breda munoz - Academia.edu (original) (raw)

Papers by breda munoz

Open Forum Infectious Diseases, Oct 1, 2019

post-surgical care guidelines to personalize and optimize care to reduce infections following app... more post-surgical care guidelines to personalize and optimize care to reduce infections following appendectomy. Disclosures. All authors: No reported disclosures. 2439. The role of positive externalities in economic evaluations of new antibiotics: modeling the impact of reduced transmission in healthcare facilities

Hospital admission and discharge dynamics facilitate pathogen transmission among individuals in c... more Hospital admission and discharge dynamics facilitate pathogen transmission among individuals in communities, hospitals, nursing homes, and other healthcare facilities. We developed a microsimulation to simulate this movement, as patients are at increased risk for healthcare-associated infections, antibiotic exposure, and other health complications while admitted to healthcare facilities. Patients can also serve as a source of infection throughout the healthcare network as they move locations. This microsimulation is a base model that can be enhanced with various disease-specific agent-based health modules. We calibrated the model to simulate patient movement in North Carolina, where over 1 million hospital admissions occur annually. Each patient originated from a unique starting location and eventually transferred to another healthcare facility or returned home. Here, we describe our calibration efforts to ensure an accurate patient flow and discuss the necessary steps to replicate this model for other healthcare networks.

2007 STORET/WQX Users Conference, Nov 1, 2007

PLOS ONE, 2020

Antibiotic exposure can lead to unintended outcomes, including drug-drug interactions, adverse dr... more Antibiotic exposure can lead to unintended outcomes, including drug-drug interactions, adverse drug events, and healthcare-associated infections like Clostridioides difficile infection (CDI). Improving antibiotic use is critical to reduce an individual's CDI risk. Antibiotic stewardship initiatives can reduce inappropriate antibiotic prescribing (e.g., unnecessary antibiotic prescribing, inappropriate antibiotic selection), impacting both hospital (healthcare)-onset (HO)-CDI and community-associated (CA)-CDI. Previous computational and mathematical modeling studies have demonstrated a reduction in CDI incidence associated with antibiotic stewardship initiatives in hospital settings. Although the impact of antibiotic stewardship initiatives in long-term care facilities (LTCFs), including nursing homes, and in outpatient settings have been documented, the effects of specific interventions on CDI incidence are not well understood. We examined the relative effectiveness of antibiotic stewardship interventions on CDI incidence using a geospatially explicit agent-based model of a regional healthcare network in North Carolina. We simulated reductions in unnecessary antibiotic prescribing and inappropriate antibiotic selection with intervention scenarios at individual and network healthcare facilities, including short-term acute care hospitals (STACHs), nursing homes, and outpatient locations. Modeled antibiotic prescription rates were calculated using patient-level data on antibiotic length of therapy for the 10 modeled network STACHs. By simulating a 30% reduction in antibiotics prescribed across all inpatient and outpatient locations, we found the greatest reductions on network CDI incidence among tested scenarios, namely a 17% decrease in HO-CDI incidence and 7% decrease in CA-CDI. Among intervention scenarios of reducing inappropriate antibiotic selection, we found a greater impact on network CDI incidence when modeling this reduction in nursing

Open Forum Infectious Diseases, 2019

Background Different antibiotic classes are associated with different Clostridioides difficile in... more Background Different antibiotic classes are associated with different Clostridioides difficile infection (CDI) risk. The impact of varied antibiotic risk on CDI incidence can be explored using agent-based models (ABMs). ABMs can simulate complete systems (e.g., regional healthcare networks) comprised of discrete, unique agents (e.g., patients) which can be represented using a synthetic population, or model-generated representation of the population. We used an ABM of a North Carolina (NC) regional healthcare network to assess the impact of increasing antibiotic risk ratios (RRs) across network locations on healthcare-associated (HA) and community-associated (CA) CDI incidence. Methods The ABM describes CDI acquisition and patient movement across 14 network locations (i.e., nodes) (11 short-term acute care hospitals, 1 long-term acute care hospital, 1 nursing home, and the community). We used a sample of 2 million synthetic NC residents as ABM microdata. We updated agent states (i.e....

