To document experience with directly observed chemoprophylaxis (DOPT) compared to self-administered isoniazid (INH) among aboriginal persons in British Columbia.
DOPT was compared to self-administered delivery (SAD) over a 3-year period. All aboriginal persons who received INH chemoprophylaxis in British Columbia between 1992 and 1994 were evaluated. Therapy completion rates and adverse outcomes associated with SAD were compared with DOPT. Treatment allocation was by patient choice.
Of 608 people who received INH prophylaxis, 443 received SAD (mean age 31.6 years) and 165 received DOPT (mean age 23.9 years). Two hundred and seventy (60.9%) SAD compared to 124 (75.2%) in the DOPT group completed 6 months of INH (P = 0.0011). The 12-month completion rates were 162/443 (36.6%) for the SAD group and 84/165 (50.9%) for the DOPT group (P = 0.0014). Adverse reactions requiring discontinuation of medication occurred in 13.5% of the patients on SAD and 9.7% of those receiving DOPT (P = 0.202). The most common reason cited for failure to complete therapy was non-cooperation in both groups. There were three deaths in the SAD group, one of which was due to suicide by self-ingestion of INH.
These data demonstrate that in aboriginal people compliance with preventive therapy can be improved by DOPT. Non random allocation to treatment groups might have influenced our findings, and further prospective randomized trials and cost-effectiveness analyses are required.
To determine the current management of acute asthma in the emergency department and to evaluate outcome we reviewed the charts of 99 patients aged 15 to 55 years who presented to the emergency department of a tertiary referral, university-affiliated hospital and were subsequently discharged with a diagnosis of acute asthma. Outcome was evaluated prospectively, with a structured questionnaire, by telephone. During the visit pulsus paradoxus was documented in four patients. Spirometry was done in 63 patients; postbronchodilator values ranged from 0.9 to 4.1 L. A total of 92 patients received inhaled bronchodilator therapy, most by wet nebulization. Sixteen patients received anticholinergic agents and three received theophylline. Ingested corticosteroids were given to 27 patients. Of the 71 patients contacted, a mean of 12 days after the visit, 26 (37%) had sought further medical attention, 19 at the emergency department; 9 had required admission. Forty-six patients reported that their condition had improved, but over 60% continued to have cough, sputum production, nocturnal waking and early-morning chest tightness. The results indicate that asthma continues to be undertreated in the emergency department and highlight the importance of routine spirometry in all patients and the need for systemic corticosteroid therapy.
Cites: Chest. 1987 Sep;92(3):460-63622023
Cites: JAMA. 1983 Apr 15;249(15):2043-66403719
Cites: Chest. 1988 Oct;94(4):718-222971515
Cites: Chest. 1988 Oct;94(4):723-63168567
Cites: Am Rev Respir Dis. 1988 Sep;138(3):535-93202409
Cites: CMAJ. 1989 Jan 15;140(2):153-62910398
Cites: Chest. 1989 Apr;95(4):888-942647424
Cites: Respir Med. 1989 May;83(3):219-262595040
Cites: Am J Med. 1983 Aug;75(2):259-626881177
Cites: N Engl J Med. 1984 Mar 1;310(9):577-806694709
Cites: Am Rev Respir Dis. 1985 Aug;132(2):283-62862819
Cites: N Engl J Med. 1986 Jan 16;314(3):150-23510384
Estimations of prevalence of latent tuberculous infection (LTBI) are confounded by factors known to influence the results of the tuberculin skin test (TST) such as age, contact history and bacille Calmette-Guerin (BCG) vaccination. Appropriate interpretation of TST results is necessary to ensure LTBI treatment for those at greatest risk.
To document the prevalence of LTBI in Aboriginal people living on a reserve in British Columbia (BC) and to determine the influence of BCG.
A population-based, retrospective descriptive analysis of all epidemiological data collected for the on-reserve Aboriginal programme in BC (1951-1996).
