Eran Bendavid

Hospital Workload and Adverse Events

Context:Hospitals are under pressure to increase revenue and lower costs, and at the same time, they face dramatic variation in clinical demand. Objective:We sought to determine the relationship between peak hospital workload and rates of adverse events (AEs). Methods:A random sample of 24,676 adult patients discharged from the medical/surgical services at 4 US hospitals (2 urban and 2 suburban teaching hospitals) from October 2000 to September 2001 were screened using administrative data, leaving 6841 cases to be reviewed for the presence of AEs. Daily workload for each hospital was characterized by volume, throughput (admissions and discharges), intensity (aggregate DRG weight), and staffing (patient-to-nurse ratios). For volume, we calculated an “enhanced” occupancy rate that accounted for same-day bed occupancy by more than 1 patient. We used Poisson regressions to predict the likelihood of an AE, with control for workload and individual patient complexity, and the effects of clustering. Results:One urban teaching hospital had enhanced occupancy rates more than 100% for much of the year. At that hospital, admissions and patients per nurse were significantly related to the likelihood of an AE (P < 0.05); occupancy rate, discharges, and DRG-weighted census were significant at P < 0.10. For example, a 0.1% increase in the patient-to-nurse ratio led to a 28% increase in the AE rate. Results at the other 3 hospitals varied and were mainly non significant. Conclusions:Hospitals that operate at or over capacity may experience heightened rates of patient safety events and might consider re-engineering the structures of care to respond better during periods of high stress.

The Cost-Effectiveness of Preexposure Prophylaxis for HIV Prevention in the United States in Men Who Have Sex With Men

BACKGROUND A recent randomized, controlled trial showed that daily oral preexposure chemoprophylaxis (PrEP) was effective for HIV prevention in men who have sex with men (MSM). The Centers for Disease Control and Prevention recently provided interim guidance for PrEP in MSM at high risk for HIV. Previous studies did not reach a consistent estimate of its cost-effectiveness. OBJECTIVE To estimate the effectiveness and cost-effectiveness of PrEP in MSM in the United States. DESIGN Dynamic model of HIV transmission and progression combined with a detailed economic analysis. DATA SOURCES Published literature. TARGET POPULATION MSM aged 13 to 64 years in the United States. TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION PrEP was evaluated in both the general MSM population and in high-risk MSM and was assumed to reduce infection risk by 44% on the basis of clinical trial results. OUTCOME MEASURES New HIV infections, discounted quality-adjusted life-years (QALYs) and costs, and incremental cost-effectiveness ratios. RESULTS OF BASE-CASE ANALYSIS Initiating PrEP in 20% of MSM in the United States would reduce new HIV infections by an estimated 13% and result in a gain of 550,166 QALYs over 20 years at a cost of

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172,091 per QALY gained. Initiating PrEP in a larger proportion of MSM would prevent more infections but at an increasing cost per QALY gained (up to

Risk of cardiovascular disease from antiretroviral therapy for HIV: a systematic review.

216,480 if all MSM receive PrEP). Preexposure chemoprophylaxis in only high-risk MSM can improve cost-effectiveness. For MSM with an average of 5 partners per year, PrEP costs approximately

HIV Development Assistance and Adult Mortality in Africa

50,000 per QALY gained. Providing PrEP to all high-risk MSM for 20 years would cost

Cost-Effectiveness of HIV Monitoring Strategies in Resource-Limited Settings – A Southern African Analysis

75 billion more in health care-related costs than the status quo and

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600,000 per HIV infection prevented, compared with incremental costs of

Sustainable HIV treatment in Africa through viral-load-informed differentiated care

95 billion and

Comparative Effectiveness of HIV Testing and Treatment in Highly Endemic Regions

2 million per infection prevented for 20% coverage of all MSM. RESULTS OF SENSITIVITY ANALYSIS PrEP in the general MSM population would cost less than

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100,000 per QALY gained if the daily cost of antiretroviral drugs for PrEP was less than