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BackgroundWhen evaluating children with mild traumatic brain injuries (mTBIs) and intracranial injuries (ICIs), neurosurgeons intuitively consider injury size. However, the extent to which such measures (eg, hematoma size) improve risk prediction compared with the kids intracranial injury decision support tool for traumatic brain injury (KIIDS-TBI) model, which only includes the presence/absence of imaging findings, remains unknown.ObjectiveTo determine the extent to which measures of injury size improve risk prediction for children with mild traumatic brain injuries and ICIs.MethodsWe included children ≤18 years who presented to 1 of the 5 centers within 24 hours of TBI, had Glasgow Coma Scale scores of 13 to 15, and had ICI on neuroimaging. The data set was split into training (n = 1126) and testing (n = 374) cohorts. We used generalized linear modeling (GLM) and recursive partitioning (RP) to predict the composite of neurosurgery, intubation >24 hours, or death because of TBI. Each model's sensitivity/specificity was compared with the validated KIIDS-TBI model across 3 decision-making risk cutoffs (

Background Several antiretroviral therapy (ART) medications have been associated with increased cardiovascular risk, but less is known about the safety of modern ART. We sought to compare the risk of major adverse cardiac events (MACEs) among different ART regimens. Methods Using insurance claims databases from 2008 to 2020, we identified adults aged <65 years who newly initiated ART. We compared non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens to protease inhibitors (PI)- and integrase inhibitors (INSTI)-based regimens. We used propensity score-weighted Kaplan-Meier functions to estimate the 6, 12, 18, 24, 36, and 48 months' risk and risk differences (RD) of MACE. Results Among 37 935 ART initiators (median age, 40 years; 23% female; 26% Medicaid-insured), 45% started INSTI-, 16% PI-, and 39% NNRTI-based regimens. MACE occurred in 418 individuals (1.1%) within 48 months after ART initiation. Compared to NNRTI initiators, the risk of MACE was higher at 12 months (RD, 0.50; 95% CI, 0.14–0.99), 18 months (RD, 0.53; 95% CI, 0.11–1.06), and 24 months (RD, 0.62; 95% CI, 0.04–1.29) for PI initiators, and at 12 (RD, 0.20; 95% CI, 0.03–0.37) and 18 months (RD, 0.31; 95% CI, 0.06–0.54) for INSTI initiators; the precision of estimates was limited for longer duration of follow-up. Conclusions Among ART initiators, PI-based and INSTI-based regimens were associated with higher short-term risk of MACE compared to NNRTI-based regimens. The pattern of association between INSTIs and PIs with excess risk of MACE was similar. [ABSTRACT FROM AUTHOR]

Purpose: To characterize antibiotic utilization for outpatient community‐acquired pneumonia (CAP) in the United States. Methods: We conducted a cohort study among adults 18–64 years diagnosed with outpatient CAP and a same‐day guideline‐recommended oral antibiotic fill in the MarketScan® Commercial Database (2008–2019). We excluded patients coded for chronic lung disease or immunosuppressive disease; recent hospitalization or frequent healthcare exposure (e.g., home wound care, patients with cancer); recent antibiotics; or recent infection. We characterized utilization of broad‐spectrum antibiotics (respiratory fluoroquinolone, β‐lactam + macrolide, β‐lactam + doxycycline) versus narrow‐spectrum antibiotics (macrolide, doxycycline) overall and by patient‐ and provider‐level characteristics. Per 2007 IDSA/ATS guidelines, we stratified analyses by otherwise healthy patients and patients with comorbidities (coded for diabetes; chronic heart, liver, or renal disease; etc.). Results: Among 263 914 otherwise healthy CAP patients, 35% received broad‐spectrum antibiotics (not recommended); among 37 161 CAP patients with comorbidities, 44% received broad‐spectrum antibiotics (recommended). Ten‐day antibiotic treatment durations were the most common for all antibiotic classes except macrolides. From 2008 to 2019, broad‐spectrum antibiotic use substantially decreased from 45% to 19% in otherwise healthy patients (average annual percentage change [AAPC], −7.5% [95% CI −9.2%, −5.9%]), and from 55% to 29% in patients with comorbidities (AAPC, −5.8% [95% CI −8.8%, −2.6%]). In subgroup analyses, broad‐spectrum antibiotic use varied by age, geographic region, provider specialty, and provider location. Conclusions: Real‐world use of broad‐spectrum antibiotics for outpatient CAP declined over time but remained common, irrespective of comorbidity status. Prolonged duration of therapy was common. Antimicrobial stewardship is needed to aid selection according to comorbidity status and to promote shorter courses. [ABSTRACT FROM AUTHOR]