Health Security, 2019

Agent-based models (ABMs) describe and simulate complex systems comprising unique agents, or indi... more Agent-based models (ABMs) describe and simulate complex systems comprising unique agents, or individuals, while accounting for geospatial and temporal variability among dynamic processes. ABMs are increasingly used to study healthcare-associated infections (ie, infections acquired during admission to a healthcare facility), including Clostridioides difficile infection, currently the most common healthcare-associated infection in the United States. The overall burden and transmission dynamics of healthcare-associated infections, including C difficile infection, may be influenced by community sources and movement of people among healthcare facilities and communities. These complex dynamics warrant geospatially explicit ABMs that extend beyond single healthcare facilities to include entire systems (eg, hospitals, nursing homes and extended care facilities, the community). The agents in ABMs can be built on a synthetic population, a model-generated representation of the actual population with associated spatial (eg, home residence), temporal (eg, change in location over time), and nonspatial (eg, sociodemographic features) attributes. We describe our methods to create a geospatially explicit ABM of a major regional healthcare network using a synthetic population as microdata input. We illustrate agent movement in the healthcare network and the community, informed by patient-level medical records, aggregate hospital discharge data, healthcare facility licensing data, and published literature. We apply the ABM output to visualize agent movement in the healthcare network and the community served by the network. We provide an application example of the ABM to C difficile infection using a natural history submodel. We discuss the ABM's potential to detect network areas where disease risk is high; simulate and evaluate interventions to protect public health; adapt to other geographic locations and healthcare-associated infections, including emerging pathogens; and meaningfully translate results to public health practitioners, healthcare providers, and policymakers.

PLOS ONE, 2019

Background Cardiovascular disease (CVD) is a major contributor to the burden from non-communicabl... more Background Cardiovascular disease (CVD) is a major contributor to the burden from non-communicable diseases in Sub-Saharan Africa and hypertension is the leading risk factor for CVD. The objective of this modeling study is to assess the cost-effectiveness of a risk stratified approach to medication management in Kenya in order to achieve adequate blood pressure control to reduce CVD events. Methods We developed a microsimulation model to evaluate CVD risk over the lifetime of a cohort of individuals. Risk groups were assigned utilizing modified Framingham study distributions based on individual level risk factors from the Kenya STEPwise survey which collected details on blood pressure, blood glucose, tobacco and alcohol use and cholesterol levels. We stratified individuals into 4 risk groups: very low, low, moderate and high risk. Mortality could occur due to acute CVD events, subsequent future events (for individual who survive the initial event) and other causes. We present cost and DALYs gained due to medication management for men and women 25 to 69 years. Results Treating high risk individuals only was generally more cost-effective that treating high and moderate risk individuals. At the anticipated base levels of effectiveness, medication management was only cost-effective under the low cost scenario. The incremental cost per DALY gained with low cost ranged from 1,505to1,505 to 1,505to3,608, which is well under $4,785 (3 times GPD per capita) threshold for Kenya. Under the low cost scenario, even lower levels of effectiveness of medication management are likely to be cost-effective for high-risk men and women.

Journal of Global Health, 2017

Similar to other Sub-Saharan African countries, Kenya is experiencing an explosive growth in NCDs... more Similar to other Sub-Saharan African countries, Kenya is experiencing an explosive growth in NCDs, especially those related to cancer and cardiovascular diseases [3]. There is therefore an urgent need to determine implementable interventions to reduce the growing burden from these and other NCDs, including respiratory diseases, injuries and mental health. Although there are many ongoing research studies and demonstration programs [4], it is not clear whether these activities address the Kenyan Government' s evidence needs and priorities to support their NCD strategy [5].

Children (Basel), Mar 8, 2022

This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY

Journal of Drugs in Dermatology, Mar 1, 2023

Value in Health, Jun 1, 2023

Clinical Infectious Diseases, Aug 28, 2020

Background. As coronavirus disease 2019 (COVID-19) disseminates throughout the United States, a b... more Background. As coronavirus disease 2019 (COVID-19) disseminates throughout the United States, a better understanding of the patient characteristics associated with hospitalization, morbidity, and mortality in diverse geographic regions is essential. Methods. Hospital chargemaster data on adult patients with COVID-19 admitted to 245 hospitals across 38 states between 15 February and 20 April 2020 were assessed. The clinical course from admission, through hospitalization, and to discharge or death was analyzed. Results. A total of 11 721 patients were included (majority were >60 years of age [59.9%] and male [53.4%]). Comorbidities included hypertension (46.7%), diabetes (27.8%), cardiovascular disease (18.6%), obesity (16.1%), and chronic kidney disease (12.2%). Mechanical ventilation was required by 1967 patients (16.8%). Mortality among hospitalized patients was 21.4% and increased to 70.5% among those on mechanical ventilation. Male sex, older age, obesity, geographic region, and the presence of chronic kidney disease or a preexisting cardiovascular disease were associated with increased odds of mechanical ventilation. All aforementioned risk factors, with the exception of obesity, were associated with increased odds of death (all P values < .001). Many patients received investigational medications for treatment of COVID-19, including 48 patients on remdesivir and 4232 on hydroxychloroquine. Conclusions. This large observational cohort describes the clinical course and identifies factors associated with the outcomes of hospitalized patients with COVID-19 across the United States. These data can inform strategies to prioritize prevention and treatment for this disease.

