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Introduction: Pseudomonas citronellolis is an unusual pathogen in humans and has not been extensively described in the scientific literature. Herein, we present a case of bacteremia and septic shock due to Pseudomonas citronellolis following Campylobacter species gastroenteritis in a patient with immunosuppression. Case Presentation: An 80-year-old man with myeloproliferative disorder on ruxolitinib presented with several days of worsening abdominal pain, which rapidly developed into septic shock with multi-organ failure and explosive diarrhea. Gram-negative bacilli observed on Gram staining of his blood culture broth were later identified as Pseudomonas citronellolis and Bacteroides thetaiotaomicron . Repeated abdominal imaging revealed no evidence of intestinal perforation or megacolon. In addition, stool PCR was positive for Campylobacter species. His clinical course improved after 14 days of meropenem with complete resolution of his symptoms and organ failure. Conclusion: P. citronellolis is a rare infection in humans. We postulate that Janus Associated Kinase (JAK) inhibition in myeloproliferative disorders heightened this patient's risk of bacterial translocation and severe illness in the setting of Campylobacter gastroenteritis. P. citronellolis may be identified more frequently as a pathogen in humans as more advanced diagnostic technologies become increasingly available in clinical microbiology.

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OBJECTIVE: Despite face validity and regulatory support, empirical evidence of the benefit of culture change practices in nursing homes (NHs) has been inconclusive. We used rigorous methods and large resident-level cohorts to determine whether NH increases in culture change practice adoption in the domains of environment, staff empowerment, and resident-centered care are associated with improved resident-level quality outcomes. DESIGN: We linked national panel 2009-2011 and 2016-2017 survey data to Minimum Data Set assessment data to test the impact of increases in each of the culture change domains on resident quality outcomes. SETTING AND PARTICIPANTS: The sample included 1584 nationally representative US NHs that responded to both surveys, and more than 188,000 long-stay residents cared for in the pre- and/or postsurvey periods. METHODS: We used multivariable logistic regression with robust standard errors and a difference-in-differences methodology. Controlling for the endogeneity between increases in culture change adoption and NH characteristics that are also related to quality outcomes, we tested whether pre-post quality outcome differences (ie, improvements in outcomes) were greater for residents in NHs with culture change increases vs in those without such increases. RESULTS: NH performance on most quality indicators improved, but improvement was not significantly different by whether NHs increased or did not increase their culture change domain practices. CONCLUSIONS AND IMPLICATIONS: This study found that increases in an NH's culture change domain practices were not significantly associated with improved resident-level quality. It describes a number of potential limitations that may have contributed to the null findings.

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OBJECTIVE: To compare the impact of the introduction of two distinct sets of star ratings, quality of care, and patient experience, on home health agency (HHA) selection. DATA SOURCES: We utilized 2014-2016 home health Outcome and Assessment Information Set (OASIS) assessments, as well as publicly reported data from the Home Health Compare website. DATA COLLECTION/EXTRACTION METHODS: We identified a 5% random sample of admissions (186,498 admissions) for new Medicare Fee-for-Service home health users. STUDY DESIGN: This admission-level assessment compared HHA selection before (July 2014-June 2015) and after (February-December 2016) star ratings were published. We utilized a conditional logit, discrete choice model, which accounted for all HHAs that each patient could have selected (i.e., the choice set) based on ZIP codes. Our explanatory variables of interest were the interactions between star ratings and time period (pre/post stars). We stratified our analyses by race, admission source, and Medicaid eligibility. We adjusted for HHA characteristics and distance between patients' homes and HHAs. PRINCIPAL FINDINGS: The introduction of star ratings was associated with a 0.88-percentage-point increase in the probability of selecting a high-quality HHA and a 0.81-percentage-point increase in the probability of selecting a highly ranked patient experience HHA. Patients admitted from the community, and black and Medicare-Medicaid dual-eligible beneficiaries experienced larger increases in their likelihood of selecting high-rated agencies than inpatient, white, and nondual beneficiaries. CONCLUSIONS: The introduction of quality of care and patient experience stars were associated with changes in HHA selection; however, the strength of these relationships was weaker than observed in other health care settings where a single star rating was reported. The introduction of star ratings may mitigate disparities in HHA selection. Our findings highlight the importance of reporting information about quality and satisfaction separately and conducting research to understand the mechanisms driving HHA selection.

