Jiri Vlcek

Economic evaluation of sublingual vs subcutaneous allergen immunotherapy

BACKGROUND Sublingual allergen immunotherapy (SLIT) is a commonly used alternative route of administration to standard subcutaneous immunotherapy (SCIT) in Europe. Despite its wide use, the cost-effectiveness of SLIT vs SCIT has not been well established. OBJECTIVE To evaluate the cost and effectiveness of SLIT compared with SCIT in patients with allergic rhinoconjunctivitis during a 3-year specific allergen immunotherapy (SIT) from a third-party payers, a patients, and societys perspectives. METHODS We performed an open-label randomized clinical trial of patients receiving SLIT (n = 19), patients receiving SCIT (n = 23), and a control group (n = 22). The outcome measures were Rhinoconjunctivitis Quality of Life Questionnaire score, visual analog scale score, symptomatic medication reduction, and direct and indirect costs. RESULTS SLIT offered clinical benefits to patients comparable to those provided by SCIT. From the perspective of a third-party payer, the total average direct medical cost per patient of 3-year SIT was estimated at Euro 416 vs Euro 482 in the SLIT and SCIT groups, respectively. A patient who received SLIT paid less than a patient who received SCIT for all out-of-pocket costs (Euro176 for SLIT vs Euro 255 for SCIT) but more for sole allergen extracts (Euro 72 for SLIT vs Euro 55 for SCIT). When both direct and indirect costs were considered, the 3-year SIT expenditures per patient reached Euro 684 vs Euro 1,004 in the SLIT and SCIT groups, respectively. CONCLUSIONS SLIT represents a less expensive alternative relative to subcutaneous administration from all perspectives. However, from a patients perspective, SCIT offers a less expensive alternative for patients who do not experience loss of income and travel costs associated with treatment.

Antibiotic use and knowledge in the community of Yemen, Saudi Arabia, and Uzbekistan

INTRODUCTION Inappropriate use of antibiotics has resulted in a dramatic increase of antimicrobial resistance in developing countries. We examined knowledge, attitudes, and practices of antibiotic use in three Asian countries. METHODOLOGY A nationwide cross-sectional study of teachers in large cities of Yemen, Saudi Arabia, and Uzbekistan was conducted. A random sample of 1,200 teachers was selected in each country. Data were collected through a questionnaire-based survey and then analyzed using descriptive and multivariate statistical methods. RESULTS The prevalence of non-prescription antibiotic use ranged from 48% in Saudi Arabia to 78% in Yemen and Uzbekistan. Pharmacies were the main source of non-prescribed antibiotics. The most common reasons for antibiotic use were cough (40%) and influenza (34%). Forty-nine percent of respondents discontinued antibiotics when they felt better. Although awareness of the dangers of antibiotic use correlated inversely with self-medication, understanding of the appropriate use of antibiotics was limited. CONCLUSIONS The prevalence of antibiotic self-medication in the educated adult population in the studied countries was found to be alarmingly high. Effective strategies involving regulatory enforcement prohibiting sales of antibiotics without prescription should be implemented along with educational interventions for health professionals and the public.

Polypharmacy and malnutrition.

Purpose of reviewMalnutrition and polypharmacy increase with age and polymorbidity and their relationship is based on a number of mechanisms. The occurrence of malnutrition in both in-patients and out-patients and its dependence on polymorbidity and age are well known, but the interrelation of polypharmacy and malnutrition has been far less investigated. The countries with the highest occurrence of polypharmacy in Europe include the Czech Republic and Finland, whereas the lowest prevalence of polypharmacy is found in Norway and the Netherlands. Recent findingsThe occurrence, consequences and mutual relationship of malnutrition and polypharmacy are described. Up-to-date knowledge regarding the influence of drugs on nutritional status is summarized. SummaryThe effect of polypharmacy on nutrition is suggested from the observations that problems with nutrition occur mostly in elderly patients, and that such patients are more frequently subject to polypharmacy. It is known that about 65% of hospitalized patients have a worse nutritional status than their healthy contemporaries. A worsened nutritional status may adversely influence the process of treatment.