Concern over consistency and completeness of surgical site infection (SSI) surveillance has increased due to public reporting of hospital SSI rates and imminent non-payment rules for hospitals that do not meet national benchmarks. Already, hospitals no longer receive additional payment from the Centers for Medicare & Medicaid Services (CMS) for certain infections following coronary artery bypass graft (CABG) surgery, orthopedic procedures, and bariatric surgery. One major concern is incomplete and differential post-discharge surveillance. At present, substantial variation exists in how and whether hospitals identify SSI events after the hospitalization in which the surgery occurred. Parameters used for SSI surveillance such as the duration of the window of time that surveillance takes place following the surgical procedure can impact the completeness of surveillance data. Determination of the optimal surveillance time period involves balancing the potential increased case ascertainment associated with a longer follow-up period with the increased resources that would be required. Currently, the time window for identifying potentially preventable SSIs related to events at the time of surgery is not fully standardized. The Centers for Disease Control and Prevention (CDC) National Healthcare Surveillance Network (NHSN) requires a 365-day postoperative surveillance period for procedures involving implants and a 30-day period for non-implant procedures. In contrast, the National Surgical Quality Improvement Program (NSQIP) and the Society of Thoracic Surgeons (STS) systems employ 30-day post-operative surveillance regardless of implant. As consensus builds towards national quality measures for hospital-specific SSI rates, it will be important to assess the frequency of events beyond the 30-day post-surgical window that may quantify the value of various durations of surveillance, and ultimately inform the choice of specific outcome measures.

ObjectiveTo evaluate the use of routinely collected electronic health data in Medicare claims to identify surgical site infections (SSIs) following hip arthroplasty, knee arthroplasty, and vascular surgery.DesignRetrospective cohort study.SettingFour academic hospitals that perform prospective SSI surveillance.MethodsWe developed lists of International Classification of Diseases, Ninth Revision, and Current Procedural Terminology diagnosis and procedure codes to identify potential SSIs. We then screened for these codes in Medicare claims submitted by each hospital on patients older than 65 years of age who had undergone 1 of the study procedures during 2007. Each site reviewed medical records of patients identified by either claims codes or traditional infection control surveillance to confirm SSI using Centers for Disease Control and Prevention/National Healthcare Safety Network criteria. We assessed the performance of both methods against all chart-confirmed SSIs identified by either method.ResultsClaims-based surveillance detected 1.8-4.7-fold more SSIs than traditional surveillance, including detection of all previously identified cases. For hip and vascular surgery, there was a 5-fold and 1.6-fold increase in detection of deep and organ/space infections, respectively, with no increased detection of deep and organ/space infections following knee surgery. Use of claims to trigger chart review led to confirmation of SSI in 1 out of 3 charts for hip arthroplasty, 1 out of 5 charts for knee arthroplasty, and 1 out of 2 charts for vascular surgery.ConclusionClaims-based SSI surveillance markedly increased the number of SSIs detected following hip arthroplasty, knee arthroplasty, and vascular surgery. It deserves consideration as a more effective approach to target chart reviews for identifying SSIs.

ObjectiveTo evaluate whether longitudinal insurer claims data allow reliable identification of elevated hospital surgical site infection (SSI) rates.DesignWe conducted a retrospective cohort study of Medicare beneficiaries who underwent coronary artery bypass grafting (CABG) in US hospitals performing at least 80 procedures in 2005. Hospitals were assigned to deciles by using case mix-adjusted probabilities of having an SSI-related inpatient or outpatient claim code within 60 days of surgery. We then reviewed medical records of randomly selected patients to assess whether chart-confirmed SSI risk was higher in hospitals in the worst deciles compared with the best deciles.ParticipantsFee-for-service Medicare beneficiaries who underwent CABG in these hospitals in 2005.ResultsWe evaluated 114,673 patients who underwent CABG in 671 hospitals. In the best decile, 7.8% (958/12,307) of patients had an SSI-related code, compared with 24.8% (2,747/11,068) in the worst decile ([Formula: see text]). Medical record review confirmed SSI in 40% (388/980) of those with SSI-related codes. In the best decile, the chart-confirmed annual SSI rate was 3.2%, compared with 9.4% in the worst decile, with an adjusted odds ratio of SSI of 2.7 (confidence interval, 2.2-3.3; [Formula: see text]) for CABG performed in a worst-decile hospital compared with a best-decile hospital.ConclusionsClaims data can identify groups of hospitals with unusually high or low post-CABG SSI rates. Assessment of claims is more reproducible and efficient than current surveillance methods. This example of secondary use of routinely recorded electronic health information to assess quality of care can identify hospitals that may benefit from prevention programs.