The medication discrepancy detection service: A cost-effective multidisciplinary clinical approach

ObjectiveTo estimate the effectiveness of a Medication Discrepancy Detection Service (MDDS), a collaborative service between the community pharmacy and Primary Care.DesignNon-controlled before-and-after study.SettingBidasoa Integrated Healthcare Organisation, Gipuzkoa, Spain.ParticipantsThe service was provided by a multidisciplinary group of community pharmacists (CPs), general practitioners (GPs), and primary care pharmacists, to patients with discrepancies between their active medical charts and medicines that they were actually taking.OutcomesThe primary outcomes were the number of medicines, the type of discrepancy, and GPs’ decisions. Secondary outcomes were time spent by CPs, emergency department (ED) visits, hospital admissions, and costs.ResultsThe MDDS was provided to 143 patients, and GPs resolved discrepancies for 126 patients. CPs identified 259 discrepancies, among which the main one was patients not taking medicines listed on their active medical charts (66.7%, n = 152). The main GPs’ decision was to withdraw the treatment (54.8%, n = 125), which meant that the number of medicines per patient was reduced by 0.92 (9.12 ± 3.82 vs. 8.20 ± 3.81; p < .0001). The number of ED visits and hospital admissions per patient were reduced by 0.10 (0.61 ± .13 vs 0.52 ± 0.91; p = .405 and 0.17 (0.33 ± 0.66 vs. 0.16 ± 0.42; p = .007), respectively. The cost per patient was reduced by €444.9 (€1003.3 ± 2165.3 vs. €558.4 ± 1273.0; p = .018).ConclusionThe MDDS resulted in a reduction in the number of medicines per patients and number of hospital admissions, and the service was associated with affordable, cost-effective ratios.     

Costs of disposable material in the operating room do not show high correlation with surgical time: Implications for hospital payment

ObjectivesThe objectives of this study are to analyze the variation of the surgical time and of disposable costs per surgical procedure and to analyze the association between disposable costs and the surgical time.MethodsThe registration of data was done in an operating room of a 419 bed general hospital, over a period of three months (n = 1556 surgical procedures). Disposable material per procedure used was recorded through a barcode scanning method.ResultsThe average cost (standard deviation) of disposable material is €183.66 (€183.44). The mean surgical time (standard deviation) is 96 min (63). Results have shown that the homogeneity of operating time and DM costs was quite good per surgical procedure. The correlation between the surgical time and DM costs is not high (r = 0.65).ConclusionsIn a context of Diagnosis Related Group (DRG) based hospital payment, it is important that costs information systems are able to precisely calculate costs per case. Our results show that the correlation between surgical time and costs of disposable materials is not good. Therefore, empirical data or itemized lists should be used instead of surgical time as a cost driver for the allocation of costs of disposable materials to patients.     

Economic challenges of using innovative medical devices in major public health pathologies: Example of acute ischemic stroke management by mechanical thrombectomy

BackgroundActivity-based Funding can induce financial imbalances for health institutions if innovative medical devices (MD) used to perform acts are included in Diagnosis Related Groups (DRG) tariff. To be reimbursed in addition to the DRG tariff, innovative MD must have received a favorable evaluation by the French National Authority for Health (Haute Autorité de Santé) and be registered on the positive list. The aim of this study was to evaluate the expenses and incomes generated by each scenario (before and after the reimbursement of MD), and the financial reports. This study concerned the management of ischemic stroke by mechanical thrombectomy devices, in high-volume French hospital.MethodsAll patients who have had an acute ischemic stroke and admitted to the interventional neuroradiology unit between January 2016 and December 2017 were included retrospectively in this monocentric study. They were divided into four subgroups based on the severity of the DRG. The cost study was carried out using the French National Cost Study Methodology adjusted for the duration of the stays and by micro-costing on MD.ResultsA total of 267 patients were included. Over the study period, the average cost of the hospital stay was €10,492 ± 6364 for a refund of €9838 ± 6749 per patient. The acts performed became profitable once the MD were registered on the positive list (€−1017 ± 3551 vs. €560 ± 2671; P < 0.05). Despite this reimbursement, this activity remained in deficit for DRG lowest severity (level 1) patients (€−492 ± 1244). Specific MD used for mechanical thrombectomy represented 37% of the total cost of stay.ConclusionThe time required to evaluate MD reimbursement files is too long compared to their development. As a result, practitioners are in difficulty to be able to carry out acts according to the consensual practices of their learned societies, without causing any financial deficit of their institutions.     

