse effects involving more widely prescribed opioid analgesics. This was a retrospective matched national cohort study of patients in care at the Department of Veterans Affairs (VA) between October 2010-September 2019. Patients prescribed LTOT were matched 1:2 to patients not prescribed LTOT on age, sex, service region, and VA dental coverage. Cox regression models estimated the association between LTOT and a composite infection-related dental outcome (CIDO). Sensitivity analyses excluded patients with cancer, restricted to patients with comprehensive dental coverage, and to patients with ≥180 days of follow-up time, respectively. The cohort comprised 2,173,435 patients including 787,825 (36%) receiving LTOT; 612,101 (28%) experienced CIDO. In both simple and multivariable regression models, LTOT exposure was associated with greater CIDO risk; HR (95% CI) =1.24 (1.23, 1.25); aHR (95% CI) =1.08 (1.07, 1.08), respectively; p < 0.001. Sensitivity analyses showed similar results except among patients with full dental coverage for whom CIDO rates were substantially higher and LTOT was not statistically significantly associated with risk. he observed positive association between LTOT and CIDO in this large VA sample may inform patient-provider discussions and decision-making around use of LTOT. High CIDO rates among patients with full VA dental coverage may reflect their unique vulnerability to dental infection associated with service-related dental or disabling conditions. Limitations include risk for ascertainment bias, unclear generalizability to a broader clinical population, and the potential for residual confounding.

Poor colon preparation may negatively affect colonoscopy accuracy, result in cancelation, or need for repeat procedure. The glucagon-like peptide-1 receptor agonist (GLP-1RA) class of medications delay gastric emptying, although the clinical impact of this on the quality of colon preparation is not known. This was a retrospective matched cohort study in a multi-center, outpatient setting. Colonoscopy reports for patients prescribed GLP-1RA at the time of procedure were compared to a cohort matched for diabetes and cirrhosis who were not prescribed GLP-1RA at the time of procedure. The primary endpoint was a composite of indicators for inadequate bowel preparation. The current study's objective is to analyze the effects of GLP-1RA medications on the quality of colonoscopy preparation. There were 503 patients in each cohort and baseline characteristics were similar. Use of GLP-1RA at the time of colonoscopy was associated with a greater odds of the composite outcome (125 vs 56, odds ratio [OR] = 2.6; 95% CI, 1.9-3.7). There were also increased odds for individual outcome components including proceduralist documenting inadequate, suboptimal, or poor bowel preparation, narrative comments related to inadequate bowel preparation, and recommendation for extended bowel preparation with future colonoscopy. Repeat procedure was also more common in the GLP-1RA cohort (26 vs 9, OR = 3.0; 95% CI, 1.4-6.5). This study assessed the impact of the GLP-1RA class of medication on the quality of bowel preparation for lower endoscopies. Glucagon-like peptide-1 receptor agonist use increased the odds of inadequate bowel preparation and repeat procedure.

IntroductionThe adverse effects of corticosteroids are dose‐dependent, and guidance is to use the lowest effective dose in most disease states. The study facility recently reported a steroid stewardship program that reduced steroid dosing in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients by 50%. The purpose of this post‐hoc analysis was to evaluate the effect of this intervention on glycemic control in hospitalized AECOPD before and after cohorts.MethodsThis was a retrospective post‐hoc review of hospitalized patients in a before and after study design (n = 27 in each group). The primary endpoint was the proportion of glucose readings >180 mg/dL. Baseline characteristics, mean glucose levels, and corrective insulin were also collected. Continuous variables were compared with a Student's t‐test (or Mann–Whitney U where appropriate) and nominal variables with a chi‐square test in R Studio.ResultsThere was a significantly higher proportion of glucose >180 mg/dL readings in the pre‐intervention cohort: 38% vs. 25% (p = 0.007). The mean glucose levels were numerically lower post‐intervention but did not reach statistical significance (160 mg/dL vs. 145 mg/dL, p = 0.27) both in diabetics (192 mg/dL vs. 181 mg/dl, p = 0.69) and non‐diabetics (142 mg/dL vs. 125 mg/dL, p = 0.08). The use of correctional insulin was similar: a median of 25 units vs. 24.5 units (p = 0.92).ConclusionA stewardship program focused on steroid reduction in AECOPD significantly lowered the proportion of hyperglycemic readings but did not significantly affect mean glucose and corrective insulin usage while hospitalized.

This study examines the relationship between the early identification of hearing loss and language outcomes for deaf/hard of hearing (D/HH) children, with bilateral or unilateral hearing loss and with or without additional disabilities. It was hypothesized that hearing loss identified by 3 months of age would be associated with better language outcomes. Using a prospective, longitudinal design, 86 families completed developmental instruments at two time points: at an average age of 14.8 months and an average age of 32.1 months. Multiple regression examined how hearing loss identified by 3 months of age contributed to later language outcomes while controlling for developmental level at the first time point. Hearing loss identified by 3 months of age was positively associated with better language outcomes for D/HH children at 32 months of age; however, D/HH children still exhibited language delays, compared to normative scores for same-aged hearing peers for reported measures. Language outcomes of children with unilateral hearing loss were not better than those of children with mild-to-moderate bilateral hearing loss. Children with additional disabilities and more severe bilateral hearing loss had lower language scores than those without.

