Retention in Care and Outpatient Costs for Children Receiving Antiretroviral Therapy in Zambia: A Retrospective Cohort Analysis

BackgroundThere are few published estimates of the cost of pediatric antiretroviral therapy (ART) in Africa. Our objective was to estimate the outpatient cost of providing ART to children remaining in care at six public sector clinics in Zambia during the first three years after ART initiation, stratified by service delivery site and time on treatment.MethodsData on resource utilization (drugs, diagnostics, outpatient visits, fixed costs) and treatment outcomes (in care, died, lost to follow up) were extracted from medical records for 1,334 children at six sites who initiated ART at 50%) at four sites. At the two remaining sites, outpatient visits and fixed costs together accounted for >50% of outpatient costs. The distribution of costs is slightly skewed, with median costs 3% to 13% lower than average costs during the first year after ART initiation depending on site.ConclusionsOutpatient costs for children initiating ART in Zambia are low and comparable to reported outpatient costs for adults. Outpatient costs and retention in care vary widely by site, suggesting opportunities for efficiency gains. Taking advantage of such opportunities will help ensure that targets for pediatric treatment coverage can be met

Meeting human resources for health staffing goals by 2018: a quantitative analysis of policy options in Zambia

<p>Abstract</p> <p>Background</p> <p>The Ministry of Health (MOH) in Zambia is currently operating with fewer than half of the health workers required to deliver basic health services. The MOH has developed a human resources for health (HRH) strategic plan to address the crisis through improved training, hiring, and retention. However, the projected success of each strategy or combination of strategies is unclear.</p> <p>Methods</p> <p>We developed a model to forecast the size of the public sector health workforce in Zambia over the next ten years to identify a combination of interventions that would expand the workforce to meet staffing targets. The key forecasting variables are training enrolment, graduation rates, public sector entry rates for graduates, and attrition of workforce staff. We model, using Excel (Office, Microsoft; 2007), the effects of changes in these variables on the projected number of doctors, clinical officers, nurses and midwives in the public sector workforce in 2018.</p> <p>Results</p> <p>With no changes to current training, hiring, and attrition conditions, the total number of doctors, clinical officers, nurses, and midwives will increase from 44% to 59% of the minimum necessary staff by 2018. No combination of changes in staff retention, graduation rates, and public sector entry rates of graduates by 2010, without including training expansion, is sufficient to meet staffing targets by 2018 for any cadre except midwives. Training enrolment needs to increase by a factor of between three and thirteen for doctors, three and four for clinical officers, two and three for nurses, and one and two for midwives by 2010 to reach staffing targets by 2018. Necessary enrolment increases can be held to a minimum if the rates of retention, graduation, and public sector entry increase to 100% by 2010, but will need to increase if these rates remain at 2008 levels.</p> <p>Conclusions</p> <p>Meeting the minimum need for health workers in Zambia this decade will require an increase in health training school enrolment. Supplemental interventions targeting attrition, graduation and public sector entry rates can help close the gap. HRH modelling can help MOH policy makers determine the relative priority and level of investment needed to expand Zambia's workforce to target staffing levels.</p

Recurrent Chromosome 16p13.1 Duplications Are a Risk Factor for Aortic Dissections

Chromosomal deletions or reciprocal duplications of the 16p13.1 region have been implicated in a variety of neuropsychiatric disorders such as autism, schizophrenia, epilepsies, and attention-deficit hyperactivity disorder (ADHD). In this study, we investigated the association of recurrent genomic copy number variants (CNVs) with thoracic aortic aneurysms and dissections (TAAD). By using SNP arrays to screen and comparative genomic hybridization microarrays to validate, we identified 16p13.1 duplications in 8 out of 765 patients of European descent with adult-onset TAAD compared with 4 of 4,569 controls matched for ethnicity (P = 5.0×10−5, OR = 12.2). The findings were replicated in an independent cohort of 467 patients of European descent with TAAD (P = 0.005, OR = 14.7). Patients with 16p13.1 duplications were more likely to harbor a second rare CNV (P = 0.012) and to present with aortic dissections (P = 0.010) than patients without duplications. Duplications of 16p13.1 were identified in 2 of 130 patients with familial TAAD, but the duplications did not segregate with TAAD in the families. MYH11, a gene known to predispose to TAAD, lies in the duplicated region of 16p13.1, and increased MYH11 expression was found in aortic tissues from TAAD patients with 16p13.1 duplications compared with control aortas. These data suggest chromosome 16p13.1 duplications confer a risk for TAAD in addition to the established risk for neuropsychiatric disorders. It also indicates that recurrent CNVs may predispose to disorders involving more than one organ system, an observation critical to the understanding of the role of recurrent CNVs in human disease and a finding that may be common to other recurrent CNVs involving multiple genes

