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PubMed2000

A prospective economic evaluation of basiliximab (Simulect) therapy following renal transplantation.

BACKGROUND: Immunoprophylaxis with basiliximab (Simulect), an anti-interleukin-2-receptor (anti-IL-2R; CD25) chimeric monoclonal antibody, has been demonstrated to significantly reduce the incidence of acute cellular rejection in adult renal allograft recipients (32% vs. placebo, p < 0.01). METHODS: An economic evaluation was conducted as part of a U.S. multi-center, randomized, double-blind, placebo-controlled clinical trial comparing basiliximab plus dual immunosuppressive therapy (cyclosporine modified [Neoral] and corticosteroids) to dual therapy alone. Healthcare resources utilized by the 346 subjects in the 'intent-to-treat' population were prospectively collected over the 1-yr study period. Direct medical costs were determined for all hospitalizations, outpatient provider visits, procedures (excluding the initial transplant procedure), laboratory and diagnostic tests, and immunosuppressants, including basiliximab when administered. RESULTS: Total first-year medical costs were lower for the basiliximab group than for the placebo group ($28 927 vs. $32 300, difference = $3373). although this difference was not statistically significant. First-year hospital costs for treating acute rejection were also lower for the basiliximab group ($9328 vs. $10761, difference = $1433); however, this difference did not achieve statistical significance. Importantly, the efficacy analysis demonstrated a significant reduction in the incidence of acute rejection (38 vs. 55%, p < 0.01) in the basiliximab arm, and this was accomplished without increasing the overall cost of care. Fewer basiliximab-treated patients (8 vs. 15%,, p = 0.03) were hospitalized. This observation suggested less serious illness and reduced treatment costs among basiliximab-treated patients, because the overall incidence of infection was similar between the groups. The adverse event profile of patients receiving basiliximab was clinically and economically indistinguishable from that of those treated with placebo. CONCLUSION: Induction immunosuppression with basiliximab, combined with cyclosporine modified and corticosteroids, was therapeutically beneficial and contained medical costs during the initial post-transplant year.

Adrenal Cortex Hormones↗
PubMed2006

Phosphodiesterase type 5 inhibitors' extended duration of response as a variable in the treatment of erectile dysfunction.

The phosphodiesterase type 5 (PDE5) inhibitors, sildenafil, tadalafil and vardenafil, are a class of medications that are safe and effective in treating erectile dysfunction (ED). Yet, resuming sexual activity following a period of abstinence in response to ED may be anxiety-provoking for the man, his partner and their relationship, causing the sexual encounter to become a stressful event. The differences between PDE5 inhibitors in terms of duration of action can be successfully utilized by healthcare professionals to mitigate some of the psychosocial barriers that interfere with treating ED. PDE5 inhibitors with a longer duration of responsiveness provide some men with ED and their partners, a treatment option that may offer greater flexibility and potentially less anxiety surrounding the resumption of sexual activity. Shorter-acting PDE5s may be preferred by men/couples with predictable sexual scripts, excellent communication strategies and concerns regarding the duration of side effects.

3',5'-Cyclic-GMP Phosphodiesterases↗
PubMed2004

Three dimensional reconstruction of CT scan images to aid the cardiac surgeon.

Minimally invasive techniques and approaches have the potential advantages of less operative stress and healthcare resource utilization but at the "cost" of less operative field of view. Newer imaging techniques utilizing three dimensional reconstruction of computed tomography scan images (3DCT) can aid the cardiac surgeon in visualizing the geometric relationships to plan and execute complex surgical procedures via minimally invasive or standard approaches. Multidetector-row CT scanning and post-processing yield these 3DCT images. We describe representative examples of this imaging technology in planning complex surgical procedures. Vascular structures, pulmonary and atrial venous relationships and cardiac ventricular functional anatomy are all visualized. Utilizing advances in imaging should allow surgeons to rapidly adopt newer technologies and minimally invasive techniques.

Arteries↗
PubMed2000

The Bristol 'OA500 study': progression and impact of the disease after 8 years.