British Journal of Dermatology

Atopic dermatitis disproportionately affects diverse patient populations. Furthermore, complex fa... more Atopic dermatitis disproportionately affects diverse patient populations. Furthermore, complex factors may influence the burden of disease and access to treatment amongst different racial and ethnic groups. The aim of this study is to evaluate health disparities and real-world management patterns in distinct populations treated for AD in routine clinical practice. The study included patients with AD (≥age 6) enrolled in TARGET-DERM, an observational, longitudinal study of over 2500 participants across 43 US academic/community centers. Participants were classified in four race/ethnicity categories as reported in enrollment forms and/or patient self-reported: non-Hispanic (NH) White, Black, Asian/Pacific Islander (API) and Hispanic. Patient characteristics analysed included demographics, clinical characteristics, investigator-assessed and patient-reported outcomes, and treatment history. A total of 1928 patients (mean age 34 years; 58% female; 60% enrolled at community-based centers) ...

British Journal of Dermatology

Severity of atopic dermatitis (AD) itch and lesions is associated with poor quality of life. Howe... more Severity of atopic dermatitis (AD) itch and lesions is associated with poor quality of life. However, there is limited evidence describing the combined impact of itch and skin severity on patient outcomes in AD. This study aims to assess the independent and combined effects of itch and skin severity on patient-reported symptoms and quality-of-life outcomes. The study included adult participants (age ≥18 years) with AD enrolled in TARGET-DERM AD, an observational, longitudinal study of more than 3158 participants across 43 academic/community centers in the USA and Canada. Itch severity was assessed by the Patient-Reported Outcome Measurement Information System Itch-Severity, specifically the item evaluating ‘itch at its worst’, a 0–10 numeric rating scale. A score of 0 or 1 was interpreted as no/minimal itch. Skin severity was assessed by the validated Investigators Global Assessment of AD (vIGA-AD), with a score of 0 or 1 representing clear/almost clear skin (vIGA-AD 0/1). The assoc...

Journal of the American Academy of Dermatology

SKIN The Journal of Cutaneous Medicine

Clinical Gastroenterology and Hepatology

Open Forum Infectious Diseases, Oct 1, 2019

post-surgical care guidelines to personalize and optimize care to reduce infections following app... more post-surgical care guidelines to personalize and optimize care to reduce infections following appendectomy. Disclosures. All authors: No reported disclosures. 2439. The role of positive externalities in economic evaluations of new antibiotics: modeling the impact of reduced transmission in healthcare facilities

Hospital admission and discharge dynamics facilitate pathogen transmission among individuals in c... more Hospital admission and discharge dynamics facilitate pathogen transmission among individuals in communities, hospitals, nursing homes, and other healthcare facilities. We developed a microsimulation to simulate this movement, as patients are at increased risk for healthcare-associated infections, antibiotic exposure, and other health complications while admitted to healthcare facilities. Patients can also serve as a source of infection throughout the healthcare network as they move locations. This microsimulation is a base model that can be enhanced with various disease-specific agent-based health modules. We calibrated the model to simulate patient movement in North Carolina, where over 1 million hospital admissions occur annually. Each patient originated from a unique starting location and eventually transferred to another healthcare facility or returned home. Here, we describe our calibration efforts to ensure an accurate patient flow and discuss the necessary steps to replicate this model for other healthcare networks.

2007 STORET/WQX Users Conference, Nov 1, 2007

PLOS ONE, 2020

Antibiotic exposure can lead to unintended outcomes, including drug-drug interactions, adverse dr... more Antibiotic exposure can lead to unintended outcomes, including drug-drug interactions, adverse drug events, and healthcare-associated infections like Clostridioides difficile infection (CDI). Improving antibiotic use is critical to reduce an individual's CDI risk. Antibiotic stewardship initiatives can reduce inappropriate antibiotic prescribing (e.g., unnecessary antibiotic prescribing, inappropriate antibiotic selection), impacting both hospital (healthcare)-onset (HO)-CDI and community-associated (CA)-CDI. Previous computational and mathematical modeling studies have demonstrated a reduction in CDI incidence associated with antibiotic stewardship initiatives in hospital settings. Although the impact of antibiotic stewardship initiatives in long-term care facilities (LTCFs), including nursing homes, and in outpatient settings have been documented, the effects of specific interventions on CDI incidence are not well understood. We examined the relative effectiveness of antibiotic stewardship interventions on CDI incidence using a geospatially explicit agent-based model of a regional healthcare network in North Carolina. We simulated reductions in unnecessary antibiotic prescribing and inappropriate antibiotic selection with intervention scenarios at individual and network healthcare facilities, including short-term acute care hospitals (STACHs), nursing homes, and outpatient locations. Modeled antibiotic prescription rates were calculated using patient-level data on antibiotic length of therapy for the 10 modeled network STACHs. By simulating a 30% reduction in antibiotics prescribed across all inpatient and outpatient locations, we found the greatest reductions on network CDI incidence among tested scenarios, namely a 17% decrease in HO-CDI incidence and 7% decrease in CA-CDI. Among intervention scenarios of reducing inappropriate antibiotic selection, we found a greater impact on network CDI incidence when modeling this reduction in nursing

