Americo Cicchetti

Costs of Bloodstream Infections Caused by Escherichia coli and Influence of Extended-Spectrum-β-Lactamase Production and Inadequate Initial Antibiotic Therapy

ABSTRACT Escherichia coli is the leading cause of bloodstream infections (BSIs) caused by Gram-negative bacteria. The increasing prevalence of antibiotic-resistant E. coli strains, particularly those producing extended-spectrum β-lactamases (ESBLs), increases the odds that empirically prescribed antimicrobial therapy for these infections will be inadequate, but the economic impact of this risk has not been fully evaluated. In the present retrospective 1-year analysis of 134 consecutive E. coli BSIs in our hospital, we explored the clinical and economic impacts of (i) inadequate initial antimicrobial treatment (IIAT) (i.e., empirical treatment with drugs to which the isolate had displayed in vitro resistance) of these infections and (ii) ESBL production by the bloodstream isolate. Cost data were obtained from the hospital accounting system. Compared with the 107 (79.8%) adequately treated patients, the 27 (20.1%) who received IIAT had a higher proportion of ESBL BSIs (74.0% versus 15.8%), longer (+6 days) and more costly (+EUR 4,322.00) post-BSI-onset hospital stays, and higher 21-day mortality rates (40.7% versus 5.6%). Compared with the 97 non-ESBL infections, the 37 (27.6%) ESBL BSIs were also associated with longer (+7 days) and more costly (+EUR 5,026.00) post-BSI-onset hospital stays and increased 21-day mortality (29.7% versus 6.1%). These findings confirm that the hospital costs and mortality associated with E. coli BSIs are significantly increased by ESBL production and by IIAT.

The Jefferson Scale of Physician Empathy: preliminary psychometrics and group comparisons in Italian physicians.

Purpose To examine the psychometrics of the Jefferson Scale of Physician Empathy (JSPE) among a sample of Italian physicians. Method The JSPE was translated into Italian using back-translation procedures to ensure the accuracy of the translation. The translated JSPE was administered to 778 physicians at three hospitals in Rome, Italy in 2002. Individual empathy scores were calculated, as well as descriptive statistics at the item and scale level. Group comparisons of empathy scores were also made among men and women, physicians practicing in medical or surgical specialties, physicians working in different hospitals, and at physicians at various levels of career rank. Results Results are reported for 289 participants who completed the JSPE. Item-total score correlations were all positive and statistically significant. The prominent component of “perspective taking,” which is the most important underlying construct of the scale, emerged in the factor analysis of the JSPE and was similar in both Italian and American samples. However, more factors appeared among Italian physicians, indicating that the underlying construct of empathy may be more complex among Italians. Cronbach coefficient alpha was .85. None of the group differences observed among physicians classified by gender, hospital of practice, specialty, or level of career rank reached statistical significance. Conclusions Findings generally provide support for the construct validity and reliability of the Italian version of the JSPE. Further research is needed to determine whether the lack of statistically significant differences in empathy by gender and specialty is related to cultural peculiarities, the translation of the scale, or sampling.

Cost-effectiveness of boceprevir or telaprevir for untreated patients with genotype 1 chronic hepatitis C

Randomized controlled trials (RCTs) show that triple therapy (TT) with peginterferon alpha, ribavirin, and boceprevir (BOC) or telaprevir (TVR) is more effective than peginterferon‐ribavirin dual therapy (DT) in the treatment of previously untreated patients with genotype 1 (G1) chronic hepatitis C (CHC). We assessed the cost‐effectiveness of TT compared to DT in the treatment of untreated patients with G1 CHC. We created a Markov Decision Model to evaluate, in untreated Caucasian patients age 50 years, weight 70 kg, with G1 CHC and Metavir F2 liver fibrosis score, for a time horizon of 20 years, the cost‐effectiveness of the following five competing strategies: 1) boceprevir response‐guided therapy (BOC‐RGT); 2) boceprevir IL28B genotype‐guided strategy (BOC‐IL28B); 3) boceprevir rapid virologic response (RVR)‐guided strategy (BOC‐RVR); 4) telaprevir response‐guided therapy (TVR‐RGT); 5) telaprevir IL28B genotype‐guided strategy (TVR‐IL28B). Outcomes included life‐years gained (LYG), costs (in 2011 euros) and incremental cost‐effectiveness ratio (ICER). In the base‐case analysis BOC‐RVR and TVR‐IL28B strategies were the most effective and cost‐effective of evaluated strategies. LYG was 4.04 with BOC‐RVR and 4.42 with TVR‐IL28B. ICER compared with DT was €8.304 per LYG for BOC‐RVR and €11.455 per LYG for TVR‐IL28B. The model was highly sensitive to IL28B CC genotype, likelihood of RVR and sustained virologic response, and BOC/TVR prices. Conclusion: In untreated G1 CHC patients age 50 years, TT with first‐generation protease inhibitors is cost‐effective compared with DT. Multiple strategies to reduce costs and improve effectiveness include RVR or genotype‐guided treatment. (HEPATOLOGY 2012;56:850–860)

