In the United States, the Health Insurance Portability and Accountability Act (HIPAA) protects the confidentiality of patient data and requires the informed consent of the patient and approval of the ...Internal Review Board to use data for research purposes, but these requirements can be waived if data is de-identified. For clinical data to be considered de-identified, the HIPAA "Safe Harbor" technique requires 18 data elements (called PHI: Protected Health Information) to be removed. The de-identification of narrative text documents is often realized manually, and requires significant resources. Well aware of these issues, several authors have investigated automated de-identification of narrative text documents from the electronic health record, and a review of recent research in this domain is presented here.
This review focuses on recently published research (after 1995), and includes relevant publications from bibliographic queries in PubMed, conference proceedings, the ACM Digital Library, and interesting publications referenced in already included papers.
The literature search returned more than 200 publications. The majority focused only on structured data de-identification instead of narrative text, on image de-identification, or described manual de-identification, and were therefore excluded. Finally, 18 publications describing automated text de-identification were selected for detailed analysis of the architecture and methods used, the types of PHI detected and removed, the external resources used, and the types of clinical documents targeted. All text de-identification systems aimed to identify and remove person names, and many included other types of PHI. Most systems used only one or two specific clinical document types, and were mostly based on two different groups of methodologies: pattern matching and machine learning. Many systems combined both approaches for different types of PHI, but the majority relied only on pattern matching, rules, and dictionaries.
In general, methods based on dictionaries performed better with PHI that is rarely mentioned in clinical text, but are more difficult to generalize. Methods based on machine learning tend to perform better, especially with PHI that is not mentioned in the dictionaries used. Finally, the issues of anonymization, sufficient performance, and "over-scrubbing" are discussed in this publication.
The impact of antibiotic timing on sepsis outcomes remains controversial due to conflicting results from previous studies.
This study investigated the association of door-to-antibiotic time with ...long-term mortality in ED patients with sepsis.
This retrospective cohort study included nontrauma adult ED patients with clinical sepsis admitted to four hospitals from 2013 to 2017. Only patients’ first eligible encounter was included. Multivariable logistic regression was used to measure the adjusted association between door-to-antibiotic time and 1-year mortality. Secondary analyses used alternative antibiotic timing measures (antibiotic initiation within 1 or 3 h and separate comparison of antibiotic exposure at each hour up to hour 6), alternative outcomes (hospital, 30-day, and 90-day mortality), and alternative statistical methods to mitigate indication bias.
Among 10,811 eligible patients, median door-to-antibiotic time was 166 min (interquartile range, 115-230 min), and 1-year mortality was 19%. After adjustment, each additional hour from ED arrival to antibiotic initiation was associated with a 10% (95% CI, 5-14; P < .001) increased odds of 1-year mortality. The association remained linear when each 1-h interval of door-to-antibiotic time was independently compared with door-to-antibiotic time ≤ 1 h and was similar for hospital, 30-day, and 90-day mortality. Mortality at 1 year was higher when door-to-antibiotic times were > 3 h vs ≤ 3 h (adjusted OR, 1.27; 95% CI, 1.13-1.43) but not > 1 h vs ≤ 1 h (adjusted OR, 1.26; 95% CI, 0.98-1.62).
Delays in ED antibiotic initiation time are associated with clinically important increases in long-term, risk-adjusted sepsis mortality.
Abstract
Background
This study reports estimates of the healthcare costs, length of stay, and mortality associated with infections due to multidrug-resistant bacteria among elderly individuals in the ...United States.
Methods
We conducted a retrospective cohort analysis of patients aged ≥65 admitted for inpatient stays in the Department of Veterans Affairs healthcare system between 1/2007–12/2018. We identified those with positive cultures for multidrug-resistant bacteria and matched each infected patient to ≤10 control patients. We then performed multivariable regression models to estimate the attributable cost and mortality due to the infection. We also constructed multistate models to estimate the attributable length of stay due to the infection. Finally, we multiplied these pathogen-specific attributable cost, length of stay, and mortality estimates by national case counts from hospitalized patients in 2017.
Results
Our cohort consisted of 87 509 patients with infections and 835 048 matched controls. Costs were higher for hospital-onset invasive infections, with attributable costs ranging from $22 293 (95% confidence interval: $19 101–$24 485) for methicillin-resistant Staphylococcus aureus (MRSA) to $57 390 ($34 070–$80 710) for carbapenem-resistant (CR) Acinetobacter. Similarly, for hospital-onset invasive infections, attributable mortality estimates ranged from 14.2% (12.2–16.2%) for MRSA to 24.1% (12.1–36.0%) for CR Acinetobacter. The aggregate cost of these infections was an estimated $1.9 billion ($1.3 billion–$2.5 billion) with 11 852 (8719–14 985) deaths and 448 224 (354 513–541 934) inpatient days in 2017.
