To evaluate the costs, consequences, effectiveness, and safety of ciprofloxacin vs standard antibiotic care in patients with an initial acute exacerbation of chronic bronchitis (AECB) as well as recurrent AECBs over a 1-year period.
A total of 240 patients, 18 years or older with chronic bronchitis, with a history of frequent exacerbations (three or more in the past year) presenting with a type 1 or 2 AECB (two or more of increased dyspnea, increased sputum volume, or sputum purulence).
The assessment included AECB symptoms, antibiotics prescribed, concomitant medications, adverse events, hospitalizations, emergency department visits, outpatient resources such as diagnostic tests, procedures, and patient and caregiver out-of-pocket expenses. Patients completed the Nottingham Health Profile, St. George's Respiratory Questionnaire, and the Health Utilities Index. The parameters were recorded with each AECB and at regular quarterly intervals for 1 year. These variables were compared between the ciprofloxacin-treated group and the usual-care-treated group.
Patients receiving ciprofloxacin experienced a median of two AECBs per patient compared to a median of three AECBs per patient receiving usual care. The mean annualized total number of AECB-symptom days was 42.9+/-2.8 in the ciprofloxacin arm compared to 45.6+/-3.0 days in the usual-care arm (p=0.50). The overall duration of the average AECB was 15.2+/-0.6 days for the ciprofloxacin arm compared to 16.3+/-0.6 days for the usual-care arm. Treatment with ciprofloxacin tended to accelerate the resolution of all AECBs compared to usual care (relative risk=1.20; 95% confidence interval [CI], 0.91 to 1.58; p=0.19). Treatment assignment did not affect the interexacerbation period but a history of severe bronchitis, prolonged chronic bronchitis, and an increased number of AECBs in the past year were associated with shorter exacerbations-free periods. There was a slight, but not statistically significant, improvement in all quality of life measures with ciprofloxacin over usual care. The only factors predictive of hospitalization were duration of chronic bronchitis (odds ratio=4.6; 95% CI, 1.6, 13.0) and severity of chronic bronchitis (odds ratio=4.3; 95% CI, 0.8, 24.6). The incremental cost difference of $578 Canadian in favor of usual care was not significant (95% CI, -$778, $1,932). The cost for the ciprofloxacin arm over the usual care arm was $18,588 Canadian per quality-adjusted life year gained. When the simple base case analysis was expanded to examine the effect of risk stratification, the presence of moderate or severe bronchitis and at least four AECBs in the previous year changed the economic and clinical analysis to one favorable to ciprofloxacin with the ciprofloxacin-treated group having a better clinical outcome at lower cost ("win-win" scenario).
Treatment with ciprofloxacin tended to accelerate the resolution of all AECBs compared to usual care; however, the difference was not statistically significant. Further, usual care was found to be more reflective of best available care rather than usual first-line agents such as amoxicillin, tetracycline, or trimethoprim-sulfamethoxazole as originally expected. Despite the similar antimicrobial activities and broad-spectrum coverage of both ciprofloxacin and usual care, the trends in clinical outcomes and all quality of life measurements favor ciprofloxacin. In patients suffering from an AECB with a history of moderate to severe chronic bronchitis and at least four AECBs in the previous year, ciprofloxacin treatment offered substantial clinical and economic benefits. In these patients, ciprofloxacin may be the preferred first antimicrobial choice.
We report findings from a multi-method study investigating drug injectors' access to needles and syringes in three large Russian cities (Moscow, Volgograd, Barnaul).
We undertook 209 qualitative interviews among drug injectors, and supplemented these with baseline data from a community-recruited survey of 1473 drug injectors.
Almost all (93%; 1277) injectors used pharmacies as their main source of clean injecting equipment, and only 7% (105) reported ever having had contact with city syringe exchange projects. Good access to syringes has coincided with the expansion of private pharmacies. Key factors contributing to pharmacy access included: geographic proximity; low cost; and the restrictive policies of exchange instituted at local syringe exchanges. A fear of police interference surrounded the use of pharmacies and syringe exchanges, and fed a reluctance to carry used needles and syringes, which in turn acted as a disincentive to syringe exchange attendance. The perceived benefits of syringe exchanges over pharmacies included the additional health services on offer and the social support provided, but these benefits were over-shadowed by disadvantages. Multivariable analyses of survey data in two cities show no differences on account of risk behaviour among injectors sourcing equipment from pharmacies compared to syringe exchanges.