OBJECTIVE: To study the natural history of peripheral joint osteoarthritis (OA) and assess its impact over eight years in a prospective study of 500 patients. METHODS: 500 consecutive patients with peripheral joint OA were recruited from a hospital-based rheumatology clinic. All were invited for review 3 and 8 years after entry. Joint sites involved, pain severity, change in index joints, global change in the condition, use of medication, surgery and walking aids were all recorded at each visit, and after eight years disability was assessed by the health assessment questionnaire (HAQ) and anxiety and depression by the Hospital anxiety and depression scale (HAD). RESULTS: At eight-year review, 349 patients were seen: 90% of those remaining alive. Outcome was heterogeneous. Sixty patients (17.2%) reported worsening in all three subjective parameters (pain, index joint and global change) compared with 22 (6.3%) who improved in all three parameters. Using this definition of worsening or improvement, strong baseline predictors of clinical outcome did not emerge. For further description, the group was split according to the index joint sites involved at entry to the study, there being 111 with knee OA alone, 87 with hand and knee OA, 72 with hand disease alone, and 29 with hip disease alone. Forty-four percent of those with lone hand disease at entry had acquired significant knee or hip OA 8 years later. The mean HAQ and HAD scores at 8 years were high, especially in those with knee disease, indicating significant disability as a result of the disease. Those with knee or knee and hand disease had the worst outcome in all parameters recorded. The data showed a general decrease in use of NSAIDs over the eight years, but an increase in utilization of analgesics, surgery (especially for hip disease) and walking aids. CONCLUSIONS: Patients with peripheral joint OA of sufficient severity to lead to hospital referral have a heterogeneous, but generally bad outcome over 8 years, the disease resulting in high levels of physical disability, anxiety and depression, with a high level of utilization of healthcare resources, including joint replacement, drugs and walking aids. The results were consistent with previous suggestions that peripheral joint OA in older people is characterized by the slow acquisition of new joint sites. Progression and outcome may depend on a complex set of psychosocial factors, as well as biological ones.

Aged↗
PubMed2004

Reactions to disability in patients with early versus established rheumatoid arthritis.

OBJECTIVES: This study examined differences in reactions to disability between early and established rheumatoid arthritis (RA) patients, and whether these reactions were related to age, physical functioning, acceptance of illness, or self-efficacy. METHODS: Thirty-four patients with early RA (< 2 years since diagnosis) and 84 patients with established RA (> 4 years since diagnosis) completed the Reactions to Impairment and Disability Inventory (RIDI), and measures of anxiety, depression, acceptance of illness, self-efficacy, and physical functioning. RESULTS: Early RA patients reported greater future denial than established RA patients. Younger patients reported more hostility than older patients. Accepting the illness was uniquely related to less anger and hostility. Higher self-efficacy for pain specifically related to greater shock, while patients with poorer self-efficacy for other symptoms reported worse anxiety, depression, shock, and anger. CONCLUSIONS: Denial may be a coping strategy in the early stages of RA: anxiety, depression, shock, and anger appear to persist. Longitudinal studies of RA patients from diagnosis are required to plan interventions timed to maximize patient benefit and optimize healthcare resource utilization.

Activities of Daily Living↗
PubMed2006

Applied relaxation in the treatment of long-lasting neck pain: a randomized controlled pilot study.

OBJECTIVES: To evaluate the feasibility of study design and method for evaluating effects of interventions on patients with long-lasting neck pain and to compare treatment effects of: (i) a pain and stress management group intervention with applied relaxation, and (ii) individual physiotherapy treatment as usual. DESIGN: Randomized controlled pilot study. SUBJECTS: Thirty-seven patients with long-lasting neck pain. METHODS: The patients were randomly assigned either to applied relaxation or treatment as usual. The applied relaxation group received 7 group sessions over a period of 7 weeks and the treatment as usual group an average of 11 individual sessions spread over 20 weeks following baseline. Twenty-nine participants completed the intervention and filled in a self-assessment questionnaire before treatment, and 7 and 20 weeks after baseline. The questionnaire comprised: Neck Disability Index, Coping Strategies Questionnaire, Hospital Anxiety and Depression Scale, Tampa Scale of Kinesiophobia, and questions regarding neck pain, analgesic use, sleep, sick-leave and utilization of healthcare. RESULTS: The applied relaxation group had better perceived control over pain at the 20 weeks follow-up compared with the treatment as usual group. CONCLUSION: The design and methods of this pilot study were feasible and will be suitable for a larger randomized controlled study.

Adaptation, Psychological↗
PubMed2001

Can syphilis be eradicated from the world?

With the description of the complete genome sequence of Treponema pallidum, the declining rates of primary and secondary syphilis in many developed countries, and the continuing development of easier, cheaper, and more reliable diagnostics, the goal of worldwide syphilis eradication may be achievable. Although syphilis is easy to detect and cure given adequate access to and utilization of healthcare, many barriers exist on the way to its elimination and ultimate eradication. This review discusses current opinions regarding the plans, prospects and obstacles to worldwide syphilis eradication.