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To facilitate home health agency (HHA) selection, CMS released patient experience star ratings on the Home Health Compare website in January 2016. Our objective was to understand the relationship between patient experience and outcomes in HHAs. We utilized publicly reported data to evaluate the relationships among patient experience star ratings, summary quality of care star ratings (comprised primarily of outcome measures), and individual outcome measures for 4,249 HHAs. Results indicate a weak correlation between patient experience and quality stars (r = .13, p < .001). The difference between the lowest and highest rated HHAs for patient experience is associated with only a half-star improvement in quality stars. The associations between patient experience and individual outcome measures varied, with functional outcomes most strongly associated with patient experience. Findings highlight the importance of reporting separate quality domains; however, conflicting ratings may complicate the HHA selection process and introduce misaligned incentives for HHAs.

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The Home Health Value-Based Purchasing Model (HHVBP) is a new Medicare model wherein home health agencies compete to achieve higher reimbursements by demonstrating improved value according to clinical and patient experience-related quality measures. Many measures used in HHVBP overlap with measures used in quality star ratings for home health agencies. Thus, improvements in quality measures used in HHVBP may also be reflected in changes in star ratings. However, it is unclear whether agencies competing in HHVBP improve their Centers for Medicare & Medicaid Services star ratings compared with those not competing. Using publicly available data from Centers for Medicare & Medicaid Services, we evaluated the effect of HHVBP on quality of patient care and patient experience composite star ratings over a 2-year period using a difference-in-differences analysis. We found evidence for a small, statistically significant increase in quality of patient care star ratings for agencies participating in HHVBP, and no effect on patient experience ratings.

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BACKGROUND AND OBJECTIVES: The study aimed to: (i) describe whether culture change (CC) practice implementation related to physical environment, resident-centered care, and staff empowerment increased within the same nursing homes (NHs) over time; and (ii) identify factors associated with observed increases. RESEARCH DESIGN AND METHODS: This was a nationally representative panel study of 1,584 U.S. NHs surveyed in 2009/2010 and 2016/2017. Survey data were merged with administrative, NH, and market-level data. Physical environment, staff empowerment, and resident-centered care domain scores were calculated at both time points. Multivariate logistic regression models examined factors associated with domain score increases. RESULTS: Overall, 22% of NHs increased their physical environment scores over time, 32% their staff empowerment scores, and 44% their resident-centered care scores. However, 32%-68% of NHs with below median baseline scores improved their domain scores over time compared with only 11%-21% of NHs with baseline scores at or above the median. Overall, NHs in states with Medicaid pay-for-performance (with CC components), in community care retirement communities, with special care units and higher occupancy had significantly higher odds of increases in physical environment scores. Only baseline domain scores were associated with increases in staff empowerment and resident-centered care scores. DISCUSSION AND IMPLICATIONS: This is the first nationally representative panel study to assess NH CC adoption. Many NHs increased their CC practices, though numerous others did not. While financial incentives and indicators of financial resources were associated with increase in physical environment scores, factors associated with staff empowerment and resident-centered care improvements remain unclear. Studies are needed to assess whether the observed increases in CC adoption are associated with greater quality of life and care gains for residents and whether there is a threshold effect beyond which the efficacy of additional practice implementation may be less impactful.

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BACKGROUND: This article describes characteristics of patients receiving home health following an initial cancer diagnosis, comparing those enrolled in Medicare Advantage (MA) and Traditional Medicare (TM), using the newly linked 2010-2014 National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare and home health Outcome and Assessment Information Set (OASIS) data. METHODS: We identified SEER-Medicare beneficiaries with at least one OASIS assessment within 3 months of cancer diagnosis in 2010-2014, and summarized their demographic and clinical characteristics. Demographic and diagnostic data were obtained from the SEER-Medicare data, while further details about cognitive status, mood, function, and medical history were obtained from OASIS. We assessed differences between MA and TM beneficiaries using chi-square tests for independence, t-tests, and Kruskal-Wallis tests. RESUTLS: We identified 104 023 patients who received home health within 3 months of cancer diagnosis: 81 587 enrolled in TM and 22 436 enrolled in MA. TM cancer patients had higher unadjusted rates of home health use than MA patients (16.3% vs 10.3%, P < .001). TM cancer patients receiving home health had more limitations in their cognitive function than their MA counterparts and longer lengths of service (mean = 42.2 days vs 39.4 days, P < .001; median = 27 vs 26 days, interquartile range = 42). CONCLUSION: This study demonstrates the large number of cancer patients in the SEER-Medicare-OASIS data and describes characteristics for TM and MA patients. These newly linked data can be used to assess home health care among older patients with cancer.

