Maria Pisu

American College of Rheumatology 2008 Recommendations for the Use of Nonbiologic and Biologic Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis

Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to these guidelines and recommendations to be voluntary, with the ultimate determination regarding their application to be made by the physician in light of each patient’s individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed or endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.

Distribution of Health Care Expenditures for HIV-Infected Patients

BACKGROUND Health care expenditures for persons infected with human immunodeficiency virus (HIV) in the United State determined on the basis of actual health care use have not been reported in the era of highly active antiretroviral therapy. METHODS Patients receiving primary care at the University of Alabama at Birmingham HIV clinic were included in the study. All encounters (except emergency room visits) that occurred within the University of Alabama at Birmingham Hospital System from 1 March 2000 to 1 March 2001 were analyzed. Medication expenditures were determined on the basis of 2001 average wholesale price. Hospitalization expenditures were determined on the basis of 2001 Medicare diagnostic related group reimbursement rates. Clinic expenditures were determined on the basis of 2001 Medicare current procedural terminology reimbursement rates. RESULTS Among the 635 patients, total annual expenditures for patients with CD4+ cell counts <50 cells/microL (36,533 dollars per patient) were 2.6-times greater than total annual expenditures for patients with CD4+ cell counts > or =350 cells/microL (13,885 dollars per patient), primarily because of increased expenditures for nonantiretroviral medication and hospitalization. Expenditures for highly active antiretroviral therapy were relatively constant at approximately 10,500 dollars per patient per year across CD4+ cell count strata. Outpatient expenditures were 1558 dollars per patient per year; however, the clinic and physician component of these expenditures represented only 359 dollars per patient per year, or 2% of annual expenses. Health care expenditures for patients with HIV infection increased substantially for those with more-advanced disease and were driven predominantly by medication costs (which accounted for 71%-84% of annual expenses). CONCLUSIONS Physician reimbursements, even with 100% billing and collections, are inadequate to support the activities of most clinics providing HIV care. These findings have important implications for the continued support of HIV treatment programs in the United States.

Culturally appropriate storytelling to improve blood pressure: a randomized trial

BACKGROUND Storytelling is emerging as a powerful tool for health promotion in vulnerable populations. However, these interventions remain largely untested in rigorous studies. OBJECTIVE To test an interactive storytelling intervention involving DVDs. DESIGN Randomized, controlled trial in which comparison patients received an attention control DVD. Separate random assignments were performed for patients with controlled or uncontrolled hypertension. (ClinicalTrials.gov registration number: NCT00875225) SETTING An inner-city safety-net clinic in the southern United States. PATIENTS 230 African Americans with hypertension. INTERVENTION 3 DVDs that contained patient stories. Storytellers were drawn from the patient population. MEASUREMENTS The outcomes were differential change in blood pressure for patients in the intervention versus the comparison group at baseline, 3 months, and 6 to 9 months. RESULTS 299 African American patients were randomly assigned between December 2007 and May 2008 and 76.9% were retained throughout the study. Most patients (71.4%) were women, and the mean age was 53.7 years. Baseline mean systolic and diastolic pressures were similar in both groups. Among patients with baseline uncontrolled hypertension, reduction favored the intervention group at 3 months for both systolic (11.21 mm Hg [95% CI, 2.51 to 19.9 mm Hg]; P = 0.012) and diastolic (6.43 mm Hg [CI, 1.49 to 11.45 mm Hg]; P = 0.012) blood pressures. Patients with baseline controlled hypertension did not significantly differ over time between study groups. Blood pressure subsequently increased for both groups, but between-group differences remained relatively constant. LIMITATION This was a single-site study with 23% loss to follow-up and only 6 months of follow-up. CONCLUSION The storytelling intervention produced substantial and significant improvements in blood pressure for patients with baseline uncontrolled hypertension. PRIMARY FUNDING SOURCE Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation.

Cost-effectiveness of hepatitis B vaccination of prison inmates

The purpose of this paper is to determine the cost-effectiveness of vaccinating inmates against hepatitis B. From the prison perspective, vaccinating inmates at intake is not cost-saving. It could be economically beneficial when the cost of a vaccine dose is <US dollars 30 per dose, or there is no prevalence of infection upon intake, or the costs of treating acute or chronic disease are about 70% higher than baseline costs, or the incidence of infection during and after custody were >1.6 and 50%, respectively. The health care system realizes net savings even when there is no incidence in prison, or there is no cost of chronic liver disease, or when only one dose of vaccine is administered. Thus, while prisons might not have economic incentives to implement hepatitis B vaccination programs, the health care system would benefit from allocating resources to them.