The use of “harmonic scalpel” versus “knot tying” for conventional “open” thyroidectomy: results of a prospective randomized study

PurposeWe evaluated the safety and cost-effectiveness of the harmonic scalpel (HS) during conventional “open” thyroidectomy (CT).Materials and methodsTwo hundred patients scheduled for conventional total thyroidectomy (TT) were included in the study and randomly assigned to TT with the use of HS (HS group) or with knot tying technique (KT group).ResultsMean operative time was significantly shorter in the HS group (P < 0.001), as well as the total operative room occupation time (P < 0.001). The cost of the disposable materials is significantly higher in the HS group (420.1 ± 23.2 vs 137.8 ± 25.3 euros; P < 0.001). Conversely, drugs, personnel and operative room charges were significantly higher in KT group patients (P < 0.001). Overall, no significant difference was found between the two groups concerning the charges of the hospitalisation (P = NS).ConclusionsHS is a safe alternative to KT, allowing for a significant reduction of operative time without increasing complications rate and overall costs and probably better utilization of health resources.

Factors associated with health-related quality of life: the role of social relationships among the elderly in an Italian region

OBJECTIVES This study examines the association between social relationships and health-related quality of life (HRQL) in the elderly in Lazio Region, Italy, a Mediterranean country where the shape and role of social links has dramatically changed. METHODS Data were extracted from a national cross-sectional survey in Italy, representative of the non-institutionalised population aged 60 years and over resident in Lazio Region during 1999--2000. HRQL was measured with the Short Health Survey Questionnaire (SF-12). Data analysis was performed using multiple linear regression models using adjustment for the main confounders. RESULTS Among the sample, 40.4% of the elderly were not married and 27.1 % were living alone. While being married and not living alone were associated with higher scores in the physical and mental quality-of-life components (P-value<0.001), more frequent visiting/seeing friends was likely to be associated with higher scores in both the physical and the mental health components (P-value<0.05). Multiple logistic regression analysis demonstrated that low physical health scores were associated with a low frequency of meeting with relatives and with living far from relatives. CONCLUSIONS In a region covering 9.2% of the whole Italian population, only a small proportion of the elderly lack frequent social ties, yet low frequency of relationships with friends is associated with a decline in quality of life measured through mental and physical scores. Our findings will be useful for drawing up welfare strategies both at the national and at the Mediterranean level, in countries, like Italy, where the primacy of family support of the elderly has been decreasing in recent years.

Health technology assessment in Italy

OBJECTIVES The aim of this study was to review the history of health technology assessment (HTA) in Italy. METHODS Founded in 1978, the Italian National Health Service (NHS) has been strongly regionalized mainly after a constitutional reform, which started a devolution process. HTA started in the 1980s at the National Institute of Health and in a few University Hospitals, with a focus on big ticket technology: that process was driven by clinical engineers. RESULTS In recent years, HTA is becoming an important tool for decision-making processes at central, regional, and local levels. In particular, the National Agency for Regional Health Services (AGENAS) and five regions (of twenty-one) are strongly committed to develop HTA initiatives connected with the planning process. CONCLUSIONS At the local level, the hospital-based HTA activity is probably the most important peculiarity of the country and the real driver of the HTA movement.