Les dépenses de soins remboursés durant la dernière année de vie,en 2008, en France

BackgroundTo measure the reimbursed health expenditures in the last year of life and the proportion it represents in total reimbursement costs in 2008, to analyse the structure of such expenditures and to identify costs by cause of death.MethodsData were obtained from the French national insurance information system (SNIIRAM). Data from the national hospital discharge database were linked to the outpatient reimbursement database for patients covered by the general health insurance scheme (n = 49 million persons). The cost of the last year of life was calculated for the exhaustive population (361,328 deaths in 2008). The supposed cause of death was mainly derived from the primary diagnosis of the last hospital stay during which the patient died.ResultsThe average reimbursed expenses during the last year of life were estimated at 22,000 € per person in 2008, with 12,500 € accounting for public hospital costs. Reimbursed health expenditures varied according to different medical causes of death: 52,300 € for HIV disease and about 40,000 € for tumors. A negative effect of age on the expenditure during the last year of life was observed. Health care spending increased with shorter time before death, the last month of life corresponding to 28% of reimbursed expenditures during the last year of life. Health care use in the last year of life represented 10.5% of the total health expenditures in 2008.ConclusionThis study found results similar to those observed in the past or in other countries. Our results show in particular that the weight of health expenditures during the last year of life on total health expenditures remains stable over the years.     

The ZEPHyR study: A randomized comparison of linezolid and vancomycin for MRSA pneumonia

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) accounts for 10–40% of hospital-acquired pneumonia, and even more in intensive care units. The current guidelines for the treatment of MRSA nosocomial pneumonia include vancomycin and linezolid. The authors of 2 prospective randomized trials comparing vancomycin and linezolid in nosocomial pneumonia had concluded to the non-inferiority of linezolid. A slight superiority of linezolid was observed in the MRSA pneumonia subgroup, in terms of clinical success and survival, but no definite conclusion could be drawn.MethodsA prospective randomized study was made to compare a fixed linezolid dose to dose-optimized vancomycin for the treatment of bacteriologically proven MRSA nosocomial pneumonia (ZEPHyR Study).ResultsAmong the 165 patients treated by linezolid (57.6%) in the PP population, 95 were clinically cured at the end of the study, compared to 81 of the 174 patients treated by vancomycin (46.6%) (IC 95% of the difference 0.5%–21.6%, P = 0.042). Nephrotoxicity in the mITT population reached 8.4% in the linezolid group compared to 18.2% in the vancomycin group.ConclusionLNZ was superior to vancomycin for the treatment of MRSA nosocomial pneumonia.     

Acute kidney injury in infective endocarditis: A retrospective analysis

BackgroundAcute kidney injury (AKI) is associated with high case fatality in infective endocarditis (IE), but epidemiological data on the frequency of AKI during IE is scarce. We aimed to describe the frequency and risk factors for AKI during the course of IE using Kidney Disease: Improving Global Outcomes consensual criteria.MethodsUsing the French hospital discharge database (French acronym PMSI), we retrospectively reviewed the charts of 112 patients presenting with a first episode of probable or definite IE between January 2010 and May 2015.ResultsSeventy-seven patients (68.8%) developed AKI. In univariate analysis, risk factors for AKI were cardiac surgery for IE (n = 29, 37.7% vs. n = 4, 1.4%, P < 0.0005), cardiac failure (n = 29, 36.7% vs. n = 1, 2.9%, P < 0.0005), diabetes mellitus (n = 14, 18.2% vs. n = 1, 0.9%, P = 0.034), and prosthetic valve IEs (n = 24, 31.2% vs. n = 4, 11.4%). No differences were observed for gentamicin exposure (n = 57, 64% vs. n = 32, 86.5%, P = 0.286). Prosthetic valve IE, cardiac failure, and vancomycin exposure were independently associated with AKI with respective odds ratio of 5.49 (95% CI 1.92–17.9), 4.37 (95% CI 4.37–465.7), and 1.084 (1.084–16.2). Mean length of hospital stay was significantly longer in patients presenting with AKI than in controls (respectively 52.4 ± 22.1 days vs. 39.6 ± 12.6, P < 0.005).ConclusionAKI is very frequent during IE, particularly in patients with prosthetic valve IE, cardiac failure, and those receiving vancomycin.     