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OBJECTIVES: We examined the relationship between nursing assistant (NA) retention and a measure capturing nursing home leadership and staff empowerment. DESIGN: Cross-sectional study using nationally representative survey data. SETTING AND PARTICIPANTS: Data from the Nursing Home Culture Change 2016-2017 Survey with nursing home administrator respondents (N = 1386) were merged with facility-level indicators. METHODS: The leadership and staff empowerment practice score is an index derived from responses to 23 survey items and categorized as low, medium, and high. Multinomial logistic regression weighted for sample design and to address culture-change selection bias identified factors associated with 4 categories of 1-year NA retention: 0% to 50%, 51% to 75%, 76% to 90%, and 91% to 100%. RESULTS: In an adjusted model, greater leadership and staff empowerment levels were consistently associated with high (76%-90% and 91%-100%) relative to low (0%-50%) NA retention. Occupancy rate, chain status, licensed practical nurse and certified nursing assistant hours per day per resident, nursing home administrator turnover, and the presence of a union were also significantly associated with higher categories of retention (vs low retention). CONCLUSIONS AND IMPLICATIONS: Modifiable leadership and staff empowerment practices are associated with NA retention. Associations are most significant when examining the highest practice scores and retention categories. Nursing homes seeking to improve NA retention might look to leadership and staff empowerment practice changes common to culture change.

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A small proportion of high-need (HN) Medicare beneficiaries account for a large share of medical expenditures in the United States. Identifying hospitals with the best outcomes for HN patients is central to identifying and spreading evidence-based practices to improve care for this population. The objective of this study was to identify and characterize top-performing hospitals for HN patients. Administrative claims data from 2013-2014 were used to identify HN beneficiaries and their treating hospital; hospitals were ranked based on their HN beneficiaries' outcomes in 2015. Hospitalization, mortality, and days spent in community were assessed, and all outcomes were risk standardized for age, sex, dual eligibility, and hospital referral region. American Hospital Association and aggregated inpatient claims data characterized hospitals. Logistic regression models estimated the odds of ranking in the top 20% on all outcomes. Of 2253 hospitals with at least 500 HN patients in the United States, 92 (4.1%) ranked in the top 20% across all outcomes. No hospital characteristics were associated with being top performing across all outcomes, but urban hospitals were significantly less likely to perform well on hospitalization and private, for-profit hospitals performed better on mortality. Small hospitals, Accountable Care Organization providers, and those providing palliative care services were more likely to rank highly on days spent in the community. Top-performing hospitals served fewer minority, dual eligible, and HN patients, suggesting that case mix may explain some of the differences in performance, and that additional work is needed to examine programs and practices at outstanding hospitals.