Global Health↗
PubMedDate not supplied

Resource planning for patient-centered, collaborative care.

In this article, we use self-reported information from 13,271 older adults and the results from several controlled trials to construct a planned-care management strategy that cuts across diseases and conditions and also addresses health disparities attributed to low socioeconomic status. Three strata result from the interaction of patients' financial status, the presence or absence of bothersome pain and psychosocial problems, and their confidence with self-care. A majority of ambulatory patients generally fall in the first stratum. More resources are required in the 2 remaining strata to attain patient-centered, collaborative care. Because the planned-care management strategy is behaviorally sophisticated, it is likely to be more efficient and effective than strategies based on concepts of disease management that focus on either a single disease or groupings of patients who are "high utilizers" of healthcare. We conclude that modern technologies and related approaches make resource planning for patient-centered, collaborative care feasible and desirable.

Aged↗
PubMed2002

Psychiatric patients' vulnerability in the wake of the September 11th terrorist attacks.

The September 11, 2001 (9/11) terrorist attacks led to speculation about the vulnerability of psychiatric patients to psychological distress following such events. This study examined the impact of national terrorist attacks on psychiatric and medical outpatients living approximately 150 to 200 miles from the attack sites (N = 308). Two to 3 weeks following 9/11, patients were given questionnaires assessing background information, healthcare service utilization, and posttraumatic stress disorder (PTSD) symptoms. Psychiatric patients (33%) were significantly more likely than medical patients (13%) to report distressing symptoms meeting criteria for PTSD (except for the duration criterion) despite no differences in learning about the attacks or personal involvement with the victims. Patients meeting PTSD criteria were more likely to schedule an appointment to speak with their physician about their reactions. Psychiatric patients not directly impacted by the 9/11 terrorist attacks are at increased risk for experiencing distressing symptoms following national terrorist attacks.

Adult↗
PubMed1997

Pubic rami fracture: a benign pelvic injury?

OBJECTIVE: To present a consecutive series of older patients with pubic rami fractures and evaluate their long term functional outcome. STUDY DESIGN: Retrospective. METHODS: Sixty-three consecutive community-dwelling, ambulatory patients who sustained a public rami fracture and were treated at one hospital were reviewed. Fifty-two of sixty-three patients (83%) had radiographic evidence of pubic rami fracture at initial presentation; in the remaining eleven patients, the diagnosis of pubic rami fracture was made after additional imaging studies. Sixty patients (95%) required hospitalization for pain control and progressive mobilization. RESULTS: The hospital length of stay for the sixty admitted patients averaged fourteen days; patients who had three or more associated medical comorbidities or required use of a cane or walker for ambulation prior to fracture were more likely to have been hospitalized greater than two weeks. Thirty-eight patients were available for one year minimum follow-up; thirty-five of thirty-eight patients (92%) were living at home, 84% had no or mild complaints of hip/groin pain, 92% had returned to their prefracture ambulatory status, and 95% had returned to their performance function in activities of daily living. CONCLUSIONS: 1) Elderly patients with pubic rami fractures utilize substantial healthcare resources based upon length of stay and need for home care services; and 2) those patients who survive have a good prognosis with regard to long term pain relief and functional outcome.

Activities of Daily Living↗
PubMed2005

Racial, ethnic, and socioeconomic disparities in estimates of AHRQ patient safety indicators.

BACKGROUND: Patient safety events that result from the happenstance of mistakes and errors should not occur systematically across racial, ethnic, or socioeconomic subgroups. OBJECTIVE: To determine whether racial and ethnic differences in patient safety events disappear when income (a proxy for socioeconomic status) is taken into account. RESEARCH DESIGN: This study analyzes administrative data from community hospitals in 16 states with reliable race/ethnicity measures in the 2000 Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality (AHRQ), using the publicly available AHRQ patient safety indicators (PSIs). RESULTS: Different indicators show different results for different racial/ethnic subgroups. Many events with higher rates for non-Hispanic blacks (compared with non-Hispanic whites) remain higher when income is taken into account, although such differences for Hispanics or Asian/Pacific Islanders (APIs) tend to disappear. Many events with lower rates for Hispanics and APIs remain lower than whites when income is taken into account, but for blacks, they disappear. DISCUSSION: The higher rates for minorities that reflect the way health care is delivered raise troubling questions about potential racial/ethnic bias and discrimination in the US health care system, problems with cultural sensitivity and effective communication, and access to high-quality health care providers. CONCLUSIONS: The AHRQ PSIs are a broad screen for potential safety events that point to needed improvement in the quality of care for specific populations.