Of 17615 persons who received a TST during the study period, 42% had received BCG. During the study period, an average of 2517 TSTs were completed per year (SD = 1228) among persons with an average age of 26 years (SD = 16). Among all subjects, the average prevalence of LTBI was 25% (95 %CI 24-25). The presence of BCG (OR = 3.1, 95%CI 2.8-3.4) and multiple BCGs (OR = 10.2, 95%CI 7.7-13.6) were both associated with a positive TST. A positive TST was also associated with a shorter duration in years between the most recent BCG and the TST.
The average prevalence of LTBI in a sequential sample of Aboriginal people living on a reserve in BC was estimated at 25%. BCG, especially in multiple doses, increased the likelihood of a positive TST.
University of British Columbia James Hogg Research Laboratories, Providence Heart and Lung Institute, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada. email@example.com
To measure the prevalence of chronic obstructive pulmonary disease (COPD) and determine the effect of age and sex on the variation in prevalence across major cities within the same country and health care system.
We used the Burden of Obstructive Lung Disease (BOLD) methodology to estimate the prevalence of COPD in adults aged = 40 years in different Canadian cities. The study used interviewer-administered questionnaires on respiratory, smoking and occupational history, medication use and comorbidities. Post-bronchodilator spirometry was used to classify subjects. We determined the prevalence and severity of COPD with and without adjustments for age and sex distribution across different cities.
The study population was 3042. Overall, 16.7% (95%CI 14.8-18.7) of study subjects met the criteria for Global Initiative for Chronic Obstructive Lung Disease (GOLD) severity Stage 1 or higher. The prevalence according to the criteria for the lower limits of normal of the ratio forced expiratory volume in 1 second/forced vital capacity was 11.6% (95%CI 9.9-13.3). COPD prevalence varied by severity across site (P = 0.0025). After age-sex adjustment, the variation disappeared (P> 0.16).
Age and sex differences account for most of the heterogeneity in COPD estimates across large cities within the same country. Adjustments for age and sex are essential in comparing COPD rates across the country.
To determine the female:male ratio and compare the severity of asthma between female and male patients presenting with acute asthma to the authors' emergency department (ED).
Patients aged 15-50 years presenting with acute asthma.
Emergency department of a university-affiliated hospital.
Retrospective analysis of asthma surveillance data and medical records of all asthma-related visits to ED over 6 months (January 1992-June 1992).
One hundred and thirty-seven patients aged 15-50 years made 196 consecutive visits to the authors' ED over 6 months. The ratio of female:male patients was 1.9 and the ratio of the number of visits made by female vs. male patients was 2.6. Initial peak expiratory flow rate (PEFR) and forced expiratory volume in 1 s (FEV1) were recorded in 94% and 49% of the visits, respectively. There was no statistically significant difference between the male and female patients in heart rate, respiratory rate or percentage of patients admitted to hospital. The mean (SD) initial FEV1 as a percentage of predicted was significantly higher in females compared to males (49% +/- 20% vs. 33% +/- 15%; P
The role of isoniazid prophylaxis in low-risk patients with positive Mantoux skin tests has recently been questioned. In general, recent research has focused on the risk/benefit ratio. We, therefore, decided to extend these data and apply a cost-effectiveness analysis of the routine use of isoniazid prophylaxis from a societal perspective. Costs per case prevented were calculated for a 20-, 50-, and 70-yr-old low-risk patient who had a positive Mantoux test with base, high, and low costings. Rates were also calculated based on the use of direct costs alone and direct and indirect costs combined. Costs varied from Canadian $8,586.00 in a 20-yr-old patient to $40,102.00 in a 70-yr-old patient per case prevented based on direct costs with costs ranging from $3,236.00 to $11,320.00 with both direct and indirect costs included. These costs could be considered reasonable from a societal perspective but do not address the issue of any increased life expectancy resulting from chemoprophylaxis.
Recent approval of interferon-gamma release assays that are more specific for Mycobacterium tuberculosis has given new options for the diagnosis of latent tuberculosis infection (LTBI).
