Alessandro Barbarino

Pneumococcal and influenza vaccination rates and their determinants in children with chronic medical conditions

BackgroundTo investigate the rates of pneumococcal and influenza vaccinations and their determinants in children with chronic medical conditions.Patients and MethodsChildren with HIV infection, cystic fibrosis, liver transplantation and diabetes mellitus were enrolled. Physicians of regional Reference Centres for each condition, primary care paediatricians and caregivers of children provided information through specific questionnaires. For diabetes, 3 Reference Centres were included.ResultsLess than 25% of children in each group received pneumococcal vaccination. Vaccination rates against influenza were 73% in patients with HIV-infection, 90% in patients with cystic fibrosis, 76% in patients with liver transplantation, and ranged from 21% to 61% in patients with diabetes mellitus. Reference Centres rather than primary care paediatricians had a major role in promoting vaccinations. Lack of information was the main reason for missing vaccination. Awareness of the severity of pneumococcus infection by key informants of at-risk children was associated with higher vaccination rate.ConclusionsVaccination rates in children with chronic conditions were poor for pneumococcus and slightly better for influenza. Barriers to vaccination include lack of awareness, health care and organization problems.

Pandemic flu: a comparative evaluation of clinical, laboratory, and radiographic findings in HIV-positive and negative children.

Eleven HIV-infected and 30 otherwise healthy children hospitalized for H1N1 influenza were studied. Leukopenia was recorded in 64% of HIV-infected and in 20% of healthy children (P = 0.01). Chest radiograph was abnormal in 18 (46%) children. Interstitial pneumonia was more frequent in HIV-positive children and consolidation was more frequent in HIV-negative children. Although the duration of symptoms and hospital stay was significantly longer in HIV-negative than in HIV-positive children, only 37% of HIV-negative children and 91% of HIV-positive received oseltamivir. The H1N1 influenza attack rate was very high (20%) in HIV-infected children, but it consistently ran a mild course.

Home Therapy with Plasma-Derived C1 Inhibitor: A Strategy to Improve Clinical Outcomes and Costs in Hereditary Angioedema

Background: Attacks of hereditary angioedema with C1 inhibitor deficiency (C1-INH-HAE) are commonly treated in the emergency department. Self-administration is emerging as an effective treatment option. In this study, we assessed the impact of home therapy with plasma-derived C1 esterase inhibitor (pdC1-INH) concentrate on treatment outcomes and costs. Methods: This is an observational study in C1-INH-HAE patients who switched to home therapy with pdC1-INH (Berinert®) after learning intravenous self-infusion in a training course at a center in Southern Italy. Before starting home therapy and after the first year of home therapy, patients were interviewed about their treatment and outcomes during the prior 12 months. Annual costs were analyzed by cost minimization from the Italian health care payer perspective and the societal perspective. Outcomes and costs before and after the switch to home therapy were compared. Results: The training course was attended by 36 participants, 17 (47.2%) of whom decided to switch to home therapy. This therapy was associated with a significant decrease in the mean annual number of hospitalizations (16.8 vs. 2.1, p = 0.003) and missed work/school days (20.3 vs. 7.1, p = 0.037) compared to conventional treatment. The times from symptom onset to treatment administration and from treatment administration to symptom improvement/resolution were not significantly different between the two strategies. The mean annual per-patient costs decreased with home therapy from EUR 30,010.57 to EUR 26,621.16 (11.3% saving) and from EUR 29,309.34 to EUR 26,522.04 (9.5% saving) from the societal and payer perspective, respectively. Conclusions: Home therapy with pdC1-INH is a feasible strategy for the management of C1-INH-HAE and may result in cost savings.

Effects of antiretroviral drug recall on perception of therapy benefits and on adherence to antiretroviral treatment in HIV-infected children.

In June 2007, the European Medicines Agency announced the recall by Roche of nelfinavir from European Union markets because of contamination of tablets with ethyl mesylate. Based on this event, we investigated the effect of switching therapy because of nelfinavir recall or for other reasons on the perception of therapy benefits and adherence to treatment in HIV-infected children and their caregivers. Thirty-eight children (mean age 12.1+/-6.7 years) were enrolled. A 35-item questionnaire was administered to the caregivers of enrolled children. Adherence was evaluated through a 4-day recall adherence instrument. Enrolled children were divided into 3 groups: patients who were shifted because of nelfinavir recall (group A, 8 patients); patients who were shifted for other reasons (group B, 12 patients); patients who were not shifted in the last 6 months (group C, 18 patients). All caregivers considered antiretroviral therapy necessary and effective for their children. However, drug shifting generated anxiety in most of them, irrespective of the reason for shifting. At baseline, 74% patients adhered to therapy. Adherence rate was related to the type of caregivers being higher in children cared for by foster parents than in children cared for by biological parents or second-degree relatives. Adherence rates did not change significantly in groups A and B after switching. Drug-switching raises concern in caregivers of HIV-infected children and induces a negative feeling irrespective of the reason for switching. However, switching, including the shift due to nelfinavir recall, did not affect adherence rates.

