Improving cost-effectiveness of hypertension management at a community health centre

Objectives. To describe the pattern of prescribing for hypertension at a community health centre (CHC) and to evaluate the impact of introducing treatment guidelines and restricting availability of less cost-effective antihypertensive drugs on prescribing patterns, costs of drug treatment and blood pressure (BP) control.Design. Before/after intervention study.Setting. Medium-sized CHC in the Cape Flats area of Cape Town.Subjects. 1 084 hypertensive patients attending the CHC, who had at least two prescriptions for antihypertensive drugs during a 1-year period starting on 1 January 1992. Interventions. 1. Implementation of stepped-care guidelines for hypertension, specifying treatment with more cost-effective drugs and minimising drug treatment. 2. Reducing availability for routine prescribing by CHC doctors of 10 less cost-effective antihypertensive drugs or drug combinations.Outcome measures. 1. Mean number of drugs prescribed per patient. 2. Proportion of prescriptions for: each major class of antihypertensive drug; restricted availability and freely prescribable drugs; and more and less cost-effective drugs. 3. Mean monthly cost of drugs prescribed per patient. 4. Mean blood pressure and proportion of BP readings controlled (<160/95 mmHg) or uncontrolled (≥160/95 mmHg).Results. A mean of 1.7 active drugs was prescribed per patient per visit. The most frequently prescribed drugs were thiazide-like diuretics (44.8%), centrally acting agents (28.4%) and b-blockers (13.2%). Mean monthly drug costs per patient decreased significantly by R1.99 (24.2%) from R8.24 to R6.25 between the first and last prescription for each patient (exclusive of any reduction due to withdrawal of treatment). This was attributable to reduced prescribing of more expensive drugs withdrawn from routine use and a 51.1% increase in prescribing of the most cost-effective drugs. The overall annual cost-saving of the changes in prescribing for this CHC are estimated at R75 150. Blood pressure control did not change significantly.Conclusion. The pattern of changes in prescribing and drug costs was consistent with a causal effect of the interventions. The study demonstrates the potential forimproving cost-effectiveness of hypertension care in primary care in South Africa and the potential for research in this setting

Hypertension care at a Cape Town community health centre

Objectives. To describe the demographic profile of hypertensive patients and the quality of care for hypertension at a Cape Town community health centre (CHC).Design. Prospective, descriptive study.Setting and subjects. Medium-sized CHC, attended by 1098 hypertensive patients during a 1-year period from 1 January 1992.Outcome measures. Default rate - proportion of due visits not attended. Loss to follow-up - proportion of patients persistently defaulting or not responding to recall. Frequency of blood pressure measurement - per 12 due visits. Compliance - proportion of patients collecting ≥ 75% of antihypertensive drugs. Blood pressure control - mean blood pressure of aggregated readings; and proportion controlled (<160/95 mmHg) on the basis of all blood pressure readings and mean blood pressures of individual patients with two or more readings during the study period.Results. More than half (51.6%) of the hypertensive patients were aged ≥ 65 years; 81.7% were female. The default rate was between 11.9% and 19.4%. Compliance was high (76.9%). Loss to follow-up was 8.1 %. Blood pressure was recorded a mean of 4.0 times per 12 due visits. There were no significant gender differences with regard to these measures. Mean blood pressure was 158.3/89.6 mmHg. Over half (56.7%) of all individual readings over the year were uncontrolled and 51.4% of patients were found to be uncontrolled when categorised by their mean blood pressure. Control was significantly poorer among women ≥ 65 years.Conclusion. We found better compliance, more frequent blood pressure measurement, and lower defaulting and loss to follow-up compared with previous South African studies in similar settings. Despite this, blood pressure control was mediocre. Possible explanations for this are discussed. The low proportion of male hypertensives attending the CHC suggests that the accessibility or acceptability of care is poor for this group. The study illustrates the potential for research in this setting and for the use of computers to monitor the quality of primary care.

