JOURNAL CLUB
The Superbugs Are Coming!
Because the media has stolen all the catchy names—MRSA, VRSA, VRE, C Diff et al—I’d like to be the first to coin the term “PREC” (penicillin-resistant E. coli).*
Department of Pediatrics, University of Rochester, Rochester, New York
The study.
This was a retrospective examination of pediatric urine culture isolates from clinical laboratories collected in a variety of inpatient and outpatient settings across the United States in 2009. The aim was to compare antibiotic resistance patterns among common uropathogens obtained for outpatients and inpatients. The key findings.
The authors identified 5560 inpatient and 25 418 outpatient urinary isolates. Here’s their table on prevalence of common species:
Male outpatient Male inpatient Female outpatient Female inpatient
AUTHOR Eric Biondi, MD
Escherichia coli
Enterobacter spp
Enterococcus spp
Klebsiella spp
50% 37% 83% 64%
5% 10% 1% 4%
17% 27% 5% 13%
10% 12% 4% 10%
You’ll have to check the article to see all the resistance patterns that were measured, but suffice it to say that inpatient resistance rates frequently exceeded outpatient resistance rates, particularly for third-generation cephalosporins and ciprofloxacin. Most notably (in my opinion anyway) was Escherichia coli resistance to ampicillin in the outpatient and inpatient settings (45% vs 55%, P < .001).
KEY WORDS evidence-based medicine, journal club www.hospitalpediatrics.org doi:10.1542/hpeds.2014-0116 Address correspondence to Eric Biondi, MD, University of Rochester, 601 Elmwood Ave, Box 667, Rochester, NY 14642. E-mail: eric_biondi@ urmc.rochester.edu HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154 - 1663; Online, 2154 - 1671). Copyright © 2014 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
Why do we care?
This article substantiates the claim previously suggested by single-center studies that resistance patterns for uropathogens differ in the outpatient and inpatient settings. Thus, we should likely be using separate inpatient- and outpatient-based antibiograms to optimize effective empirical antibiotic use for treatment of urinary tract infection. That said, it is probably worth pointing out that there is site-to-site variability in determining who gets admitted for urinary tract infections (UTI), and this study was not designed to address this confounder or, more specifically, to account for severity of illness.
* Please cite as “Biondi E. Term coined while sitting at his desk writing his final journal club, sometime around July 2014.”
408 |
VOLUME 4 • ISSUE 6 www.hospitalpediatrics.org Downloaded from http://hosppeds.aappublications.org/ at University of Pennsylvania Library on June 29, 2015
HOSPITAL Pediatrics ®
Words from a hospitalist . . . “The common, often reflexive, empiric inpatient UTI management is getting a little trickier thanks to antibiotic resistance. Fortunately, this study’s accessible analysis of gender and age-stratified patterns of UTI organism and resistance can help pediatric hospitalists make wiser empiric treatment decisions when used in combination with your local antibiogram . . . if it is based on inpatient cultures. The differences between inpatient and outpatient patterns are also reminders to investigate how your local antibiogram is constructed.” – Dr Rebecca Rosenberg, pediatric hospitalist, NYU Langone Medical Center
Saperston KN, Shapiro DJ, Hersh AL, Copp HL. A comparison of inpatient versus outpatient resistance patterns of pediatric urinary tract infection. J Urol. 2014;191(suppl 5):1608–1613.
I REFUSE TO TITLE THIS “SHOW ME THE MONEY,” BUT IT WOULD PROBABLY MAKE SENSE There seems to be this general attitude in pediatrics that financial incentives are for “the other guys”—the investment bankers, salespeople, and the surgeons. Why is that? There’s no reason to think that we don’t care, at least a little bit, about money. The study.
This one is really cool. In 2006, a large academic medical center designed a financial incentive program to improve certain quality metrics. This program included a $400 bonus for project goals met by residents and fellows, up to $1200 per year per trainee. Projects were placed in 3 domains: patient satisfaction, quality/safety, and operation/utilization. Residents and fellows could also submit their own projects for approval in the incentive program.
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
The key findings.
During the first 6 years of the incentive program (2007–2012), 5275 residents and fellows participated, including 540 residents and fellows who participated in projects submitted by trainees. On average, $724 450 were paid in bonuses each year (∼$800 per trainee). The patient satisfaction project goal was met in 4 of the 6 years, the quality/safety and operation/utilization project goals were met inconsistently (although trainees were more compliant than faculty), but trainees did appear more engaged in the quality improvement process, culminating in dozens of projects being proposed, and completed successfully, by residents and fellows. In total, trainees worked on 55 projects and achieved 71% of the goals set. It is worth pointing out that because this was not originally designed as a research study, there was no control group or baseline data from which to compare the success of the program, which limits the ability to calculate a specific return on investment. Why do we care?