To assess the cost-effectiveness of Quanti-FERON-TB Gold (QFT-G) vs. the tuberculin skin test (TST) in diagnosing LTBI in contacts of active TB cases using a decision analytic Markov model.
Three screening strategies--TST alone, QFT-G alone and sequential screening of TST then QFT-G--were evaluated. The model was further stratified according to ethnicity and bacille Calmette-Guérin (BCG) vaccination status. Data sources included published studies and empirical data. Results were reported in terms of the incremental net monetary benefit (INMB) of each strategy compared with the baseline strategy of TST-based screening in all contacts.
The most economically attractive strategy was to administer QFT-G in BCG-vaccinated contacts, and to reserve TST for all others (INMB CA$3.70/contact). The least cost-effective strategy was QFT-G for all contacts, which resulted in an INMB of CA$-11.50 per contact. Assuming a higher prevalence of recent infection, faster conversion of QFT-G, a higher rate of TB reactivation, reduction in utility or greater adherence to preventive treatment resulted in QFT-G becoming cost-effective in more subgroups.
Selected use of QFT-G appears to be cost-effective if used in a targeted fashion.
Obstructive sleep apnea-hypopnea (OSAH) is a common disorder characterized by recurrent collapse of the upper airway during sleep. Patients experience a reduced quality of life and an increased risk of motor vehicle crashes (MVCs). Continuous positive airway pressure (CPAP), which is the first-line therapy for OSAH, improves sleepiness, vigilance and quality of life.
To assess the cost-effectiveness of CPAP therapy versus no treatment for OSAH patients who are drivers.
A Markov decision analytical model with a five-year time horizon was used. The study population consisted of male and female patients, between 30 and 59 years of age, who were newly diagnosed with moderate to severe OSAH. The model evaluated the cost-effectiveness of CPAP therapy in reducing rates of MVCs and improving quality of life. Utility values were obtained from previously published studies. Rates of MVCs under the CPAP and no CPAP scenarios were calculated from Insurance Corporation of British Columbia data and a systematic review of published studies. MVCs, equipment and physician costs were obtained from the British Columbia Medical Association, published cost-of-illness studies and the price lists of established vendors of CPAP equipment in British Columbia. Findings were examined from the perspectives of a third-party payer and society.
From the third-party payer perspective, CPAP therapy was more effective but more costly than no CPAP (incremental cost-effectiveness ratio [ICER] of $3,626 per quality-adjusted life year). From the societal perspective, the ICER was similar ($2,979 per quality-adjusted life year). The ICER was most dependent on preference elicitation method used to obtain utility values, varying almost sixfold under alternative assumptions from the base-case analysis.
After considering costs and impact on quality of life, as well as the risk of MVCs in individuals with OSAH, CPAP therapy for OSAH patients is a highly efficient use of health care resources. Provincial governments who do not provide funding for CPAP therapy should reconsider.
Cites: Qual Life Res. 1998 Feb;7(2):95-1009523490
Cites: Chest. 1997 Dec;112(6):1561-69404754
Cites: Am J Respir Crit Care Med. 1999 Apr;159(4 Pt 1):1108-1410194153
Cites: Health Technol Assess. 2004 Dec;8(49):iii-iv, 1-19215544708
Cites: Lancet. 2005 Mar 19-25;365(9464):1046-5315781100
Cites: Arch Intern Med. 2006 May 8;166(9):977-8416682570
Cites: Respir Med. 2000 Jan;94(1):87-9010714485
Cites: Am J Respir Crit Care Med. 2000 Mar;161(3 Pt 1):857-910712333
Cites: Sleep. 2000 May 1;23(3):383-910811382
Cites: Annu Rev Public Health. 2000;21:587-61110884966
Cites: Scand J Work Environ Health. 2000 Jun;26(3):237-4210901116
Cites: Med Decis Making. 2000 Jul-Sep;20(3):332-4210929856
Health Outcomes and PharmacoEconomic (HOPE) Research Centre, Division of Clinical Pharmacology, Sunnybrook Research Institute, Department of Pharmacology, University of Toronto, Ontario, Canada. firstname.lastname@example.org
The cost of exacerbations in chronic obstructive pulmonary disease (COPD) has not been well studied. The aim of this study was to identify and quantify the (average) cost of moderate and severe exacerbations (ME and SE, respectively) from a Canadian perspective.
