AIDS and New England Hospitals

The Centers for Disease Control projects that nine thousand persons with AIDS will be alive in New England in 1991, representing a sevenfold increase from 1986. Our analysis indicates that more than 2 percent of medical/surgical beds in New England will be used for AIDS care by 1991, representing 766 fully occupied hospital beds. The direct cost of providing hospital care to New England\u27s AIDS patients is projected to be $195.2 million in 1991, reflecting 3 percent of all hospital inpatient costs in the region. AIDS treatment is very unevenly distributed among hospitals in New England. Just twenty hospitals (8 percent of short-term general hospitals in the region) provided over 60 percent of the care required by all AIDS patients in New England in 1986. If this trend continues, nearly 5 percent of all the beds available in these twenty institutions will be required for AIDS care by 1991. Alternatives to inpatient care are an important means of limiting the demands the AIDS epidemic places on inpatient care facilities. A number of outpatient AIDS clinics have been established in New England hospitals, including clinics at Yale-New Haven Hospital and Rhode Island Hospital. However, skilled nursing facilities in New England, as in other parts of the country, are not prepared to care for AIDS patients. Similarly, the development of in-home services for AIDS patients is just beginning in New England. Hospital planning for New England should begin addressing the need to expand alternative care services. Hospitals may begin by developing an integrated system of inpatient care with outpatient clinics and by designing units or multidisciplinary teams to care for AIDS patients. But even the best case management and discharge planning efforts cannot succeed if there is no place outside the hospital for AIDS patients to go. Each state needs to look closely at its capacity to provide long-term care, hospice care, and home care in order to fill gaps where they exist

Renal toxicity in patients with multiple myeloma receiving zoledronic acid vs. ibandronate: A retrospective medical records review

Aims : This retrospective study investigated the rates of renal impairment in patients with multiple myeloma treated with zoledronic acid and ibandronate. Materials and Methods : We retrospectively reviewed medical records in a German oncology clinic, from May 2001 to December 2005. Creatinine measurements were analyzed from baseline (before zoledronic acid or ibandronate treatment) to last evaluation for each patient. A total of 84 patients were included. Results : Zoledronic acid increased the risk of renal impairment by approximately 3-fold compared with ibandronate (renal impairment rates: zoledronic acid 37.7% vs. ibandronate 10.5%, relative risk [RR]=3.6, P=0.0029 serum creatinine [SCr]; 62.3% vs. 23.7%, RR=2.6, P=0.0001 glomerular filtration rate [GFR]). Ibandronate-treated patients switched from zoledronic acid had a significantly higher risk of renal impairment than patients receiving ibandronate monotherapy (zoledronic acid over ibandronate 39.1% vs. ibandronate monotherapy 6.7%, RR= 5.9, P=0.028 [SCr]; 65.2% vs 26.7%, RR=2.4, P=0.022 [GFR]). Multivariate analysis found significantly higher hazard ratios for zoledronic acid over ibandronate (SCr: Cox = 4.38, P=0.01; Andersen-Gill=8.22, P < 0.01; GFR: Cox = 4.31, P < 0.01; Andersen-Gill = 3.71, P < 0.01). Conclusions : Overall, this retrospective study suggests that multiple myeloma patients are more likely to experience renal impairment with zoledronic acid than with ibandronate. The risk of renal impairment increased if patients had received prior therapy with zoledronic acid

The dynamic relationship between current and previous severe hypoglycemic events: a lagged dependent variable analysis among patients with type 2 diabetes who have initiated basal insulin

<p>Past studies have found episodes of severe hypoglycemia (SH) to be serially dependent. Those studies, however, only considered the impact of a single (index) event on future risk; few have analyzed SH risk as it evolves over time in the presence (or absence) of continuing events. The objective of this study was to determine the dynamic risks of SH events conditional on preceding SH events among patients with type 2 diabetes (T2D) who have initiated basal insulin.</p> <p>We used an electronic health records database from the United States that included encounter and laboratory data and clinical notes on T2D patients who initiated basal insulin therapy between 2008 and 2011 and to identify SH events. We used a repeated-measures lagged dependent variable logistic regression model to estimate the impact of SH in one quarter on the risk of SH in the next quarter.</p> <p>We identified 7235 patients with T2D who initiated basal insulin. Patients who experienced ≥1 SH event during any quarter were more likely to have ≥1 SH event during the subsequent quarter than those who did not (predicted probabilities of 7.4% and 1.0%, respectively; <i>p</i> < 0.01). This effect was stronger than the impact of history of SH before starting basal insulin (predicted probabilities of 1.0% and 3.2%, respectively; <i>p</i> < 0.01) or of a history of SH during the titration period (predicted probabilities of 1.1% and 2.8%, respectively; <i>p</i> < 0.01).</p> <p>The risk of experiencing a SH event is highly dependent on a patient’s immediate history of SH events and therefore the value of preventing one SH event may be substantial. These results can inform patient care by providing clinicians with dynamic data on a patient’s risk of SH, which in turn can facilitate appropriate adjustment of the risk–benefit ratio for individualized patient care. These results should, however, be interpreted in light of the key limitations of our study: not all SH events may have been captured or coded in the database, data on filled prescriptions were not available, we were unable to adjust for basal insulin dose, and the post-titration follow-up period could have divided into time units other than quarters (3 month blocks) resulting in potentially different conclusions. Further real-world studies on how to best to identify patients at risk for SH events based on the presence of recent SH events, rather than on more distant ‘prior’ events, can help healthcare providers to better manage patients starting basal insulin.</p

