Risk factors for tuberculosis treatment failure,default, or relapse and outcomes of retreatment in Morocco

Background  

Patients with tuberculosis require retreatment if they fail or default from initial treatment or if they relapse following initial treatment success. Outcomes among patients receiving a standard World Health Organization Category II retreatment regimen are suboptimal, resulting in increased risk of morbidity, drug resistance, and transmission.. In this study, we evaluated the risk factors for initial treatment failure, default, or early relapse leading to the need for tuberculosis retreatment in Morocco. We also assessed retreatment outcomes and drug susceptibility testing use for retreatment patients in urban centers in Morocco, where tuberculosis incidence is stubbornly high.     

Time to unsuccessful tuberculosis treatment outcome,Cambodia, China,and Viet Nam

Objective:

To determine the frequency and characteristics of patients with unsuccessful tuberculosis (TB) treatment.

Methods:

Random selection of TB case registers among all treatment units in Cambodia, two provinces in China, and Viet Nam. The data of two calendar years were analyzed to assess unsuccessful outcomes and their time of occurrence.

Results:

Among the 33 309 TB patients, treatment was unsuccessful in respectively 10.1%, 3.0% and 9.1% of patients in Cambodia, China and Viet Nam. The risk of death was highest in Cambodia, higher among males than females, increased with age, and was more common among retreatment cases than new cases, and among patients with a high than a low sputum smear microscopy grade. Half of all deaths occurred in the first 2 months in Cambodia and within 11 weeks in China and Viet Nam. Median time to default was 3 months in Cambodia and Viet Nam, and about 2 months in China.

Conclusions:

Treatment was highly successful in the three study countries, with a low proportion of death and default. As the majority of defaulting occurs at the beginning of treatment, all countries should critically review their current policy of treatment support in this period.     

Comparative Analysis of RNTCP Indicators in a Rural and an Urban Tuberculosis Unit of Burdwan District in West Bengal

Background:

Data pertaining to managerial indicators of RNTCP are rare. The present study was done to analyze the RNTCP indicators in one rural and one urban tuberculosis unit in Burdwan, West Bengal, and find out any influencing factor.

Materials and Methods:

A comparative record analysis for the year 2007 was undertaken

Results:

The study revealed significantly more urban adolescents (P<0.001) were treated. In both areas, the proportion of NSN cases and smear positive retreatment cases among total smear positives were less than expected, while more NSP cases were registered. Significantly lesser retreatment cases (13.33%) were registered in the rural area. Smear negative and EP cases of all the patients in Cat I were significantly less in the rural area. Outcomes like cured, treatment completed, default, and death were similar approaching the RNTCP norm. But sputum conversion (78.02%) and failure rate (4.93%) were worse than the RNTCP norm in the urban area and varied significantly between two areas. The outcomes like cured, treatment completed, and default differed significantly with age in the areas. The outcome of TAD cases was different, but the outcomes of NSN, EP, and other retreatment cases were similar in two areas. Age at treatment onset was found to be the only factor associated with default.

Conclusion:

Managerial indicators may reveal something different despite common indicators showing acceptable results.     

Structuring healthcare advance directives: Evidence from Chinese end-of-life cancer patients' treatment preferences

Background

Patients' treatment decisions may be influenced by the ways in which treatment options are presented. There is little evidence on how patients with advanced cancer choose preferences for advance directives (ADs) in China. Informed by behavioural economics, we assess whether end-of-life (EOL) cancer patients held deep-seated preferences for their health care and whether default options and order effects influenced their decision-making.

Methods

We collected data on 179 advanced cancer patients who were randomly assigned to complete one of the four types of ADs: comfort-oriented care (CC) AD (comfort default AD); a life extension (LE)-oriented care option (LE default AD); CC (standard CC AD) and LE-oriented (standard LE AD). Analysis of variance test was used.

Results

In terms of the general goal of care, 32.6% of patients in the comfort default AD group retained the comfort-oriented choice, twice as many as in the standard CC group without default options. Order effect was significant in only two individual-specific palliative care choices. Most patients (65.9%) appointed their children to make EOL care decisions, but patients choosing the CC goal were twice as likely to ask their family members to adhere to their choices than patients who chose the LE goal.

