Background Antimicrobial resistance is a widely recognized public health threat, and stewardship interventions to combat this problem are well described. Less is known about antifungal stewardship (AFS) initiatives and their influence within the United States. The purpose of this study was to evaluate evidence on the impact of AFS interventions on clinical and performance measures. Methods A systematic review of English language studies identified in the PubMed and EMBASE databases was performed through November 2017. The review was conducted in accordance with PRISMA. Search terms included antifungal stewardship, antimicrobial stewardship, Candida , candidemia, candiduria, and invasive fungal disease. Eligible studies were those that described an AFS program or intervention occurring in the US and evaluated clinical or performance measures. Results Fifty-four articles were identified and 13 were included. Five studies evaluated AFS interventions and reported clinical outcomes (mortality and length of stay) and performance measures (appropriate antifungal choice and time to therapy). The remaining eight studies evaluated general stewardship interventions and reported data on antifungal consumption. All studies were single center, quasi-experimental with varying interventions across studies. AFS programs had no impact on mortality (3 of 3 studies), with an overall rate of 27% in the intervention group and 23% in the non-intervention group. Length of stay (5 of 5) was also similar between groups (range, 9–25 vs. 11–22). Time to antifungal therapy improved in 2 of 5 studies, and appropriate choice of antifungal increased in 2 of 2 studies. Antifungal consumption was significantly blunted or reduced following stewardship initiation (8 of 8), although a direct comparison between studies was not possible due to a lack of common units. Conclusion The available evidence suggests that AFS interventions can improve performance measures and decrease antifungal consumption. Although this review did not detect improvements in clinical outcomes, significant adverse outcomes were not reported.

Background Early hospital readmissions remain common in patients with conditions targeted by the CMS Hospital Readmission Reduction Program (HRRP). There is still no consensus on whether readmission measures should be adjusted based on social factors, and there are few population studies within the U.S. examining how social characteristics influence readmissions for HRRP-targeted conditions. The objective of this study was to determine if specific socio-demographic and -economic factors are associated with 30-day readmissions in HRRP-targeted conditions: acute exacerbation of chronic obstructive pulmonary disease, pneumonia, acute myocardial infarction, and heart failure. Methods The Nationwide Readmissions Database was used to identify patients admitted with HRRP-targeted conditions between January 1, 2010 and September 30, 2015. Stroke was included as a control condition because it is not included in the HRRP. Multivariate models were used to assess the relationship between three social and economic characteristics (gender, urban/rural hospital designation, and estimated median household income within the patient’s zip code) and 30-day readmission rates using a hierarchical two-level logistic model. Age-adjusted models were used to assess relationship differences between Medicare vs. non-Medicare populations. Results There were 19,253,997 weighted index hospital admissions for all diagnoses and 3,613,488 30-day readmissions between 2010 and 2015. Patients in the lowest income quartile (≤$37,999) had an increased odds of 30-day readmission across all conditions (P < 0.0001). Female gender and rural hospital designation were associated with a decreased odds of 30-day readmission for most targeted conditions (P < 0.05). Similar findings were also seen in patients ≥65 years old. Conclusions Socio-demographic and -economic factors are associated with 30-day readmission rates and should be incorporated into tools or interventions to improve discharge planning and mitigate against readmission.

Background The Hospital Readmissions Reduction Program (HRRP) was introduced to reduce readmission rates among Medicare beneficiaries, however little is known about readmissions and costs for HRRP-targeted conditions in younger populations. The primary objective of this study was to examine readmission trends and costs for targeted conditions during policy implementation among younger and older adults in the U.S. Methods We analyzed the Nationwide Readmission Database from January 2010 to September 2015 in younger (18–64 years) and older (≥65 years) patients with acute myocardial infarction (AMI), heart failure (HF), pneumonia, and acute exacerbations of chronic obstructive pulmonary disease (AECOPD). Pre- and post-HRRP periods were defined based on implementation of the policy for each condition. Readmission rates were evaluated using an interrupted time series with difference-in-difference analyses and hospital cost differences between early and late readmissions (≤30 vs. > 30 days) were evaluated using generalized linear models. Results Overall, this study included 16,884,612 hospitalizations with 3,337,266 readmissions among all age groups and 5,977,177 hospitalizations with 1,104,940 readmissions in those aged 18–64 years. Readmission rates decreased in all conditions. In the HRRP announcement period, readmissions declined significantly for those aged 40–64 years for AMI (p < 0.0001) and HF (p = 0.003). Readmissions decreased significantly in the post-HRRP period for those aged 40–64 years at a slower rate for AMI (p = 0.003) and HF (p = 0.05). Readmission rates among younger patients (18–64 years) varied within all four targeted conditions in HRRP announcement and post-HRRP periods. Adjusted models showed a significantly higher readmission cost in those readmitted within 30 days among younger and older populations for AMI (p < 0.0001), HF (p < 0.0001), pneumonia (p < 0.0001), and AECOPD (p < 0.0001). Conclusion Readmissions for targeted conditions decreased in the U.S. during the enactment of the HRRP policy and younger age groups (< 65 years) not targeted by the policy saw a mixed effect. Healthcare expenditures in younger and older populations were significantly higher for early readmissions with all targeted conditions. Further research is necessary evaluating total healthcare utilization including emergency department visits, observation units, and hospital readmissions in order to better understand the extent of the HRRP on U.S. healthcare.