Adult↗
PubMed2002

Translating vague complaints into precise symptoms: the implications of a poor medical history.

A medical history serves to record the patient's complaints and translate them into clear-cut, medically defined symptoms. A poorly defined symptom loses most of its discriminative power as a diagnostic test for a medical work-up. If physicians are uncertain about the exact meaning of a symptom, they have to account for the possibility of multiple competing interpretations for the identical set of complaints. Multiple possible interpretations of a single symptom diminish its value as a diagnostic test and result in test degeneracy. A modified Bayes' formula is used to quantify the influence of test degeneracy on post-test probability. The physician needs to help his patients to phrase their complaints in a fashion that limits the number of possible interpretations. A poor medical history diminishes the opportunity to establish a diagnostic suspicion with a high probability early on. The subsequent medical work-up has to rely on many more tests to confirm the presence of a diagnosis. The poor medical history exposes the patient, therefore, to more test-related risks, and prolongs the diagnostic process. All these downsides of a poor history ultimately increase medical resource utilization and healthcare expenditures.

Bayes Theorem↗
PubMed2004

Improving health-related quality of life in chronic obstructive pulmonary disease.

PURPOSE OF REVIEW: Most current treatments for chronic obstructive pulmonary disease (COPD) have been unable to improve survival or arrest decline in lung function. This reality highlights the importance of patient-focused outcomes that address symptom relief, functional status, and overall health-related quality ov life (HRQOL). Measures of HRQOL can complement established physiologic outcomes that have been traditionally used. RECENT FINDINGS: There are several generic and disease-specific instruments that can be used to measure HRQOL, each incorporating various aspects of physical, psychological, and social function. Basic concepts regarding these instruments are presented. Recent studies suggest that HRQOL is an important measure of prognosis and healthcare resource utilization in COPD patients. SUMMARY: An increasing number of studies now incorporate HRQOL as an outcome measure. Interventions that have shown a positive effect on some or all components of HRQOL, including inhaled corticosteroids, inhaled bronchodilators, opioids, oxygen therapy, pulmonary rehabilitation, implementation of a disease-specific self-management program, and lung volume reduction surgery are discussed in this review.

Activities of Daily Living↗
PubMed2005

Incidence and risk factors for stroke in pregnancy and the puerperium.

OBJECTIVE: To estimate the incidence, mortality, and risk factors for pregnancy-related stroke in the United States. METHODS: The Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, for the years 2000-2001 was queried for International Classification of Diseases, 9th Revision, codes for stroke among all pregnancy-related discharges. RESULTS: A total of 2,850 pregnancy-related discharges included a diagnosis of stroke for a rate of 34.2 per 100,000 deliveries. There were 117 deaths or 1.4 per 100,000 deliveries. Twenty-two percent of survivors were discharged to another facility. The risk of stroke increased with age, particularly ages 35 years and older. African-American women were at a higher risk, odds ratio (OR) 1.5 (95% confidence interval [CI] 1.2-1.9). Medical conditions that were strongly associated with stroke included migraine headache, OR 16.9 (CI 9.7-29.5), thrombophilia, OR 16.0 (CI 9.4-27.2), systemic lupus erythematosus, OR 15.2 (CI 7.4-31.2), heart disease, OR 13.2 (CI 10.2-17.0), sickle cell disease, OR 9.1 (CI 3.7-22.2), hypertension, OR 6.1(CI 4.5-8.1) and thrombocytopenia, OR 6.0 (CI 1.5-24.1). Complications of pregnancy that were significant risk factors were postpartum hemorrhage, OR 1.8 (CI 1.2-2.8), preeclampsia and gestational hypertension, OR 4.4 (CI 3.6-5.4), transfusion OR 10.3 (CI 7.1-15.1) and postpartum infection, OR 25.0 (CI 18.3-34.0). CONCLUSION: The incidence, mortality and disability from pregnancy related-stroke are higher than previously reported. African-American women are at an increased risk, as are women aged 35 years and older. Risk factors, not previously reported, include lupus, blood transfusion, and migraine headaches. Specific strategies, not currently employed, may be required to reduce the devastation caused by stroke during pregnancy and the puerperium. LEVEL OF EVIDENCE: II-2.

Adult↗
PubMed2006

Non-cardiac chest pain: an update.