Development of standardized methods for analysis of changes in antibacterial use in hospitals from 18 European countries: the European Surveillance of Antimicrobial Consumption (ESAC) longitudinal survey, 2000–06

OBJECTIVES Our objective was to develop and test standardized methods for collection and statistical analysis of longitudinal data on hospital antibacterial use from different countries. METHODS We collected data on monthly supply of antibiotics from pharmacies in one hospital from each of 18 European countries. We applied a standardized method to classify drugs, measure use in defined daily doses and compare the effect of using occupied bed-days (OBDs) or admissions as denominators for longitudinal analysis. RESULTS Antibiotic use increased in 14 (78%) hospitals and decreased in 4 hospitals. For 16 (89%) hospitals, adjustment of antibiotic use with OBDs resulted in larger changes over time than adjustment with admissions. Inclusion of all hospital clinical activity variables (admissions, length of stay and OBDs) in multivariate time series analysis identified distinct hospital groups. Nine (50%) hospitals had statistically significant changes in antibiotic use (six increasing and three decreasing) that were not explained (n = 3) or only partially explained (n = 6) by change in clinical activity. Three (17%) hospitals had no significant change in antibiotic use. In the remaining six hospitals, apparent changes in antibiotic use were largely explained by changes in clinical activity. CONCLUSIONS This is the first study to use a standardized method for data collection and longitudinal analysis of antibiotic use in different hospitals. These data suggest that determination of changes in antibiotic exposure of hospital patients over a period of time is unreliable if only one clinical activity variable (such as OBDs) is used as the denominator. We recommend inclusion of admissions, OBDs and length of stay in statistical, time series analysis of antibiotic use. This model is also relevant to longitudinal analysis of infections in hospitals.

Clinical and demographic characteristics predicting QOL in patients with epilepsy in the Czech Republic: How this can influence practice

OBJECTIVE The aim of our study was to assess the influence of different clinical and demographic variables on quality of life (QOL) in patients with epilepsy in the Czech Republic. METHODS Outpatients with epilepsy (n=268) who visited two neurology departments between 2005 and 2006 were included. Clinical and demographic characteristics were retrieved from medical records. Quality of life was measured by the Quality of Life in Epilepsy Inventory (QOLIE-31). Using multiple regression analysis, we determined which variables were associated with QOLIE-31 overall and subscale scores. RESULTS Seizure frequency, employability and psychiatric comorbidity were found to be risk factors for QOLIE-31 overall score, accounting for 33% of the variance in the regression model. Seizure frequency was strong predictor for all seven subscales. Employability explained 10% of the variance in the QOLIE overall score and was the strongest predictor for Overall QOL, Emotional Well-being, Energy/Fatigue and Cognitive Function. Gender, type of seizures, age at onset of seizures, and systemic comorbidity had no significant association in this study. CONCLUSIONS The present study confirms that besides seizure frequency, employability and comorbid psychiatric conditions are strong predictors of QOL in patients with epilepsy. Interventions focusing on psychosocial problems and identification of factors that hamper employment in patients with epilepsy are necessary for improving QOL in these patients.

Impact of a multidisciplinary approach on antibiotic consumption, cost and microbial resistance in a Czech hospital