Objectives: To evaluate differences in receipt of diabetes care services: A1C test, foot examination, dilated eye examination, flu vaccination and serum cholesterol test between privately health-insured and publicly health-insured diabetic subjects. Methods: Using the household component Medical Expenditure Panel Data Survey (MEPS) 2015 consolidated data, a secondary data analysis was carried out. Logistic regression was used to separately model the effect of insurance type on the receipt of each of the diabetes-care quality indicators: dilated eye examination, serum cholesterol test, foot examination, flu vaccination and A1C test. For subjects aged 18-64 yrs., private insurance-only versus public insurance-only users were compared using 348 eligible subjects, while for subjects above 64 yrs., Medicare-only versus Medicare plus private insurance users were compared using sample size of 240. Effects of age, education level, gender, income and race were controlled. Results: For subjects 18-64 yrs., the receipt of eye examination (OR 0.85, 95% CI: 0.51-1.41); foot examination (OR 0.716, 95% CI: 0.42-1.22), A1C test (OR 0.73, 95% CI: 0.40-1.34); flu vaccination (OR 0.901, 95% CI: 0.55-1.48); and serum cholesterol test (OR 1.35, 95% CI: 0.64-2.87); were not significantly associated with type of insurance coverage. Comparing Medicare versus Medicare plus private coverage for subjects above 64 yrs., the receipt of eye examination (OR 1.76, 95% CI: 0.88-3.50); feet examination (OR 1.13, 95% CI: 0.57-2.26), A1C test (OR 0.89, 95% CI: 0.38-2.08); and flu vaccination (OR 1.26, 95% CI: 0.63-2.50) were not significantly associated with type of coverage while odds of blood cholesterol test is higher (OR 1.35, 95% CI: 0.64-2.87) with Medicare plus private coverage users. Conclusions: Receipt of most key preventive and monitoring services among people with diabetes is similar between private and public insurance users, however elderly diabetic Medicare users with any additional private coverage are a little more likely to receive blood cholesterol test than Medicare-only users.

categorized into none (0), mild (1-3), moderate (4-6) or severe limitations (7 and up). Logistical regression was used to assess the association between functional limitations and healthcare utilization. Results: There was a total of 922 HF patients in the dataset. 251(31%) patients had none, 249(27%) had mild, 215(23%) had moderate, 207(19%) had severe functional limitations. For hospital stay, compared with those with no limitations, patients with mild (OR=1.6, 95% CI[1.1-2.5]), moderate (OR=1.6, 95% CI(1.0-2.6)], and severe limitations (OR=3.8 ,95% CI[2.5-5.7]) were more likely to be hospitalized at least once. For multiple hospital stays, patients with mild (OR=3.6, 95% CI[1.6-8.5]), moderate (OR=2.1, 95% CI(1.0-4.7)], and severe limitations (OR=3.6,95% CI[1.6-8.4]) were more likely to have $2 hospital admissions than those with no limitations. For outpatient visits, patients with mild (OR=2.0, 95% CI[1.1-3.6]), moderate (OR=2.5, 95% CI(1.3-4.8)], and severe limitations (OR=2.0,95% CI[1.1-3.8]) were more likely to have $4 outpatient visits than those with no limitations. Conclusions: Among older adults with HF, any degree of functional limitations is associated with higher utilization of healthcare. Future studies should investigate what aspects of functional limitations are predictors of higher utilization of healthcare and if any of these risk factors can be modified.