Trabajando con nuestros pacientes fumadores en atención primaria. Un análisis de coste-efectividad

ObjectiveThe aim of this work is to realize an economic evaluation of the smoking interventions in Primary Care (PC).DesignCost-Effectiveness Analysis comparing two intervention strategies; intensive and brief.SettingPatients in a general practitioner's list in a peri-urban Health Centre.ParticipantsAll the medical histories labelled as smokers; 235 and 37 in the group of brief and intensive intervention respectively.InterventionsThe brief intervention (BI) was made in the context of consultation for another purpose (1-5 minutes). The intensive intervention (II) was exclusively for smoking consultation (10-15 minutes).Main measurementsThe effectiveness data are obtained by the evaluation of intervention for smokers, in a general practitioner's list, after 6 years. We employ direct sanitary costs. We exclude drugs, non- sanitary and indirect costs. We apply the valuation of incremental cost-effectiveness ratio (ICER) of the brief interventions, intensive and total (brief + intensive) to compare not taking part with each type of intervention and II with regard to BI and probabilistic analysis to treat the uncertainty.ResultsThe total cost per abstinent patient was 406,74 €: 129,83 € for BI and 1.034,99 € for I.I.ICER Total intervention = €498, 87/patient who stops smoking.ICER BI = €235, 32/patient who stops smoking.ICER II = €1.232, 85/patient who stops smoking.ICER II/BI = €7.772,25/patient who stops smoking.ConclusionsSmoking interventions in PC are efficient. A proposal for smoking intervention in PC from an effective cost perspective could be an BI for smokers and an II on those who find more difficult to leave the habit.     

Mucoviscous characteristics of Klebsiella pneumoniae strains: A factor of clinical severity?

IntroductionHypermucoviscous Klebsiella pneumoniae (KP) strains are responsible for complicated bacteremia with multiple septic sites (liver, central nervous system, muscles). We aimed to compare the clinical severity of patients presenting with KP bacteremia based on the hypermucoviscous or non-hypermucoviscous characteristic of the strains.MethodsObservational retrospective study successively including all patients with KP bacteremia from May 2013 to March 2015 at the tertiary medical center of New Caledonia. The hypermucoviscous characteristic was defined by the string test results and molecular analysis to determine the capsular serotype.ResultsA total of 55 bacteremic patients were included in the study; 27% of isolated strains were hypermucoviscous. Hypermucoviscous strains accounted for two-thirds of community-acquired infections (72.5% vs. 33.4%, p = 0.01). The rate of intensive care hospitalization was high (hypermucoviscous 46.7%; standard 52.5%) without any difference between the two groups. No significant difference was observed in case fatality (hypermucoviscous 46.7% vs. standard 15%, p = 0.07) but patients with hypermucoviscous strains had longer hospital stays (73.5 days versus 50.7 days, p = 0.04) and longer persistence of positive blood cultures despite an appropriate treatment (OR 1.41, 95% CI: 1.0–1.96, p = 0.045).ConclusionHypermucoviscous KP bacteremia account for most community-acquired Klebsiella infections in New Caledonia and are associated with longer hospital stay and persistence of positive blood cultures despite the implementation of an appropriate treatment.     

