Publications by authors named "Steven J. Bernstein"
Importance: Little is known about the safety of midline catheters vs peripherally inserted central catheters (PICCs) for outpatient parenteral antimicrobial therapy (OPAT).
Objective: To compare outcomes from midline catheters vs PICCs for OPAT.
Design, Setting, And Participants: This retrospective cohort study included patients who received antimicrobial therapy through a midline catheter or PICC between January 2017 and November 2023 across 69 Michigan hospitals.
Importance: Acute urinary retention (UR) is common, yet variations in diagnosis and management can lead to inappropriate catheterization and harm.
Objective: To develop an algorithm for screening and management of UR among adult inpatients.
Design, Setting, And Participants: In this mixed-methods study using the RAND/UCLA Appropriateness Method and qualitative interviews, an 11-member multidisciplinary expert panel of nurses and physicians from across the US used a formal multi-round process from March to May 2015 to rate 107 clinical scenarios involving diagnosis and management of adult UR in postoperative and medical inpatients.
Background: Quality improvement (QI) programs require significant financial investment. The authors evaluated the cost-effectiveness of a physician-led, performance-incentivized, QI intervention that increased appropriate peripherally inserted central catheter (PICC) use.
Methods: The authors used an economic evaluation from a health care sector perspective.
Importance: Little is known about incidence of, risk factors for, and harms associated with inappropriate diagnosis of community-acquired pneumonia (CAP).
Objective: To characterize inappropriate diagnosis of CAP in hospitalized patients.
Design, Setting, And Participants: This prospective cohort study, including medical record review and patient telephone calls, took place across 48 Michigan hospitals.
Background: Antibiotic overuse at hospital discharge is common, costly, and harmful. While discharge-specific antibiotic stewardship interventions are effective, they are resource-intensive and often infeasible for hospitals with resource constraints. This weakness impacts generalizability of stewardship interventions and has health equity implications as not all patients have access to the benefits of stewardship based on where they receive care.
View Article and Find Full Text PDFBackground: Inappropriate diagnosis of infections results in antibiotic overuse and may delay diagnosis of underlying conditions. Here we describe the development and characteristics of 2 safety measures of inappropriate diagnosis of urinary tract infection (UTI) and community-acquired pneumonia (CAP), the most common inpatient infections on general medicine services.
Methods: Measures were developed from guidelines and literature and adapted based on data from patients hospitalized with UTI and CAP in 49 Michigan hospitals and feedback from end-users, a technical expert panel (TEP), and a patient focus group.
Background: Despite antibiotic stewardship programs existing in most acute care hospitals, there continues to be variation in appropriate antibiotic use. While existing research examines individual prescriber behavior, contextual reasons for variation are poorly understood.
Methods: We conducted an explanatory, sequential mixed-methods study of a purposeful sample of 7 hospitals with varying discharge antibiotic overuse.
Background: Midline catheters (midlines) are increasingly used in patients with advanced chronic kidney disease (CKD).
Objective: This study describes current practice and acute complications associated with midlines in CKD patients.
Designs, Setting, And Participants: Trained abstractors at 66 hospitals from the Michigan Hospital Medicine Safety (HMS) Consortium collected data on a sample of patients who received a midline during hospitalization.
Article Synopsis
- About 5-8 million Americans are on long-term opioid therapy for chronic pain, but stricter prescribing policies are causing increased abrupt discontinuations, leading to problems like untreated pain and potential use of illegal opioids.
- A study involving a panel of 24 experts from various fields in Michigan aimed to create recommendations to enhance patient access to opioid therapy through workshops and discussions.
- The panel produced 11 key recommendations focusing on three themes: reimbursement reform (highest priority), provider education, and addressing racial disparities in care, with specific suggestions like improving payment for complex chronic pain treatment and bundling payments for comprehensive care.
Importance: Hospitalized patients with asymptomatic bacteriuria (ASB) often receive unnecessary antibiotic treatment, which increases antibiotic resistance and adverse events.
Objective: To determine whether diagnostic stewardship (avoiding unnecessary urine cultures) or antibiotic stewardship (reducing unnecessary antibiotic treatment after an unnecessary culture) is associated with better outcomes in reducing antibiotic use for ASB.
Design, Setting, And Participants: This 3-year, prospective quality improvement study included hospitalized general care medicine patients with a positive urine culture among 46 hospitals participating in a collaborative quality initiative, the Michigan Hospital Medicine Safety Consortium.
Little is known about the safety of infusing vasopressors through a midline catheter. To evaluate safety outcomes after vasopressor administration through a midline. We conducted a cohort study of adults admitted to 39 hospitals in Michigan (December 2017-March 2022) who received vasopressors while either a midline or peripherally inserted central catheter (PICC) was in place.
View Article and Find Full Text PDFBackground: The RAND/UCLA Appropriateness Method (RAM), a variant of the Delphi Method, was developed to synthesize existing evidence and elicit the clinical judgement of medical experts on the appropriate treatment of specific clinical presentations. Technological advances now allow researchers to conduct expert panels on the internet, offering a cost-effective and convenient alternative to the traditional RAM. For example, the Department of Veterans Affairs recently used a web-based RAM to validate clinical recommendations for de-intensifying routine primary care services.