HIV prevention coverage indicators need to include measures of pharmacy-based syringe distribution and not only measures of syringe exchange coverage. There is an urgent need to pilot pharmacy-based distribution and exchange projects in Russia as well as other forms of secondary syringe distribution. Alongside expanding the reach of dedicated syringe exchange projects, pharmacy-based syringe distribution, and exchange, may help improve coverage of cost effective HIV prevention measures targeting drug injectors.
It is a well-known fact that experience is important for safe driving. Previously, this presented a problem since experience was mostly gained during the most dangerous period of driving-the first years with a licence. In many countries, this "experience paradox" has been addressed by providing increased opportunities to gain experience through supervised practice. One question, however, which still needs to be answered is what has been lost and what has been gained through supervised practice. Does this method lead to fewer accidents after licensing and/or has the number of accidents in driving practice increased? There were three aims in the study. The first was to calculate the size of the accident problem in terms of the number of accidents, health risk and accident risk during practising. The second aim was to evaluate the solution of the "experience paradox" that supervised practice suggests by calculating the costs in terms of accidents during driving practice and the benefits in terms of reduced accident involvement after obtaining a licence. The third aim was to analyse conflict types that occur during driving practice. National register data on licence holders and police-reported injury accidents and self-reported exposure were used. The results show that during the period 1994-2000, 444 driving practice injury accidents were registered, compared to 13657 accidents during the first 2 years with a licence. The health risk during the period after licensing was 33 times higher and the accident risk 10 times higher than the corresponding risk during practice. The cost-benefit analysis showed that the benefits in terms of accident reduction after licensing were 30 times higher than the costs in terms of driving practice accidents. It is recommended that measures to reduce such accidents should focus on better education of the lay instructor, but not on introducing measures to reduce the amount of lay-instructed practice.
The FACET (Formoterol and Corticosteroid Establishing Therapy) study established that there is a clear clinical benefit in adding formoterol to budesonide therapy in patients who have persistent symptoms of asthma despite treatment with low to moderate doses of an inhaled corticosteroid. We combined the clinical results from the FACET study with an expert survey on average resource use in connection with mild and severe asthma exacerbations in the U.K., Sweden and Spain. The primary objective of this study was to assess the health economics of adding the inhaled long-acting beta2-agonist formoterol to the inhaled corticosteroid budesonide in the treatment of asthma. The extra costs of adding the inhaled beta2-agonist formoterol to the corticosteroid budesonide in asthmatic patients in Sweden were offset by savings from reduced use of resources for exacerbations. For Spain the picture was mixed. Adding formoterol to low dose budesonide generated savings, whereas for moderate doses of budesonide about 75% of the extra formoterol costs could be recouped. In the U.K., other savings offset about half of the extra cost of formoterol. All cost-effectiveness ratios are within accepted cost-effectiveness ranges reported from previous studies. If productivity losses were included, there were net savings in all three countries, ranging from Euro 267-1183 per patient per year. In conclusion, adding the inhaled, long-acting beta2-agonist formoterol to low-moderate doses of the inhaled corticosteroid budesonide generated significant gains in all outcome measures with partial or complete offset of costs. Adding formoterol to budesonide can thus be considered to be cost-effective.
Web-based surveys may have advantages related to the speed and cost of data collection as well as data quality. However, they may be biased by low and selective participation. We predicted that such biases would distort point-estimates such as average symptom level or prevalence but not patterns of associations with putative risk-factors.
A structured psychiatric interview was administered to parents in two successive surveys of child mental health. In 2003, parents were interviewed face-to-face, whereas in 2006 they completed the interview online. In both surveys, interviews were preceded by paper questionnaires covering child and family characteristics.
The rate of parents logging onto the web site was comparable to the response rate for face-to-face interviews, but the rate of full response (completing all sections of the interview) was much lower for web-based interviews. Full response was less frequent for non-traditional families, immigrant parents, and less educated parents. Participation bias affected point estimates of psychopathology but had little effect on associations with putative risk factors. The time and cost of full web-based interviews was only a quarter of that for face-to-face interviews.
Web-based surveys may be performed faster and at lower cost than more traditional approaches with personal interviews. Selective participation seems a particular threat to point estimates of psychopathology, while patterns of associations are more robust.