ObjectiveThe study objective was to evaluate the impact of a restrictive antibiotic policy, efficacy of inpatient therapeutic and prophylactic antibiotic regimens and susceptibility patterns of infecting bacteria in 2000–2004.SettingA 500-bed general hospital in the Czech Republic.MethodA retrospective computerized survey of antibiotic prescribing practices over a five-year period 2000–2004, using medical records and laboratory data from the hospital information system (HIS).Main outcome measureConsumption of antibiotics expressed in defined daily doses (DDDs) and Euros per 1,000 bed days. Resistance to antibiotics, average length of hospital stay, rate of inpatients treated with antibiotics, number of nosocomial infections per 1,000 bed days, median length of hospital stay and total mortality.ResultsDue to a restrictive antibiotic policy implemented in 2002, the use of several antibiotics in 2003 was significantly reduced but the consumption of several other antibiotics rose in 2003. In comparison with 2001 the cost of antibiotic agents (in € per 1,000 inpatient days) fell significantly by 31% in 2003 (€ 969.07 vs. € 671.34). The hospital saved about € 29,288 after the first year of implementation of the new antibiotic policy. The use of restricted antibiotics increased by 8%; however, the expenditure decreased by 26%. For non-restricted antibiotics, the use and expenditure decreased by 71% and 41%, respectively. Consequently, a net reduction of 55% (€ 804.36 vs. € 359.36) was achieved.ConclusionThe intervention was effective in reducing the use and cost of antibiotics. The HIS is a helpful tool for observing and evaluating the impacts of the measures taken and can be used for assessment of pharmacotherapy outcomes.

Adherence in adults with type 1 diabetes mellitus correlates with treatment satisfaction but not with adverse events

Purpose Diabetes self-care and self-monitoring adherence has a positive effect on the metabolic control of the disease. The aim of this study was to analyze the adherence to self-care recommendations and to identify its correlates in adults with type 1 diabetes mellitus. Patients and methods One hundred and eleven patients with type 1 diabetes were enrolled in an observational cross-sectional study conducted at the Diabetes Center of the University Hospital in Hradec Králové, Czech Republic. Diabetes self-care adherence was measured by the Self Care Inventory-Revised, and treatment satisfaction by the Diabetes Treatment Satisfaction Questionnaire-status version. Additional data were collected from self-administered questionnaires and medical records. The Mann–Whitney test, Spearman correlations, and multiple linear regressions were used in the statistical analysis. Results The mean age of patients was 42.4 years; 59.5% of them were females and 53.2% of all patients used an insulin pump. The mean glycosylated hemoglobin (HbA1c) was 66.2 ± 15.3 mmol/mol and the mean insulin dosage was 0.6 ± 0.3 IU insulin/kg/day. The number of hypoglycemic episodes (including severe) that patients had in the last month before taking the survey was 3.6 ± 3.2. Self-care adherence was associated with treatment satisfaction (0.495; P = 0.004) along with frequency of self-monitoring of before meal blood glucose (0.267; P = 0.003). It was not associated with the incidence of hypoglycemic events or any other insulin therapy-related problems or with socio-demographic or clinical characteristics. Conclusion Treatment satisfaction is one of the key factors that need to be targeted to maximize benefits to patients. Self-care adherence in adults with type 1 diabetes did not correlate with socio-demographic and clinical characteristics, nor with adverse events.

Irrational prescribing of over-the-counter (OTC) medicines in general practice: testing the feasibility of an educational intervention among physicians in five European countries

BackgroundIrrational prescribing of over-the-counter (OTC) medicines in general practice is common in Southern Europe. Recent findings from a research project funded by the European Commission (FP7), the “OTC SOCIOMED”, conducted in seven European countries, indicate that physicians in countries in the Mediterranean Europe region prescribe medicines to a higher degree in comparison to physicians in other participating European countries. In light of these findings, a feasibility study has been designed to explore the acceptance of a pilot educational intervention targeting physicians in general practice in various settings in the Mediterranean Europe region.MethodsThis feasibility study utilized an educational intervention was designed using the Theory of Planned Behaviour (TPB). It took place in geographically-defined primary care areas in Cyprus, France, Greece, Malta, and Turkey. General Practitioners (GPs) were recruited in each country and randomly assigned into two study groups in each of the participating countries. The intervention included a one-day intensive training programme, a poster presentation, and regular visits of trained professionals to the workplaces of participants. Reminder messages and email messages were, also, sent to participants over a 4-week period. A pre- and post-test evaluation study design with quantitative and qualitative data was employed. The primary outcome of this feasibility pilot intervention was to reduce GPs’ intention to provide medicines following the educational intervention, and its secondary outcomes included a reduction of prescribed medicines following the intervention, as well as an assessment of its practicality and acceptance by the participating GPs.ResultsMedian intention scores in the intervention groups were reduced, following the educational intervention, in comparison to the control group. Descriptive analysis of related questions indicated a high overall acceptance and perceived practicality of the intervention programme by GPs, with median scores above 5 on a 7-point Likert scale.ConclusionsEvidence from this intervention will estimate the parameters required to design a larger study aimed at assessing the effectiveness of such educational interventions. In addition, it could also help inform health policy makers and decision makers regarding the management of behavioural changes in the prescribing patterns of physicians in Mediterranean Europe, particularly in Southern European countries.