Rationale and protocol for a cluster randomized pragmatic clinical trial testing behavioral economic implementation strategies to improve tobacco treatment rates for cancer patients who smoke

Background Routine evidence-based tobacco use treatment minimizes cancer-specific and all-cause mortality, reduces treatment-related toxicity, and improves quality of life among patients receiving cancer care. Few cancer centers employ mechanisms to systematically refer patients to evidence-based tobacco cessation services. Implementation strategies informed by behavioral economics can increase tobacco use treatment engagement within oncology care. Methods A four-arm cluster-randomized pragmatic trial will be conducted across nine clinical sites within the Implementation Science Center in Cancer Control Implementation Lab to compare the effect of behavioral economic implementation strategies delivered through embedded messages (or “nudges”) promoting patient engagement with the Tobacco Use Treatment Service (TUTS). Nudges are electronic medical record (EMR)-based messages delivered to patients, clinicians, or both, designed to counteract known patient and clinician biases that reduce treatment engagement. We used rapid cycle approaches (RCA) informed by relevant stakeholder experiences to refine and optimize our implementation strategies and methods prior to trial initiation. Data will be obtained via the EMR, clinician survey, and semi-structured interviews with a subset of clinicians and patients. The primary measure of implementation is penetration, defined as the TUTS referral rate. Secondary outcome measures of implementation include patient treatment engagement (defined as the number of patients who receive FDA-approved medication or behavioral counseling), quit attempts, and abstinence rates. The semi-structured interviews, guided by the Consolidated Framework for Implementation Research, will assess contextual factors and patient and clinician experiences with the nudges. Discussion This study will be the first in the oncology setting to compare the effectiveness of nudges to clinicians and patients, both head-to-head and in combination, as implementation strategies to improve TUTS referral and engagement. We expect the study to (1) yield insights into the effectiveness of nudges as an implementation strategy to improve uptake of evidence-based tobacco use treatment within cancer care, and (2) advance our understanding of the multilevel contextual factors that drive response to these strategies. These results will lay the foundation for how patients with cancer who smoke are best engaged in tobacco use treatment and may lead to future research focused on scaling this approach across diverse centers. Trial registration Clinicaltrials.gov, NCT04737031 . Registered 3 February 2021

Operating Room First Start Efficiency Throughout a Large Urban Hospital System

Background: Operating room delays decrease health care system efficiency and increase hospital costs. Data on delays in a multihospital system are sparse. Purpose: In an effort to improve our operating room efficiency, we investigated operating room delays, the causes and the impending financial impact. Methods: A retrospective analysis on first case-of-the-day surgeries at three hospitals during 2013 was conducted. Delays were defined as in-room time being after scheduled surgery start time. Length of delay and causes were recorded. Patient demographics, body mass index, hospital facility, total number of procedures, provider specialty and time of patient arrival were incorporated into a logistic regression model to identify significant variables. Hosmer-Lemeshow was used to measure goodness-of-fit and predictive power. Cost was calculated using published estimates. Results: 5,607 cases were examined and 88% were delayed. Surgeons (21%), anesthesiologists (6.17%), patients (5.42%), staff (3.60%), facility (2.10%) and other (2.35%) were identified as causes. Mean time for patient arrival to surgery was 104.57 min. Mean time between arrival and room placement was 127.38 min. The average delay time from scheduled surgery start was 24.26 min. Logistic regression identified hospital facility (P \u3c 0.0001), surgical specialty (P \u3c 0.0001), patient age (P = 0.0004) and late patient arrival (P = 0.0005) as significant predictors of delay. Operating room delays were responsible for $444,074 in lost revenue. Conclusion: In our study, 88% of first start cases were delayed, the majority of which were caused by the surgeon. However, hospital facility, surgical subspecialty, patient age and arrival time also significantly affected delays. Correction of operating room delays can significantly reduce hospital costs

