Publications

RATIONALE

Predicting which patients are at highest risk for readmission after hospitalization for pneumonia could enable hospitals to proactively reallocate scarce resources to reduce 30-day readmissions.

OBJECTIVES

To synthesize the available literature on readmission risk prediction models for adults who are hospitalized because of pneumonia and describe their performance.

METHODS

We systematically searched Ovid MEDLINE, Embase, The Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature databases from inception through July 2015. We included studies of adults discharged with pneumonia that developed or validated a model that predicted hospital readmission. Two independent reviewers abstracted data and assessed the risk of bias.

MEASUREMENTS AND MAIN RESULTS

Of 992 citations reviewed, 7 studies met inclusion criteria, which included 11 unique risk prediction models. All-cause 30-day readmission rates ranged from 11.8 to 20.8% (median, 17.3%). Model discrimination (C statistic) ranged from 0.59 to 0.77 (median, 0.63) with the highest-quality, best-validated model, the Centers for Medicare and Medicaid Services Pneumonia Administrative Model performing modestly (C Statistic of 0.63 in 4 separate multicenter cohorts). The best performing model (C statistic of 0.77) was a single-site study that lacked internal validation. The models had adequate calibration, with patients predicted as high risk for readmission having a higher average observed readmission rate than those predicted to be low risk. None of the studies included pneumonia illness severity scores, and only one included measures of in-hospital clinical trajectory and stability on discharge, robust predictors of readmission.

CONCLUSIONS

We found a limited number of validated pneumonia-specific readmission models, and their predictive ability was modest. To improve predictive accuracy, future models should include measures of pneumonia illness severity, hospital complications, and stability on discharge.

Anti-synthetase syndrome is an autoimmune condition, characterized by antibodies directed against an aminoacycl transfer RNA synthetase along with clinical features that can include interstitial lung disease, myositis, Raynaud's phenomenon, and arthritis. There is a higher prevalence and increased severity of interstitial lung disease in patients with anti-synthetase syndrome, as compared to dermatomyositis and polymyositis, inflammatory myopathies with which it may overlap phenotypically. Diagnosis is made by a multidisciplinary approach, synthesizing rheumatology and pulmonary evaluations, along with serologic, radiographic, and occasionally muscle and/or lung biopsy results. Patients with anti-synthetase syndrome often require multi-modality immunosuppressive therapy in order to control the muscle and/or pulmonary manifestations of their disease. The long-term care of these patients mandates careful attention to the adverse effects and complications of chronic immunosuppressive therapy, as well as disease-related sequelae that can include progressive interstitial lung disease necessitating lung transplantation, pulmonary hypertension, malignancy and decreased survival. It is hoped that greater awareness of the clinical features of this syndrome will allow for earlier diagnosis and appropriate treatment to improve outcomes in patients with anti-synthetase syndrome.

HIV self tests (HIVST) have the potential to increase testing among young adults. However, little is known about high-risk young adults' perception of the HIVST as a risk reduction tool and how they would use the HIVST in their everyday lives. Our study sought to examine these factors. Twenty-one ethnically diverse participants (ages 18-24) used the HIVST at our study site, completed surveys, and underwent an in-depth interview. Descriptive statistics were used to analyze the survey responses, and interview data were coded using constructs from the information-motivation-behavioral skills model. Information deficits included: how to use the HIVST and the "window period" for sero-conversion. Motivations supporting HIVST use included: not needing to visit the clinic, fast results, easy access, and use in non-monogamous relationships. Behavioral skills discussed included: coping with a positive test, handling partner violence after a positive test, and accessing HIV services. These findings can inform the use of the HIVST for improving HIV testing rates and reducing HIV risk behavior.

BACKGROUND

Adverse drug events (ADEs) among patients self-administering medications in home/community settings are a common cause of emergency department (ED) visits, but the causes of these ambulatory ADEs remain unclear. Root cause analysis, rarely applied in outpatient settings, may reveal the underlying factors that contribute to adverse events.

STUDY OBJECTIVES

To elicit patient and provider perspectives on ambulatory ADEs and apply root cause analysis methodology to identify cross-cutting themes among these events.