Healthy adherer effect - the pitfall in the interpretation of the effect of medication adherence on health outcomes

RATIONALE, AIMS AND OBJECTIVES Different designs of studies monitoring adherence may cause bias and subsequent unavailability to compare results. Healthy adherer effect (HAE) is a type of bias reflecting patient behaviour. It cannot be easily monitored in study population and can favourably affect health outcomes that may be incorrectly attributed to drug therapy. The aim of this paper was to assess the HAE impact on health outcomes of studies concerning medication adherence. METHODS Systematic review of literature from PubMed, EMBASE and Cochrane Register of Controlled Trials identified all randomized controlled or observational studies dealing with HAE. Included studies were analysed with respect to relationships between HAE, adherence to therapy and health outcomes. RESULTS Seven studies were identified - two randomized controlled and five cohort studies. Significant occurrence of HAE in relation to mortality was not observed while one study indicated the presence of HAE in relation to surrogate (bone mineral density). Cohort studies were mainly based on drug class effect, but HAE was not revealed. Factors associated with patient behaviour (e.g. smoking, regular preventive screening) were also not clearly associated with the occurrence of HAE, but their inclusion in design of cohort studies can help to detect health seeking behaviour. CONCLUSION Only a few studies concerning HAE were found, but they did not obtain any consistent conclusions. HAE impact was supposed particularly on treatment outcomes that may be easier affected by patient behaviour. However, researchers and clinicians should be still aware of HAE, interpret results carefully and verified them in further studies.

Delay in the diagnosis and treatment of pulmonary tuberculosis in Uzbekistan: a cross-sectional study

BackgroundEarly diagnosis and prompt effective therapy are crucial for the prevention of tuberculosis (TB) transmission, particularly in regions with high levels of multi-drug resistant TB. This study aimed to evaluate the extent of delay in diagnosis and treatment of TB in Uzbekistan and identify associated risk factors.MethodsA cross-sectional study was performed on hospital patients with newly diagnosed TB. The time between the onset of respiratory symptoms and initiation of anti-TB treatment was assessed and delays were divided into patient, health system and total delays. Univariable and multivariable logistic regression analysis was used to evaluate determinants of diagnostic and treatment delay.ResultsAmong 538 patients enrolled, the median delay from onset of symptoms until treatment with anti-TB drugs was 50 days. Analysis of the factors affecting health-seeking behaviour and timely treatment showed the presence of the patient factor. Self-medication was the first health-seeking action for 231 (43%) patients and proved to be a significant predictor of delay (p = 0.005), as well as coughing (p = 0.009), loss of weight (p = 0.001), and visiting private and primary healthcare facilities (p = 0.03 and p = 0.02, respectively).ConclusionTB diagnostic and treatment delay was mainly contributed to by patient delay and should be reduced through increasing public awareness of TB symptoms and improving public health-seeking behaviour for timely initiation of anti-TB treatment. Efforts should be made to minimise irrational use of antibiotics and support interventions to restrict over-the-counter availability of antibiotics.