Conclusion

Patients with advanced cancer did not hold deep-seated preferences for EOL care. Default options shaped decisions between CC and LE-oriented care. Order effect only shaped decisions in some specific treatment targets. The structure of ADs matters and influence different treatment outcomes, including the role of palliative care.

Patient or Public Contribution

Between August and November 2018, from 640 cancer hospital medical records fitting the selection criteria at a 3A level hospital in Shandong Province, we randomly selected 188 terminal EOL advanced cancer patients using a random generator programme to ensure all eligible patients had an equal chance of selection. Each respondent completes one of the four AD surveys. While respondents might require support in making their healthcare choices, they were informed about the purpose of our research study, and that their survey choices would not affect their actual treatment plan. Patients who did not agree to participate were not surveyed.     

Treatment outcomes of new adult tuberculosis patients in relation to HIV status in Zimbabwe

Setting:

All public health facilities in Chitungwiza District, Zimbabwe.

Objective:

To determine, in new tuberculosis (TB) patients registered in 2009, 1) the proportion of persons human immunodeficiency virus (HIV) tested, stratified by age, sex and type of TB, and 2) treatment outcomes in relation to type of TB and HIV status.

Design:

Retrospective cohort study.

Results:

Of 1800 TB patients, 1100 (61%) were tested, of whom 877 (80%) were HIV-positive and 75 (9%) were documented as receiving antiretroviral treatment (ART). HIV testing and HIV positivity were similar between patients with different types of TB. Overall, the treatment success rate was 70%, and 17% had transferred out. Being HIV-positive on ART was associated with better treatment success and lower transfer out; age ≥55 years was associated with poor treatment success and higher death rates. Defaulting was more common in those who did not undergo smear testing or in extra-pulmonary TB patients, while deaths were higher in males.

Conclusion:

In a Zimbabwe district, less than two thirds of TB patients were tested. Better treatment success was observed in patients documented as HIV-positive and on ART. Important lessons for improved TB control include increasing HIV testing uptake for better access to ART, more comprehensive recording practices on ART and better reporting on true outcomes of transfer-out patients.     

Assessing the impact of heart failure specialist services on patient populations

Background

The assessment of the impact of healthcare interventions may help commissioners of healthcare services to make optimal decisions. This can be particularly the case if the impact assessment relates to specific patient populations and uses timely local data. We examined the potential impact on readmissions and mortality of specialist heart failure services capable of delivering treatments such as b-blockers and Nurse-Led Educational Intervention (N-LEI).

Methods

Statistical modelling of prevented or postponed events among previously hospitalised patients, using estimates of: treatment uptake and contraindications (based on local audit data); treatment effectiveness and intolerance (based on literature); and annual number of hospitalization per patient and annual risk of death (based on routine data).

Results

Optimal treatment uptake among eligible but untreated patients would over one year prevent or postpone 11% of all expected readmissions and 18% of all expected deaths for spironolactone, 13% of all expected readmisisons and 22% of all expected deaths for b-blockers (carvedilol) and 20% of all expected readmissions and an uncertain number of deaths for N-LEI. Optimal combined treatment uptake for all three interventions during one year among all eligible but untreated patients would prevent or postpone 37% of all expected readmissions and a minimum of 36% of all expected deaths.

Conclusion

In a population of previously hospitalised patients with low previous uptake of b-blockers and no uptake of N-LEI, optimal combined uptake of interventions through specialist heart failure services can potentially help prevent or postpone approximately four times as many readmissions and a minimum of twice as many deaths compared with simply optimising uptake of spironolactone (not necessarily requiring specialist services). Examination of the impact of different heart failure interventions can inform rational planning of relevant healthcare services.     

Noncompliance to DOTS: How it can be Decreased

Background:

Tuberculosis is a communicable disease requiring prolonged treatment.The therapeutic regimens as recommended by WHO have been shown to be highly effective for both preventing and treating tuberculosis but poor adherence to medication is a major barrier to its global control.

Aim:

The aim was to elicit reasons of treatment default from a cohort of tuberculosis patients treated under Directly Observed Treatment Short course chemotherapy.

Settings and design:

Thiscross-sectional study was conducted in Agra city using the multistage simple random sampling.

