Educational outcomes of family-based HIV-infected and affected children from Maharashtra,India

India is home to 0.14 million children, living with HIV. Little is known about their educational needs. The present analysis estimated educational outcomes of family-based children affected by HIV/AIDS (CABA) and impact of their HIV status on educational outcomes. A situation analysis was undertaken in four districts from Maharashtra, India. A total of 510 parents/guardians of family-based CABA were interviewed. Data of single child per household, aged 6–16 years, were analyzed. Child not infected/not tested for HIV and having one/both parents infected with HIV was defined as HIV affected. Logistic regression analysis was used to understand determinants of ‘currently out of school’ and ‘lag behind age appropriate standard’. Of the total 472 CABA, 237 and 235 were HIV infected and affected respectively, 43% were girls, 70% were below 13 years of age, 51% resided in rural area, 83% belonged to lower economic strata and 61% had lost one/both parents. Higher proportion of HIV-infected children had history of hospitalization in the past year (26%) compared with HIV affected (7%). Majority of HIV-infected children (84%) were taking ART. A total of 23 (4.87%) children were currently out of school and 43 (9.23%) lagged behind age appropriate standard. Compared to HIV-affected, HIV-infected children were more likely to be out of school (aOR = 7.16, 95% CI = 1.79–42.47) and lagged behind age appropriate standard (aOR = 2.82, 95% CI = 1.17–6.81). Children 14–16 years old had higher risk of being out of school (aOR = 11.55, 95% CI = 3.46–50.65) and lag (aOR = 3.85, 95% CI = 1.79–8.29), compared to 6–13 years old children. Having lost mother and caregiver being illiterate independently predicted the lag. Among HIV-infected children, the most common reason for discontinuation of school was child’s illness. The analysis highlights greater educational disadvantages of HIV-infected children and its possible linkage with ill health of these children.     

Hospitalization of HIV positive patients: Significant demand affecting all hospital sectors

Background

In a context of the evolution of severe morbidities in patients living with HIV (PLWH), the aim of this study was to describe reasons for hospitalization and the mode of care for the patients requiring hospitalization.

Community-Acquired Pneumonia Episode Costs by Age and Risk in Commercially Insured US Adults Aged ≥50 Years

Background

Community-acquired pneumonia (CAP) causes substantial clinical and economic burden. While several studies have reported the cost to treat CAP, there is little information on the cost to treat by age, risk profile, and hospitalization in US adults aged ≥50 years.

Objective

To quantify the cost, from a payer perspective, of treating CAP at the episode level, stratified by age, risk profile, and hospitalization.

Methods

A retrospective study of claims data from a large US health plan (1 January 2006–31 December 2008) was conducted. Patients aged ≥50 years having at least one medical claim with a primary diagnosis for pneumonia were identified. A CAP episode was defined as the period between the first and last pneumonia ICD-9 code with a chest X-ray claim. Episode-level variables included risk stratum based on presence of an immunocompromising/chronic condition, age group, number and length of inpatient and outpatient CAP episodes, and all-cause and CAP-related healthcare costs (adjusted to 2011 costs).

Results

Among the 27,659 study patients, 28,575 CAP episodes (20,454 outpatient; 8,121 inpatient) occurred. Mean age of patients with a CAP episode was 62.6. Low-risk patients accounted for 44.4 % of all CAP episodes. Mean CAP episode length was 31.8 days for an inpatient episode and 10.2 days for an outpatient episode. Mean all-cause total healthcare cost for an inpatient CAP episode ranged from $11,148 to $51,219 depending on risk stratum and age group. Mean outpatient episode-related costs were much lower than inpatient episode-related costs.

Conclusions

Cost to treat CAP requiring hospitalization is high regardless of age or the presence of underlying comorbidities. Given that almost half of the patients in this study did not have traditional risk factors for CAP, it is clear that better preventative strategies are needed.     

