Cynthia S. Palmer

Economic assessment of the community-acquired pneumonia intervention trial employing levofloxacin.

OBJECTIVE The purpose of this study was to assess use of a critical pathway designed to manage community-acquired pneumonia more efficiently than its management with conventional therapy. METHODS Economic outcomes were assessed in conjunction with a cluster-design, randomized, controlled trial. Nineteen participating Canadian hospitals were randomized to implement the critical pathway (n = 9) or conventional therapy (n = 10). The critical pathway included a clinical prediction rule to guide the admission decision, treatment with levofloxacin, and practice guidelines. Patient data on medical resource use, lost productivity, and quality of life were collected prospectively for > or =6 weeks after treatment. Costs were calculated from the government, health care system, and societal perspectives, with imputation of missing outpatient costs and the costs of lost productivity when necessary. Bootstrapping was used to identify 95% CIs for the total cost per patient. RESULTS The analysis included all eligible patients in the critical pathway (n = 716) and conventional therapy (n = 1027) arms. There were fewer hospital admissions in the critical pathway arm than in the conventional therapy arm, both overall (46.5% vs 62.2%; P = 0.01) and in low-risk patients (33.2% vs 46.8%; P < 0.001). Compared with conventional therapy, hospitals in the critical pathway arm had 1.6 fewer bed days per patient managed (P = 0.05) and used fewer inpatient medical resources. The 2 study arms had similar outpatient, readmission, and lost-productivity costs, and similar quality-of-life outcomes. The critical pathway produced cost savings from all 3 perspectives that ranged from

The Economic and Clinical Efficiency of Point-of-Care Testing for Critically Ill Patients: A Decision-Analysis Model

457 to

Predictors for chemotherapy-related severe or febrile neutropenia: a review of the clinical literature:

994 per patient. CONCLUSIONS The critical pathway employing levofloxacin resulted in cost savings compared with conventional therapy and did not compromise health outcomes.

The relation of patient satisfaction with treatment of otitis externa to clinical outcomes : Development of an instrument

Our study objective was to assess economic and clin ical outcomes of use of a point-of-care (POC) blood analy sis device for postoperative coronary artery bypass graft (CABG) patients. A decision analytic model was devel oped for patients with high expected use of blood analy sis, high potential benefit from rapid turn around time of results, a large annual volume of patients, and sub stantial expense associated with surgery. Published lit erature and clinical experts provided incidence, outcome, and cost estimates associated with four clinical scenar ios potentially influenced by POC testing (ventricular arrhythmias, cardiac arrest, severe postoperative bleed ing, and iatrogenic anemia). We found that changes in clinical outcomes were predominantly dependent on com parative turn around time or CABG patient volume. The positive clinical impact of using POC testing was con sistently associated with a positive economic impact. POC blood gas analysis may be associated with decreased incidence of adverse clinical events or earlier detection of such events, resulting in significant cost savings. This study also supports previous findings that the costs of STAT blood analysis are more personnel-related than equipment-related.

A model of the cost-effectiveness of directly observed therapy for treatment of tuberculosis.

Purpose. This paper summarizes a literature review of the risk factors and predictors for chemo-therapy-related severe or febrile neutropenia (grades 3 and 4). It explores the extent to which the literature supports the current ASCO guidelines, and assesses the feasibility of developing a predictive algorithm for patients who would benefit from rHuG-CSF (Neupogen). Methods. An electronic literature search for English articles and abstracts identified 718 abstracts for review. From these, 121 articles were reviewed in depth. The review captured risk factors and predictors for grade 3-4 and/or febrile neutropenia, study design, patient characteristics, chemotherapy treatment, and the incidence of grade 3-4 and/or febrile neutropenia. Results. Twenty-eight potential risk factors and predictors for severe or febrile neutropenia among cancer patients were identified and could be classified as patient-related, treatment-related, or disease-related characteristics. Some results were inconsistent across studies due to a lack of standardized methods of assessment and reporting. Approximately 1/3 of the factors were mentioned in more than one study and provided information on the statistical significance of findings. Several factors had cross-study support of their value and confirmed previous findings. Strong predictors of severe/febrile neutropenia included advanced age, performance status, myelosuppressive chemotherapy regimen, early low blood counts, the depth of the absolute neutrophil count (ANC) nadir, and a precipitous, early drop in blood counts of all hematopoietic cell types. Conclusions. This literature review identified several key predictors and risk factors for development of grades 3 and 4 neutropenia in cancer patients. While additional confirmation is needed, there is sufficient consistency in the literature to support use of risk factors to identify patients who may need supportive care. Some of these risk factors were included in the ASCO CSF guidelines for the use of prophylactic support such as G-CSF; however, the ASCO publications have not included other important risk factors, such as age and early reduced ANC levels.

Health-care expenditures for tuberculosis in the United States

This survey was undertaken to develop a short, comprehensive measure of patient satisfaction with pharmacologic treatment for otitis externa and to assess the relationships between satisfaction, disease symptoms, and medication side effects. Otitis externa was diagnosed in 41 patients recruited from 6 sites; 34 patients completed and returned the study instruments and were included in the study. Patients or their caregivers administered polymyxin/neomycin/hydrocortisone ear drops prescribed by a physician and completed a daily diary for 10 days and a satisfaction questionnaire at the end of the treatment period. The main outcome measures were the subscale scores for patient satisfaction and their relation to medication side effects, symptoms of ear infection, activity limitations, pain, and adherence to prescription regimens. The questionnaire and its subscales demonstrated good psychometric properties (ie, reliability coefficients >0.75, except for 1 subscale). Overall satisfaction was found to be significantly correlated with relief of symptoms, ability to return to normal activities, ease of administration, and medication side effects. Satisfaction subscale scores were correlated with patient-reported severity of medication side effects and disease symptoms. More than half the patients took drops for more than the prescribed number of days, and one third took more than the prescribed number of drops per administration (ie, overadherence). The relation between satisfaction and adherence was weak, perhaps due to the high rates of overadherence. Our results demonstrate that patient satisfaction with otic medication can be assessed across various aspects of satisfaction and that it is correlated with reported disease symptoms and medication side effects. This type of multifaceted assessment may help physicians select between medications with different side-effect profiles and administration schedules. Larger studies are needed to evaluate the relationship between satisfaction with an otic medication and adherence to a medication regimen.

Cost-Effectiveness Analysis of an Intranasal Influenza Vaccine for the Prevention of Influenza in Healthy Children

A hypothetical cohort of 25,000 TB patients and their contacts were followed for a 10-year period; rates of treatment default, infectiousness following partial treatment, relapse, hospitalization, and development of drug-resistant TB were included. The average cost per case cured was

Serum Lipid Screening to Identify High-Risk Individuals for Coronary Death The Results of the Lipid Research Clinics Prevalence Cohort

16,846 with 15% of patients starting DOT,

Treatment of Otitis Externa–Reply–I

17,323 with 100% starting DOT, and

Cost-effectiveness of directly observed therapy for treatment of tuberculosis:

20,106 with none starting DOT. The incremental cost per additional case cured was