The antigenicity and cholesteroid nature of mycolic acids determined by recombinant chicken antibodies

<div><p>Mycolic acids (MA) are major, species-specific lipid components of Mycobacteria and related genera. In <i>Mycobacterium tuberculosis</i>, it is made up of alpha-, methoxy- and keto-MA, each with specific biological functions and conformational characteristics. Antibodies in tuberculosis (TB) patient sera respond differently towards the three MA classes and were reported to cross-react with cholesterol. To understand the antigenicity and cholesterol cross-reactivity of MA, we generated three different chicken -derived phage-displayed single-chain variable fragments (scFv) that reacted similarly towards the natural mixture of MA, but the first recognized all three classes of chemically synthetic MAs, the second only the two oxygenated types of MAs and the third only methoxy MA. The cholesterol cross-reactivity was investigated after grafting each of the three scFv types onto two configurations of constant chain domains–CH1-4 and CH2-4. Weak but significant cross-reactivity with cholesterol was found only with CH2-4 versions, notably those two that were also able to recognize the <i>trans</i>-keto MA. The cholesteroid nature of mycobacterial mycolic acids therefore seems to be determined by the <i>trans</i>-keto MA subclass. The significantly weaker binding to cholesterol in comparison to MA confirms the potential TB diagnostic application of these antibodies.</p></div

Mimotopes and Proteome Analyses Using Human Genomic and cDNA Epitope Phage Display

In the post-genomic era, validation of candidate gene targets frequently requires proteinbased strategies. Phage display is a powerful tool to define protein-protein interactions by generating peptide binders against target antigens. Epitope phage display libraries have the potential to enrich coding exon sequences from human genomic loci. We evaluated genomic and cDNA phage display strategies to identify genes in the 5q31 Interleukin gene cluster and to enrich cell surface receptor tyrosine kinase genes from a breast cancer cDNA library. A genomic display library containing 2 × 10 6 clones with exon-sized inserts was selected with antibodies specific for human Interleukin-4 (IL-4) and Interleukin-13. The library was enriched significantly after two selection rounds and DNA sequencing revealed unique clones. One clone matched a cognate IL-4 epitope; however, the majority of clone insert sequences corresponded to E. coli genomic DNA. These bacterial sequences act as ‘mimotopes’ (mimetic sequences of the true epitope), correspond to open reading frames, generate displayed peptides, and compete for binding during phage selection. The specificity of these mimotopes for IL-4 was confirmed by competition ELISA. Other E. coli mimotopes were generated using additional antibodies. Mimotopes for a receptor tyrosine kinase gene were also selected using a breast cancer SKBR-3 cDNA phage display library, screened against an anti-erbB2 monoclonal antibody. Identification of mimotopes in genomic and cDNA phage libraries is essential for phage display-based protein validation assays and two-hybrid phage approaches that examine protein-protein interactions. The predominance of E. coli mimotopes suggests that the E. coli genome may be useful to generate peptide diversity biased towards protein coding sequences

'Going private': a qualitative comparison of medical specialists' job satisfaction in the public and private sectors of South Africa

BACKGROUND: There is a highly inequitable distribution of health workers between public and private sectors in South Africa, partly due to within-country migration trends. This article elaborates what South African medical specialists find satisfying about working in the public and private sectors, at present, and how to better incentivize retention in the public sector. METHODS: Seventy-four qualitative interviews were conducted - among specialists and key informants - based in one public and one private urban hospital in South Africa. Interviews were coded to determine common job satisfaction factors, both financial and non-financial in nature. This served as background to a broader study on the impacts of specialist 'dual practice', that is, moonlighting. All qualitative specialist respondents were engaged in dual practice, generally working in both public and private sectors. Respondents were thus able to compare what was satisfying about these sectors, having experience of both. RESULTS: Results demonstrate that although there are strong financial incentives for specialists to migrate from the public to the private sector, public work can be attractive in some ways. For example, the public hospital sector generally provides more of a team environment, more academic opportunities, and greater opportunities to feel 'needed' and 'relevant'. However, public specialists suffer under poor resource availability, lack of trust for the Department of Health, and poor perceived career opportunities. These non-financial issues of public sector dissatisfaction appeared just as important, if not more important, than wage disparities. CONCLUSIONS: The results are useful for understanding both what brings specialists to migrate to the private sector, and what keeps some working in the public sector. Policy recommendations center around boosting public sector resources and building trust of the public sector through including health workers more in decision-making, inter alia. These interventions may be more cost-effective for retention than wage increases, and imply that it is not necessarily just a matter of putting more money into the public sector to increase retention

Epitope Mapping of Neutralizing Botulinum Neurotoxin A Antibodies by Phage Display

Single-chain antibodies neutralize activity and bind nonoverlapping epitopes of botulinum A neurotoxin. Two phage display epitope libraries were constructed from the 1.3 kb of binding domain cDNA. The minimal epitopes selected against the single-chain Fv-Fc antibodies correspond to conformational epitopes with amino acid residues 1115 to 1223 (S25), 1131 to 1264 (3D12), and 889 to 1294 (C25)