Materials and Methods:

A total of 900 patients attending DOTS centres of the selected designated microscopy centers (DMCs) were included in the study from January 2007 onward. The information was obtained from treatment cards of patients and those who defaulted were further interviewed in community.

Statistical analysis:

Chi-square test was applied to observe the significance of association using the Epi Info software (version 6).

Results:

More default was observed among the age group of >45 years (22.8%), male (18.7%), business men (30.6%), and retired and unemployed patients. Other factors associated with higher default were pulmonary disease (18.2%), retreatment cases (30.6%) and category II patients (26.4%). Important reasons of default were side effects following medication (43.2%), improvement in symptoms (14.4%), and lack of time (13.5%). No relief in symptoms and lack of awareness were other important reasons.

Conclusions:

Noncompliance was found to be mainly due to side effects of medicines, lack of time, and unawareness. So educating the patient about various aspects of tuberculosis and some measures to decrease side effects are of utmost importance.     

Age- and gender-specific risk of death after first hospitalization for heart failure

Background  

Hospitalization for heart failure (HF) is associated with high-in-hospital and short- and long-term post discharge mortality. Age and gender are important predictors of mortality in hospitalized HF patients. However, studies assessing short- and long-term risk of death stratified by age and gender are scarce.     

Equity in the use of antithrombotic drugs,beta-blockers and statins among Finnish coronary patients

Background  

Earlier studies have mainly reported the use of antithrombotic drugs, beta-blockers and statins among hospital patient populations or MI patients. This study aimed to describe the use of these drugs among middle-aged Finnish coronary patients and to identify patient groups in risk of being prescribed inadequate medication for secondary prevention of coronary heart disease.     

Improving the public health utility of global cardiovascular mortality data: the rise of ischemic heart disease

Background  

High-quality, cause-specific mortality data are critical for effective health policy. Yet vague cause of death codes, such as heart failure, are highly prevalent in global mortality data. We propose an empirical method correcting mortality data for the use of heart failure as an underlying cause of death.     

Deaths from heart failure: using coarsened exact matching to correct cause-of-death statistics

Background  

Incomplete information on death certificates makes recorded cause-of-death data less useful for public health monitoring and planning. Certifying physicians sometimes list only the mode of death without indicating the underlying disease or diseases that led to the death. Inconsistent cause-of-death assignment among cardiovascular causes of death is of particular concern. This can prevent valid epidemiologic comparisons across countries and over time.     

Malnutrition syndrome, but not body mass index, is associated to worse prognosis in heart failure patients

Background & aims

Many studies have suggested that obese patients with chronic heart failure have a better prognosis than leaner patients. The main purpose of this study was to assess the prognostic value of body mass index in patients with chronic heart failure, independently of other poor prognosis parameters.

Methods

This retrospective study included 405 heart failure patients. Anthropometric, body composition, clinical, biochemical, and echocardiographic data were collected from all patients. Patients were classified as: underweight (<20 kg/m²), normal (20–24.9 kg/m²), overweight (25–29.9 kg/m²), and obese (≥30 kg/m²). The endpoints were all-cause and cardiovascular mortality.

Results

Cox regression analysis on all-cause mortality showed that normal weight patients were at significantly lower risk of death [RR = 0.231 (CI_95% 0.085–0.627)] as compared with obese patients, while underweight and overweight categories did not show a significantly different risk compared with the reference category. Age, gender, ejection fraction, systolic heart failure, angiotensin II receptor blockers use, hemoglobin levels, and handgrip strength were independent predictors of all-cause mortality. Cardiovascular deaths showed the same trend.

Conclusion

A lower body mass index does not predict all-cause and cardiovascular mortality among chronic heart failure patients, independently of other nutritional, body composition, and clinical status parameters.     

Hospital costs for treatment of acute heart failure: economic analysis of the REVIVE II study

Background  

Acute heart failure (AHF) is the leading cause of hospital admission among older Americans. The Randomized EValuation of Intravenous Levosimendan Efficacy (REVIVE II) trial compared patients randomly assigned to a single infusion of levosimendan (levo) or placebo (SOC), each in addition to local standard treatments for AHF. We report an economic analysis of REVIVE II from the hospital perspective.     