View Article and Find Full Text PDFArticle Synopsis
- The study focuses on improving the quality of blood coagulation tests, specifically prothrombin time, international normalized ratio, and partial thromboplastin time.
- It examines the effects of implementing a best practices advisory aimed at enhancing these testing procedures.
- The goal is to measure any significant changes in test results following the advisory to ensure better patient outcomes.
Objective: To describe MiPATH (the Michigan Plan for Appropriate Tailored Healthcare in pregnancy) panel process and key recommendations for prenatal care delivery.
Methods: We conducted an appropriateness study using the RAND Corporation and University of California Los Angeles Appropriateness Method, a modified e-Delphi process, to develop MiPATH recommendations using sequential steps: 1) definition and scope of key terms, 2) literature review and data synthesis, 3) case scenario development, 4) panel selection and scenario revisions, and 5) two rounds of panel appropriateness ratings with deliberation. Recommendations were developed for average-risk pregnant individuals (eg, individuals not requiring care by maternal-fetal medicine specialists).
Background: The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) provides evidence-based criteria for peripherally inserted central catheter (PICC) use. Whether implementing MAGIC improves PICC appropriateness and reduces complications is unknown.
Methods: A quasiexperimental study design to implement MAGIC in 52 Michigan hospitals was used.
Importance: Much of health care involves established, routine use of medical services for chronic conditions or prevention. Stopping these services when the evidence changes or if the benefits no longer outweigh the risks is essential. Yet, most guidelines focus on escalating care and provide few explicit recommendations to stop or scale back (ie, deintensify) treatment and testing.
View Article and Find Full Text PDFBackground: Antibiotics are commonly prescribed to patients as they leave the hospital. We aimed to create a comprehensive metric to characterize antibiotic overuse after discharge among hospitalized patients treated for pneumonia or urinary tract infection (UTI), and to determine whether overuse varied across hospitals and conditions.
Methods: In a retrospective cohort study of hospitalized patients treated for pneumonia or UTI in 46 hospitals between 1 July 2017-30 July 2019, we quantified the proportion of patients discharged with antibiotic overuse, defined as unnecessary antibiotic use, excess antibiotic duration, or suboptimal fluoroquinolone use.
Article Synopsis
- The Michigan Appropriateness Guide for Intravenous Catheters in pediatrics (miniMAGIC) aims to improve decision-making for vascular access devices in pediatric patients by providing evidence-based guidance on selection, characteristics, and insertion techniques.
- The development of miniMAGIC followed a structured process using the RAND Corporation and UCLA Appropriateness Method, involving expert input and case scenarios to define the relevant scope.
- The findings establish clear criteria for choosing intravenous catheters across different pediatric age groups and clinical settings, focusing on minimizing harm and considering patient preferences, while also identifying areas for further research and innovation.
Objective: To critically review the evidence for the selection and insertion of pediatric vascular access devices (VADs).
Data Sources: Data were sourced from the US National Library of Medicine, Cumulative Index to Nursing and Allied Health, the Cochrane Library databases, Embase, and international clinical trial databases.
Study Selection: Clinical practice guidelines, systematic reviews, cohort designs, randomized control trials (RCTs), quasi RCTs, before-after trials, or case-control studies that reported on complications and/or risk as well as reliability of VADs in patients aged 0 to 18 years were included.
Objectives: To describe the methodology undertaken to provide guidance on the appropriateness, as well as inappropriateness, of vascular access device selection, characteristics, and insertion technique for pediatric patients.
Methods: The RAND Corporation-University of California, Los Angeles Appropriateness Method was used. After definition of key terms and scope, a systematic review of the pediatric vascular access literature was undertaken.
In a 2016 survey of 46 Michigan hospitals, we identified four key needs for antibiotic stewardship: clinically-relevant antibiotic data, monitoring compliance, syndrome-specific interventions, and discharge stewardship. A stewardship initiative now addresses these needs within the Michigan Hospital Medicine Safety Consortium.
View Article and Find Full Text PDFObjectives: To formally assess the appropriateness of different timings of urethral catheter removal after transurethral prostate resection or ablation. Although urethral catheter placement is routine after this common treatment for benign prostatic hyperplasia (BPH), no guidelines inform duration of catheter use.
Study Design: RAND/UCLA Appropriateness Methodology.
Article Synopsis
- * Out of over 20,500 patients who received PICCs, 23.1% had an estimated glomerular filtration rate (eGFR) below 45 mL/min/1.73 m², with a notable variation in PICC placement across different hospitals and units (ICUs vs. wards).
- * Complications related to PICC placements were similar in patients with eGFR below and above 45 mL/min/1.73 m², with rates of 15.3%
Article Synopsis
- Indwelling urinary catheters are frequently used in general and orthopaedic surgeries but can cause infections and other issues; however, there is little guidance on their proper use during surgery.
- The study utilized panels of experts to evaluate when catheter placement and removal are appropriate, analyzing various surgical scenarios to assign ratings based on the balance of risks and benefits.
- Results showed that catheter use appropriateness varies by procedure, with recommendations for placement and removal grouped into three categories, emphasizing timely removal to enhance patient safety post-surgery.