Association between daily antiretroviral pill burden and treatment adherence, hospitalisation risk, and other healthcare utilisation and costs in a US medicaid population with HIV

Objectives: Lower pill burden leads to improved antiretroviral therapy (ART) adherence among HIV patients. Simpler dosing regimens have not been widely explored in real-world populations. We retrospectively assessed ART adherence, all-cause hospitalisation risk and costs, and other healthcare utilisation and costs in Medicaid enrollees with HIV treated with ART as a once-daily single-tablet regimen (STR) or two or more pills per day (2+PPD). Design: Patients with an HIV diagnosis from 2005 to 2009 receiving complete ART (ie, two nucleoside/nucleotide reverse transcriptase inhibitors plus a third agent) for ≥60 days as STR or 2+PPD were selected and followed until the first of (1) discontinuation of the complete ART, (2) loss of enrolment or (3) end of database. Adherence was measured using the medication possession ratio. Monthly all-cause healthcare utilisation and costs were observed from regimen initiation until follow-up end. Results: Of the 7381 patients who met inclusion criteria, 1797 were treated with STR and 5584 with 2+PPD. STR patients were significantly more likely to reach 95% adherence and had fewer hospitalisations than 2+PPD patients (both p<0.01). STR patients had mean (SD) total monthly costs of $2959 ($4962); 2+PPD patients had $3544 ($5811; p<0.001). Hospital costs accounted for 53.8% and pharmacy costs accounted for 32.5% of this difference. Multivariate analyses found that STR led to a 23% reduction in hospitalisations and a 17% reduction in overall healthcare costs. ART adherence appears to be a key mechanism mediating hospitalisation risk, as patients with ≥95% adherence (regardless of regimen type) had a lower hospitalisation rate compared with <95% adherence. Conclusions: While it was expected that STR patients would have lower pharmacy costs, we also found that STR patients had fewer hospitalisations and lower hospital costs than 2+PPD patients, resulting in significantly lower total healthcare costs for STR patients

The Role of Race in Admission to a Dual Diagnosis Unit Versus General Inpatient Psychiatric Unit in those with Active Substance Use

Psychiatric disorders are highly comorbid with substance use disorders, and the presence of co-occurring conditions increases severity of illness and complicates recovery. Those with comorbid mental illness and substance use disorders may benefit from specialized services, specifically integrated dual diagnosis treatment. Admission to a dual diagnosis unit requires health care providers to consider a number of factors, including severity of illness, psychiatric history, bed availability, and providers’ perceived likelihood of benefit of specialized services. Ideally, decisions regarding the necessity of substance use treatment are made independent of race, and yet, racial disparities exist among those who are offered substance use treatment. The aim of this study was to evaluate the demographic differences of patients who are identified as having active substance use admitted from the comprehensive psychiatric emergency program (CPEP) to a dual diagnosis unit versus those admitted to a general inpatient psychiatric unit. Our study consists of a retrospective analysis of patients, aged 18–90 (n = 100), admitted to either a dual diagnosis unit (8B) or general psychiatric unit (6K) at Mount Sinai Beth Israel (MSBI), a private metropolitan hospital in New York City, between November 1st to November 30th, 2020. We hypothesized that there are racial disparities in unit assignments while accounting for a variety of potentially relevant demographic and clinical variables. The primary outcome was a comparison of demographic factors, particularly racial composition, of those admitted to the dual diagnosis unit versus those admitted to the general psychiatric unit. After accounting for 6 clinical and 3 other demographic variables, patients of Black race were over 5 times more likely (adjusted odds ratio 5.31; P = 0.011) to be assigned to 8B than patients of White, Asian, or Other race. Additional contributors to 8B assignment were male gender, IM or IV PRNs, and documented substance use ('Table 1'). There were no significant differences between Black and Non-Black patients in rates of substance use detected on toxicology ('Table 2'). These findings suggest that race may be a driving factor in unit assignment, and unconscious racial bias may potentially confound admission decision-making, limiting access to available resources and services for some populations. More research is needed to understand factors contributing to racial disparities in substance use treatment

Prescribing and using self-injectable antiretrovirals: How concordant are physician and patient perspectives?