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Importance: Medicare Advantage (MA) enrollment is increasing, with one-third of Medicare beneficiaries currently selecting MA. Despite this growth, it is difficult to assess the quality of the health care professionals and organizations that serve MA beneficiaries or to compare them with health care professionals and organizations serving traditional Medicare (TM) beneficiaries. Elderly individuals served by home health agencies (HHAs) may be particularly susceptible to the negative outcomes associated with low-quality care. Objective: To compare the quality of HHAs that serve TM and MA beneficiaries. Design, Setting, and Participants: This cross-sectional, admission-level analysis used data from 4 391 980 home health admissions identified using the Outcome and Assessment Information Set (most commonly known as OASIS) admission assessments of Medicare beneficiaries in 2015 from Medicare-certified HHAs. A multinomial logistic regression model was used to assess whether an association existed between the Medicare plan type and HHA quality. The model was adjusted for patient demographics, acuity, and characteristics of the zip codes. Sensitivity analyses controlled for zip code fixed effects. The present analysis was conducted between October 2018 and March 2019. Exposures: Home health users were classified as TM or MA beneficiaries using the Master Beneficiary Summary File. The MA beneficiaries were further classified as enrolled in a high- or low-quality MA plan on the basis of publicly reported MA star ratings. Main Outcomes and Measures: Quality of HHA derived from the publicly reported patient care star ratings: low quality (1.0-2.5 stars), average quality (3.0-3.5 stars), or high quality (≥4.0 stars). Results: Of 4 391 980 admissions, most (75.5%) were for TM beneficiaries (mean [SD] age, 76.1 [12.2] years), with 16.6% of beneficiaries enrolled in high-quality MA plans (mean [SD] age, 77.8 [10.0] years) and 7.9% in low-quality MA plans (mean [SD] age, 74.4 [11.4] years). Individuals enrolled in low-rated MA plans were most likely to be nonwhite (percentages of nonwhite individuals in TM, 14.3%; in high-quality MA, 19.8%; and in low-quality MA, 36.5%) and dual Medicare-Medicaid eligible (percentages for dual eligible in TM, 30.5%; in high-quality MA, 19.5%; and in low-quality MA, 43.3%). Among TM beneficiaries, 30.4% received care from high-quality HHAs, whereas 17.0% received care from low-quality HHAs. Compared with TM beneficiaries, those in a low-quality MA plan were 3.0 percentage points (95% CI, 2.6%-3.4%) more likely to be treated by a low-quality HHA and 4.9 percentage points (95% CI, -5.4% to -4.3%) less likely to be treated by a high-quality HHA. The MA beneficiaries in high-quality plans were also less likely to receive care from high-quality vs low-quality HHAs (-2.8% [95% CI, -3.1% to -2.2%] vs 1.0% [95% CI, 0.7%-1.3%]). Conclusions and Relevance: Compared with TM beneficiaries, MA beneficiaries residing in the same zip code enrolled in either high- or low-quality MA plans may receive treatment from lower-quality HHAs. Policy makers may consider incentivizing MA plans to include higher-quality HHAs in their networks and improving patient education regarding HHA quality.

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INTRODUCTION: Fecal microbiota transplantation resolves recurrent Clostridium difficile infections in greater than 82% of patients. Highly screened, processed universal donor fecal material is available. We compared cost and scheduling efficiency of fecal microbiota transplantation by universal donors to patient-directed donors. METHODS: Medical records from a prospectively maintained database of recurrent C. difficile patients who underwent fecal microbiota transplantation between 2012 and 2017 were reviewed retrospectively. Patient-directed donor stool was prepared in our microbiology laboratory using protocol-based screening. We transitioned to purchasing and using universal donor fecal material in 2015. Clinical outcomes, adverse events, time between consult to infusion, consultation fees, and material costs were compared. This was a retrospective comparison of two historical cohorts. RESULTS: A total of 111 fecal microbiota transplantations were performed on 105 patients (56 from patient-directed donors and 55 from universal donors). Median recipient age was 66 years (18-96) with male to female ratio of 1:2.7, equivalent in both cohorts. Total consultation fees were significantly lower in the universal donor group owing to fewer infectious disease consultations. Costs for donor screening and stool preparation were lower in the universal donor cohort ($485.0 vs. $1189.90 ± 541.4, p < 0.001, 95% CI 559.9-849.9). Time from consultations to infusion was shorter in the universal donor cohort (18.9 ± 19.1 vs. 36.4 ± 23.3 days, p < 0.001, 95% CI 9.521-25.591). Recurrences within 8 weeks after fecal microbiota transplantation were equivalent (p = 0.354). Adverse events were equivalent. CONCLUSIONS: Fecal microbiota transplantation using universal donors versus patient-directed donors for recurrent C. difficile showed comparable efficacy and short-term complications. The use of universal donors resulted in significant cost savings and scheduling efficiency.

