Data describing outcomes of solid organ transplant (SOT) recipients with coronavirus disease 2019 (COVID‐19) are variable, and the association between SOT status and mortality remains unclear. In this study, we compare clinical outcomes of SOT recipients hospitalized with COVID‐19 between March 10, and September 1, 2020, to a matched cohort of non‐SOT recipients at a national healthcare system in the United States (US). From a population of 43 461 hospitalized COVID‐19‐positive patients, we created a coarsened exact matched cohort of 4035 patients including 128 SOT recipients and 3907 weighted matched non‐SOT controls. Multiple logistic regression was used to evaluate association between SOT status and clinical outcomes. Among the 4035 patients, median age was 60 years, 61.7% were male, 21.9% were Black/African American, and 50.8% identified as Hispanic/Latino ethnicity. Patients with a history of SOT were more likely to die within the study period when compared to matched non‐SOT recipients (21.9% and 14.9%, respectively; odds ratio [OR] 1.93; 95% confidence interval [CI]: 1.18–3.15). Moreover, SOT status was associated with increased odds of receiving invasive mechanical ventilation (OR [95% CI]: 2.34 [1.51–3.65]), developing acute kidney injury (OR [95% CI]: 2.41 [1.59–3.65]), and receiving vasopressor support during hospitalization (OR [95% CI]: 2.14 [1.31–3.48]).

Background There is an urgent need to understand the real-world effectiveness of remdesivir in the treatment of SARS-CoV-2. Methods This was a retrospective comparative effectiveness study. Individuals hospitalized in a large private healthcare network in the US from February 23, 2020 through February 11, 2021 with a positive test for SARS-CoV-2 and ICD-10 diagnosis codes consistent with symptomatic COVID-19 were included. Remdesivir recipients were matched to controls using time-dependent propensity scores. The primary outcome was time to improvement with a secondary outcome of time to death. Results Of 96,859 COVID-19 patients, 42,473 (43.9%) received at least one remdesivir dose. The median age of remdesivir recipients was 65 years, 23,701 (55.8%) were male and 22,819 (53.7%) were non-white. Matches were found for 18,328 patients (43.2%). Remdesivir recipients were significantly more likely to achieve clinical improvement by 28 days (adjusted hazard ratio [1.19, 95% confidence interval (CI), 1.16-1.22]). Remdesivir patients on no oxygen (aHR 1.30, 95% CI 1.22-1.38) or low-flow oxygen (aHR 1.23, 95% CI 1.19-1.27) were significantly more likely to achieve clinical improvement by 28 days. There was no significant impact on the likelihood of mortality overall (aHR 1.02, 95% CI 0.97-1.08). Remdesivir recipients on low-flow oxygen were significantly less likely to die than controls (aHR 0.85, 95% CI 0.77-0.92; 28-day mortality 8.4% [865 deaths] for remdesivir patients, 12.5% [1,334 deaths] for controls). Conclusions These results support the use of remdesivir for hospitalized COVID-19 patients on no or low-flow oxygen. Routine initiation of remdesivir in more severely ill patients is unlikely to be beneficial.

BackgroundFree and charitable clinics are a critical part of America’s healthcare safety net. Although informatics tools have the potential to mitigate many of the organizational and service-related challenges facing these clinics, little research attention has been paid to the workflows and potential impact of electronic systems in these settings. In previous work, we performed a qualitative investigation at a free clinic dispensary to identify workflow challenges that may be alleviated through introduction of informatics interventions. However, this earlier study did not quantify the magnitude of these challenges. Time-motion studies offer a precise standard in quantifying healthcare workers’ time expenditures on clinical activities, and can provide valuable insight into system specifications. These data, informed by a lean healthcare perspective, provide a quality improvement framework intended to maximize value and eliminate waste in inefficient workflow processes.MethodsWe performed a continuous observation time-motion study in the Birmingham Free Clinic dispensary. Two researchers followed pharmacists over the course of three general clinic sessions and recorded the duration of specific tasks. Pharmacists were then asked to identify tasks as value-added or non-value-added to facilitate calculation of the value quotient, a metric used to determine a workflow’s level of efficiency.ResultsFour high-level workflow categories occupied almost 95 % of pharmacist time: prescription (Rx) preparation (39.8 %), clinician interaction (21.5 %), EMR operations (14.8 %), and patient interaction (18.7 %). Pharmacists invested the largest portion of time in prescription preparation, with 21.8 % of pharmacist time spent handwriting medication labels. Based on value categorizations made by the pharmacists, the average value quotient was found to be 40.3 %, indicating that pharmacists spend more than half of their time completing tasks they consider to be non-value-added.ConclusionsOur results show that pharmacists spend a large portion of their time preparing prescriptions, primarily the handwritten labeling of medication bottles and documentation tasks, which is not an optimal utilization of pharmacist expertise. The value quotient further supports that there are many wasteful tasks that may benefit from workflow redesign and health information technology, which could result in efficiency improvements for pharmacists.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1787-6) contains supplementary material, which is available to authorized users.

