Understanding and Addressing Variation in Healthcare-Associated Infections After Durable Ventricular Assist Device Therapy

项目摘要/摘要 耐用的心脏辅助装置(VAD)提供长期的机械循环支持，作为 心脏移植或作为永久治疗，并有可能使超过25万名患者受益 指导药物治疗难治的晚期心力衰竭(HF)。每10个人中有6个以上 VaD患者在植入后发生医疗保健相关感染(HAI)。更广泛地采用耐用 VaD治疗受到HAI的阻碍，因为它们与死亡率有关(1年内风险增加5.6倍 死亡率)和医疗保健支出(每名患者264K-86.9万美元)。 大多数在VAD治疗环境中评估HAI的研究都局限于对Small 试验，或单中心体验。虽然一些人认为HAI比率较低的中心选择更健康 患者，其他人则反驳说，改进的做法(例如，标准化经验性和靶向抗菌剂 治疗)或加强提供者团队合作更能预测改善的结果。虽然以证据为基础 存在HAI预防指南和实施工具(如核对表)，这些方法不是 全面(例如，忽略特定于设备的决定因素)或可针对本地环境进行定制，从而限制 预防禽流感的可用性、采用率和显著有效性的可能性。了解障碍 各中心内最大限度地采用预防措施的促进者将作为 为有针对性的战略奠定基础。如果没有这种知识，以证据为基础、以行动为导向的建议 在预防VAD植入后的HAIS方面，当地采用的效果有限，最终是有效的。 我们的长期目标是发展并随后推动基于证据的人工智能的广泛采用 永久性VAD植入后的预防措施。这项建议的目标是确定预防措施 对VAD植入后最重要的HAIS的建议。为了达到这一目标，我们将 对2009-2017年间在美国接受VAD治疗的成人患者进行混合方法研究，并制定一项 循证建议的模块化工具包。为了确定预防禽流感的最佳做法，我们将 检查中心级别HAI比率的差异，以确定低比率中心使用的策略和障碍 到降低高比率中心的HAI比率。我们将使用一个新的数据集，包括管理 索赔和详细的临床数据，以及深入的中心调查，以实现以下目标：(I)确定 HAI比率中央一级可变性的决定因素，(2)全面了解障碍和 用于实现低中心HAI比率的促进者，以及(Iii)开发、迭代地增强和传播最佳 适用于各种中心环境的预防HAI实践工具包。 通过确定介入研究的靶点，我们的研究将对临床实践产生积极影响。 此外，我们的混合方法将作为评估和改进临床护理的更多模式。 宽泛地--尤其是在复杂的外科手术中。

Project Summary/Abstract Durable ventricular assist devices (VADs) provide long-term mechanical circulatory support as a bridge to cardiac transplantation or as permanent therapy, and have the potential to benefit more than 250K patients with advanced heart failure (HF) refractory to guideline-directed medical therapy. Upwards of six out of every 10 VAD patients develop a healthcare-associated infection (HAI) following implant. Broader adoption of durable VAD therapy is hindered by HAIs given their association with mortality (5.6-fold increased risk of 1-year mortality) and healthcare expenditures ($264K – $869K per patient). Most studies evaluating HAIs in the setting of VAD therapy have been limited to post-hoc analyses of small trials, or single center experiences. While some argue that centers with lower HAI rates select healthier patients, others counter that improved practices (e.g., standardizing empirical and targeted antimicrobial therapy) or enhanced provider teamwork are more predictive of improved outcomes. While evidence-based HAI prevention guidelines and implementation tools (e.g., checklists) exist, these approaches are not comprehensive (e.g., neglecting device-specific determinants) or customizable to local context, thus limiting usability, adoption, and likelihood of significant effectiveness for preventing HAIs. Understanding the barriers and facilitators within individual centers for maximizing adoption of prevention measures would serve as the foundation for targeted strategies. Without this knowledge, evidence-based, action-oriented recommendations will have limited local adoption and ultimately effectiveness in preventing HAIs after VAD implantation. Our long-term goal is to develop and subsequently promote wide-scale adoption of evidence-based HAI prevention practices following durable VAD implantation. The objective of this proposal is to identify prevention recommendations for the most significant HAIs after VAD implantation. To achieve this objective, we will undertake a mixed methods study of adult patients receiving VADs in the U.S. from 2009 – 2017 and develop a modular toolkit of evidence-based recommendations. To determine best practices for preventing HAIs, we will examine center-level differences in HAI rates to identify strategies used by centers with low rates, and barriers to lowering HAI rates among centers with high rates. We will use a novel dataset including administrative claims and detailed clinical data, along with in-depth center surveys, to address the following aims: (i) identify determinants of center-level variability in HAI rates, (ii) develop a comprehensive understanding of barriers and facilitators for achieving low center HAI rates, and (iii) develop, iteratively enhance, and disseminate a best practices toolkit for preventing HAIs that accommodates various center contexts. Our studies will have a positive impact on clinical practice by identifying targets for an interventional study. Moreover, our mixed methods approach will serve as a model for evaluating and improving clinical care more broadly – especially in the setting of complex surgical procedures.