Efectividad de una estrategia de apoyo individualizado al empleo para personas con trastornos mentales graves

ObjectiveTo assess the effectiveness of an individual placement and support (IPS) strategy in people with severe mental disorders in Tenerife Island (Spain).MethodsPatients of Community Mental Health Services with severe mental disorders were randomly assigned to two groups. One of them received IPS (n = 124), and the control group (n = 75) was advised in the usual job search. Patients were followed up for an average of 3.4 years and an analysis was made of how many patients worked at least one day, working hours, wages, the number of contracts and the number of hospital admissions. Non-parametric methods were used to compare the results (Mann-Whitney U test).ResultsThe percentage of patients who worked at least one day was 99% in the IPS group compared with 75% in the control group; they worked on average 30.1 weeks per year vs 7.4; the monthly salary was € 777.9 vs € 599.9; the number of contracts per person was 3.89 vs 4.85, and hospital admissions were 0.19 vs 2.1.ConclusionsThe IPS strategy is effective for the labour integration of people with severe mental illness getting them to work longer, have higher wages and fewer hospital admissions.     

Assessment of energy expenditure,physical activity and sleep pattern in patients with frequent symptomatic ventricular ectopic beats

BackgroundVentricular ectopic beats (VEBs) are considered as benign ventricular arrhythmias in patients without structural heart disease. However, symptomatic frequent VEBs can adversely affect energy metabolism. The present study aimed to determine the effect of symptomatic frequent VEBs on energy expenditure, physical activity and sleep pattern.MethodsThirty-seven patients with symptomatic frequent VEBs and no structural heart diseases were enrolled. Patients underwent simultaneous 24-hour-ambulatory Holter electrocardiogram monitoring and the BodyMedia armband device monitoring which measures energy expenditure. Data acquired from both devices were compared with the data acquired from healthy volunteers in the control group.ResultsTotal energy expenditure (TEE) was higher in the patient group than the control group (1470 ± 353 kcal vs 1125 ± 275 kcal, P < 0.001). Average metabolic equivalence (aMETs) (1.1 ± 0.2 vs. 1.3 ± 0.2, P = 0.028), physical activity duration (PAD) (0.35 vs. 0.48, P = 0.007) and sleep duration (SDN) (3.15 vs. 4.31, P = 0.004) were significantly lower in the patient group than control group. VEBs frequency was inversely correlated with only SDN (r = −0.374, P = 0.027).ConclusionTotal energy expenditure (TEE) is increased in patients with symptomatic frequent VEBs in comparison with healthy subjects while PAD, average metabolic equivalence (aMETs) and SDN are decreased. VEBs frequency was inversely correlated with SDN.     

Burden of Early-Stage Triple-Negative Breast Cancer in a US Managed Care Plan

ObjectiveTriple-negative breast cancer (TNBC) is a high-grade breast cancer with an aggressive clinical course. We examined the recurrence rate, health care utilization, and cost of early-stage TNBC in the US managed care setting.Study DesignA retrospective study using linked cancer registry, health care claims, and social administration databases.MethodsThis retrospective study used the Impact Intelligence Oncology Management cancer registry, linked to 1999-2009 administrative claims, from a national managed care health plan and also Social Security Administration mortality data. Patients with stage I-III TNBC and non-TNBC were followed from diagnosis to recurrence, disenrollment, or end of observation period. Risk-adjusted recurrence rate, health care utilization, and costs during the follow-up period were compared.ResultsA total of 1967 women (403 with TNBC) were included; 289 (14.7%) had local/distant recurrence during the follow-up period. Patients with TNBC were younger (53.68 vs. 56.16 years, P < .0001) and more likely to experience recurrence compared with non-TNBC (21.6% vs. 12.9%, P < .0001; adjusted hazard ratio = 2.11, P < .0001). In terms of adjusted annual health care utilization and costs, patients with TNBC had significantly higher numbers of hospitalizations (1.20 vs. 0.90, P = .001); hospitalization days (8.80 vs. 4.97, P < .0001); and emergency department (ED) visits (1.45 vs. 0.95, P = .009). They also had significantly higher inpatient costs (all-cause: $9154 vs. $5501; cancer-related: $5632 vs. $2869; P < .0001 for both); and ED costs (all-cause: $303 vs. $182, P = .003; cancer-related: $240 vs. $138, P = .012).ConclusionsThis study demonstrates that, compared with non-TNBC, early-stage TNBC is associated with higher rate of recurrence, resulting in increased health care utilization and costs.     