BackgroundThe Birmingham Free Clinic (BFC) in Pittsburgh, Pennsylvania, USA is a free, walk-in clinic that serves medically uninsured populations through the use of volunteer health care providers and an on-site medication dispensary. The introduction of an electronic medical record (EMR) has improved several aspects of clinic workflow. However, pharmacists’ tasks involving medication management and dispensing have become more challenging since EMR implementation due to its inability to support workflows between the medical and pharmaceutical services. To inform the design of a systematic intervention, we conducted a needs assessment study to identify workflow challenges and process inefficiencies in the dispensary.MethodsWe used contextual inquiry to document the dispensary workflow and facilitate identification of critical aspects of intervention design specific to the user. Pharmacists were observed according to contextual inquiry guidelines. Graphical models were produced to aid data and process visualization. We created a list of themes describing workflow challenges and asked the pharmacists to rank them in order of significance to narrow the scope of intervention design.ResultsThree pharmacists were observed at the BFC. Observer notes were documented and analyzed to produce 13 themes outlining the primary challenges pharmacists encounter during dispensation at the BFC. The dispensary workflow is labor intensive, redundant, and inefficient when integrated with the clinical service. Observations identified inefficiencies that may benefit from the introduction of informatics interventions including: medication labeling, insufficient process notification, triple documentation, and inventory control.ConclusionsWe propose a system for Prescription Management and General Inventory Control (RxMAGIC). RxMAGIC is a framework designed to mitigate workflow challenges and improve the processes of medication management and inventory control. While RxMAGIC is described in the context of the BFC dispensary, we believe it will be generalizable to pharmacies in other low-resource settings, both domestically and internationally.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1308-7) contains supplementary material, which is available to authorized users.

Abstract. Adequate laboratory infrastructure in sub-Saharan Africa is vital for tackling the burden of infectious diseases such as human immunodeficiency virus and acquired immune deficiency syndrome, malaria, and tuberculosis, yet laboratories are ill-integrated into the diagnostic and care delivery process in low-resource settings. Although much of the literature focuses on disease-specific challenges around laboratory testing, we sought to identify horizontal challenges to the laboratory testing process through interviews with clinicians involved in the diagnostic process. Based on 22 interviews with physicians, nurses, clinical officers, medical students, and laboratory technicians, technologists and supervisors, we identified 12 distinct challenges in the areas of staff, materials, workflow, and the blood bank. These challenges underscore the informational challenges that compound more visible resource shortages in the laboratory testing process, which lend themselves to horizontal strengthening efforts around the diagnostic process.

The Computer Science, Biology, and Biomedical Informatics (CoSBBI) program was initiated in 2011 to expose the critical role of informatics in biomedicine to talented high school students.[1] By involving them in Science, Technology, Engineering, and Math (STEM) training at the high school level and providing mentorship and research opportunities throughout the formative years of their education, CoSBBI creates a research infrastructure designed to develop young informaticians. Our central premise is that the trajectory necessary to be an expert in the emerging fields of biomedical informatics and pathology informatics requires accelerated learning at an early age.In our 4th year of CoSBBI as a part of the University of Pittsburgh Cancer Institute (UPCI) Academy (http://www.upci.upmc.edu/summeracademy/), and our 2nd year of CoSBBI as an independent informatics-based academy, we enhanced our classroom curriculum, added hands-on computer science instruction, and expanded research projects to include clinical informatics. We also conducted a qualitative evaluation of the program to identify areas that need improvement in order to achieve our goal of creating a pipeline of exceptionally well-trained applicants for both the disciplines of pathology informatics and biomedical informatics in the era of big data and personalized medicine.