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CONTEXT: The nursing home (NH) culture change (CC) movement, which emphasizes person-centered care, is particularly relevant to meeting the unique needs of residents near the end of life. OBJECTIVES: We aimed to evaluate the NH-reported adoption of person-centered end-of-life culture change (EOL-CC) practices and identify NH characteristics associated with greater adoption. METHODS: We used NH and state policy data for 1358 NHs completing a nationally representative 2016/17 NH Culture Change Survey. An 18-point EOL-CC score was created by summarizing responses from six survey items related to practices for residents who were dying/had died. NHs were divided into quartiles reflecting their EOL-CC score, and multivariable ordered logistic regression was used to identify NH characteristics associated with having higher (quartile) scores. RESULTS: The mean EOL-CC score was 13.7 (SD = 3.0). Correlates of higher scores differed from those previously found for non-EOL-CC practices. Higher NH leadership scores and nonprofit status were consistently associated with higher EOL-CC scores. For example, a three-point leadership score increase was associated with higher odds of an NH performing in the top EOL-CC quartile (odds ratio [OR] = 2.0, 95% CI: 1.82-2.30), whereas for-profit status was associated with lower odds (OR = 0.7, 95% CI: 0.49-0.90). The availability of palliative care consults was associated with a greater likelihood of EOL-CC scores above the median (OR = 1.5, 95% CI: 1.10-1.93), but not in the top or bottom quartile. CONCLUSION: NH-reported adoption of EOL-CC practices varies, and the presence of palliative care consults in NHs explains only some of this variation. Findings support the importance of evaluating EOL-CC practices separately from other culture change practices.

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BACKGROUND AND OBJECTIVES: Given the dynamic nursing home (NH) industry and evolving regulatory environment, depiction of contemporary NH culture-change (person/resident-centered) care practice is of interest. Thus, we aimed to portray the 2016/2017 prevalence of NH culture change-related processes and structures and to identify factors associated with greater practice prevalence. RESEARCH DESIGN AND METHODS: We administered a nationwide survey to 2142 NH Administrators at NHs previously responding to a 2009/2010 survey. Seventy-four percent of administrators (1583) responded (with no detectable nonresponse bias) enabling us to generalize (weighted) findings to US NHs. From responses, we created index scores for practice domains of resident-centered care, staff empowerment, physical environment, leadership, and family and community engagement. Facility-level covariate data came from the survey and the Certification and Survey Provider Enhanced Reporting system. Ordered logistic regression identified the factors associated with higher index scores. RESULTS: Eighty-eight percent of administrators reported some facility-level involvement in NH culture change, with higher reported involvement consistently associated with higher domain index scores. NHs performed the best (82.6/100 weighted points) on the standardized resident-centered care practices index, and had the lowest scores (54.8) on the family and community engagement index. Multivariable results indicate higher index scores in NHs with higher leadership scores and in states having Medicaid pay-for-performance with culture change-related quality measures. CONCLUSIONS: The relatively higher resident-centered care scores (compared with other domain scores) suggest an emphasis on person-centered care in many US NHs. Findings also support pay-for-performance as a potential mechanism to incentivize preferred NH practice.

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BACKGROUND: Since 1990, the National Cancer Institute (NCI) and Centers for Medicare and Medicaid Services (CMS) have collaborated to create linked data resources to improve our understanding of patterns of care, health care costs, and trends in utilization. However, existing data linkages have not included measures of patient experiences with care. OBJECTIVE: To describe a new resource for quality of care research based on a linkage between the Medicare Consumer Assessment of Healthcare Providers and Systems (CAHPS®) patient surveys and the NCI's Surveillance, Epidemiology and End Results (SEER) data. DESIGN: This is an observational study of CAHPS respondents and includes both fee-for-service and Medicare Advantage beneficiaries with and without cancer. The data linkage includes: CAHPS survey data collected between 1998 and 2010 to assess patient reports on multiple aspects of their care, such as access to needed and timely care, doctor communication, as well as patients' global ratings of their personal doctor, specialists, overall health care, and their health plan; SEER registry data (1973-2007) on cancer site, stage, treatment, death information, and patient demographics; and longitudinal Medicare claims data (2002-2011) for fee-for-service beneficiaries on utilization and costs of care. PARTICIPANTS: In total, 150,750 respondents were in the cancer cohort and 571,318 were in the non-cancer cohort. MAIN MEASURES: The data linkage includes SEER data on cancer site, stage, treatment, death information, and patient demographics, in addition to longitudinal data from Medicare claims and information on patient experiences from CAHPS surveys. KEY RESULTS: Sizable proportions of cases from common cancers (e.g., breast, colorectal, prostate) and short-term survival cancers (e.g., pancreas) by time since diagnosis enable comparisons across the cancer care trajectory by MA vs. FFS coverage. CONCLUSIONS: SEER-CAHPS is a valuable resource for information about Medicare beneficiaries' experiences of care across different diagnoses and treatment modalities, and enables comparisons by type of insurance.