This group got residents and fellows to submit dozens of quality improvement projects on their own and to accomplish the goals contained within them. Although we can’t perform a marginal cost-benefit analysis here, it does appear that using carefully thought out financial incentives to congruently align the goals of the institution and trainees may be worth at least a cursory look. And why shouldn’t they be? There may be some scientific debate regarding financial incentives, but every other business sector uses them, and trainees will likely be included in some incentive program
upon beginning their first posttraining job anyway. In the words of the expert . . . “Pediatric hospitalists are in the ideal position to mentor the next generation of physicians in improving the quality, safety, and efficiency of clinical care, and introduce them to the increasingly prevalent pay-for-performance reimbursement model. This paper offers an innovative framework in which these goals can be accomplished to everyone’s benefit: residents, hospitalists, institutions, and most of all, patients.” – Dr Michael S. Leonard, Chief Quality Officer and pediatric hospitalist, Golisano Children’s Hospital at UR Medicine
Vidyarthi AR, Green AL, Rosenbluth G, Baron RB. Engaging residents and fellows to improve institution-wide quality: the first six years of a novel financial incentive program. Acad Med. 2014;89(3):460–468.
STRRRRREEEETTTTCCHHHHED TOO THIN How many patients should be on your daily census? In pediatrics, the answer eludes us. We know that we have to balance clinical outcomes and patient safety against the potentially excessive costs of limiting workload, but to what extent? An article in JAMA Internal Medicine this month may help shed some light on the issue, at least in the adult world anyway, by aiming to determine the associations among workload, efficiency, and quality of inpatient care. The study.
This was a retrospective cohort study of 20 241 inpatient adult admissions at a large academic community hospital system from 2008 to 2011. Outcomes of interest included, among other
Downloaded from http://hosppeds.aappublications.org/ at University of Pennsylvania Library on June 29, 2015
| 409
HOSPITAL Pediatrics ®
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
things, length of stay (LOS), cost, and patient satisfaction.
patient. Changes in workload were not associated with patient satisfaction.
The key findings.
Why do we care?
When hospital occupancy was 85% capacity, LOS decreased slightly as the census began to climb and then increased significantly. Hospital costs (converted from charges in this paper) increased by $111 per patient for each additional
Increasing the workload of hospitalists is associated with increased LOS and cost.
410 |
In the words of the expert . . . “What is the mechanism for the observed association between workload and length of stay/costs? This efficiency [of hospitalists] is explained partly by the ability of a hospitalist to see a patient in the morning and then drive a hospitalization forward, for example, by talking to consultants . . . . A hospitalist with a census of 20 patients,
who starts rounds at 7:30 AM and spends 15 minutes with each patient, will not see patient number 20 until after noon. It is plausible that a potential discharge might be delayed or an extra test ordered simply to move things forward.1” – Dr. Robert Wachter, Chief of Hospital Medicine, Department of Medicine, University of California, San Francisco (quotes taken directly from accompanying article commentary)
Elliott DJ, Young RS, Brice J, et al. Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med. 2014;174(5):786–793. 1. Wachter RM. Hospitalist workload: the search for the magic number. JAMA Intern Med. 2014;174(5):794–795.
VOLUME 4 • ISSUE 6 www.hospitalpediatrics.org Downloaded from http://hosppeds.aappublications.org/ at University of Pennsylvania Library on June 29, 2015
The Superbugs Are Coming! Eric Biondi Hospital Pediatrics 2014;4;408 DOI: 10.1542/hpeds.2014-0116
Updated Information & Services
including high resolution figures, can be found at: http://hosppeds.aappublications.org/content/4/6/408
Subspecialty Collections
This article, along with others on similar topics, appears in the following collection(s): Administration/Practice Management http://hosppeds.aappublications.org/cgi/collection/administration:pra ctice_management_sub Evidence-Based Medicine http://hosppeds.aappublications.org/cgi/collection/evidence-based_m edicine_sub Quality Improvement http://hosppeds.aappublications.org/cgi/collection/quality_improvem ent_sub
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://hosppeds.aappublications.org/site/misc/Permissions.xhtml
Reprints
Information about ordering reprints can be found online: http://hosppeds.aappublications.org/site/misc/reprints.xhtml
Downloaded from http://hosppeds.aappublications.org/ at University of Pennsylvania Library on June 29, 2015
The Superbugs Are Coming! Eric Biondi Hospital Pediatrics 2014;4;408 DOI: 10.1542/hpeds.2014-0116
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://hosppeds.aappublications.org/content/4/6/408
Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 2012. Hospital Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 2154-1663.
Downloaded from http://hosppeds.aappublications.org/ at University of Pennsylvania Library on June 29, 2015
The Superbugs Are Coming!