Background: With over 83 million cases and 1.8 million deaths reported worldwide by the end of 2020 for SARS-CoV-2 (COVID-19), there is an urgent need to enhance identification of high-risk populations to properly evaluate therapy effectiveness with real-world evidence and improve outcomes. Methods: Baseline and daily indicators were evaluated using electronic health records for 46,971 patients hospitalized with COVID-19 from 176 HCA Healthcare-affiliated hospitals, presenting from March to September 2020, to develop a real-time risk model (RTRM) of all-cause, hospitalized mortality. Patient facility, dates-of-care, clinico-demographics, comorbidities, vitals, laboratory markers, and respiratory support findings were aggregated in a logistic regression model. Findings: The RTRM predicted overall mortality as well as mortality 1, 3, and 7 days in advance with an area under the receiver operating characteristic curve (AUCROC) of 0.905, 0.911, 0.905, and 0.901 respectively, significantly outperforming a combined model of age and daily modified WHO progression scale (all p<0.0001; AUCROC, 0.846, 0.848, 0.850, and 0.852). The RTRM delineated risk at presentation from ongoing risk associated with medical care and showed that mortality rates decreased over time due to both decreased severity and changes in care. Interpretation: To our knowledge, this study is the largest of its kind to comprehensively evaluate predictors and incorporate daily risk measures of COVID-19 mortality. The RTRM validates current literature trends in mortality across time and allows direct translation for research and clinical applications.

Infections due to Micrococcus pyogenes (Staphylococcus) are becoming increasingly difficult to manage because of the remarkable tendency of members of this genus to develop resistance to penicillin and other antibiotics. Although the individual strains vary considerably in this respect, the majority of staphylococci isolated from hospital patients and personnel in several clinics are currently being found to be penicillin-resistant.* During the past few years we have followed the course of several patients with staphylococcal endocarditis. Of interest is a comparison of the results of therapy in this group with a much larger series obtained by reviewing the records of all such cases at the Johns Hopkins Hospital for the past 20 years. This series was divided arbitrarily into three periods. The first was 1933-1943, a time in which no well-established antibiotic treatment was available, although penicillin was used in a few of the later cases in doses which we now realize were inadequate. The second period, extending from 1944 through 1948, was expected to represent the time during which effective doses of penicillin were used with most strains of staphylococci still sensitive to that agent.f The third period includes the five years from 1949 through 1953. Of 12 cases in this group, 42% of the organisms were penicillinresistant. One purpose of this study is to evaluate the special problems related to that complication. During the 20-year period 1933 through 1953, there were 104 instances of staphylococcal bacteremia, excluding cases in which the bacteremia represented a terminal epi¬ sode in patients who were near death from some unrelated disease. The present report is concerned with an analysis of the 38 pa¬ tients in this group who we felt fulfilled the criteria for the diagnosis of staphylococcal endocarditis. Here the question of definition becomes somewhat difficult, and so we have established two categories. The first category includes 25 cases of endocarditis proved by autopsy, and the second includes 13 cases in which the diagnosis was "clinically cer¬ tain." In the prepenicillin era nearly all patients with staphylococcal endocarditis died, but since then the infection has been cured often enough to bring up the question of whether or not the diagnosis is justified in patients who survive. The cases which qualified as clinically certain instances of acute endocarditis were those with repeatedly positive blood cultures in the presence of definite signs of some type of valvular dis¬ ease, which may or may not have been present with the onset of the infection. Sig¬ nificant changes in the character of the mur¬ murs while under observation or embolie phenomena of more than transient nature involving the skin, brain, lungs, kidneys, or other peripheral arteries were taken as further evidence in favor of endocarditis. Of these 38 cases, 22 fell into the 10 years of Period I, 3 in the 5 years of Period II, and 13 in the 5 years of Period III. The striking fall in incidence in the second period * References 1-4.t...