Critical Care Medicine: January 2022 - Volume 50 - Issue 1 - p 456 doi: 10.1097/01.ccm.0000809996.04488.50

Corticosteroid overprescribing is well documented in real-world practice. There is currently no evidence to guide best practices for steroid stewardship. The aim of this study was to assess the effects of a 3-part stewardship intervention strategy on inpatient steroid prescribing in patients with acute exacerbations of COPD (AECOPD). Investigators implemented a 3-part stewardship initiative consisting of (1) an anonymous survey for providers on steroid prescribing in a simplified case of AECOPD, (2) face-to-face education and review of survey results, and (3) prospective audit and feedback from a clinical pharmacist. This was a quasi-experimental before-and-after study evaluating hospitalized adults diagnosed with AECOPD in two 12-month study periods before (April 2019-March 2020) and after (May 2020-April 2021) implementation. The primary outcome was mean inpatient steroid dosing. Secondary outcomes were duration of therapy, length of stay (LOS), 30-day readmissions, 30-day mortality, and incidence of hyperglycemia. Per power analysis, there were 27 patients per cohort. The interventions resulted in a significant reduction in prednisone equivalents during hospitalization: 118 mg vs 53 mg (P = 0.0003). This decrease was similar in ICU (160 mg vs 61 mg, P = 0.008) and non-ICU (102 mg vs 49 mg, P = 0.004) locations. There was no significant difference in duration of therapy (8 days vs 7 days, P = 0.44), length of stay (3.3 days vs 3.9 days, P = 0.21), 30-day mortality (4% vs 7%, P = 0.55), 30-day readmissions (15% vs 7%, P = 0.39), or rate of hyperglycemia (48% vs 44%, P = 0.78). A multifaceted stewardship intervention significantly reduced steroid dosing in hospitalized AECOPD patients. This reduction was not associated with known deleterious effects.

Objective: Most positive studies in procalcitonin (PCT) utilization were done in large, tertiary medical centers. Furthermore, there is a paucity of data describing the implementation process. This article is the first to describe in detail the implementation process and initial outcomes after 6 months of PCT testing in a rural, 65-bed, primary hospital. Methods: Education before and during PCT implementation as well as facility rollout are described. Initial outcomes were assessed using a before and after quasi-experimental study design comparing 2 identical 6-month time periods: May to October 2016 and May to October 2017. Antibiotic consumption is described with days of therapy (DOT) per 1000 patient days (PD). Antimicrobial purchasing costs, admission rates, and length of stay (LOS) are also compared. Results: Antimicrobial consumption was variable with the greatest reduction at 6 months: 856 DOT/1000 PD before versus 576 DOT/1000 PD after (P < .0001). Admission rates and LOS were unaffected. There was no associated savings in antibiotic purchasing costs: $114 189.79 before and $139 829.26 after (difference +$25 639.47). Conclusion: Although implementation of PCT testing is feasible in a rural health care facility, after 6 months, it was associated with a marginal decrease in antibiotic consumption with no decrease in admission rates, LOS, or antibiotic cost savings.

BackgroundIn the private sector, dentists prescribe approximately 1 out of every 10 antibiotic prescriptions and are the top specialty prescriber of antibiotics. However, antibiotic prescribing practices of VA dentists have not been reported. Standardized metrics of antibiotic consumption (ie, antibiotic days) are useful to guide stewardship efforts, but have not been reported for dentistry. Thus, the purpose of this study was to report antibiotic use metrics in the VA with an emphasis on antibiotics prescribed by dentists.MethodsCross-sectional study of all Veteran users of VA dental care from all dental clinics (n = 205) in 2013. Antibiotic data were collected at the patient-level where >1 day and/or >1 dose of a systemic antibiotic was ordered and dispensed. Metrics included: antibiotic days (AD; average number of days/patient where any antibiotic was administered) and days of therapy (DOT; average number of days/patient where a unique agent was administered). Dentists were identified by VA personnel files with the professional designation of ‘Dentistry.’ Antibiotics in the carbapenem, quinolone, anti-pseudomonal penicillin, third-/fourth-generation cephalosporin, macrolide, tetracycline, and aminoglycoside classes were considered to be broad spectrum. Student’s t-test was used for statistical analysis; P < 0.05 was considered significant.ResultsIn 2013, >1 antibiotic dose/day was prescribed to 16.2% of VA dental patients (total = 476,451 patients). By class, aminopenicillins were most frequently prescribed (69.4%), followed by lincomycins (21.9%). The overall mean AD was 11.4 (range = 1–309) days and DOT was 11.5 (1–309). Of the Veterans who received an antibiotic from a dentist, only 2.3% received a broad-spectrum agent. However, broad-spectrum AD (15.0) was significantly longer than narrow spectrum AD (11.2; P < 0.0001).ConclusionWhile the prevalence of broad-spectrum prescribing was low, the patient-level duration of antibiotics prescribed by VA dentists is surprising. Thus, there may be an opportunity to expand antimicrobial stewardship efforts to dental providers.DisclosuresJ. C. McGregor, Merck & Co.: Grant Investigator, Research grant

Michiele Schrieber, RN, MSN, CCM Acting Associate Director Patient Care Services Veterans Health Care System of the Ozarks Fayetteville, Arkansas

The Global Burden of Disease Study showed there was a 34.5% increase in years lived with disability due to dental caries from 1990 to 2010. With the aging of 76 million baby boomers, dental caries will continue to pose a significant challenge for older adults. Test the effectiveness of prescription or professionally applied fluoride in the prevention of new dental restorations in a clinical setting where patients are medically compromised and more dentally impaired than the general population. A retrospective cohort study, using multiple electronic databases within the Department of Veterans Affairs. Propensity scores were used to adjust for confounding by indication and logistic regression modeled the outcome and included all expected covariates. The study sample included 140,114 high caries risk Veterans with a mean of 3.4 physical comorbidities, 1.2 mental comorbidities, and 11 medication groups per patient. Patients who received clinical fluoride treatments had 17-20% decreased odds of requiring a restoration during the follow-up period. Prescription self-applied or professionally applied fluoride provided either before or during an episode of care significantly reduced the likelihood of new restorations in high caries risk and medically compromised Veterans.