Comparación entre tres métodos de medida de la multimorbilidad en función del uso de recursos sanitarios en atención primaria

ObjectiveTo compare three methods of measuring multiple morbidity according to the use of health resources (cost of care) in primary healthcare (PHC).DesignRetrospective study using computerized medical records.SettingThirteen PHC teams in Catalonia (Spain).ParticipantsAssigned patients requiring care in 2008.Main measurementsThe socio-demographic variables were co-morbidity and costs. Methods of comparison were: a) Combined Comorbidity Index (CCI): an index itself was developed from the scores of acute and chronic episodes, b) Charlson Index (ChI), and c) Adjusted Clinical Groups case-mix: resource use bands (RUB). The cost model was constructed by differentiating between fixed (operational) and variable costs. Statistical analysis: 3 multiple lineal regression models were developed to assess the explanatory power of each measurement of co-morbidity which were compared from the determination coefficient (R²), p< .05.ResultsThe study included 227,235 patients. The mean unit of cost was €654.2. The CCI explained an R² = 50.4%, the ChI an R² = 29.2% and BUR an R² = 39.7% of the variability of the cost. The behaviour of the ICC is acceptable, albeit with low scores (1 to 3 points), showing inconclusive results.ConclusionsThe CCI may be a simple method of predicting PHC costs in routine clinical practice. If confirmed, these results will allow improvements in the comparison of the case-mix.     

Caractéristiques des centres de santé et conseils prénatals de préparation à la naissance

AimCounseling relating to birth preparedness is an essential component of the WHO Focused Antenatal Care model. During the antenatal visits, women should receive the information and education they need to make choices to reduce maternal and neonatal risks. The objective of this study conducted among women attending antenatal visits in rural Burkina Faso was to search for a link between the characteristics of the center delivering the health care and the probability of being exposed to information and advice relating to birth preparedness.MethodsA multilevel study was performed using survey data from women (n = 464) attending health centres (n = 30) in two rural districts in Burkina Faso (Dori and Koupela). The women were interviewed using the modified questionnaire of the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO).ResultsWomen reported receiving advice about institutional delivery (72%), signs of danger (55%), cost of institutional delivery (38%) and advice on transportation in the event of emergency (12%). One independent factor was found to be associated with reception of birth preparedness advice: number of antenatal visits attended. Compared with women from Dori, women from Koupela were more likely to have received information on signs of danger (OR = 3.72; 95%CI: 1.26–7.89), institutional delivery (OR = 4.37; 95%CI: 1.70–10.14), and cost of care (OR = 3.01; 95%CI: 1.21–7.46). The reduced volume of consultations per day and the availability of printed materials significantly remain associated with information on the danger signs and with the institutional delivery advices. Comparison by center activity level showed that women attending health centers delivering less than 10 antenatal visits per day were more likely to receive information on signs of danger (OR = 2.63; 95%CI: 1.12–6.24) and to be advised about institution delivery (OR = 6.30; 95%CI: 2.47–13.90) compared to health centers delivering more than 20 antenatal visits per day. Women attending health centres equipped with printed materials (posters, illustrated documents) were more likely to receive information on signs of danger (OR = 4.25; 95%CI: 1.81–12.54) and be advised about institutional delivery (OR = 6.85; 95%CI: 3.17–14.77).ConclusionEfforts should be made to reach women with birth preparedness messages. Rural health centres in Burkna Faso need help to upgrade their organizational services and provide patients with printed materials so they can improve antenatal care delivery.     

