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Conditional reflex to urine culture: Evaluation of a diagnostic stewardship intervention within the Veterans’ Affairs and Centers for Disease Control and Prevention Practice-Based Research Network

Published online by Cambridge University Press:  25 August 2020

Kimberly C. Claeys*
Affiliation:
Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland
Min Zhan
Affiliation:
Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Lisa Pineles
Affiliation:
Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Alison Lydecker
Affiliation:
Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Gosia Clore
Affiliation:
Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
Michihiko Goto
Affiliation:
Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
Surbhi Leekha
Affiliation:
Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland
Darren Linkin
Affiliation:
Division of Infectious Diseases, Philadelphia Veterans’ Medical Center, Philadelphia, Pennsylvania
Charlesnika T. Evans
Affiliation:
Center of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans’ Affairs, Edward Hines Jr. VA Hospital, Hines, Illinois Department of Preventive Medicine and Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
Barbara W. Trautner
Affiliation:
Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans’ Affairs Medical Center and Department of Medicine, Baylor College of Medicine, Houston, Texas
Matthew B. Goetz
Affiliation:
VA Greater Los Angeles Healthcare System, David Geffen School of Medicine at UCLA, Los Angeles, California
Jonathan D. Baghdadi
Affiliation:
Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland Veterans’ Affairs Maryland Health Care System, Baltimore, Maryland
Eli N. Perencevich
Affiliation:
Department of Internal Medicine, University of Iowa, Iowa City, Iowa Center for Access & Delivery Research and Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, Iowa
Daniel J. Morgan
Affiliation:
Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland Veterans’ Affairs Maryland Health Care System, Baltimore, Maryland
*
Author for correspondence: Kimberly C. Claeys, E-mail: kclaeys@rx.umaryland.edu

Abstract

Objective:

In the absence of pyuria, positive urine cultures are unlikely to represent infection. Conditional urine reflex culture policies have the potential to limit unnecessary urine culturing. We evaluated the impact of this diagnostic stewardship intervention.

Design:

We conducted a retrospective, quasi-experimental (nonrandomized) study, with interrupted time series, from August 2013 to January 2018 to examine rates of urine cultures before versus after the policy intervention. We compared 3 intervention sites to 3 control sites in an aggregated series using segmented negative binomial regression.

Setting:

The study included 6 acute-care hospitals within the Veterans’ Health Administration across the United States.

Participants:

Adult patients with at least 1 urinalysis ordered during acute-care admission, excluding pregnant patients or those undergoing urological procedures, were included.

Methods:

At the intervention sites, urine cultures were performed if a preceding urinalysis met prespecified criteria. No such restrictions occurred at the control sites. The primary outcome was the rate of urine cultures performed per 1,000 patient days. The safety outcome was the rate of gram-negative bloodstream infection per 1,000 patient days.

Results:

The study included 224,573 urine cultures from 50,901 admissions in 24,759 unique patients. Among the intervention sites, the overall average number of urine cultures performed did not significantly decrease relative to the preintervention period (5.9% decrease; P = 0.8) but did decrease by 21% relative to control sites (P < .01). We detected no significant difference in the rates of gram-negative bloodstream infection among intervention or control sites (P = .49).

Conclusions:

Conditional urine reflex culture policies were associated with a decrease in urine culturing without a change in the incidence of gram-negative bloodstream infection.

Type
Original Article
Copyright
© 2020 by The Society for Healthcare Epidemiology of America. All rights reserved.

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