Return to Work 2–5 Years After Stroke: A Cross Sectional Study in a Hospital-Based Population

Purpose To describe factors associated with RTW in patients 2–5 years after stroke. Methods Cross sectional study, including patients 2–5 years after hospitalization for a first-ever stroke, who were <65 years and had been gainfully employed before stroke. Patients completed a set of questionnaires on working status and educational level, physical functioning (Frenchay Activities Index, FAI), mental functioning (Hospital Anxiety and Depression Scale, HADS), Coping Orientations to Problems Experienced, (COPE easy) and quality of life (Short-Form(SF)-36 and EQ(Euroqol)-5D). Caregivers completed the Caregiver Strain Index (CSI). Baseline stroke characteristics were gathered retrospectively. Baseline characteristics and current health status were compared between patients who did and did not RTW by means of logistic regression analysis with odds ratios (OR) and 95 % confidence intervals (CI), adjusted for age and gender. Results Forty-six patients were included, mean age of 47.7 years (SD 9.7), mean time since stroke of 36 months (SD 11.4); 18 (39 %) had RTW. After adjusting for age and gender a shorter length of hospitalization was associated with RTW (OR 0.87; CI 0.77–0.99). Of the current health status, a lower HADS depression score (0.76; 0.63–0.92), a less avoidant coping style (1.99; 0.80–5.00), better scores on the FAI (1.13; 1.03–1.25), the mental component summary score of the SF36 (1.07; 1.01–1.13), the EQ5D (349; 3.33–36687) and the CSI (0.68; 0.50–0.92) were associated with the chance of RTW. Conclusions A minority of working patients RTW after stroke; a shorter duration of the initial hospitalization was associated with a favorable work outcome. The significant association between work status and activities, mental aspects and quality of life underlines the need to develop effective interventions supporting RTW.     

Nutritional Risk and Nutritional Status at Admission and Discharge among Chinese Hospitalized Patients: A Prospective,Nationwide, Multicenter Study

Objective: The objective of this study was to assess nutritional risk and status of Chinese hospitalized patients at admission and discharge and relations with clinical outcomes.

Methods: A prospective, nationwide, multicenter study was conducted from June to September 2014 in 34 large hospitals in 18 cities in China. Patients ≥ 18 years with a hospital stay of 7–30 days were recruited. Anthropometric and laboratory indicators, nutritional risk screening, and assessment by Nutritional Risk Screening 2002 (NRS 2002) and subjective global assessment (SGA) were performed within 24 hours of admission and discharge. Clinical data during hospitalization were collected.

Results: A total of 6,638 patients met the criteria with a male: female ratio of 1.39:1 and an average age of 59.72 ± 15.40 years. At admission, the proportion of patients with nutritional risk, body mass index (BMI) < 18.5 kg/m², and moderate to severe malnutrition was 40.12%, 8.92%, and 26.45%, respectively, whereas at discharge, these percentages were 42.28%, 8.91%, and 30.57%, respectively. The values of all of these indicators were higher in patients 65 years of age and older. Patients with nutritional risk at admission had a longer average hospital stay (14.02 ± 6.42 vs 13.09 ± 5.703 days), higher incidence of total complications (6.90% vs 1.52%), and greater total medical expenses (3.39 ± 7.50 vs 3.00 ± 3.38 million RMB; all p < 0.01) than patients without nutritional risk. Similar results were obtained for the patients with nutritional risk at discharge.

Conclusion: The prevalence of nutritional risk and malnutrition, including moderate to severe malnutrition, at discharge is higher than that observed at admission; the clinical outcome of patients with nutritional risk is poor.     

The Association between Depression and Medication Nonpersistence in New Users of Antidiabetic Drugs

Objectives

To measure the association between depression and nonpersistence with antidiabetic drugs (ADs) among new users of oral ADs and to estimate factors associated with nonpersistence among these new users with depression.