METHODS

Emergency department clinical pharmacists screened, identified, and enrolled a convenience sample of adult patients 18 years or older who presented to a single, urban, academic ED with symptoms or diagnoses consistent with suspected ADEs. Semistructured phone interviews were conducted with the patients and their providers. We conducted a qualitative analysis. We applied a prespecified version of the injury prevention framework (deductive coding), identifying themes relating to the agent (drug), host (patient), and environment (social and health systems). These themes were used to construct a root cause analysis for each ADE.

RESULTS

From 18 interviews overall, we identified the following themes within the injury prevention framework. Agent factors included high-risk drugs, narrow therapeutic indices, and uncommon severe effects. Host factors included patient capacity or understanding of how to use medications, awareness of side effects, mistrust of the medical system, patients with multiple comorbidities, difficult risk-benefit assessments, and high health-care users. Environmental factors included lack of social support, and health systems issues included access to care, encompassing medication availability, access to specialists, and a lack of continuity and communication among prescribing physicians. Root cause analysis revealed multiple underlying factors relating to agent, host, and environment for each event.

CONCLUSION

Patient and physician perspectives can inform a root cause analysis of ambulatory ADEs. Such methodology may be applied to understand the factors that contribute to ambulatory ADEs and serve as the formative work for future interventions improving home/community medication use.

BACKGROUND

Attrition along the HIV care continuum slows gains in mitigating the South African HIV epidemic. Understanding population-level gaps in HIV identification, linkage, retention in care, and viral suppression is critical to target programming.

METHODS

We conducted a population-based household survey, HIV rapid testing, point-of-care CD4 testing, and viral load measurement from dried blood spots using multistage cluster sampling in 2 subdistricts of North West Province from January to March, 2014. We used weighting and multiple imputation of missing data to estimate HIV prevalence, undiagnosed infection, linkage and retention in care, medication adherence, and viral suppression.

RESULTS

We sampled 1044 respondents aged 18-49. HIV prevalence was 20.0% (95% confidence interval: 13.7 to 26.2) for men and 26.7% (95% confidence interval: 22.1 to 31.4) for women. Among those HIV positive, 48.4% of men and 75.7% of women were aware of their serostatus; 44.0% of men and 74.8% of women reported ever linking to HIV care; 33.1% of men and 58.4% of women were retained in care; and 21.6% of men and 50.0% of women had dried blood spots viral loads <5000 copies per milliliter. Among those already linked to care, 81.7% on antiretroviral treatment (ART) and 56.0% of those not on ART were retained in care, and 51.8% currently retained in care on ART had viral loads <5000 copies per milliliter.

CONCLUSIONS

Despite expanded treatment in South Africa, attrition along the continuum of HIV care is slowing prevention progress. Improved detection is critically needed, particularly among men. Reported linkage and retention is reasonable for those on ART; however, failure to achieve viral suppression is worrisome.

OBJECTIVE

The purpose of this study was to evaluate trajectories of and predictors for changes in upper extremity (UE) function in women (n = 396) during the first year after breast cancer treatment.

DESIGN

Prospective, longitudinal assessments of shoulder range of motion (ROM), grip strength, and perceived interference of function were performed before and for 1 year after surgery. Demographic, clinical, and treatment characteristics were evaluated as predictors of postoperative function.

RESULTS

Women had a mean (SD) age of 54.9 (11.6) years, and 64% were white. Small but statistically significant reductions in shoulder ROM were found on the affected side over 12 months (P < 0.001). Predictors of interindividual differences in ROM at the 1-month assessment were ethnicity, neoadjuvant chemotherapy, type of surgery, axillary lymph node dissection, and preoperative ROM. Predictors of interindividual differences in changes over time in postoperative ROM were living alone, type of surgery, axillary lymph node dissection, and adjuvant chemotherapy. Declines in mean grip strength from before through 1 month after surgery were small and not clinically meaningful. Women with greater preoperative breast pain interference scores had higher postoperative interference scores at all postoperative assessments.

CONCLUSION

Some of the modifiable risk factors identified in this study can be targeted for intervention to improve UE function in these women.