Tumor diameter as a predictor of lymphatic dissemination in endometrioid endometrial cancer

OBJECTIVES: To assess the utility of tumor diameter (TD) for predicting lymphatic dissemination (LD) and determining need for lymphadenectomy following diagnosis of endometrioid endometrial cancer. METHODS: Patients diagnosed with stage I-III endometrioid endometrial cancer during 2003-2013 who underwent complete lymphadenectomy during hysterectomy were studied. Intraoperative predictors of LD included TD, grade, myometrial invasion (MI), age, body mass index, and race/ethnicity. Candidate logistic regression models of LD were evaluated for model fit and predictive power. RESULTS: Of 737 cancer patients, 68 (9.2%) were node-positive. Single-variable models with only continuous TD (c-statistic 0.77, 95% CI 0.71-0.83) and dichotomous TD with 50-mm cut-off (TD50; c-statistic 0.73, 95% CI 0.67-0.78) were significantly more predictive than with the standard 20-mm cut-off (c-statistic 0.56, 95% CI 0.53-0.59). Overall, the most important LD predictors were TD50 and MI3rds (three-category form). The best candidate model (c-statistic 0.84, 95% CI 0.80-0.88) suggested odds of LD were five times greater for TD \u3e50mm than ≤50mm (OR 4.91, 95% CI 2.73-8.82) and six and ten times greater for MI \u3e33% to ≤66% (OR, 5.70; 95% CI, 2.25-14.5) and \u3e66% (OR 10.2, 95% CI 4.11-25.4), respectively, than ≤33%. Best-model false-negative (0%) and positive (57.2%) rates demonstrated marked improvement over traditional risk-stratification false-negative (1.5%) and positive (76.2%) rates (c-statistic 0.77, 95% CI 0.72-0.82). CONCLUSIONS: Tumor diameter is an important predictor of LD. Our risk model, containing modified forms of MI and TD, yielded a lower false-negative rate and can significantly decrease the number of lymphadenectomies performed on low-risk women

Robustness of a Newly Proposed Risk Schema for Lymphatic Dissemination in Endometrioid Endometrial Cancer

Background: Surgical management for endometrioid endometrial cancer (EEC) includes complete lymph node dissection for all patients at risk of lymphatic dissemination. The standard risk schema, defined by Mayo Clinic, identifies low-risk patients as those with grade 1/2 EEC, myometrial invasion (MI) ≤ 50%, and tumor diameter (TD) ≤ 2 cm. We recently proposed (and published) a risk schema containing modified forms of grade, MI and TD that suggests a significant decrease in false-negative rate and need for lymphadenectomy in low-risk women. Purpose: Evaluate robustness of our proposed schema for lymphatic dissemination risk stratification in a subsequent EEC patient cohort. Methods: We retrospectively applied the proposed schema to patients diagnosed with stage I–III EEC during 2014–2015 who underwent pelvic and/or para-aortic lymph node removal. Cancer Registry data were confirmed via chart review. Consistent with the cohort studied during model development, the validation cohort included non-Hispanic white or black patients with complete data describing TD (≤ 50 mm or \u3e 50 mm), MI (≤ 33%, \u3e 33% to ≤ 66%, or \u3e 66%) and grade (1 or 2–3). Results: In the validation cohort, 29 (11.7%) of the 247 EEC patients were node-positive (vs 9.2% of 737 patients in the development cohort). Risk stratification using the proposed schema produced similar false-positive rates during model development (57.2%) and validation (54.6%), both 20% lower than when using the standard schema (76.2% and 74.3%, respectively). False-negative rates, however, were noticeably different between development and validation cohorts using both the proposed (0% and 13.8%) and standard (1.47% and 6.90%) schemas, suggesting a shift toward low-risk classification in node-positive patients of the validation cohort. Conclusion: Application of the proposed risk stratification schema to an alternative patient cohort verified the utility of modified risk criteria, including TD with 50-mm cutoff, for identifying low-risk EEC patients who may not require node evaluation. However, in the validation cohort, greater prevalence of lymph node metastasis and low-risk classification of node-positive patients was observed. Discrepancy between cohorts is likely due to greater utilization of sentinel lymph node mapping during the validation period, allowing for increased detection of low-volume metastases. Continued model development and validation is needed, especially to account for the increased sensitivity of new technologies