Examining age as a moderating effect on the relationship between alcohol use and viral suppression among women living with HIV

This study sought to examine if age moderated the effect of alcohol on viral suppression among women living with HIV. A secondary data analysis, using data from the 550 Clinic Women’s HIV Cohort Study was completed. Individuals were included if they were HIV positive, sought care in an urban clinic in Kentucky between 2009 and 2012, and had ≥1 year of follow-up. The primary independent variable was current alcohol use; the moderating variable was age (<50 years versus ≥50 years); and the outcome was suppression. Logistic regression models examined the interaction between age and alcohol. Among 360 women (average age 45.8 ± 10.1 years, 38 percent were ≥50 years), approximately 32.0 percent had consumed alcohol, and 40 percent achieved suppression. Women aged ≥50 years were more likely to achieve suppression than younger women. Age interacted significantly with alcohol (p = .038). Stratified by age, alcohol was associated with poor viral suppression among older women; for older women, alcohol users had lower odds of suppression compared to nonusers (odds ratio = 0.37; 95 percent confidence interval = 0.14–0.99). Alcohol may impede the opportunity for older women to achieve suppression. Further study is needed to examine alcohol use among older women, specifically addressing quantity and frequency and their impact on suppression.     

Cost-effectiveness analysis, prevention of atopic dermatitis by oral application of bacterial lysate in newborns/small children

Objectives

The aim of this analysis was to determine the cost-effectiveness compared to placebo of prophylactic treatment with sterile bacterial lysate (Escherichia coli and Enterococcus faecalis) (verum) of newborns/small children with heredity for atopy [atopic dermatitis (AD)]. Infants were followed from the age of 5 weeks until 3 years of age. During this time, the number of children with AD who were treated with verum or placebo was observed at eight visits. Cost-effectiveness analyses were performed at different time points.

Methods

A randomized, double-blind placebo-controlled clinical trial performed in Germany included 606 newborns. After randomization, n = 303 patients were classified in the placebo group and n = 303 in the verum group. A total of 119 participants left the study, so data from n = 250 patients of the placebo group and n = 237 patients of the verum group were available for analysis. At the beginning of the study, newborns were treated prophylactically with bacterial lysate or placebo for 26 weeks. After this, children were observed until the age of 3 years. A systematic literature research was done to evaluate treatment costs of atopic eczema in newborn/small children. Finally, 17 publications were included and checked for searched treatment costs of AD. A study was then initiated to evaluate the direct costs to statutory health insurance. Based on the described clinical trial, a decision tree model was developed. Using the evaluated direct costs and prevalence according to the clinical trial, the developed model can be used in cost-effectiveness analyses.

Results

The focus of the analyses was on the subgroup “single heredity for atopy” in clinical trials. Cost-effectiveness analysis showed an advantage for bacterial lysate after 3 years. To further support this result a model extension was executed; the model was expanded from 3 to 6 years. Cost-effectiveness of bacterial lysate was also proven after 6 years.

Conclusion

Prophylactic treatment with bacterial lysate of infants with single heredity for atopy for 26 weeks in the 1st year of life is cost-effective at the age of 3 and 6 years, i.e. prophylactic use of bacterial lysate generated lower costs by leading to lower prevalence compared to placebo.     

Marital Age Disparity Among Orphaned Young Women and Their Husbands: A Mixed Methods Study in Rural Zimbabwe

Our study reports the results from a mixed method study comparing age-similar (AS) marriages of orphaned young women to age disparate (AD) marriages, defined as spousal age difference of 5 or more years. Research in Zimbabwe and sub-Saharan Africa suggests that AD sexual relationships between older men and young women increase the risk for HIV but few studies have examined this association among married couples or explored why young women marry much older men. In this study, a total of 35 orphaned young women aged 17–26 years in rural Zimbabwe participated in semi-structured interviews during 2012–2013. Twenty-four were in AD marriages and 11 AS. All had participated in a 5-year HIV prevention trial, during which they had married and dropped out of school. We examined two research questions: were AD wives more likely than AS to cite economic considerations as a reason to marry, and were AD marriages associated with different health and economic outcomes compared to AS? Our results showed that the reasons the women married were essentially the same among the two groups; economic considerations for marriage were uncommon. Nevertheless, AD wives generally fared somewhat better than AS wives on economic and well-being measures. HIV prevalence was similar; however, the AD group accounted for all five cases of herpes simplex virus-2. Findings suggest the complexity of sexual and reproductive health in rural Africa, where AD marriages are common and accepted. The challenge for primary prevention is to develop strategies to mitigate the risk of sexually transmitted infections, as well as the potential abuse of young women, within the appropriate cultural context.     