Gender differences in discontinuation of antiretroviral treatment regimens.

Background:Reported reasons for change or discontinuation of antiretroviral therapy (δART) include adverse events, intolerability, and nonadherence. Little is known how reasons for δART differ by gender. Methods:In a retrospective cohort study, rates and reasons for δART alterations in a large University-based HIV clinic cohort were evaluated. Logistic regression analyses were used to evaluate the relationship between reasons for δART and gender. Cox proportional hazard models were used to investigate time to δART. Results:In total, 631 HIV-positive individuals were analyzed. Women (n = 164) and men (n = 467) were equally likely (53.0% and 54.4%, respectively) to discontinue treatment within 12 month of initiating a new regimen. Reasons for δART, however, were different based on gender-women were more likely to δART due to poor adherence [adjusted odds ratio (OR), 1.44; 95% confidence interval (CI): 0.85 to 2.42], dermatologic symptoms (adjusted OR, 2.88; 95% CI: 1.01 to 8.18), neurological reasons (adjusted OR, 1.82; 95% CI: 0.98 to 3.39), constitutional symptoms (adjusted OR, 2.23; 95% CI: 1.10 to 4.51), and concurrent medical conditions (adjusted OR, 2.03; 95% CI: 1.00 to 4.12). Conclusions:Although the rates of δART are similar among men and women in clinical practice, the reasons for treatment changes are different based on gender. The potential for unique patterns of adverse events and poor adherence among women requires further investigation.

Does economic burden influence quality of life in breast cancer survivors

GOALS Economic burden is emerging as a crucial dimension in our understanding of adjustment to cancer during treatment. Yet, economic burden is rarely examined in cancer survivorship. The goal of this paper is to describe the effect of economic hardship and burden among women with breast cancer. METHODS We examined baseline and follow-up (3 and 6 month) data reported by 132 stage I and II breast cancer survivors assigned to the Wait Control arm of the Breast Cancer Education Intervention (BCEI), a clinical trial of education and support interventions. Repeated measures models fitted with linear mixed models were used to examine relationships between aspects of economic burden and overall quality of life (QOL) scores. Structural equation models (SEM) were used to examine the relationship between overall economic burden and QOL. RESULTS Nineteen economic events were reported. The proportion of survivors who reported increase in insurance premiums increased in the 6-month study period (p=.022). The proportion of survivors reporting change in motivation (p=.016), productivity (p=.002), quality of work (p=.01), days missed from work (p<.001) and sacrificing other things (p=.001) declined. An increase in economic events was significantly associated with poorer quality of life at each of the study time points. CONCLUSION Economic burden of breast cancer extends into post-treatment survivorship. Better understanding of economic impact and managing economic burden may help maintain QOL.

Household-based costs and benefits of vaccinating healthy children in daycare against influenza virus: results from a pilot study.

AbstractBackground: Vaccinating children against influenza virus may reduce infections in immunised children and household contacts, thereby reducing the household-based cost associated with respiratory illnesses. Objective: To evaluate the impact of influenza virus vaccination of daycare children on costs of respiratory illnesses of the children and their household contacts from the household and societal perspective. Study design: Cost analysis of data from a randomised controlled trial covering the period November to April of 1996–7 and 1998–9. Children (127 in 1996–7 and 133 in 1998–9) from daycare centres in Californian (USA) naval bases received influenza virus vaccine (inactivated) or hepatitis A virus vaccination. Outcome measures: Direct and indirect costs (1997 and 1999 US dollars) of respiratory illnesses in households of vaccinated and not vaccinated daycare children, excluding the cost of vaccination. Results: There were no statistically significant differences in household costs of respiratory illness between households with or without influenza virus-vaccinated children (

Increased Black–White Disparities in Mortality After the Introduction of Lifesaving Innovations: A Possible Consequence of US Federal Laws

US635 vs

The Patient Care Connect Program: Transforming Health Care Through Lay Navigation

US492: p = 0.98 [1996–7];

Medication adherence among rural, low-income hypertensive adults: a randomized trial of a multimedia community-based intervention.

US412.70 vs