The selection of agents for any treatment regimen is in part influenced by physician and patient attitudes. This study investigated attitudinal motivators and barriers to the use of self-injectable antiretroviral agents among physicians and patients and measured the degree of concordance between physician and patient perspectives

Tai Chi for Osteopenic Women: Design and Rationale of a Pragmatic Randomized Controlled Trial

Background: Post-menopausal osteopenic women are at increased risk for skeletal fractures. Current osteopenia treatment guidelines include exercise, however, optimal exercise regimens for attenuating bone mineral density (BMD) loss, or for addressing other fracture-related risk factors (e.g. poor balance, decreased muscle strength) are not well-defined. Tai Chi is an increasingly popular weight bearing mind-body exercise that has been reported to positively impact BMD dynamics and improve postural control, however, current evidence is inconclusive. This study will determine the effectiveness of Tai Chi in reducing rates of bone turnover in post-menopausal osteopenic women, compared with standard care, and will preliminarily explore biomechanical processes that might inform how Tai Chi impacts BMD and associated fracture risks. Methods/Design: A total of 86 post-menopausal women, aged 45-70y, T-score of the hip and/or spine -1.0 and -2.5, have been recruited from primary care clinics of a large healthcare system based in Boston. They have been randomized to a group-based 9-month Tai Chi program plus standard care or to standard care only. A unique aspect of this trial is its pragmatic design, which allows participants randomized to Tai Chi to choose from a pre-screened list of community-based Tai Chi programs. Interviewers masked to participants' treatment group assess outcomes at baseline and 3 and 9 months after randomization. Primary outcomes are serum markers of bone resorption (C-terminal cross linking telopeptide of type I collagen), bone formation (osteocalcin), and BMD of the lumbar spine and proximal femur (dual-energy X-ray absorptiometry). Secondary outcomes include health-related quality-of-life, exercise behavior, and psychological well-being. In addition, kinetic and kinematic characterization of gait, standing, and rising from a chair are assessed in subset of participants (n = 16) to explore the feasibility of modeling skeletal mechanical loads and postural control as mediators of fracture risk. Discussion: Results of this study will provide preliminary evidence regarding the value of Tai Chi as an intervention for decreasing fracture risk in osteopenic women. They will also inform the feasibility, value and potential limitations related to the use of pragmatic designs for the study of Tai Chi and related mind-body exercise. If the results are positive, this will help focus future, more in-depth, research on the most promising potential mechanisms of action identified by this study. Trial registration: This trial is registered in Clinical Trials.gov, with the ID number of NCT01039012

Faculty Roundtable Discussion

SELECTING INITIAL REGIMENS MR. FROST (MODERATOR): I want to ask Dr. Saag, the question that I think is probably one of the most frequently asked. What do you start treatment with? Suppose a new patient, with no retroviral history, comes to you with a CD4 count between 400 and 500 and a viral load of 10,000 to 15,000 copies. DR. SAAG: There is more to consider in initial therapies than just retroviral load and CD4 count. It is also about who are they as a person, how motivated are they, and are they ready to start therapy? DR. SAAG: Alright. Then in talking to you, I would find out whether you want to be hyperaggressive or whether you want to be more conservative in treatment approach

Question and Answer Session

PROPHYLAXIS OF OPPORTUNISTIC INFECTIONS QUESTION: In your clinic do you stop prophylaxis for PCP when patients go up above a CD4 count of 200? DR. CURRIER: Not routinely. I enroll the patients in the ongoing study, if they are interested. Sometimes patients stop prophylaxis on their own and do not tell me that they have decided to discontinue it. But I have not been routinely recommending discontinuation without more data. MR. FROST (MODERATOR): What about mycobacterium avium complex (MAC)? DR. CURRIER: It is [stopped]. But I do not go around discontinuing it as a matter of routine

Visible and near-infrared multispectral analysis of geochemically measured rock fragments at the Opportunity landing site in Meridiani Planum

We have used visible and near‐infrared Panoramic Camera (Pancam) spectral data acquired by the Opportunity rover to analyze 15 rock fragments at the Meridiani Planum landing site. These spectral results were then compared to geochemistry measurements made by the in situ instruments M&ouml;ssbauer (MB) and Alpha Particle X‐ray Spectrometer (APXS) to determine the feasibility of mineralogic characterization from Pancam data. Our results suggest that dust and alteration rinds coat many rock fragments, which limits our ability to adequately measure the mineralogy of some rocks from Pancam spectra relative to the different field of view and penetration depths of MB and APXS. Viewing and lighting geometry, along with sampling size, also complicate the spectral characterization of the rocks. Rock fragments with the same geochemistry of sulfate‐rich outcrops have similar spectra, although the sulfate‐rich composition cannot be ascertained based upon Pancam spectra alone. FeNi meteorites have spectral characteristics, particularly ferric oxide coatings, that generally differentiate them from other rocks at the landing site. Stony meteorites and impact fragments with unknown compositions have a diverse range of spectral properties and are not well constrained nor diagnostic in Pancam data. Bounce Rock, with its unique basalt composition, is easily differentiated in the Pancam data from all other rock types at Meridiani Planum. Our Pancam analyses of small pebbles adjacent to these 15 rock fragments suggests that other rock types may exist at the landing site but have not yet been geochemically measured