Gender differences in care for acquired immunodeficiency syndrome-related Pneumocystis carinii pneumonia.
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AIDS-Related Opportunistic Infections↗
Biomedical subjects
C L Bennett
Publications and source records attributed to C L Bennett.
Prostate cancer patients' utilities for health states: how it looks depends on where you stand.
Two versions of the time-tradeoff (TTO) method were compared. In the personal TTO version, 31 prostate cancer patients decided whether they personally would give up some longevity to have perfect health rather than a longer life in a state of poor health associated with prostate cancer. In the impersonal version, 28 patients compared two hypothetical friends, one of whom has perfect health but will live less time than the other who is in poor health, and decided which person they would rather be. All patients evaluated three hypothetical health states. The two TTO methods were assessed by examining 1) how well they distinguished three health states of varying degrees of dysfunction and 2) patients' willingness to trade time for quality of life. Patients using the impersonal TTO version were more likely than those using the personal version to order the three health states appropriately (68% vs 16%, p < 0.0001) and were more willing to trade off length of life for quality of life (p < 0.05).
Activities of Daily Living↗
Multi-city study of quality of care for HIV-related Pneumocystis carinii pneumonia: successfully collecting highly sensitive information.
Pneumocystis carinii pneumonia (PCP) has been the major cause of death and the most common opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS), with in-hospital mortality rates as high as 60% in some hospitals. To investigate whether there were large variations in quality of care for hospitalized patients with PCP, researchers at RAND Corporation, in 1989, designed and initiated a multi-city study of patterns of care. Mounting a successful primary data collection effort in several cities requires a substantial effort from collaborators in many different settings. In addition, studies of persons with AIDS require careful consideration of issues related to the highly sensitive nature of data sources such as medical records of persons with AIDS, collection of reliable and accurate information, and protection of hospital and patient confidentiality and anonymity. The research team developed an interactive well-coordinated program to select hospitals and patients for evaluation, ensure confidentiality and anonymity, prepare materials, recruit collaborators, and obtain detailed clinical data about the care of patients with PCP. This paper summarizes major data collection and related project activities including design and sampling decisions, fieldwork preparation and implementation, and patient and hospital characteristics.
AIDS-Related Opportunistic Infections↗
Cost-effectiveness models of clinical trials of new pharmaceuticals for AIDS-related Pneumocystis carinii pneumonia: are they helpful to policy makers?
BACKGROUND: Pneumocystis carinii pneumonia (PCP) has been the most common and most costly complication of acquired immunodeficiency syndrome (AIDS). Because of concern over the high costs of care for persons with AIDS, policy makers have instituted a number of new measures to encourage cost-effectiveness. Although the clinical efficacy of new pharmaceutical agents is evaluated extensively before approval, comparative trials of a new agent with its major competitor are sometimes not carried out, and estimates of cost-effectiveness are therefore difficult to obtain. METHODS: We describe methodologic issues associated with the development of economic models of new pharmaceutical agents and illustrate these issues with an analysis of second-line therapeutic options for PCP. RESULTS: A new drug, trimetrexate, and the standard second-line therapy, pentamidine, are both inferior to the standard first-line therapy, trimethoprim/sulfamethoxazole, as initial therapy for moderate to severe PCP. However, as many as half of the patients with PCP are either intolerant or refractory to trimethoprim/sulfamethoxazole therapy for PCP. Economic models suggest that, if the two drugs have identical survival rates, then trimetrexate, despite a higher acquisition cost, is both less expensive and more effective in achieving toxicity-free survival than pentamidine in patients who require second-line therapy for PCP. Sensitivity analyses indicate that trimetrexate is less expensive than pentamidine over a wide range of estimates of costs and effectiveness. CONCLUSIONS: To make well-informed therapeutic decisions, policy makers and physicians require head-to-head studies of a new pharmaceutical agent with its major competitor. However, economic models can be used to derive estimates of cost-effectiveness of new pharmaceutical agents when such data are lacking. The interpretation of these models raises general issues related to the perspective of the investigators, study design, estimation of costs of care, rates of response, toxicity, and survival, and generalizability of the results to other settings as well as methodologic issues that are unique to human immunodeficiency virus (HIV) disease. If a comparative trial found better survival rates, then cost-effectiveness models would be of limited usefulness; almost all physicians would use the drug with the higher survival rate.
AIDS-Related Opportunistic Infections↗
Patterns of care for HIV-related Pneumocystis carinii pneumonia in a university medical program: a case study.
BACKGROUND/OBJECTIVE: Previous studies have identified large variations in patterns of in-hospital acquired immunodeficiency syndrome (AIDS) care among groups of hospitals and physicians. We evaluated the patterns of care for patients with AIDS-related Pneumocystis carinii pneumonia (PCP) care at a single university program with patients treated at an adjacent county and Veterans' Administration (VA) hospital. All medical care was provided by physicians in a single residency program, but attending physician staffs were separate. SETTING AND PATIENTS: A randomized sample of patients with human immunodeficiency virus (HIV)-related PCP from the two hospitals who received care between 1987 and 1990. RESULTS: During the study years, the VA hospital provided care for approximately one fourth as many AIDS patients as the county hospital. Patients at the VA hospital had a higher bronchoscopy rate (39.7% versus 27.7%, P = .05), higher intensive-care unit (ICU) rate (11.8% versus 2.9%, P = .008), longer hospitalizations (mean length of stay of 18.9 versus 13.9 days, P = .004), but delayed initiation of anti-PCP therapy (median of day 2 versus day 1, P < .05). The odds of death were significantly different between the VA and county hospitals, even after adjusting for differences in important patient characteristics. CONCLUSION: Patterns of in-hospital PCP care differed between the two hospitals of this medical school. Possible explanations include organizational differences related to level of attending physician HIV experience, hospital case loads of AIDS patients, or specific hospital considerations such as concerns over tuberculosis exposure.