Open Forum Infectious Diseases, 2019

Background Different antibiotic classes are associated with different Clostridioides difficile in... more Background Different antibiotic classes are associated with different Clostridioides difficile infection (CDI) risk. The impact of varied antibiotic risk on CDI incidence can be explored using agent-based models (ABMs). ABMs can simulate complete systems (e.g., regional healthcare networks) comprised of discrete, unique agents (e.g., patients) which can be represented using a synthetic population, or model-generated representation of the population. We used an ABM of a North Carolina (NC) regional healthcare network to assess the impact of increasing antibiotic risk ratios (RRs) across network locations on healthcare-associated (HA) and community-associated (CA) CDI incidence. Methods The ABM describes CDI acquisition and patient movement across 14 network locations (i.e., nodes) (11 short-term acute care hospitals, 1 long-term acute care hospital, 1 nursing home, and the community). We used a sample of 2 million synthetic NC residents as ABM microdata. We updated agent states (i.e....

Health Security, 2019

Agent-based models (ABMs) describe and simulate complex systems comprising unique agents, or indi... more Agent-based models (ABMs) describe and simulate complex systems comprising unique agents, or individuals, while accounting for geospatial and temporal variability among dynamic processes. ABMs are increasingly used to study healthcare-associated infections (ie, infections acquired during admission to a healthcare facility), including Clostridioides difficile infection, currently the most common healthcare-associated infection in the United States. The overall burden and transmission dynamics of healthcare-associated infections, including C difficile infection, may be influenced by community sources and movement of people among healthcare facilities and communities. These complex dynamics warrant geospatially explicit ABMs that extend beyond single healthcare facilities to include entire systems (eg, hospitals, nursing homes and extended care facilities, the community). The agents in ABMs can be built on a synthetic population, a model-generated representation of the actual population with associated spatial (eg, home residence), temporal (eg, change in location over time), and nonspatial (eg, sociodemographic features) attributes. We describe our methods to create a geospatially explicit ABM of a major regional healthcare network using a synthetic population as microdata input. We illustrate agent movement in the healthcare network and the community, informed by patient-level medical records, aggregate hospital discharge data, healthcare facility licensing data, and published literature. We apply the ABM output to visualize agent movement in the healthcare network and the community served by the network. We provide an application example of the ABM to C difficile infection using a natural history submodel. We discuss the ABM's potential to detect network areas where disease risk is high; simulate and evaluate interventions to protect public health; adapt to other geographic locations and healthcare-associated infections, including emerging pathogens; and meaningfully translate results to public health practitioners, healthcare providers, and policymakers.

PLOS ONE, 2019

Background Cardiovascular disease (CVD) is a major contributor to the burden from non-communicabl... more Background Cardiovascular disease (CVD) is a major contributor to the burden from non-communicable diseases in Sub-Saharan Africa and hypertension is the leading risk factor for CVD. The objective of this modeling study is to assess the cost-effectiveness of a risk stratified approach to medication management in Kenya in order to achieve adequate blood pressure control to reduce CVD events. Methods We developed a microsimulation model to evaluate CVD risk over the lifetime of a cohort of individuals. Risk groups were assigned utilizing modified Framingham study distributions based on individual level risk factors from the Kenya STEPwise survey which collected details on blood pressure, blood glucose, tobacco and alcohol use and cholesterol levels. We stratified individuals into 4 risk groups: very low, low, moderate and high risk. Mortality could occur due to acute CVD events, subsequent future events (for individual who survive the initial event) and other causes. We present cost and DALYs gained due to medication management for men and women 25 to 69 years. Results Treating high risk individuals only was generally more cost-effective that treating high and moderate risk individuals. At the anticipated base levels of effectiveness, medication management was only cost-effective under the low cost scenario. The incremental cost per DALY gained with low cost ranged from 1,505to1,505 to 1,505to3,608, which is well under $4,785 (3 times GPD per capita) threshold for Kenya. Under the low cost scenario, even lower levels of effectiveness of medication management are likely to be cost-effective for high-risk men and women.