Opinions and use of advance directives by physicians at a tertiary care hospital

The physician-patient relationship is an essential part of end-of-life planning, including discussions of advance directives (AD). Physicians likely to encounter AD issues with their patients were identified and queried as to their knowledge, opinion, and experience with ADs. Though most physicians felt ADs were helpful to both physicians and patients, considerably less were familiar with hospital policies and the different types of ADs. Formal education in the use and function of ADs also appears to be lacking, suggesting a need to improve the way in which ADs are addressed during medical training.     

More counselling for end-of-life decisions by GPs with own advance directives: A postal survey among German general practitioners

Background: Although general practitioners (GPs) are among the preferred contact persons for discussing end-of-life issues including advance directives (ADs), there is little data on how GPs manage such consultations.

Objectives: This postal survey asked German GPs about their counselling for end-of-life decisions.

Methods: In 2015, a two-sided questionnaire was mailed to 959 GPs. GPs were asked for details of their consultations on ADs: frequency, duration, template use, and whether they have own ADs. Statistical analysis evaluated physician characteristics associated with an above-average number of consultations on AD.

Results: The participation rate was 50.3% (n?=?482), 70.5% of the GPs were male; the average age was 54 years. GPs had an average of 18 years of professional experience, and 61.4% serve more than 900 patients per three months. Most (96.9%) GPs perform consultations on living wills (LW) and/or powers of attorney (PA), mainly in selected patients (72.3%). More than 20 consultations each on LWs and PAs are performed by 60% and 50% of GPs, respectively. The estimated mean duration of consultations was 21?min for LWs and 16?min for PAs. Predefined templates were used in 72% of the GPs, 50% of GPs had their ADs. A statistical model showed that GPs with ADs and/or a qualification in palliative medicine were more likely to counsel ≥20 patients per year for each document.

Conclusion: The study confirmed that nearly all German GPs surveyed provide counselling on ADs. Physicians with ADs counsel more frequently than those without such documents.     

Factors Associated with Human Immunodeficiency Virus Screening of Women During Pregnancy,Labor and Delivery,United States, 2005–2006

The purpose of this study was to estimate prenatal human immunodeficiency virus (HIV) screening rates prior to and on admission to labor and delivery (L&D) and to examine factors associated with HIV screening, including hospital policies, with a comparison of HIV and hepatitis B prenatal screening practices and hospital policies. In March 2006, a survey of hospitals (n = 190) and review of paired maternal and infant medical records (n = 4,762) were conducted in 50 US states, DC, and Puerto Rico. Data from the survey and medical record review were analyzed using SAS software v9.2 (SAS Institute, Cary, NC). HIV testing before delivery occurred among 3,438 women (73.9 %); African American and Hispanic women were more likely to be tested than white women [aOR 2.22, 95 % CI (1.6–3.1) and aOR 1.55, 95 % CI (1.1–2.2), respectively]. Among women without previous HIV testing, 138 (16.6 %) were tested after admission to labor and delivery. Policies to test women with undocumented HIV status in at delivery were present in 65 (36.3 %) hospitals. HIV testing after admission to L&D was more likely in hospitals with policies to test women with undocumented HIV status [aOR 5.91, 95 % CI (2.0–17.8)]. Overall, policies and screening practices for HIV were consistently less prevalent than those for hepatitis B. Many women are not being routinely screened for HIV before or at delivery. Women with unknown HIV status were more likely to be tested in L&D in hospitals with testing policies.     