Acquired Immunodeficiency Syndrome↗
Diffusion of laparoscopic cholecystectomy in the Veterans Affairs health care system, 1991-1995.
CONTEXT: Laparoscopic cholecystectomy has become the most widely used treatment for gallbladder disease. In HMO, Medicare, and fee-for-service settings, cholecystectomy rates increased 28% to 59% after introduction of laparoscopic cholecystectomy. OBJECTIVE: To investigate the impact of the introduction of laparoscopic cholecystectomy on cholecystectomy rates and the operative mortality rate in Veterans Affairs (VA) hospitals. DESIGN: Sequential cross-sectional study. PATIENTS: All patients who underwent cholecystectomy from 1991 (before introduction of laparoscopic cholecystectomy) to 1995. SETTING: 133 VA hospitals. OUTCOME MEASURES: Cholecystectomy rates, use of laparoscopic or open cholecystectomy, and operative mortality rate. RESULTS: The annual number of cholecystectomies in the VA system increased by 10% from 1991 to 1995; the laparoscopic procedure accounted for 25% of the caseload in 1992 and 52% in 1995. Compared with patients having laparoscopic cholecystectomy, those having open cholecystectomy were more likely to be older, be male, and have acute cholecystitis or comorbid illnesses (P < 0.001). The operative mortality rate of open cholecystectomy increased by 46% during this 4-year period (from 2.4% to 3.4%) and was constant for laparoscopic cholecystectomy (about 0.5%). Given the increasing use of the laparoscopic procedure, however, the overall mortality rate of cholecystectomy during surgery decreased by 22% (from 2.4% to 1.8%). Despite increased use of the surgery, the absolute number of deaths decreased by 9%. CONCLUSIONS: The introduction of laparoscopic cholecystectomy in the VA system was not accompanied by a large increase in cholecystectomy rates, as it was in fee-for-service, Medicare, and HMO systems. Because the rate of operations has changed only slightly, the total number of cholecystectomy-related deaths has decreased.
Cholecystectomy, Laparoscopic↗
A substitute for clinical thinking?
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Computers↗
Racial differences in care among hospitalized patients with Pneumocystis carinii pneumonia in Chicago, New York, Los Angeles, Miami, and Raleigh-Durham.
BACKGROUND: While strategies for medical care for human immunodeficiency virus-related Pneumocystis carinii pneumonia (PCP) are well established, racial variations in care have not been evaluated. OBJECTIVE: To determine whether sociodemographic characteristics influence patterns of care and patient outcomes, by analyzing the use of diagnostic tests and anti-PCP medications and in-hospital mortality rates for persons who were hospitalized with human immunodeficiency virus-related PCP. METHODS: Retrospective chart review of a cohort of 627 Veterans Administration (VA) patients and 1547 non-VA patients with empirically treated or cytologically confirmed PCP who were hospitalized from 1987 to 1990. Outcomes included representative aspects of the process of care for PCP and short-term mortality rates. RESULTS: Among VA patients, black and Hispanic patients were not significantly different from white patients with regard to in-hospital mortality rates, use and timing of a bronchoscopy, or receipt of timely anti-PCP medications. Among non-VA patients, black and Hispanic patients were more likely to die in the hospital and less likely to undergo a diagnostic bronchoscopy in the first 2 days of hospitalization. These racial and ethnic group differences in the use of a bronchoscopy and in-hospital mortality among non-VA patients were almost fully accounted for by differences in health insurance status and hospital characteristics. CONCLUSIONS: Racial factors do not appear to be an important determinant of the intensity of diagnostic or therapeutic care among patients who are hospitalized with PCP. Variations in care are largely attributable to differences in health insurance and admitting hospital characteristics.
AIDS-Related Opportunistic Infections↗
Finland's health care system. Universal access to health care in a capitalistic democracy.
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Delivery of Health Care↗
Western impressions of the Hong Kong health care system.
Hong Kong, Taiwan, Singapore, and Malaysia are initiating health care reform to meet the changing demands of populations with improved socioeconomic status and access to modern technologies and who are living longer than in previous generations. Hong Kong, in particular, is facing a unique set of circumstances as its people prepare for the transition in 1997 from a British colony to a Special Administrative Region of China. While spending only 4% of its gross domestic product on health care, it has a large and regulated public hospital system for most inpatient medical care and a separate, loosely regulated private health care system for most outpatient medical care. In 1993 the Secretary for Health and Welfare of Hong Kong initiated a year-long process to debate the pros and cons of 5 fundamental programs for health care reform. After a year of open consultation, options were chosen. We describe the Hong Kong health care system, the fundamental changes that have been adopted, and lessons for reformers in the United States.
Adult↗