Identifying and characterizing COPD patients in US managed care. A retrospective,cross-sectional analysis of administrative claims data

Background  

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death among US adults and is projected to be the third by 2020. In anticipation of the increasing burden imposed on healthcare systems and payers by patients with COPD, a means of identifying COPD patients who incur higher healthcare utilization and costs is needed.     

Early recognition of heart failure in patients with diabetes type 2 in primary care. A prospective diagnostic efficiency study. (UHFO-DM2)

Background  

We hypothesize that the prevalence of unknown heart failure in diabetic patients aged 60 years and over is relatively high (15% or more) and that a cost-effective strategy can be developed to detect heart failure in these patients. The strategy is expected to include some signs and symptoms (such as dyspnoea, orthopnoea, pulmonary crepitations and laterally displaced apical beat), natriuretic peptide measurements (Amino-terminal B-type natriuretic peptide) and possibly electrocardiography. In a subset of patients straightforward echocardiography may show to be cost-effective. With information from our study the detection of previously unknown heart failure in diabetic patients could be improved and enable the physician to initiate beneficial morbidity and mortality reducing heart failure treatment more timely.     

Factors Affecting Receipt of Expensive Cancer Treatments and Mortality: Evidence from Stem Cell Transplantation for Leukemia and Lymphoma

Objective

To identify factors that affect whether patients diagnosed with either leukemia or lymphoma receive a stem cell transplant and secondly if receipt of stem cell transplantation is linked to improved survival.

Data

California inpatient discharge records (2002–2003) for patients with either leukemia or lymphoma linked with vital statistics death records (2002–2005).

Study Design

Bivariate Probit treatment effects model that accounts for both the type of treatment received and survival while controlling for nonrandom selection due to unobservable factors.

Principal Findings

Having private insurance coverage and residence in a well-educated county increased the chances a patient with either disease received HSCT. Increasing age and travel distance to the nearest transplant hospital had the opposite effect. Receipt of HSCT had a significant impact on mortality. We found the probability of death was 4.3 percentage points higher for leukemia patients who did NOT have HSCT. Receipt of HSCT reduced the chances of dying by almost 50 percent. The likelihood of death among lymphoma patients who underwent HSCT was almost 5 percentage points lower, a 70 percent reduction in the probability of death.

Conclusions

The findings raise concern about access to expensive, but highly effective cancer treatments for patients with certain hematologic malignancies.     

Improvement of primary care for patients with chronic heart failure: a pilot study

Background  

Many patients with chronic heart failure (CHF) receive treatment in primary care, but data have shown that the quality of care for these patients needs to be improved. We aimed to evaluate the impact and feasibility of a programme for improving primary care for patients with CHF.     

Drug treatment program patients' hepatitis C virus (HCV) education needs and their use of available HCV education services

Background  

In spite of the disproportionate prevalence of hepatitis C virus (HCV) infection among drug users, many remain uninformed or misinformed about the virus. Drug treatment programs are important sites of opportunity for providing HCV education to their patients, and many programs do, in fact, offer this education in a variety of formats. Little is known, however, about the level of HCV knowledge among drug treatment program patients, and the extent to which they utilize their programs' HCV education services.     

Risk adjustment performance of Charlson and Elixhauser comorbidities in ICD-9 and ICD-10 administrative databases

Background  

The performance of the Charlson and Elixhauser comorbidity measures in predicting patient outcomes have been well validated with ICD-9 data but not with ICD-10 data, especially in disease specific patient cohorts. The objective of this study was to assess the performance of these two comorbidity measures in the prediction of in-hospital and 1 year mortality among patients with congestive heart failure (CHF), diabetes, chronic renal failure (CRF), stroke and patients undergoing coronary artery bypass grafting (CABG).     

To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints,claims and incident reports?

Background  

Patient record review is believed to be the most useful method for estimating the rate of adverse events among hospitalised patients. However, the method has some practical and financial disadvantages. Some of these disadvantages might be overcome by using existing reporting systems in which patient safety issues are already reported, such as incidents reported by healthcare professionals and complaints and medico-legal claims filled by patients or their relatives. The aim of the study is to examine to what extent the hospital reporting systems cover the adverse events identified by patient record review.