Flu and pneumococcal immunisations in HIV-infected children: methodological quality of current recommendations.

Objective To assess the quality of guidelines, consensus statements and systematic reviews on flu and pneumococcal immunisations in HIV-infected children. Method The authors screened PubMed and Embase databases until the year 2009 for guidelines, consensus statements and systematic reviews on flu and pneumococcal immunisations in HIV-infected patients. The authors also explored relevant websites of agencies/institutions involved with HIV infection, immunisation or guidelines. The Appraisal of Guidelines for Research and Evaluation instrument and the checklists of the Scottish Intercollegiate Guidelines Network were used to evaluate the scientific quality of guidelines and systematic reviews. Results Eighteen articles were identified. Only one guideline was of good overall quality. Generally the weakest domains were ‘Applicability’ and ‘Editorial Independence.’ Although of poor methodological quality, the main recommendations on flu and pneumococcus vaccinations were similar. There were minor differences in the type of pneumococcal vaccines in relation to patients age, namely based on the settings in which recommendations were produced. Conclusions Although guidelines and systematic reviews on flu and pneumococcal vaccination in HIV-infected children came from authoritative institutions, their overall quality is poor, with the weakest fields being the methodological domains.

Value co-creation in healthcare: evidence from innovative therapeutic alternatives for hereditary angioedema

BackgroundOur research focuses on the co-creation of value in healthcare with reference to a case of hereditary angioedema with C1 inhibitor deficiency (C1-INH-HAE). Our work is mainly based on the concept of value co-creation in healthcare. The aim of this study is to assess the impact of an alternative treatment strategy – self-administration – by focusing on treatment outcomes and costs to understand if innovative therapeutic solutions can create value for patients and healthcare systems.MethodsThis paper compares home-based and hospital-based therapeutic strategies (independent of treatment type) with a cost minimization analysis. It encompasses compliance issues and focuses on both payer and societal perspectives, also benefiting from an operationalization of the service-dominant logic model for healthcare delivery. Data were collected over a 6-month period (August 2014–January 2015) through monthly patient interviews. Archival data were used for variable measurement.ResultsThirty-nine out of 62 patients enrolled in the study, experienced at least one HAE attacks, equally distributed between home and hospital-based strategies. No evidence of correlation between therapeutic strategy and disease severity score (p = 0.351), compliance (p = 0.399), and quality of life (p = 0.971), were found. Total direct cost per attack amounts to € 1224 for home-based strategy with respect to € 1454 for hospital-based strategy, with a savings of € 230. The economic advantage of the home-based strategy almost doubles if the societal perspective was considered due to a further savings of €169 (less missed work/school days and no travel expenses).ConclusionsOur study suggests that home-based therapies represent a feasible strategy for managing C1-INH-HAE and may result in lower costs and increased value for both patients and the healthcare systems. The findings are relevant to the debate on and extend the extant literature to provide a broader view of value co-creation dynamics for home-based therapies in healthcare and their positive effects. The insights are relevant to practitioners and policy makers.

P21 - Evaluation of modifications in SCORMA Index and grading in the follow-up of a pediatric population with mastocytosis

Background Mastocytosis is a rare disease affecting both children and adults. It is characterized by accumulation of mast-cells in the skin and/or other tissues so that two main variants are distinguished: cutaneous (CM) and systemic (SM) mastocytosis. Most pediatric patients have primarily CM and complete remission will develop in a considerable number of patients during puberty. Less frequently, skin lesions persist and these patients are often diagnosed with SM in adulthood. Our study investigates the correlation between SCORMA (SCORing MAstocytosis) Index (SC-I), a scoring system that assesses the clinical extent and intensity of cutaneous mastocytosis, and Grading system, that evaluates skin-specific symptoms and treatment status, in the follow-up of pediatric patients with mastocytosis. Furthermore, we evaluate the role of SC-I modifications in the assessment of the severity of disease.