Documentation of advance directives among home health and hospice patients: United States, 2007

This report provides nationally representative data on documentation of advance directives (ADs) among home health (HH) and hospice patients. Advance directives were recorded for 29% of HH patients and 90% of hospice discharges. Among HH patients, increasing age and use of assistive devices were associated with greater odds of having an AD, while being Hispanic or black (relative to white) and enrolled in Medicaid decreased the odds of having ADs. Among hospice discharges, being enrolled in Medicare and having 4 or 5 activities of daily living (ADL) limitations were associated with higher odds of ADs while depression, use of emergency services, and being black (relative to White) were associated with lower odds. Even after adjustment for potentially confounding factors, racial differences persist in AD documentation in both care settings.     

HIV Testing of Tuberculosis Patients by Public and Private Providers in New York City

Thirty percent of tuberculosis (TB) patients in New York City in 2007 were not tested for HIV, which may be attributable to differential testing behaviors between private and public TB providers. Adult TB cases in New York City from 2001 to 2007 (n = 5,172) were evaluated for an association between TB provider type (private or public) and HIV testing. Outcomes examined were offers of HIV tests and patient refusal of HIV testing, using multivariate logistic and binomial regression, respectively. HIV test offers were less frequent among patients who visited only private providers than patients who visited only public providers [males: adjusted odds ratio (aOR) 0.33, 95 % confidence interval (CI) 0.15–0.74; females: aOR 0.26, 95 % CI 0.12–0.57]. Changing from private to public providers was associated with an increase in HIV tests offered among male patients (aOR 1.96, 95 % CI 1.04–3.70). Among patients who did not use substances, those who visited only private providers were more likely to refuse HIV testing than those who visited only public providers [males: adjusted prevalence ratio (aPR) 1.26, 95 % CI 0.99–1.60; females: aPR 1.78, 95 % CI 1.43–2.22]. Patients of private providers were less likely to have an HIV test performed during their TB treatment. Education of TB providers should emphasize HIV testing of all TB patients, especially among patients who are traditionally considered low-risk.     

Maternal smoking as a risk factor for childhood intussusception

Risk factors for intussusception have only rarely been reported. We examined the association between the risk of hospital admission for intussusception and maternal smoking, using a nationwide population-based longitudinal survey begun in Japan in 2010. Maternal smoking status was queried at 6 months of age, and responses to questions at 18 months of age about history of hospitalization for intussusception during the previous year were used as an outcome of interest. We conducted logistic regression analyses controlling for potential confounding factors. Maternal smoking increased the risk of hospitalization for intussusception (adjusted OR = 2.75, 95% CI [1.09, 6.96]) compared with not smoking, and a dose-response relationship was observed for the association. Maternal smoking is associated with an increased risk of intussusception development in children between the ages of 6 and 18 months.     

HIV Diagnoses and Prevalence in the Southern Region of the United States, 2007–2010

On a number of leading health indicators, including HIV disease, individuals in the southern states of the United States fare worse than those in other regions. We analyzed data on adults and adolescents diagnosed with HIV infection through December 2010, and reported to the Centers for Disease Control and Prevention (CDC) through June 2011 from 46 states with confidential name-based HIV reporting since January 2007 to describe the impact of HIV in the South. In 2010 46.0 % of all new diagnoses of HIV infection occurred in the South. Compared to other regions, a higher percentage of diagnoses in the South were among women (23.8 %), blacks/African Americans (57.2 %), and among those in the heterosexual contact category (15.0 % for males; 88.5 % for females). From 2007 to 2010 the estimated number and rate of diagnoses of HIV infection decreased significantly in the South overall (estimated annual percentage change [EAPC] = ?1.5 % [95 %CI ?2.3 %, ?0.7 %] and ?2.1 % [95 % CI ?4.0 %, ?0.2 %], respectively) and among most groups of women, but there was no change in the number or rate of diagnoses of HIV infection among men overall. Significant decreases in men 30–39 and 40–49 years of age were offset by increases in young men 13–19 and 20–29 years of age. A continued focus on this area of high HIV burden is needed to yield success in the fight against HIV disease.     

