Browsing by Author "Boggan, JC"
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Item Open Access An adverse reaction to a medication given to treat an adverse reaction: a teachable moment.(JAMA Intern Med, 2014-07) Rohrhoff, NJ; McNeill, DB; Boggan, JCItem Open Access An Automated Surveillance Strategy to Identify Infectious Complications After Cardiac Implantable Electronic Device Procedures.(Open Forum Infect Dis, 2015-12) Boggan, JC; Baker, AW; Lewis, SS; Dicks, KV; Durkin, MJ; Moehring, RW; Chen, LF; Knelson, LP; Hegland, DD; Anderson, DJBackground. The optimum approach for infectious complication surveillance for cardiac implantable electronic device (CIED) procedures is unclear. We created an automated surveillance tool for infectious complications after CIED procedures. Methods. Adults having CIED procedures between January 1, 2005 and December 31, 2011 at Duke University Hospital were identified retrospectively using International Classification of Diseases, 9th revision (ICD-9) procedure codes. Potential infections were identified with combinations of ICD-9 diagnosis codes and microbiology data for 365 days postprocedure. All microbiology-identified and a subset of ICD-9 code-identified possible cases, as well as a subset of procedures without microbiology or ICD-9 codes, were reviewed. Test performance characteristics for specific queries were calculated. Results. Overall, 6097 patients had 7137 procedures. Of these, 1686 procedures with potential infectious complications were identified: 174 by both ICD-9 code and microbiology, 14 only by microbiology, and 1498 only by ICD-9 criteria. We reviewed 558 potential cases, including all 188 microbiology-identified cases, 250 randomly selected ICD-9 cases, and 120 with neither. Overall, 65 unique infections were identified, including 5 of 250 reviewed cases identified only by ICD-9 codes. Queries that included microbiology data and ICD-9 code 996.61 had good overall test performance, with sensitivities of approximately 90% and specificities of approximately 80%. Queries with ICD-9 codes alone had poor specificity. Extrapolation of reviewed infectious rates to nonreviewed cases yields an estimated rate of infection of 1.3%. Conclusions. Electronic queries with combinations of ICD-9 codes and microbiologic data can be created and have good test performance characteristics for identifying likely infectious complications of CIED procedures.Item Open Access An evaluation of physician predictions of discharge on a general medicine service.(J Hosp Med, 2015-12) Sullivan, B; Ming, D; Boggan, JC; Schulteis, RD; Thomas, S; Choi, J; Bae, JThe goal of this study was to evaluate general medicine physicians' ability to predict hospital discharge. We prospectively asked study subjects to predict whether each patient under their care would be discharged on the next day, on the same day, or neither. Discharge predictions were recorded at 3 time points: mornings (7-9 am), midday (12-2 pm), or afternoons (5-7 pm), for a total of 2641 predictions. For predictions of next-day discharge, the sensitivity (SN) and positive predictive value (PPV) were lowest in the morning (27% and 33%, respectively), but increased by the afternoon (SN 67%, PPV 69%). Similarly, for same-day discharge predictions, SN and PPV were highest at midday (88% and 79%, respectively). We found that although physicians have difficulty predicting next-day discharges in the morning prior to the day of expected discharge, their ability to correctly predict discharges continually improved as the time to actual discharge decreased. Journal of Hospital Medicine 2015;10:808-810. © 2015 Society of Hospital Medicine.Item Open Access Guideline-based decision support has a small, non-sustained effect on transthoracic echocardiography ordering frequency.(BMJ Qual Saf, 2016-01) Boggan, JC; Schulteis, RD; Donahue, M; Simel, DLBACKGROUND: Guidance for appropriate utilisation of transthoracic echocardiograms (TTEs) can be incorporated into ordering prompts, potentially affecting the number of requests. METHODS: We incorporated data from the 2011 Appropriate Use Criteria for Echocardiography, the 2010 National Institute for Clinical Excellence Guideline on Chronic Heart Failure, and American College of Cardiology Choosing Wisely list on TTE use for dyspnoea, oedema and valvular disease into electronic ordering systems at Durham Veterans Affairs Medical Center. Our primary outcome was TTE orders per month. Secondary outcomes included rates of outpatient TTE ordering per 100 visits and frequency of brain natriuretic peptide (BNP) ordering prior to TTE. Outcomes were measured for 20 months before and 12 months after the intervention. RESULTS: The number of TTEs ordered did not decrease (338±32 TTEs/month prior vs 320±33 afterwards, p=0.12). Rates of outpatient TTE ordering decreased minimally post intervention (2.28 per 100 primary care/cardiology visits prior vs 1.99 afterwards, p<0.01). Effects on TTE ordering and ordering rate significantly interacted with time from intervention (p<0.02 for both), as the small initial effects waned after 6 months. The percentage of TTE orders with preceding BNP increased (36.5% prior vs 42.2% after for inpatients, p=0.01; 10.8% prior vs 14.5% after for outpatients, p<0.01). CONCLUSIONS: Ordering prompts for TTEs initially minimally reduced the number of TTEs ordered and increased BNP measurement at a single institution, but the effect on TTEs ordered was likely insignificant from a utilisation standpoint and decayed over time.Item Open Access House staff perceptions of how handoff quality influences code blue and rapid response team events.(Am J Med Qual, 2015-05) Miller, D; Mitchell, A; Sadun, R; Boggan, JCItem Open Access Pediatric-specific antimicrobial susceptibility data and empiric antibiotic selection.