中文版免疫抑制药物依从性Basel评估量表在肝移植受者中应用的信效度研究

目的将免疫抑制药物依从性Basel评估量表引入我国,并研究中文版免疫抑制药物依从性Basel评估量表在肝移植受者中应用的信效度。方法选取北京市某三级甲等医院移植随访门诊就诊的肝移植受者为研究对象。在征得量表研发方同意后,对量表进行跨文化调试。首先对量表进行翻译和回译,再根据专家委员会的意见对量表进行修改。并在正式调查前,对修改后的量表进行预调查。通过内在一致性信度以及2周重测信度对量表进行信度分析;通过探索性因子分析对其进行效度研究。结果量表的Cronbach'sα系数为0.697,重测信度为0.964;探索性因子分析提取了1个公因子,共解释54.73%的总方差变异。结论免疫抑制药物依从性Basel评估量表条目设置简明,在肝移植受者中应用信效度均较好。     

Increased all-cause mortality with psychotropic medication in Parkinson's disease and controls: A national register-based study

AimUse of medication and polypharmacy is common as the population ages and its disease burden increases. We evaluated the association of antidepressants, benzodiazepines, antipsychotics and combinations of psychotropic drugs with all-cause mortality in patients with Parkinson's disease (PD) and a matched group without PD.MethodWe identified 5861 PD patients and 31,395 control subjects matched by age, gender and marital status, and obtained register data on medication use and vital status between 1997 and 2007.ResultsAll-cause mortality was significantly higher with the use of most groups of psychotropic medication in PD patients and controls. Hazard ratios were as follows for the medication types: selective serotonin reuptake inhibitors or serotonin-noradrenalin reuptake inhibitors, PD HR = 1.19, 95% CI = 1.04−1.36; Control HR = 1.77, 95% CI = 1.64−1.91; benzodiazepines, PD HR = 1.17, 95% CI = 0.99−1.38; Control HR = 1.39, 95% CI = 1.29−1.51; benzodiazepine-like drugs, PD HR = 1.33, 95% CI = 1.11−1.59; Control HR = 1.27, 95% CI = 1.18−1.37; first-generation antipsychotics, PD HR = 1.89, 95% CI = 1.42−2.53; Control HR = 2.12, 95% CI = 1.82−2.47; second-generation antipsychotics, PD HR = 1.46, 95% CI = 1.20−1.76; Control HR = 2.00, 95% CI 1.66−2.43; and combinations of these drugs compared with non-medicated PD patients and controls. Discontinuation of medication was associated with decreased mortality in both groups.ConclusionsThe use of psychotropic medication in the elderly is associated with increased mortality, independent of concurrent neurodegeneration due to PD. Confounding by indication may partly explain the higher hazard ratios in medicated controls compared with medicated PD patients. Our findings indicate that neurodegeneration should not be a separate contraindication per se for the use of psychotropic drug in patients with PD, but its use should be based on careful clinical evaluation and follow-up.     

Individual and county level predictors of asthma related emergency department visits among children on Medicaid: A multilevel approach

Objective: Disparities in asthma outcomes are well documented in the United States. Interventions to promote equity in asthma outcomes could target factors at the individual and community levels. The objective of this analysis was to understand the effect of individual (race, gender, age, and preventive inhaler use) and county-level factors (demographic, socioeconomic, health care, air-quality) on asthma emergency department (ED) visits among Medicaid-enrolled children. This was a retrospective cohort study of Medicaid-enrolled children with asthma in 29 states in 2009. Multilevel regression models of asthma ED visits were constructed utilizing individual-level variables (race, gender, age, and preventive inhaler use) from the Medicaid enrollment file and county-level variables reflecting population and health system characteristics from the Area Resource File (ARF). County-level measures of air quality were obtained from Environmental Protection Agency (EPA) data. Results: The primary modifiable risk factor at the individual level was found to be the ratio of long-term controller medications to total asthma medications. County-level factors accounted for roughly 6% of the variance in the asthma ED visit risk. Increasing county-level racial segregation (OR=1.04, 95% CI=1.01-1.08) was associated with increasing risk of asthma ED visits. Greater supply of pulmonary physicians at the county level (OR=0.81, 95% CI=0.68-0.97) was associated with a reduction in risk of asthma ED visits. Conclusions: At the patient care level, proper use of controller medications is the factor most amenable to intervention. There is also a societal imperative to address negative social determinants, such as residential segregation.     

Cost-effectiveness and budget impact of long-acting risperidone in Portugal: a modeling exercise

ABSTRACT

Background: Previous analyses have shown that long-acting risperidone (LAR) is cost-effective in several Western countries. In Portugal, however, the costs of key services are lower. Therefore, available evidence in other countries may have limited relevance.

Objective: To estimate costs and effects of LAR versus a conventional depot and a short-acting oral atypical antipsyhcotic over a 5-year period in Portugal.

Methods: An existing discrete event model was adapted to reflect the Portuguese healthcare setting, based on expert opinion, clinical, epidemiological, and cost data. The model compares three scenarios. In scenario 1, patients start with a conventional depot; in scenario 2, with LAR; and in scenario 3, with oral risperidone. The model simulates individual patient histories while taking into account patient characteristics such as risk to society and side-effects. Subsequently, the model simulates patient histories in terms of outpatient appointments, psychotic episodes, treatment, compliance, symptom scores, lack of ability to take care presenting an actual risk, and treatment setting. Outcomes were number of psychotic episodes, cumulative symptom score and direct medical costs. Univariate sensitivity analyses were carried out.

Results: Compared to a conventional depot and an oral atypical, LAR was estimated to save approximately €3603 and €4682 per patient (respectively) and avoid 0.44 and 0.59 relapses per patient in 5 years. Sensitivity analyses showed that the outcome of dominance was only sensitive to estimates about unit costs of hospital/institutionalization, potential risk, and to the reduction in symptoms by use of atypicals.

Conclusion: Based on this modeling exercise, it could be expected that LAR may be a cost-effective treatment with limited budget impact in Portugal. However, further studies are required to test the generalizability of the results of the present modeling study to the larger population of Portugal.