Worry as a Mechanism to Motivate Information Seeking about Protective End-of-Life Communication Behaviors

Making known one’s end-of-life (EOL) care wishes via the processes of advance care planning (ACP) and advance directive (AD) completion is associated with many positive outcomes for patients including lower healthcare costs, greater patient-provider relationship satisfaction, increased quality of life, and more. Despite these benefits, fewer than 30% of patients in the United States engage in ACP or complete ADs. These low numbers are most likely due to several causes, including low self-efficacy and low motivation to engage in the process. Several researchers have examined the persuasive power of using worry to motivate patients to engage in preventive health behaviors. The present study expands upon this body of literature by examining patient intentions to seek information related to ACP and AD after being exposed to stimuli intended to arouse differing levels of worry regarding bad EOL outcomes. Participants (N = 804) were randomly assigned to either the high worry, low worry, or control group and asked to complete a questionnaire examining beliefs and information seeking intentions regarding ACP and AD completion. Additionally, to control for participants’ level of trait worry, each participant completed the Penn State Worry Questionnaire, which was treated as a covariate in the final analysis. A repeated measures MANCOVA found a statistically significant increase for the worrying conditions on the participants’ intention to seek information about ACP and ADs from time 1 to time 2 for those in the worry experimental conditions. However, those in the control group did not show a statistically significant increase. Additionally, exposure to the high worry condition was predictive of engaging in actual information seeking behavior about EOL care. Results of the experiment indicate worry is associated with greater motivation to engage in information seeking about ACP and AD. This study contributes to the literature on worry as a persuasive mechanism to motivate patients to engage in important preventative health behaviors.     

Reduced hospitalization rates are not associated with increased mortality or readmission rates in an emergency department in Israel

Background and Aim

In 2011 the Israeli Ministry of Health (MOH) instructed hospitals to limit occupancy in the internal medicine wards to 120%, which was followed by a nationwide reduction in hospitalization rates. We examined how readmission and mortality rates changed in the five years following the changes in occupancy rates and hospitalization rates.

Methods

All visits to the Tel Aviv Medical Center internal Emergency Medicine Department (ED) in 2010, 2014 and 2016 were captured, with exclusion of visits by patients below 16 of age and patients with incomplete or faulty data. The main outcomes were one-week readmission rates and one-month death rates. The secondary outcomes were admission rate, ED visit length & admission-delay time (minutes), and rates of admission-delayed patients.

Results

After exclusion, a total of 168,891 internal medicine ED patients were included in the analysis. Mean age was 58.0 and 49% were males. During the relevant period (2010–2016), total medical ED visits increased by 11% - 53,327, 56,588 and 59,066 in 2010, 2014 and 2016 respectively. Hospitalization rates decreased from 46% in 2010 to 35% in 2015 (p <?0.001), with the most prominent reduction in the elderly population. One-week readmission rates were 6.5, 6.4 and 6.7% in 2010, 2014 and 2016 respectively (p =?0.347 and p =?0.21). One-month mortality was similar in 2010 and 2014 (4.4 and 4.5%, p =?0.388) and lower in 2016 (4.1%, p =?0.048 compared with 2010). Average ED visit length increased from 184?min in 2010 to 238 and 262?min in 2014 & 2016 (p <?0.001 for both) and average delay time to ward admission increased from 97?min in 2010 to 179 and 240 in 2014 & 2016 (p <?0.001 for both). In 2010 24% of the admitted patients were delayed in the ED more than 2?h, numbers that increased to 53% in 2014 and 66% in 2016 (p?<?0.001 for both).

Conclusion

Following the 2011 MOH’s decision to establish a 120% occupancy limit for internal medicine wards along with natural growth in population volume, significant changes were noted in the work of a large, presumably representative emergency department in Israel. Although a steady increase in total ED visits along with a steady reduction in hospitalization rates were observed, the readmission and mortality rates remained low. The increase in the average length of ED visits and in the delay from ED admission to a ward reflects higher burden on the ED.The study was not able to establish a causal connection between the MOH directive and the subsequent changes in ED activity. Nonetheless, the study has significant potential implications for policy makers, including the presence of senior ED physicians during afterhours, creation of short-stay diagnostic units and proper adjustments in ED size and personnel.