Journal of Global Health, 2017

Similar to other Sub-Saharan African countries, Kenya is experiencing an explosive growth in NCDs... more Similar to other Sub-Saharan African countries, Kenya is experiencing an explosive growth in NCDs, especially those related to cancer and cardiovascular diseases [3]. There is therefore an urgent need to determine implementable interventions to reduce the growing burden from these and other NCDs, including respiratory diseases, injuries and mental health. Although there are many ongoing research studies and demonstration programs [4], it is not clear whether these activities address the Kenyan Government' s evidence needs and priorities to support their NCD strategy [5].

Children (Basel), Mar 8, 2022

This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY

Journal of Drugs in Dermatology, Mar 1, 2023

Value in Health, Jun 1, 2023

Clinical Infectious Diseases, Aug 28, 2020

Background. As coronavirus disease 2019 (COVID-19) disseminates throughout the United States, a b... more Background. As coronavirus disease 2019 (COVID-19) disseminates throughout the United States, a better understanding of the patient characteristics associated with hospitalization, morbidity, and mortality in diverse geographic regions is essential. Methods. Hospital chargemaster data on adult patients with COVID-19 admitted to 245 hospitals across 38 states between 15 February and 20 April 2020 were assessed. The clinical course from admission, through hospitalization, and to discharge or death was analyzed. Results. A total of 11 721 patients were included (majority were >60 years of age [59.9%] and male [53.4%]). Comorbidities included hypertension (46.7%), diabetes (27.8%), cardiovascular disease (18.6%), obesity (16.1%), and chronic kidney disease (12.2%). Mechanical ventilation was required by 1967 patients (16.8%). Mortality among hospitalized patients was 21.4% and increased to 70.5% among those on mechanical ventilation. Male sex, older age, obesity, geographic region, and the presence of chronic kidney disease or a preexisting cardiovascular disease were associated with increased odds of mechanical ventilation. All aforementioned risk factors, with the exception of obesity, were associated with increased odds of death (all P values < .001). Many patients received investigational medications for treatment of COVID-19, including 48 patients on remdesivir and 4232 on hydroxychloroquine. Conclusions. This large observational cohort describes the clinical course and identifies factors associated with the outcomes of hospitalized patients with COVID-19 across the United States. These data can inform strategies to prioritize prevention and treatment for this disease.

British Journal of Dermatology

Atopic dermatitis disproportionately affects diverse patient populations. Furthermore, complex fa... more Atopic dermatitis disproportionately affects diverse patient populations. Furthermore, complex factors may influence the burden of disease and access to treatment amongst different racial and ethnic groups. The aim of this study is to evaluate health disparities and real-world management patterns in distinct populations treated for AD in routine clinical practice. The study included patients with AD (≥age 6) enrolled in TARGET-DERM, an observational, longitudinal study of over 2500 participants across 43 US academic/community centers. Participants were classified in four race/ethnicity categories as reported in enrollment forms and/or patient self-reported: non-Hispanic (NH) White, Black, Asian/Pacific Islander (API) and Hispanic. Patient characteristics analysed included demographics, clinical characteristics, investigator-assessed and patient-reported outcomes, and treatment history. A total of 1928 patients (mean age 34 years; 58% female; 60% enrolled at community-based centers) ...

British Journal of Dermatology

Severity of atopic dermatitis (AD) itch and lesions is associated with poor quality of life. Howe... more Severity of atopic dermatitis (AD) itch and lesions is associated with poor quality of life. However, there is limited evidence describing the combined impact of itch and skin severity on patient outcomes in AD. This study aims to assess the independent and combined effects of itch and skin severity on patient-reported symptoms and quality-of-life outcomes. The study included adult participants (age ≥18 years) with AD enrolled in TARGET-DERM AD, an observational, longitudinal study of more than 3158 participants across 43 academic/community centers in the USA and Canada. Itch severity was assessed by the Patient-Reported Outcome Measurement Information System Itch-Severity, specifically the item evaluating ‘itch at its worst’, a 0–10 numeric rating scale. A score of 0 or 1 was interpreted as no/minimal itch. Skin severity was assessed by the validated Investigators Global Assessment of AD (vIGA-AD), with a score of 0 or 1 representing clear/almost clear skin (vIGA-AD 0/1). The assoc...

Journal of the American Academy of Dermatology

SKIN The Journal of Cutaneous Medicine

Clinical Gastroenterology and Hepatology