OBJECTIVES: This study analyzed the reduction in risk of head injuries associated with use of bicycle helmets among persons ages 3 to 70 and the cost-effectiveness of helmet use based on this estimated risk reduction. METHODS: To derive our cost-effectiveness estimates, we combined injury incidence data gathered through a detailed and comprehensive injury registration system in Norway, acute medical treatment cost information for the Norwegian health service, and information reported in the scientific literature regarding the health protective effects of helmet use. The analysis included all cases of head injuries reported through the registration system from 1990 through 1996. We performed an age-stratified analysis to determine the incidence of bicycle-related head injuries, the 5-year reduction in absolute risk of injury, the number needed to treat, and the cost-effectiveness of helmet use. To test the robustness of the findings to parameter assumptions, we performed sensitivity analysis. RESULTS: The risk of head injury was highest among children aged 5 to 16. The greatest reduction in absolute risk of head injury, 1.0 to 1.4% over 5 years estimated helmet lifetime, occurred among children who started using a helmet between the ages of 3 and 13. Estimates indicate that it would cost approximately U.S. $2,200 in bicycle helmet expenses to prevent any one upper head injury in children ages 3-13. In contrast, it would cost U.S. $10,000-25,000 to avoid a single injury among adults. CONCLUSIONS: Bicycle safety helmets appear to be several times more cost-effective for children than adults, primarily because of the higher risk of head injury among children. Programs aiming to increase helmet use should consider the differences in injury risk and cost-effectiveness among different age groups and target their efforts accordingly.
AIMS: The aim of this population-based study was to explore the age-specific additional direct healthcare cost for patients with diabetes compared with the non-diabetic population. METHODS: In 1999-2005, patients with diabetes in the Swedish county of Ostergötland (n = 20,876) were identified from an administrative database. Cost data on the healthcare expenditure in primary healthcare, out-patient hospital care and in-patient care for the entire county population (n = approximately 415,000) in 2005 were extracted from a cost per patient (CPP) database, which includes information on all utilized healthcare resources in the county. Data on drug sales were obtained from the Swedish Prescribed Drug Register. RESULTS: The cost per person was 1.8 times higher in patients with diabetes than in the non-diabetic population, 7.7 times higher in children and 1.3 times higher in subjects aged > 75 years. The additional cost per person for diabetes was euro 1971; euro 3930 and euro 1367, respectively, for children and subjects aged > 75 years. The proportion of total additional diabetes costs attributable to in-patient care increased with age from 25 to 50%; in-patient care was the most expensive component at all ages except in children, for whom visiting a specialist was most expensive. The diabetes-related segment of the total healthcare cost was 6.6%, increasing from 2.0% in children to 10.3% in the age group 65-74 years, declining to 6.2% in the oldest age group. CONCLUSIONS: The direct medical cost of diabetes varies considerably by age. Knowledge about the influence of age on healthcare costs to society will be important in future planning of diabetes management.
OBJECTIVE--To assess the cost-effectiveness of identifying asymptomatic carriers of Chlamydia trachomatis among adolescent males. DESIGN--Cost-effectiveness analysis based on cohort analytic studies previously reported and average salaries and costs of medical care in Sweden. SETTING--Adolescent males attending a primary care center for routine health checks. PARTICIPANTS--Estimates of costs and benefits are based on a cohort of 1000 adolescent males and their female contacts. INTERVENTION--Screening with enzyme immunoassay (EIA), either on leukocyte esterase (LE)--positive urine samples (LE-EIA screening) or on all urine samples (EIA screening), was compared with no screening (no treatment or contact tracing). The effects of confirming positive EIA results with a blocking assay and alternative antibiotic regimens on the outcome of the screening strategies were also evaluated. RESULTS--Compared with no screening, the LE-EIA and EIA screening strategies reduced the overall costs when the prevalence of chlamydial infection in males exceeded 2% and 10%, respectively. Enzyme immunoassay screening achieved an overall cure rate that was 12.2% to 12.6% (95% confidence interval) better, but reduced the incremental savings by at least $2144 per cured male, in comparison with LE-EIA screening. Confirmation of positive EIA results reduced the overall cost of the LE-EIA screening strategy when the prevalence of C trachomatis among males was less than 8%. Compared with a 7-day course of doxycycline, a single oral dose of azithromycin administered under supervision in the clinic improved the cure rates of both EIA and LE-EIA screening strategies by 15.1% to 16.3% and 11.2% to 12.0%, respectively, while reducing the corresponding overall costs by 5% and 9%, respectively, regardless of the prevalence of chlamydial infection in males. CONCLUSION--The use of LE-EIA screening combined with treatment of positive cases with azithromycin was the most cost-effective intervention strategy focusing on asymptomatic male carriers of C trachomatis. Positive EIA results should be confirmed when screening low-risk populations.
Comment In: JAMA. 1993 Nov 3;270(17):2097-88411579