Resources used during ME and SE were identified in a year long prospective, observational study (Resource Utilization Study In COPD (RUSIC)). The units of analysis were ME and SE. Unit costs (2006$CAN), based on provincial, hospital and published sources, were applied to resources. The overall cost per ME and SE were calculated. The population burden of exacerbations was also calculated.
Among study participants (N=609, aged 68.6+/-9.4 years, 58.3% male) there were 790 exacerbations: 639 (80.9%) MEs and 151 (19.1%) SEs. Of the 790 exacerbations, 618 (78.2%), 245 (31.0%) and 151 (19.1%) included a visit to an outpatient clinic, emergency department (ED) or hospital, respectively. For ME, 85.9% and 13.1% involved visits to GPs and respirologists, respectively. Pharmacologic treatment changes in the outpatient setting involved antibiotics (63.1%) and corticosteroids (34.7%). The overall mean costs for outpatient and ED services for MEs were $126 (N=574) and $515 (N=105), respectively. The average overall cost of a ME was $641. For SEs, the average hospital stay was 10.0 days. The overall mean costs of outpatient, ED and hospitalization services for SE were $114 (N=44), $774 (N=140) and $8669 (N=151), respectively. The average overall cost of a SE was $9557.
The economic burden associated with MEs and especially SEs, in Canada, is considerable and likely has a substantial impact on healthcare costs. The overall burden of exacerbations has been estimated in the range of $646 million to $736 million per annum.
Cryptogenic organizing pneumonia (COP), also known as bronchiolitis obliterans organizing pneumonia (BOOP), is an uncommon lung disease characterized by the presence of granulation tissue within the alveolar ducts and alveoli. Because of the limited published literature on this topic and limited information on outcome we reviewed our own experience over an 8-year period and also critically evaluated the literature. We reviewed all cases of COP diagnosed from 1985 through 1992 at Vancouver General Hospital: 25 patients (14 male, 11 female) aged 20-77 years (mean, 49 yr, SD +/- 17 yr). Nine patients had myeloproliferative disorder, including 6 who had allogenic bone marrow transplants; 2 patients had connective tissue disease; and 14 patients had no underlying disease (idiopathic). Data retrieved retrospectively from clinical records included demographics, risk factors, symptoms, chest radiographs, computerized tomograms, lung function tests, therapy prescribed, and response to therapy. Symptoms included dyspnea and cough (n = 15) (60%), cough only (n = 10) (40%), and fever (n = 15) (60%). Twenty-two patients were diagnosed by open lung biopsy and 3 by transbronchial biopsy. Lung imaging showed bilateral patchy airspace consolidation or nodular opacities as the main finding in 22 patients. Pulmonary function tests showed a combined restrictive and obstructive pattern. All patients received prednisone therapy except 1 patient whose idiopathic findings resolved completely with minimal treatment. Eight patients died, including 4 of the 9 patients with myeloproliferative disorder--2 from a combination of respiratory failure due to COP and graft-versus-host disease. One of 2 patients with connective tissue disease died, and 3 of 14 patients with idiopathic COP died. COP is an uncommon condition but should be considered in patients with bilateral airspace disease, especially those who fail to respond to antibiotics for presumed pneumonia. Although pulmonary function tests and CT scan findings in conjunction with the clinical features usually suggest the diagnosis, definite confirmation usually requires either open lung biopsy or transbronchial biopsy. Histologic confirmation of the diagnosis is particularly warranted as therapy with corticosteroids is usually needed for a number of months. The prognosis is excellent with idiopathic cases but more guarded especially when COP is associated with lymphoproliferative or connective tissue disease.