Because the media has stolen all the catchy names—MRSA, VRSA, VRE, C Diff et al—I’d like to be the first to coin the term “PREC” (penicillin-resistant E. coli).*
Department of Pediatrics, University of Rochester, Rochester, New York
The study.
This was a retrospective examination of pediatric urine culture isolates from clinical laboratories collected in a variety of inpatient and outpatient settings across the United States in 2009. The aim was to compare antibiotic resistance patterns among common uropathogens obtained for outpatients and inpatients. The key findings.
The authors identified 5560 inpatient and 25 418 outpatient urinary isolates. Here’s their table on prevalence of common species:
Male outpatient Male inpatient Female outpatient Female inpatient
AUTHOR Eric Biondi, MD
Escherichia coli
Enterobacter spp
Enterococcus spp
Klebsiella spp
50% 37% 83% 64%
5% 10% 1% 4%
17% 27% 5% 13%
10% 12% 4% 10%
You’ll have to check the article to see all the resistance patterns that were measured, but suffice it to say that inpatient resistance rates frequently exceeded outpatient resistance rates, particularly for third-generation cephalosporins and ciprofloxacin. Most notably (in my opinion anyway) was Escherichia coli resistance to ampicillin in the outpatient and inpatient settings (45% vs 55%, P < .001).
KEY WORDS evidence-based medicine, journal club www.hospitalpediatrics.org doi:10.1542/hpeds.2014-0116 Address correspondence to Eric Biondi, MD, University of Rochester, 601 Elmwood Ave, Box 667, Rochester, NY 14642. E-mail: eric_biondi@ urmc.rochester.edu HOSPITAL PEDIATRICS (ISSN Numbers: Print, 2154 - 1663; Online, 2154 - 1671). Copyright © 2014 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
Why do we care?
This article substantiates the claim previously suggested by single-center studies that resistance patterns for uropathogens differ in the outpatient and inpatient settings. Thus, we should likely be using separate inpatient- and outpatient-based antibiograms to optimize effective empirical antibiotic use for treatment of urinary tract infection. That said, it is probably worth pointing out that there is site-to-site variability in determining who gets admitted for urinary tract infections (UTI), and this study was not designed to address this confounder or, more specifically, to account for severity of illness.
* Please cite as “Biondi E. Term coined while sitting at his desk writing his final journal club, sometime around July 2014.”
408 |
VOLUME 4 • ISSUE 6 www.hospitalpediatrics.org Downloaded from http://hosppeds.aappublications.org/ at University of Pennsylvania Library on June 29, 2015
HOSPITAL Pediatrics ®
Words from a hospitalist . . . “The common, often reflexive, empiric inpatient UTI management is getting a little trickier thanks to antibiotic resistance. Fortunately, this study’s accessible analysis of gender and age-stratified patterns of UTI organism and resistance can help pediatric hospitalists make wiser empiric treatment decisions when used in combination with your local antibiogram . . . if it is based on inpatient cultures. The differences between inpatient and outpatient patterns are also reminders to investigate how your local antibiogram is constructed.” – Dr Rebecca Rosenberg, pediatric hospitalist, NYU Langone Medical Center
Saperston KN, Shapiro DJ, Hersh AL, Copp HL. A comparison of inpatient versus outpatient resistance patterns of pediatric urinary tract infection. J Urol. 2014;191(suppl 5):1608–1613.
I REFUSE TO TITLE THIS “SHOW ME THE MONEY,” BUT IT WOULD PROBABLY MAKE SENSE There seems to be this general attitude in pediatrics that financial incentives are for “the other guys”—the investment bankers, salespeople, and the surgeons. Why is that? There’s no reason to think that we don’t care, at least a little bit, about money. The study.
This one is really cool. In 2006, a large academic medical center designed a financial incentive program to improve certain quality metrics. This program included a $400 bonus for project goals met by residents and fellows, up to $1200 per year per trainee. Projects were placed in 3 domains: patient satisfaction, quality/safety, and operation/utilization. Residents and fellows could also submit their own projects for approval in the incentive program.
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
The key findings.
During the first 6 years of the incentive program (2007–2012), 5275 residents and fellows participated, including 540 residents and fellows who participated in projects submitted by trainees. On average, $724 450 were paid in bonuses each year (∼$800 per trainee). The patient satisfaction project goal was met in 4 of the 6 years, the quality/safety and operation/utilization project goals were met inconsistently (although trainees were more compliant than faculty), but trainees did appear more engaged in the quality improvement process, culminating in dozens of projects being proposed, and completed successfully, by residents and fellows. In total, trainees worked on 55 projects and achieved 71% of the goals set. It is worth pointing out that because this was not originally designed as a research study, there was no control group or baseline data from which to compare the success of the program, which limits the ability to calculate a specific return on investment. Why do we care?