Non-cardiac chest pain (NCCP) is very common, affecting up to a quarter of the USA adult population. Recent studies have shown that the disorder has a profound impact on patient's quality of life and is associated with marked increase in utilization of healthcare resources. Non-cardiac chest pain is a heterogeneous disorder with gastrointestinal and non-gastrointestinal causes. After excluding a cardiac cause, most NCCP patients are treated by cardiologists or primary care physicians and only the minority are referred to a gastroenterologist for further work-up. Gastro-oesophageal reflux disease (GORD) is the most common cause for NCCP. The role of oesophageal dysmotility in NCCP has been discounted in recent years. However, visceral hyperalgesia has been shown to play an important role in symptom generation of non-GORD-related NCCP. The main therapeutic interventions in GORD-related NCCP patients are potent antireflux modalities and pain modulators in those with non-GORD-related NCCP.

Chest Pain↗
PubMed2005

Drop attacks in older adults: systematic assessment has a high diagnostic yield.

OBJECTIVES: To investigate the causes of recurrent drop attacks in older patients with a comprehensive battery of investigations in the largest series reported to date. DESIGN: Observational with mean followup of 18 months. SETTING: Inner city emergency department and tertiary facility in Newcastle upon Tyne, United Kingdom. PARTICIPANTS: Ninety-three consecutive patients aged 55 and older with three or more drop attacks in the 6 months before evaluation. METHODS: Subjects underwent a comprehensive diagnostic evaluation, with particular attention to traditional (e.g., gait and balance abnormalities, medications) and more recently identified (e.g., carotid sinus hypersensitivity) risk factors for drop attacks. RESULTS: Subjects tended to be older (mean age+/-standard deviation 77.4+/-9.0) and female (70; 75%) and to have a mean of 10.4 drop attacks before evaluation. Fifty-three (57%) had suffered soft tissue injuries needing medical attention and 32 (34%) fractures secondary to drop attacks. An attributable diagnosis was achieved in all but nine subjects (90%). Cardiovascular diagnoses (49; 53%) were most commonly implicated, with neurological (27; 29%) and gait and balance abnormalities (17; 18%) and drug-related causes (11; 12%) providing the majority of the remaining diagnoses. CONCLUSION: Drop attacks in older subjects are associated with high levels of morbidity and healthcare resource utilization. Attributable diagnoses are achievable in the majority of cases with a systematic investigative approach. The high diagnostic yield more than justifies the approach described.

Age Factors↗
PubMed2004

The rate and cost of hospital readmissions for preventable conditions.

The study estimates the rate and cost of preventable readmissions within 6 months after a first preventable admission, by age-group, and by payer and race within age-group. The descriptive results are contrasted with several hypotheses. The hospital discharge data are for residents of New York, Pennsylvania, Tennessee, and Wisconsin in 1999, from files of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. About 19 percent of persons with an initial preventable admission had at least one preventable readmission rate within 6 months. Hospital cost for preventable readmissions during 6 months was about 730 million US dollars. There were substantial differences in readmission rates by payer group and by race. Some evidence suggests that preventable readmissions may partly reflect complexity of underlying problems. Interventions to reduce cost might focus on identifying high-risk patients before discharge and devising new approaches to follow-up.

Adolescent↗
PubMedDate not supplied

Microeconomic loans and health education to families in impoverished communities: implications for the HIV pandemic.

Poverty is among the root causes of death and poor health worldwide. Project HOPE's Village Health Bank (VHB) program is a public health intervention that combines integrated microcredit lending and health education. Groups of 18 to 25 women receive small loans, and biweekly, one-hour health education sessions. Since 1993, about 50,000 women in 949 VHBs have participated in seven countries in the Americas, Africa, and Southeast Asia, receiving more than US$25 million in loans and 8,445 hours of health education. Members of VHBs are charged modest interest rates that enable them to become self-sufficient (eg, able to cover all operating charges, including the costs of the health education staff, and the necessary loan capital to continue without infusion of outside resources). The VHB program produces substantial economic improvements for individuals and groups, and benefits in health knowledge and behaviors, including increased utilization of healthcare services. Data from Guatemala, Malawi, and Thailand demonstrate that VHBs in countries with high HIV prevalence have been comparably successful in spite of the enormous added burdens of chronic illness, deaths, and orphans in need of support. For example, in 2004, 48 percent of 266 VHB members in Malawi experienced at least one death in their household in the preceding year, and 67 percent housed one or more orphans with an average of two orphans per household. Because of the unique combination of increased household economic stability and improved health knowledge, the VHB program is now being adapted to families of people affected by HIV/AIDS, including orphans.

Acquired Immunodeficiency Syndrome↗