Health technology assessment agencies: An international overview of organizational aspects

OBJECTIVES The aim of the study is to make an international comparison of Health Technology Assessment (HTA) Agencies, to show their similarities and differences. METHODS An e-mail questionnaire was sent to thirty HTA agencies internationally. Questions related to the structure of the agency, the relationship with health-related institutions, the prescriptiveness of the decisions taken, the main core and the modalities to spread the assessment, and the type of funding. RESULTS Twenty-four HTA Agencies answered the questionnaire: 25 percent in America, 4.2 percent in Australia, and 70.8 percent in Europe. Fifty-four percent of HTA Agencies are governmental institutions (83.3 percent have central government funding), while 62.5 percent have relationships with health-related governmental institutions. Of the agencies, 87 percent reported that their decisions are not prescriptive, while for 20.8 percent and 8.3 percent of them stated that this was the case totally or partially, respectively, especially for the governmental and American Agencies. Seventeen agencies (70.8 percent) declared their work on multiannual programs (77 percent of the governmental HTA Agencies and 100 percent of the American ones). The assessments mainly addressed diagnostic procedures (85.7 percent) and pharmaceuticals (25 percent). The most common way to disseminate results is by means of paper report (91.7 percent), followed by the Internet (16.7 percent), and seminars to expert audiences (12.5 percent). CONCLUSIONS The comparative analysis of HTA Agencies showed that governmental and American Agencies have a profound impact on the prescriptiveness of their assessment, and this could be linked to the fact that these types of Agencies work on multiannual programs. European and American HTA Agencies have many similarities in terms of type of assessment, funding, and dissemination of results.

Hospital managers’ need for information in decision-making – An interview study in nine European countries

Assessments of new health technologies in Europe are often made at the hospital level. However, the guidelines for health technology assessment (HTA), e.g. the EUnetHTA Core Model, are produced by national HTA organizations and focus on decision-making at the national level. This paper describes the results of an interview study with European hospital managers about their need for information when deciding about investments in new treatments. The study is part of the AdHopHTA project. Face-to-face, structured interviews were conducted with 53 hospital managers from nine European countries. The hospital managers identified the clinical, economic, safety and organizational aspects of new treatments as being the most relevant for decision-making. With regard to economic aspects, the hospital managers typically had a narrower focus on budget impact and reimbursement. In addition to the information included in traditional HTAs, hospital managers sometimes needed information on the political and strategic aspects of new treatments, in particular the relationship between the treatment and the strategic goals of the hospital. If further studies are able to verify our results, guidelines for hospital-based HTA should be altered to reflect the information needs of hospital managers when deciding about investments in new treatments.

Dynamic analysis of interhospital collaboration and competition: Empirical evidence from an Italian regional health system

BACKGROUND Policymakers stimulate competition in universalistic health-care systems while encouraging the formation of service provision networks among hospital organizations. This article addresses a gap in the extant literature by empirically analyzing simultaneous collaboration and competition between hospitals within the Italian National Health Service, where important procompetition reforms have been implemented. PURPOSE To explore how rising competition between hospitals relates to their propensity to collaborate with other local providers. METHODS Longitudinal data on interhospital collaboration and competition collected in an Italian region from 2003 to 2007 are analyzed. Social network analysis techniques are applied to study the structure and dynamics of interhospital collaboration. Negative binomial regressions are employed to explore how interhospital competition relates to the collaborative network over time. RESULTS Competition among providers does not hinder interhospital collaboration. Collaboration is primarily local, with resource complementarity and differentials in the volume of activity and hospital performance explaining the propensity to collaborate. CONCLUSIONS Formation of collaborative networks among hospitals is not hampered by reforms aimed at fostering market forces. Because procompetition reforms elicit peculiar forms of managed competition in universalistic health systems, studies are needed to clarify whether the positive association between interhospital competition and collaboration can be generalized to other health-care settings.

Relating price determination to disease prevalence

For orphan drugs, the yearly cost per patient is inversely related to the prevalence of the disease.1 2 3 4 5 Although this relation is widely recognised qualitatively, to our knowledge, no attempt has been made to define it mathematically. We examined the decisions made for non-cancer orphan drugs approved in Italy over the past years and developed the …