This group got residents and fellows to submit dozens of quality improvement projects on their own and to accomplish the goals contained within them. Although we can’t perform a marginal cost-benefit analysis here, it does appear that using carefully thought out financial incentives to congruently align the goals of the institution and trainees may be worth at least a cursory look. And why shouldn’t they be? There may be some scientific debate regarding financial incentives, but every other business sector uses them, and trainees will likely be included in some incentive program
upon beginning their first posttraining job anyway. In the words of the expert . . . “Pediatric hospitalists are in the ideal position to mentor the next generation of physicians in improving the quality, safety, and efficiency of clinical care, and introduce them to the increasingly prevalent pay-for-performance reimbursement model. This paper offers an innovative framework in which these goals can be accomplished to everyone’s benefit: residents, hospitalists, institutions, and most of all, patients.” – Dr Michael S. Leonard, Chief Quality Officer and pediatric hospitalist, Golisano Children’s Hospital at UR Medicine
Vidyarthi AR, Green AL, Rosenbluth G, Baron RB. Engaging residents and fellows to improve institution-wide quality: the first six years of a novel financial incentive program. Acad Med. 2014;89(3):460–468.
STRRRRREEEETTTTCCHHHHED TOO THIN How many patients should be on your daily census? In pediatrics, the answer eludes us. We know that we have to balance clinical outcomes and patient safety against the potentially excessive costs of limiting workload, but to what extent? An article in JAMA Internal Medicine this month may help shed some light on the issue, at least in the adult world anyway, by aiming to determine the associations among workload, efficiency, and quality of inpatient care. The study.
This was a retrospective cohort study of 20 241 inpatient adult admissions at a large academic community hospital system from 2008 to 2011. Outcomes of interest included, among other
Downloaded from http://hosppeds.aappublications.org/ at University of Pennsylvania Library on June 29, 2015
| 409
HOSPITAL Pediatrics ®
AN OFFICIAL JOURNAL OF THE AMERICAN ACADEMY OF PEDIATRICS
things, length of stay (LOS), cost, and patient satisfaction.
patient. Changes in workload were not associated with patient satisfaction.
The key findings.
Why do we care?
When hospital occupancy was 85% capacity, LOS decreased slightly as the census began to climb and then increased significantly. Hospital costs (converted from charges in this paper) increased by $111 per patient for each additional
Increasing the workload of hospitalists is associated with increased LOS and cost.
410 |
In the words of the expert . . . “What is the mechanism for the observed association between workload and length of stay/costs? This efficiency [of hospitalists] is explained partly by the ability of a hospitalist to see a patient in the morning and then drive a hospitalization forward, for example, by talking to consultants . . . . A hospitalist with a census of 20 patients,
who starts rounds at 7:30 AM and spends 15 minutes with each patient, will not see patient number 20 until after noon. It is plausible that a potential discharge might be delayed or an extra test ordered simply to move things forward.1” – Dr. Robert Wachter, Chief of Hospital Medicine, Department of Medicine, University of California, San Francisco (quotes taken directly from accompanying article commentary)
Elliott DJ, Young RS, Brice J, et al. Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med. 2014;174(5):786–793. 1. Wachter RM. Hospitalist workload: the search for the magic number. JAMA Intern Med. 2014;174(5):794–795.
VOLUME 4 • ISSUE 6 www.hospitalpediatrics.org Downloaded from http://hosppeds.aappublications.org/ at University of Pennsylvania Library on June 29, 2015
The Superbugs Are Coming! Eric Biondi Hospital Pediatrics 2014;4;408 DOI: 10.1542/hpeds.2014-0116
Updated Information & Services
including high resolution figures, can be found at: http://hosppeds.aappublications.org/content/4/6/408
Subspecialty Collections
This article, along with others on similar topics, appears in the following collection(s): Administration/Practice Management http://hosppeds.aappublications.org/cgi/collection/administration:pra ctice_management_sub Evidence-Based Medicine http://hosppeds.aappublications.org/cgi/collection/evidence-based_m edicine_sub Quality Improvement http://hosppeds.aappublications.org/cgi/collection/quality_improvem ent_sub
Permissions & Licensing
Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://hosppeds.aappublications.org/site/misc/Permissions.xhtml
Reprints
Information about ordering reprints can be found online: http://hosppeds.aappublications.org/site/misc/reprints.xhtml
Downloaded from http://hosppeds.aappublications.org/ at University of Pennsylvania Library on June 29, 2015
The Superbugs Are Coming! Eric Biondi Hospital Pediatrics 2014;4;408 DOI: 10.1542/hpeds.2014-0116
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://hosppeds.aappublications.org/content/4/6/408
Hospital Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 2012. Hospital Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 2154-1663.
Downloaded from http://hosppeds.aappublications.org/ at University of Pennsylvania Library on June 29, 2015
