New Vanderbilt-led research shows hospitals are doing a better job of using antibiotics less commonly associated with antibiotic resistance to treat children hospitalized with community-acquired pneumonia. 

The report, "Antibiotic Choice for Children Hospitalized with Pneumonia and Adherence to National Guidelines," was released in the journal Pediatrics.

This study was nested within a larger study, the Centers for Disease Control and Prevention's Etiology of Pneumonia in the Community. The multi-center EPIC study was a prospective, population-based study of community-acquired pneumonia hospitalizations among children in the United States that sought to address critical gaps in the knowledge about pneumonia. 

Study authors examined the impact and implementation of the new national guidelines that call for prescribing penicillin or ampicillin, known as narrow-spectrum antibiotics, to treat most children hospitalized with pneumonia. The guidelines were published in 2011 by the Pediatric Infectious Disease Society and the Infectious Diseases Society of America.

Prior to the new prescribing guidelines, third-generation cephalosporins, a broader-spectrum class of antibiotics, were commonly used. Results showed that after the release of the guidelines, hospitals were less likely to prescribe third-generation cephalosporins, using it about 44.8 percent of the time by the end of the study compared with 57.3 percent use expected from pre-guidelines trends.After the guidelines release, the use of narrow-spectrum antibiotics increased from 3.9 percent to 15.2 percent.

"Third-generation cephalosporins are broader-spectrum antibiotics (compared with ampicillin) and are unnecessary for the treatment of uncomplicated pneumonia in children. Their use contributes to antibiotic resistance, a major public health problem, both nationally and globally," said study lead-author Derek Williams, M.D., assistant professor of pediatrics, and member of the Vanderbilt Vaccine Research Program and the Division of Hospital Medicine."

From January 2010 to June 2012, children who were admitted with pneumonia at Monroe Carell Jr. Children's Hospital at Vanderbilt, LeBonheur Children's Medical Center and the University of Utah were recruited for the EPIC study. Researchers enrolled 2,638 children younger than 18, but for the current study 507 children who did not receive antibiotics or were younger than 3 months of age were excluded. The final study population included 2,121 children.

Following the new prescribing guidelines, two of the three hospitals in the study implemented active dissemination efforts targeting the new recommendations, while the third hospital had no formal efforts to distribute the guidelines. By the end of the study, only the two hospitals that actively disseminated the guidelines showed statistically significant declines in cephalosporin use.

As a follow-up to this project, the researchers are currently studying changes in antibiotic prescribing at more than 30 children's hospitals to more precisely identify determinants of antibiotic selection and uptake of evidence-based practice change at the local level.

Tearing down the barriers to care transitions

New research could soon automate hospital discharge communication, adding critical data and cutting the time it takes the information to reach community health care providers from weeks to hours.

The preliminary study, led by Sharon Hewner, assistant professor in the School of Nursing, could speed delivery of the hospital discharge summary to under 24 hours and potentially reduce the number of patients readmitted to hospitals.

The research, "Exploring Barriers to Care Continuity during Transitions: A Mixed-methods Study to Identify Health Information Exchange Opportunities," is funded by a $35,000 UB Innovative Micro-Programs Accelerating Collaboration in Themes (IMPACT) grant.

"It takes too long to get the information to primary care," says Hewner. "If the summary comes in three weeks after the person has been discharged from a hospital, the chances are pretty good that they've already been back, either to the emergency room or for hospitalization."

A discharge summary is a medical record sent to a patient's primary doctor after the patient is released from a hospital that outlines the diagnosis, test results and prescribed treatments.

Although hospitals have been using electronic health records for nearly 10 years, most software is geared toward processing billing. The discharge summary still relies on "snail mail," or the U.S. Postal Service, largely because it is seen as the final step in medical care and, therefore, doesn't require quick processing.

Researchers will use observational data collected at Kaleida Health's hospitals on clinician workflows and documentation around care transitions between the hospital and community.

To create a discharge summary, hospital physicians dictate a report that includes a patient's diagnosis and medical treatment that is later transcribed and mailed to the patient's primary physician.

Current summaries often omit information from nurses, social workers or therapists that can make a difference in a person's ability to manage his or her own care. The records typically take 10-14 days to reach primary care providers, long after the 48-hour window for follow-up of high-risk cases has passed, says Hewner.

Common problems include duplication of medications already in the home and confusion about where hospitals should send the summary, she says.

Mistakes that could be minimized with an automated discharge summary that treats a patient's release from a hospital as the next step in the patient's care, rather than the final step, she says.

To ensure the electronic summary is accepted by all hospitals and doctor's offices, Hewner will model the summary after the continuity of care document — a medical record created by the Office of the National Coordinator for Health Information Technology in the U.S. Department of Health and Human Services — that all health record software programs are required to be able to read. To transfer the electronic document, a hospital physician would only need to modify and approve the record's existing data.