Conclusions
Efforts to prevent these infections due to multidrug-resistant bacteria could save a significant number of lives and healthcare resources.
Using data from the VA healthcare system, we found that infections due to multidrug-resistant bacteria were associated with $1.8 billion in healthcare costs, 10 509 deaths, and 434 507 inpatient days among US elderly individuals during a 1-year period.
Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert ...panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.
Summary Background Hospital readmissions are common after major surgery, although it is unknown whether patients achieve improved outcomes when they are readmitted to, and receive care at, the index ...hospital where their surgical procedure was done. We examined the association between readmission destination and mortality risk in the USA in Medicare beneficiaries after a range of common operations. Methods By use of claims data from Medicare beneficiaries in the USA between Jan 1, 2001, and Nov 15, 2011, we assessed patients who needed hospital readmission within 30 days after open abdominal aortic aneurysm repair, infrainguinal arterial bypass, aortobifemoral bypass, coronary artery bypass surgery, oesophagectomy, colectomy, pancreatectomy, cholecystectomy, ventral hernia repair, craniotomy, hip replacement, or knee replacement. We used logistic regression models incorporating inverse probability weighting and instrumental variable analysis to measure associations between readmission destination (index vs non-index hospital) and risk of 90 day mortality for patients who underwent surgery who needed hospital readmission. Findings 9 440 503 patients underwent one of 12 major operations, and the number of patients readmitted or transferred back to the index hospital where their operation was done varied from 186 336 (65·8%) of 283 131 patients who were readmitted after coronary artery bypass grafting, to 142 142 (83·2%) of 170 789 patients who were readmitted after colectomy. Readmission was more likely to be to the index hospital than to a non-index hospital if the readmission was for a surgical complication (189 384 23% of 834 070 patients readmitted to index hospital vs 36 792 13% of 276 976 patients readmitted non-index hospital, p<0·0001). Readmission to the index hospital was associated with a 26% lower risk of 90 day mortality than was readmission to a non-index hospital, with inverse probability weighting used to control for selection bias (odds ratio OR 0·74, 95% CI 0·66–0·83). This effect was significant (p<0·0001) for all procedures in inverse probability-weighted models, and was largest for patients who were readmitted after pancreatectomy (OR 0·56, 95% CI 0·45–0·69) and aortobifemoral bypass (OR 0·69, 95% CI 0·61–0·77). By use of hospital-level variation among regional index hospital readmission rates as an instrument, instrumental variable analysis showed that the patients with the highest probability of returning to the index hospital had 8% lower risk of mortality (OR 0·92 95% CI 0·91–0·94) than did patients who were less likely to be readmitted to the index hospital. Interpretation In the USA, patients who are readmitted to hospital after various major operations consistently achieve improved survival if they return to the hospital where their surgery took place. These findings might have important implications for cost-effectiveness-driven regional centralisation of surgical care. Funding None.
Use of empirical broad-spectrum antibiotics for pneumonia has increased owing to concern for resistant organisms, including methicillin-resistant Staphylococcus aureus (MRSA). The association of ...empirical anti-MRSA therapy with outcomes among patients with pneumonia is unknown, even for high-risk patients.
To compare 30-day mortality among patients hospitalized for pneumonia receiving empirical anti-MRSA therapy vs standard empirical antibiotic regimens.
Retrospective multicenter cohort study was conducted of all hospitalizations in which patients received either anti-MRSA or standard therapy for community-onset pneumonia in the Veterans Health Administration health care system from January 1, 2008, to December 31, 2013. Subgroups of patients analyzed were those with initial intensive care unit admission, MRSA risk factors, positive results of a MRSA surveillance test, and positive results of a MRSA admission culture. Primary analysis was an inverse probability of treatment-weighted propensity score analysis using generalized estimating equation regression; secondary analyses included an instrumental variable analysis. Statistical analysis was conducted from June 14 to November 20, 2019.
Empirical anti-MRSA therapy plus standard pneumonia therapy vs standard therapy alone within the first day of hospitalization.
Risk of 30-day all-cause mortality after adjustment for patient comorbidities, vital signs, and laboratory results. Secondary outcomes included the development of kidney injury and secondary infections with Clostridioides difficile, vancomycin-resistant Enterococcus species, or gram-negative bacilli.