Evaluation of pneumococcal urinary antigen testing for respiratory tract infection investigations

ObjectiveThe pneumococcal urinary antigen test enables rapid bacteriological diagnosis in respiratory tract infections. The objective was to identify factors associated with a positive pneumococcal urinary antigen test result.Patients and methodsThis seven-year retrospective monocentric study was performed on consecutive patients presenting with respiratory tract infections reported as pneumococcal-positive. Epidemiological, biological, and radiological factors were analyzed, and severity scores were calculated.ResultsA total of 223 patients were included. Significant associations were observed between positive test results and age over 65 years (P = 0.01), positive test results and immunosuppression factors (blood disease [25% Ag+ group vs. 4% Ag− group, P = 0.001], immunosuppressive therapy [10% Ag+ group vs. 0% Ag− group, P = 0.02]). Clinically, fever (64% Ag+ group vs. 42% Ag− group, P = 0.01) and cough (46% Ag+ group vs. 19% Ag− group, P < 0.01) were associated with a positive result, as were radiological alveolar opacities (67% Ag+ group vs. 44% Ag− group, P = 0.01). High PSI score was associated with the Ag+ group (79% vs. 56% Ag− group, P = 0.001).ConclusionAge, immunosuppressive factors, typical pneumococcal symptoms, and PSI scores were associated with a positive pneumococcal urinary antigen result.     

Las combinaciones fijas en hipertensión: análisis de impacto presupuestario para el Sistema Nacional de Salud Español de la comercialización de la combinación fija de olmesartan/amlodipino

ObjectiveTo carry out a budget impact analysis (BIA) of olmesartan/amlodipine (20/5, 40/5 and 40/10 mg) marketed as a fixed combination (FC) in its approved indication for the National Health System (NHS).DesigWe developed a decision tree model in order to estimate usual hypertension treatment algorithm in Spanish clinical practice.SettingsThe BIA has been developed from the perspective of the NHS for a period of 3 years (years 2010-2012).ParticipantsSpanish hypertensive population ≥ 35 years old.InterventionsIntroduction into the market of a fixed combination (FC) olmesartan/amlodipine in Spain.Primary measuresExpected costs to be assumed by the Spanish NHS (RRP-VAT) for hypertensive population able to be treated with the FC versus currently assumed costs by the NHS with free combination olmesartan and amlodipine.ResultsEstimated pharmaceutical costs in hypertensive population treated with olmesartan and amlodipine (2 pills) would be €25.2 M (1^st year), €26.4 M (2011), €27.6 M (2012), with a total 3-year period of €79.2 M. According to patient tree model, the population able to be treated with FC would be 71,283 patients (2010), with a growth rate of 4.8% in the successive years, which supposes an annual cost of €21.2 M (2010), €21.8 M (2011) and €22.4 M (2012), with a total 3-year period of €65.4 M. The BIA shows savings of €13.8 M in a total 3-year period.ConclusionThe BIA of FC olmesartan/amlodipine could generate net savings of €13.8 M for the NHS in the period ranging from years 2010 to 2012.     

Overweight and obesity in Eastern Morocco: Prevalence and associated risk factors among high school students

BackgroundOverweight and obesity in children and adolescents have become a major public health problem affecting most countries worldwide. The purpose of the study was to assess the prevalence and risk factors of overweight and obesity among public high school students in Eastern Morocco.MethodsA cross-sectional survey was conducted between February and May 2014 among a sample of 2271 students (1086 girls and 1185 boys). References from the International Obesity Task Force (IOTF) were used to determine the prevalence of overweight and obesity.ResultsThe prevalence of overweight and obesity reached 12.2% (14.2% in girls vs 10.4% in boys, P < 0.01) and 3.0% (3.1% in girls vs 2.8% in boys), respectively. Risk factors associated with overweight and obesity were urban residence (OR = 1.76; [1.18–2.63]; P < 0.01), father's income ≥ 5000 MAD (OR = 1.32; [1.02–1.70]; P < 0.05), father's overweight (including obesity) (OR = 1.87; [1.38–2.54]; P < 0.001) and female sex (OR = 1.31; [1.02–1.68]; P < 0.05).ConclusionThe prevalence of overweight/obesity has reached an alarming rate among high school students in the Eastern region of Morocco. The findings of the present study suggest an urgent need to set up a strategy to prevent and combat this epidemic.