(Pediatrics, 2012-09) Boggan, JC; Navar-Boggan, AM; Jhaveri, ROBJECTIVE: Duke University Health System (DUHS) generates annual antibiograms combining adult and pediatric data. We hypothesized significant susceptibility differences exist for pediatric isolates and that distributing these results would alter antibiotic choices. METHODS: Susceptibility rates for Escherichia coli isolates from patients aged ≤12 years between July 2009 and September 2010 were compared with the 2009 DUHS antibiogram. Pediatric attending and resident physicians answered case-based vignettes about children aged 3 months and 12 years with urinary tract infections. Each vignette contained 3 identical scenarios with no antibiogram, the 2009 DUHS antibiogram, and a pediatric-specific antibiogram provided. Effective antibiotics exhibited >80% in vitro susceptibility. Frequency of antibiotic selection was analyzed by using descriptive statistics. RESULTS: Three hundred seventy-five pediatric isolates were identified. Pediatric isolates were more resistant to ampicillin and trimethoprim-sulfamethoxazole (TMP-SMX) and less resistant to amoxicillin-clavulanate and ciprofloxacin (P < .0005 for all). Seventy-five resident and attending physicians completed surveys. In infant vignettes, physicians selected amoxicillin-clavulanate (P < .05) and nitrofurantoin (P < .01) more often and TMP-SMX (P < .01) less often with pediatric-specific data. Effective antibiotic choices increased from 68.6% to 82.2% (P = .06) to 92.5% (P < .01) across scenarios. In adolescent vignettes, providers reduced TMP-SMX use from 66.2% to 42.6% to 19.0% (P < .01 for both). Effective antibiotic choices increased from 32.4% to 57.4% to 79.4% (P < .01 and P = .01). CONCLUSIONS: Pediatric E. coli isolates differ significantly in antimicrobial susceptibility at our institution, particularly to frequently administered oral antibiotics. Knowledge of pediatric-specific data altered empirical antibiotic choices in case vignettes. Care of pediatric patients could be improved with use of a pediatric-specific antibiogram.Item Open Access Poor Positive Predictive Value of Lyme Disease Serologic Testing in an Area of Low Disease Incidence.(Clin Infect Dis, 2015-11-01) Lantos, PM; Branda, JA; Boggan, JC; Chudgar, SM; Wilson, EA; Ruffin, F; Fowler, VG; Auwaerter, PG; Nigrovic, LEBACKGROUND: Lyme disease is diagnosed by 2-tiered serologic testing in patients with a compatible clinical illness, but the significance of positive test results in low-prevalence regions has not been investigated. METHODS: We reviewed the medical records of patients who tested positive for Lyme disease with standardized 2-tiered serologic testing between 2005 and 2010 at a single hospital system in a region with little endemic Lyme disease. Based on clinical findings, we calculated the positive predictive value of Lyme disease serology. Next, we reviewed the outcome of serologic testing in patients with select clinical syndromes compatible with disseminated Lyme disease (arthritis, cranial neuropathy, or meningitis). RESULTS: During the 6-year study period 4723 patients were tested for Lyme disease, but only 76 (1.6%) had positive results by established laboratory criteria. Among 70 seropositive patients whose medical records were available for review, 12 (17%; 95% confidence interval, 9%-28%) were found to have Lyme disease (6 with documented travel to endemic regions). During the same time period, 297 patients with a clinical illness compatible with disseminated Lyme disease underwent 2-tiered serologic testing. Six of them (2%; 95% confidence interval, 0.7%-4.3%) were seropositive, 3 with documented travel and 1 who had an alternative diagnosis that explained the clinical findings. CONCLUSIONS: In this low-prevalence cohort, fewer than 20% of positive Lyme disease tests are obtained from patients with clinically likely Lyme disease. Positive Lyme disease test results may have little diagnostic value in this setting.Item Open Access Prevalence of hypertension and peripheral arterial disease in adults in Léogâne, Haiti(Journal of Global Health Reports) Boggan, JC; McCarthy, SH; Pritchard, JE; O’brien, G; Walmer, DKItem Open Access Reductions in telemetry order duration do not reduce telemetry utilization.(J Hosp Med, 2014-12) Boggan, JC; Navar-Boggan, AM; Patel, V; Schulteis, RD; Simel, DLItem Open Access Variability in performance measures for assessment of hypertension control.(Am Heart J, 2013-05) Navar-Boggan, AM; Shah, BR; Boggan, JC; Stafford, JA; Peterson, EDBACKGROUND: Definitions of multiple performance measures exist for the assessment of blood pressure control; however, limited data on how these technical variations may affect actual measured performance are available. METHODS: We evaluated patients with hypertension followed routinely by cardiologists at Duke University Health System from 2009 to 2010. Provider hypertension control was compared based on reading at the last clinic visit vs the average blood pressure across all visits. The impact of home blood pressure measurements and patient exclusions endorsed by the American Heart Association, the American College of Cardiology, and the Physician Consortium for Performance Improvement were evaluated using medical record reviews. RESULTS: Among 5,552 hypertensive patients, the rate of blood pressure control based on last clinic visit was 69.1%; however, significant clinic-to-clinic variability was seen in serial clinic blood pressure measurements in individual patients (average 18 mm Hg). As a result, provider performance ratings varied considerably depending on whether a single reading or average blood pressure reading was used. The inclusion of home blood pressure measurements resulted in modestly higher rates of blood pressure control performance (+6% overall). Similarly, excluding patients who met guideline-recommended exclusion criteria increased blood pressure control rates only slightly (+3% overall). In contrast, excluding patients who were on 2 or more antihypertensive medications would have raised blood pressure control rates to 96% overall. CONCLUSION: Depending on definitions used, overall and provider-specific blood pressure control rates can vary considerably. Technical aspects of blood pressure performance measures may affect perceived quality gaps and comparative provider ratings.