Among 88 605 hospitalized patients (86 851 men; median age, 70 years interquartile range, 62-81 years), empirical anti-MRSA therapy was administered to 33 632 (38%); 8929 patients (10%) died within 30 days. Compared with standard therapy alone, in weighted propensity score analysis, empirical anti-MRSA therapy plus standard therapy was significantly associated with an increased adjusted risk of death (adjusted risk ratio aRR, 1.4 95% CI, 1.3-1.5), kidney injury (aRR, 1.4 95% CI, 1.3-1.5), and secondary C difficile infections (aRR, 1.6 95% CI, 1.3-1.9), vancomycin-resistant Enterococcus spp infections (aRR, 1.6 95% CI, 1.0-2.3), and secondary gram-negative rod infections (aRR, 1.5 95% CI, 1.2-1.8). Similar associations between anti-MRSA therapy use and 30-day mortality were found by instrumental variable analysis (aRR, 1.6 95% CI, 1.4-1.9) and among patients admitted to the intensive care unit (aRR, 1.3 95% CI, 1.2-1.5), those with a high risk for MRSA (aRR, 1.2 95% CI, 1.1-1.4), and those with MRSA detected on surveillance testing (aRR, 1.6 95% CI, 1.3-1.9). No significant favorable association was found between empirical anti-MRSA therapy and death among patients with MRSA detected on culture (aRR, 1.1 95% CI, 0.8-1.4).
This study suggests that empirical anti-MRSA therapy was not associated with reduced mortality for any group of patients hospitalized for pneumonia. These results contribute to a growing body of evidence that questions the value of empirical use of anti-MRSA therapy using existing risk approaches.
Abstract
Background
Treating patients with infections due to multidrug-resistant pathogens often requires substantial healthcare resources. The purpose of this study was to report estimates of the ...healthcare costs associated with infections due to multidrug-resistant bacteria in the United States (US).
Methods
We performed retrospective cohort studies of patients admitted for inpatient stays in the Department of Veterans Affairs healthcare system between January 2007 and October 2015. We performed multivariable generalized linear models to estimate the attributable cost by comparing outcomes in patients with and without positive cultures for multidrug-resistant bacteria. Finally, we multiplied these pathogen-specific, per-infection attributable cost estimates by national counts of infections due to each pathogen from patients hospitalized in a cohort of 722 US hospitals from 2017 to generate estimates of the population-level healthcare costs in the US attributable to these infections.
Results
Our analysis cohort consisted of 16 676 patients with community-onset infections and 172 712 matched controls and 8246 patients with hospital-onset infections and 66 939 matched controls. The highest cost was seen in hospital-onset invasive infections, with attributable costs (95% confidence intervals) ranging from $30 998 ($25 272–$36 724) for methicillin-resistant Staphylococcus aureus to $74 306 ($20 377–$128 235) for carbapenem-resistant (CR) Acinetobacter. The highest attributable costs for community-onset invasive infections were seen in CR Acinetobacter ($62 396; $20 370–$104 422). Treatment of these infections cost an estimated $4.6 billion ($4.1 billion–$5.1 billion) in 2017 in the US for community- and hospital-onset infections combined.
Conclusions
We found that antimicrobial-resistant infections led to substantial healthcare costs.
This study reports estimates of the healthcare costs associated with infections due to multidrug-resistant bacteria in the US. Treatment of these infections costs an estimated $4.6 billion in 2017 in the US for community- and hospital-onset infections combined.
Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert ...panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.
Abstract
Background
Empirical antibiotic use is common in the hospital. Here, we characterize patterns of antibiotic use, infectious diagnoses, and microbiological laboratory results among ...hospitalized patients and aim to quantify the proportion of antibiotic use that is potentially attributable to specific bacterial pathogens.
Methods
We conducted an observational study using electronic health records from acute care facilities in the US Veterans Affairs Healthcare System. From October 2017 to September 2018, 482 381 hospitalizations for 332 657 unique patients that met all criteria were included. At least 1 antibiotic was administered at 202 037 (41.9%) of included hospital stays. We measured frequency of antibiotic use, microbiological specimen collection, and bacterial isolation by diagnosis category and antibiotic group. A tiered system based on specimen collection sites and diagnoses was used to attribute antibiotic use to presumptive causative organisms.
Results
Specimens were collected at 130 012 (64.4%) hospitalizations with any antibiotic use, and at least 1 bacterial organism was isolated at 35.1% of these stays. Frequency of bacterial isolation varied widely by diagnosis category and antibiotic group. Under increasingly lenient criteria, 10.2%–31.4% of 974 733 antibiotic days of therapy could be linked to a potential bacterial pathogen.
Conclusions
Overall, the vast majority of antibiotic use could be linked to either an infectious diagnosis or microbiological specimen. Nearly one-half of antibiotic use occurred when there was a specimen collected but no bacterial organism identified, underscoring the need for rapid and improved diagnostics to optimize antibiotic use.
More than two-thirds of antibiotic use among hospitalized patients may occur at stays without a bacterial isolate. Metrics linked to diagnosis and microbiology may be useful for antibiotic stewardship, and rapid and improved diagnostics are needed to optimize antibiotic use.
At the beginning of the 21st century, antimicrobial resistance is common, has developed against every class of antimicrobial drug, and appears to be spreading into new clinical niches. We describe ...determinants likely to influence the future epidemiology and health impact of antimicrobial-resistant infections. Understanding these factors will ultimately optimize preventive strategies for an unpredictable future.
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