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OBJECTIVES: Patients who are immunocompromised (IC) are at increased risk of Clostridium difficile infection (CDI), which has increased to epidemic proportions over the past decade. Fecal microbiota transplantation (FMT) appears effective for the treatment of CDI, although there is concern that IC patients may be at increased risk of having adverse events (AEs) related to FMT. This study describes the multicenter experience of FMT in IC patients. METHODS: A multicenter retrospective series was performed on the use of FMT in IC patients with CDI that was recurrent, refractory, or severe. We aimed to describe rates of CDI cure after FMT as well as AEs experienced by IC patients after FMT. A 32-item questionnaire soliciting demographic and pre- and post-FMT data was completed for 99 patients at 16 centers, of whom 80 were eligible for inclusion. Outcomes included (i) rates of CDI cure after FMT, (ii) serious adverse events (SAEs) such as death or hospitalization within 12 weeks of FMT, (iii) infection within 12 weeks of FMT, and (iv) AEs (related and unrelated) to FMT. RESULTS: Cases included adult (75) and pediatric (5) patients treated with FMT for recurrent (55%), refractory (11%), and severe and/or overlap of recurrent/refractory and severe CDI (34%). In all, 79% were outpatients at the time of FMT. The mean follow-up period between FMT and data collection was 11 months (range 3-46 months). Reasons for IC included: HIV/AIDS (3), solid organ transplant (19), oncologic condition (7), immunosuppressive therapy for inflammatory bowel disease (IBD; 36), and other medical conditions/medications (15). The CDI cure rate after a single FMT was 78%, with 62 patients suffering no recurrence at least 12 weeks post FMT. Twelve patients underwent repeat FMT, of whom eight had no further CDI. Thus, the overall cure rate was 89%. Twelve (15%) had any SAE within 12 weeks post FMT, of which 10 were hospitalizations. Two deaths occurred within 12 weeks of FMT, one of which was the result of aspiration during sedation for FMT administered via colonoscopy; the other was unrelated to FMT. None suffered infections definitely related to FMT, but two patients developed unrelated infections and five had self-limited diarrheal illness in which no causal organism was identified. One patient had a superficial mucosal tear caused by the colonoscopy performed for the FMT, and three patients reported mild, self-limited abdominal discomfort post FMT. Five (14% of IBD patients) experienced disease flare post FMT. Three ulcerative colitis (UC) patients underwent colectomy related to course of UC >100 days after FMT. CONCLUSIONS: This series demonstrates the effective use of FMT for CDI in IC patients with few SAEs or related AEs. Importantly, there were no related infectious complications in these high-risk patients.

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CONTEXT: Patients in tertiary care hospitals are more complex than in the past, but the implications of this are poorly understood as "patient complexity" has been difficult to quantify. OBJECTIVE: We developed a tool, the Complexity Ruler, to quantify the amount of data (as bits) in the patient's medical record. We designated the amount of data in the medical record as the cognitive complexity of the medical record (CCMR). We hypothesized that CCMR is a useful surrogate for true patient complexity and that higher CCMR correlates with risk of major adverse events. DESIGN: The Complexity Ruler was validated by comparing the measured CCMR with physician rankings of patient complexity on specific inpatient services. It was tested in a case-control model of all patients with major adverse events at a tertiary care pediatric hospital from 2005 to 2006. MAIN OUTCOME MEASURES: The main outcome measure was an externally reported major adverse event. We measured CCMR for 24 hours before the event, and we estimated lifetime CCMR. RESULTS: Above empirically derived cutoffs, 24-hour and lifetime CCMR were risk factors for major adverse events (odds ratios, 5.3 and 6.5, respectively). In a multivariate analysis, CCMR alone was essentially as predictive of risk as a model that started with 30-plus clinical factors. CONCLUSIONS: CCMR correlates with physician assessment of complexity and risk of adverse events. We hypothesize that increased CCMR increases the risk of physician cognitive overload. An automated version of the Complexity Ruler could allow identification of at-risk patients in real time.