Forecast: Lowest medical cost trend in the past decade

PwC's Health Research Institute projects U.S. medical inflation will dip to 6.5 percent in 2016, capping a 10-year trend of slowing employer medical cost-trend growth in the employer-sponsored market.

In the latest installment of its annual report "Medical Cost Trend: Behind the Numbers," HRI identifies three factors that are expected to reduce the medical growth rate in 2016:

  1. The Affordable Care Act's looming "Cadillac tax" on high-priced plans, which is accelerating cost-shifting from employers to employees to reduce costs;
  2. Greater adoption of  "virtual care" technology that can be more efficient and convenient than traditional medical care; and
  3. New health advisers helping to steer consumers to more efficient health care.

Despite the year-over-year slowdown, HRI also reported that medical inflation still outpaces general inflation, underscoring the challenges ahead for the health industry. In fact, "Behind the Numbers" identified two factors that will likely exert inflationary pressure on health spending in the year ahead:

  1. New specialty drugs entering the market in 2015 and 2016 will continue to push health spending growth upward; and
  2. Major cyber-security breaches are forcing health companies to step up investments to guard personal health data, adding to the overall cost of delivering care.

"While the health industry has improved in efficiency over the past decade, the slowing employer medical cost growth is due to the increased role of savvy health consumers facing higher cost-sharing responsibilities and more complex decisions," said Kelly Barnes, PwC's U.S. health industries leader. "This will continue to impact the New Health Economy in the coming years."

After accounting for likely changes in benefit design, such as higher deductibles and narrow networks, HRI projects a net growth rate of 4.5 percent in 2016. Benefit design changes typically hold down spending growth by shifting financial responsibility to consumers, who often choose less expensive options.

Hospital stays longer, costlier with poorly controlled blood sugar

Diabetes patients with abnormal blood sugar levels had longer, more costly hospital stays than those with glucose levels in a healthy range, according to studies presented in June by Scripps Whittier Diabetes Institute researchers at the 75th Scientific Sessions of the American Diabetes Association.

The findings come as more patients are being admitted to U.S. hospitals with diabetes as an underlying condition. A recent UCLA public health report indicated that one of every three hospital patients admitted in California has a diagnosis of diabetes. At the same time, changing health care payment models are increasing pressure on health systems to reduce costs while improving patient outcomes.

"Data from the new studies suggest poorly controlled blood sugar readings could serve as a marker for better managing the care of patients with diabetes both during their hospital stays and after they have been discharged," said Athena Philis-Tsimikas, M.D., an endocrinologist, corporate vice president of the Scripps Whittier Diabetes Institute and co-author of the papers presented at the ADA conference.

"Our research supports having more caregivers in the hospital and clinic settings who are focused on identifying these patients and working to make sure their diabetes is properly managed," she said.

For the first study, researchers used data for 9,995 patients with diabetes who were admitted to all Scripps Health hospitals in San Diego County between 2012 and 2013 and underwent blood sugar monitoring during their stays. After controlling for age and gender, patients with poor glucose control (one or more readings exceeding 400 mg/dL) had significantly longer hospital stays averaging 8.50 days than those with good glucose control (readings ranging between 70 and 199 mg/dL) who had stays averaging 5.74 days. Total hospitalization costs for patients with poor glucose control averaged $16,382, while costs for patients with good blood sugar control averaged $13,896.

The second study examined blood sugar data for 2,024 patients with diabetes who were admitted to Scripps Memorial Hospital Encinitas between 2009 and 2011.

After adjusting for patient demographics, admitted medical conditions and severity of illness, those who experienced high glucose readings (greater than 180 mg/dL) or low glucose readings (below 70 mg/dL) had significantly longer stays and incurred higher total costs when compared with patients whose glucose levels remained in normal ranges during their hospitalization.

A third study looked at diabetes patients receiving care at two Scripps Coastal Medical Center ambulatory clinics in San Diego County. At one clinic, 236 patients (the intervention group) received conventional support along with care from a multidisciplinary team that included a nurse care manager, a nurse focused on managing patient depression and a health coach. At the other clinic, another 238 patients served as a comparison group, receiving only conventional support during the same period.

Over 12 months, the percentage of all intervention group patients with good control of glycated hemoglobin (HbA1c), which is a risk indicator for developing diabetes-related conditions, increased significantly from 75.8 to 91.8. At the same time, the percentage of patients in the comparison group with good control of HbA1c rose only slightly from 77.3 to 79.2.

Among a subset of interventional group patients with moderate or high risk of developing diabetes-related complications, the percent with good control of HbA1c increased from 63.5 to 90.2.

Taken together, the research supports efforts by Tsimikas for more than 15 years to imbed multidisciplinary teams focused on diabetes care and management in clinics and hospitals. "We don't have enough physicians who can care for every patient for the amount of time required," she said. "Surrounding doctors with a specialized care team lets them provide more effective care to patients with diabetes, operate more efficiently and deliver improved outcomes."