Cost of Treatment of Febrile Acute Respiratory Infection (FARI) Among Under-Five Children Attending Health Facilities of Ballabgarh,Haryana

Objective

To estimate the expenditure incurred towards treatment of an episode of respiratory infection among under-fives in outpatient and inpatient departments of primary and secondary level health facilities.

Methods

During March 2011 – September 2012, under-five children presenting with febrile acute respiratory infection (FARI) in the outpatient (OPD) and inpatient (IPD) departments of public and private health facilities of Ballabgarh, Haryana were enrolled in the study. Children who were free from co-morbidities and whose contact number or proper address were available, were enrolled and followed up over telephone or by house visits till recovery. Information was collected on expenditure incurred towards treatment of FARI. Work loss of each day was valued as per capita national income per day. Cost of service in public facilities were supplemented by WHO-CHOICE estimates. The cost of respiratory episode in different settings are expressed in median and inter quartile range (IQR).

Results

One hundred fourteen children from OPD and 75 from IPD were enrolled and followed up till recovery. Among eligible children 40% and 20% in OPD and IPD were excluded respectively as they could not provide address or contact number. The median costs of an episode treated in OPD and IPD were INR 447(IQR: INR 294–669) and INR 7506.06 (IQR: INR 3765–10,406) respectively.

Conclusions

Respiratory infections are responsible for substantial economic burden, especially with huge proportion of out-of-pocket expenditure. Total cost of a respiratory episode that required hospitalization was 1.5 times the per capita monthly income of an Indian.

     

Opting out of an integrated healthcare system: dual-system use is associated with poorer glycemic control in veterans with diabetes

AIMS: To test for an association between quality of care and patient choice to obtain care outside an integrated healthcare delivery system. METHODS: We used administrative data to define dual-system use (Veterans Health Administration (VHA) and Medicare) in 1999 for VHA users with diabetes over 65 years old. Quality of diabetes care was determined by the last hemoglobin A1c (HA1c) value in 2000. The distance to nearest VHA facility minus the distance to nearest non-federal hospital was the instrumental variable in a two-part regression model which controlled for observed and unobserved factors. RESULTS: In 1999, 57.4% of subjects received care from both VHA and Medicare providers; their mean proportion of visits to Medicare providers was 0.41 (median 0.38). After controlling for observed and unobserved factors, higher proportions of Medicare visits were significantly associated with higher HA1c values; a 40% increase in the proportion of Medicare visits by those who did not use Medicare was associated with a 0.23% point increase in HA1c value. CONCLUSIONS: Dual-system use was associated with higher HA1c values, suggesting that veterans who chose to receive care outside the integrated VHA may have worse intermediate clinical outcomes than those who received care exclusively within the system.     

New choices for patients needing kidney transplantation across antibody barriers

Antibodies in the blood of a kidney transplant recipient can provide a barrier to transplantation, which is additional to the usual possibility of cellular rejection. The antibodies most frequently encountered are ABO (blood group) and human leucocyte antigen (HLA) (tissue-type) antibodies. About 250 living donor transplants each year in the United Kingdom have been stopped because of an antibody barrier. It is now possible to offer a choice of treatment modalities to these people, including exchange transplantation and antibody-incompatible transplantation. It is likely that both schemes will complement each other and both are available in the United Kingdom.     

Gout and coronary artery disease: Epidemiologic clues

Gout is the leading cause of inflammatory arthritis, typically affecting men and characterized by intermittent, abrupt onset of intense inflammation. The association between gout, atherosclerosis, and vascular disease has been noted in medical literature since the end of the 19th century, yet it has not been well studied. This review critically appraises the few epidemiologic studies that ask if gout is a risk factor for coronary artery disease. An exhaustive literature search using search engines and cross-referencing found four major studies and several smaller studies that have evaluated gout as a risk factor for coronary artery disease. The available studies were too heterogeneous to permit formal meta-analysis. Although there are gaps in evidence pointing to a causative pathway, overall, evidence exists for a relationship between gouty arthritis and coronary artery disease independent of traditional risk factors.     

Time trends of paediatric HIV infection in North India

Paediatric HIV infection continues to pose a serious threat in the developing world. While in the developed world, mother to child transmission has been reduced to less than 3%, in India no regular zidovudine (azidothymidine) intervention programmes operate. Some 20 million babies are born each year and the number of infected babies could be >50,000 per year. The present study was designed to assess the change, if any, in the time trends of HIV infection in children over the last 15 years as observed at the surveillance centre attached to Nehru Hospital, Chandigarh. All patients reporting to the surveillance centre at the PGIME&R, Chandigarh were subjected to a detailed history and screened for HIV by the three tests protocol recommended by the WHO. In babies under 18 months of age, viral load assay or DNA analysis was done to confirm infection. Timetrends were ascertained over a 15-year period to assess the impact of information, education and communication programme launched by National AIDS Control Organisation. Data indicates that the total number of HIV positive cases increased 10-fold over the last 10 years. During 1991, 41 cases were recorded; the number increased to 439 in year 2001, and 574 in 2004 (r=0.98). A similar trend was observed in the paediatric age group. During the initial 5 years ie, 1987 to 1992 only 7 paediatric cases were documented positive while the number increased to 45 in the year 2001 to 64 in the year 2004 with a cumulative figure of 323 children. Linear regression analysis showed a highly significant trend (r=0.94). Out of the 323 cases, 44.6% were symptomatic. Maximum number of babies were observed in the age group of 3-5 years. Thirty-nine patients (12%) had acquired the infection through blood. Thus the information, education and communication programme has had very little impact on the HIV epidemic and it calls for urgent antiretroviral intervention in antenatal mothers to control the emerging paediatric HIV epidemic.     

Ethical decision-making about older adults and moral intensity: an international study of physicians

Through discourse with international groups of physicians, we conducted a cross-cultural analysis of the types of ethical dilemmas physicians face. Qualitative analysis was used to categorise the dilemmas into seven themes, which we compared among the physicians by country of practice. These themes were a-theoretically-driven and grounded heavily within the text. We then subjected the dilemmas to an analysis of moral intensity, which represents an important (albeit novel within healthcare research) theoretical perspective of ethical decision making. These constructs (ie, culture and moral intensity) represent salient determinants of ethical behaviour and our cross-cultural sample afforded us the opportunity to consider both the pragmatic aspects of culture, as they are perceived by physicians, as well as the theory-driven concept of moral intensity. By examining both culture and moral intensity, we hope to better elucidate the complexities of ethical decision-making determinants among physicians in their daily practice. Doing so may potentially have practical implications for ethics training of medical students and foreign physicians.