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OBJECTIVES/HYPOTHESIS: There is controversy about which children should be admitted after adenotonsillectomy (T&A) and limited clinical evidence to help with this decision. Current practice has evolved based on empirical or anecdotal evidence. We sought to identify practice variations in postoperative admission after T&A in tertiary care pediatric hospitals. STUDY DESIGN: Retrospective database study using administrative information stored in the Pediatric Health Information System (PHIS) database. METHODS: There were 29,920 T&As performed in 24 pediatric hospitals included in the PHIS database between July 1, 2009 and June 30, 2010. Patients were identified as outpatient (discharged the same day) or inpatient (not discharged on the day of surgery). We examined admission rates across different hospitals stratified by age, obstructive sleep apnea (OSA), and other complex chronic conditions. RESULTS: Younger age, the existence of a complex chronic condition, and OSA were all associated with higher post-T&A admission rates. Admission rates ranged from >94% for children under 2 years of age, with OSA and at least one medical comorbidity, to 14% for children older than 5 years, without OSA and without any medical comorbidities. Between-hospital variability was extreme; for example, for 3 to 5 year olds, the admission rate varied from 5% to 90% between hospitals. Very significant variation remained even after controlling for age, comorbidities, and OSA. CONCLUSIONS: Post T&A admission rates vary tremendously across comparable tertiary-care pediatric hospitals. There is a crucial need for a better understanding of the risk of complications on the first postoperative night, and the appropriate indications for monitored admission on that night. LEVEL OF EVIDENCE: 4.

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OBJECTIVES/HYPOTHESIS: To identify clinical risk factors for oxygen desaturation in the first 24 hours post-tonsillectomy, thus permitting the identification of those patients who warrant inpatient monitoring. STUDY DESIGN: A retrospective analysis of 4092 consecutive patients undergoing tonsillectomy over a two-year period. METHODS: Detailed clinical data were recorded for all patients who desaturated in the postoperative period (n = 294) and randomly selected controls (n = 368). Univariate and multivariate analysis was performed in order to identify independent risk factors for desaturation. RESULTS: There were 294/4092 patients (7.2%) who experienced desaturations (defined as sustained saturations <90%) in the first 24 hours postoperatively (mean nadir, 78.7%). Multivariate analysis identified seven independent clinical risk factors for desaturation in the initial 24 hours post-tonsillectomy: trisomy 21, weight, coexistent cardiac disease, a coexistent syndromic diagnosis, a clinical diagnosis of obstructive sleep apnea (OSA), a coexistent neurologic diagnosis, and a prior diagnosis of pulmonary disease. A policy that admits all patients exhibiting any one of these risk factors except OSA would have identified 92% of the patients who subsequently desaturated. However, such a policy would also have required admission of 60% of the patients in our control group. CONCLUSIONS: These findings are generally consistent with the Clinical Practice Guidelines recently published by the American Academy of Otolaryngology. In a tertiary care center, it may not be possible to identify an algorithm that admits all children at risk of desaturation while permitting the discharge of a high percentage of patients. LEVEL OF EVIDENCE: 3b.

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BACKGROUND: From 2005 through 2007, Seattle health care providers identified cases of primary multiclass drug-resistant (MDR) HIV-1 with common patterns of resistance to antiretrovirals (ARVs). Through surveillance activities and genetic analysis, the local Health Department and the University of Washington identified phylogenetically linked cases among ARV treatment-naive and -experienced individuals. METHODS: HIV-1 pol nucleotide consensus sequences submitted to the University of Washington Clinical Virology Laboratory were assessed for phylogenetically related MDR HIV. Demographic and clinical data collected included HIV diagnosis date, ARV history, and laboratory results. RESULTS: Seven ARV-naive men had phylogenetically linked MDR strains with resistance to most ARVs; these were linked to 2 ARV-experienced men. All 9 men reported methamphetamine use and multiple anonymous male partners. Primary transmissions were diagnosed for more than a 2-year period, 2005-2007. Three, including the 2 ARV-experienced men, were prescribed ARVs. CONCLUSIONS: This cluster of 9 men with phylogenetically related highly drug-resistant MDR HIV strains and common risk factors but without reported direct epidemiologic links may have important implications to public health. This cluster demonstrates the importance of primary resistance testing and of collaboration between the public and private medical community in identifying MDR outbreaks. Public health interventions and surveillance are needed to reduce transmission of MDR HIV-1.

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