Cost Effectiveness of Peginterferon alpha-2a Plus Ribavirin versus Interferon alpha-2b Plus Ribavirin as Initial Therapy for Treatment-Naive Chronic Hepatitis C

Introduction: In adults with previously untreated chronic hepatitis C (CHC), the combination of peginterferon alpha-2a plus ribavirin produces a higher rate of sustained virological response (SVR) than interferon alpha-2b plus ribavirin, but it is still unproven whether this increase is cost effective. The objective of this study was to determine if the gain in SVR with peginterferon alpha-2a plus ribavirin is worth the incremental cost. Methods: We constructed a Markov model of disease progression in which cohorts of patients received peginterferon alpha-2a plus ribavirin or interferon alpha-2b plus ribavirin for 48 weeks (hepatitis C virus [HCV] genotype 1 and non-1 patients with fibrosis) or 24 weeks (genotype non-1 patients without fibrosis), and were followed for their expected lifetimes. The reference patient was a 45-year-old male with CHC without cirrhosis. The SVRs with peginterferon alpha-2a plus ribavirin and interferon alpha-2b plus ribavirin used to populate the model were 46% and 36% for patients infected with HCV genotype 1 and 76% and 61% for patients infected with HCV non-1 genotypes, respectively. QOL and costs for each health state were based on literature estimates and on Italian treatment patterns. Costs were in 2002 euros and benefits were discounted at 3%. Sensitivity analyses on key clinical and economic parameters were performed. The analysis was reported from the perspective of the Italian National Health Service. Results: In patients infected with HCV genotype 1, peginterferon alpha-2a plus ribavirin increased life-years (LYs) by 0.78 years and QALYs by 0.67 years, compared with interferon alpha-2b and ribavirin. The incremental cost per LY and QALY gained was Conclusion: Our model suggests that peginterferon alpha-2a plus ribavirin is cost effective compared with conventional interferon alpha-2b plus ribavirin for treatment of naive adults with CHC, regardless of HCV genotype, under a wide range of assumptions regarding treatment effectiveness and costs.Cost-effectiveness, Cost-utility, Hepatitis-C, Interferon-alpha-2b, Peginterferon-alfa-2a, Ribavirin

Renal toxicity in patients with multiple myeloma receiving zoledronic acid vs. ibandronate: A retrospective medical records review

Aims : This retrospective study investigated the rates of renal impairment in patients with multiple myeloma treated with zoledronic acid and ibandronate. Materials and Methods : We retrospectively reviewed medical records in a German oncology clinic, from May 2001 to December 2005. Creatinine measurements were analyzed from baseline (before zoledronic acid or ibandronate treatment) to last evaluation for each patient. A total of 84 patients were included. Results : Zoledronic acid increased the risk of renal impairment by approximately 3-fold compared with ibandronate (renal impairment rates: zoledronic acid 37.7% vs. ibandronate 10.5%, relative risk [RR]=3.6, P=0.0029 serum creatinine [SCr]; 62.3% vs. 23.7%, RR=2.6, P=0.0001 glomerular filtration rate [GFR] filtration rate [GFR). Ibandronate-treated patients switched from zoledronic acid had a significantly higher risk of renal impairment than patients receiving ibandronate monotherapy (zoledronic acid over ibandronate 39.1% vs. ibandronate monotherapy 6.7%, RR= 5.9, P=0.028 [SCr]; 65.2% vs 26.7%, RR=2.4, P=0.022 [GFR]). Multivariate analysis found significantly higher hazard ratios for zoledronic acid over ibandronate (SCr: Cox = 4.38, P=0.01; Andersen-Gill=8.22, P < 0.01; GFR: Cox = 4.31, P < 0.01; Andersen-Gill = 3.71, P < 0.01). Conclusions : Overall, this retrospective study suggests that multiple myeloma patients are more likely to experience renal impairment with zoledronic acid than with ibandronate. The risk of renal impairment increased if patients had received prior therapy with zoledronic acid

Peginterferon alpha-2a (40kD) [Pegasys(R)] Improves HR-QOL Outcomes Compared with Unmodified Interferon alpha-2a [Roferon(R)-A]: In Patients with Chronic Hepatitis C

Background: Use of unmodified interferon alpha-2a in chronic hepatitis C is associated with impaired health-related quality of life during therapy. Treatment with peginterferon alpha-2a (40kD) provides an improved sustained response over unmodified interferon alpha-2a. Objectives: To compare health-related quality of life during treatment for patients receiving peginterferon alpha-2a (40kD) [Pegasys(R)] versus unmodified interferon alpha-2a [Roferon(R)]. Design: A randomised, international, multicentre, open-label, parallel group study. Setting: 36 centres worldwide. Patients: Interferon-naive patients (n = 531) with chronic hepatitis C. Interventions: Peginterferon alpha-2a (40kD) 180mug once a week (n = 267) for 48 weeks or unmodified interferon alpha-2a 6 million IU three times a week for 12 weeks followed by 36 weeks of 3 million IU three times a week (n = 264). Measurements: Fatigue Severity Scale and 36-item Short-Form Health Survey (SF-36). Results: At weeks 2 and 12, differences favouring peginterferon alpha-2a (40kD) were seen on seven of eight domains and both summary scores of the SF-36 (pAntivirals, Hepatitis C, Interferon alpha 2a, PEG interferon alpha 2a, Pharmacoeconomics, Quality of life