Utility scores can be assessed indirectly using preference-based instruments and used as weightings for quality-adjusted life years in economic analyses. It is not clear whether available instruments yield similar results or what domains of health are contributing to the overall score in a sample of patients with rheumatoid arthritis (RA).
Our study included 313 individuals with rheumatologist-confirmed RA.
A self-completed survey that permitted scoring of 4 indirect utility instruments (the Health Utilities Index Mark 2 and 3 (HUI-2 and HUI-3), the EuroQoL (EQ-5D), and the Short Form 6D (SF-6D) was the basis of our study.
Mean (standard deviation) global utility scores were 0.63 (0.24) for the SF-6D, 0.66 (0.13) for the EQ-5D, 0.71 (0.19) for the HUI-2, and 0.53 (0.29) for the HUI-3 (P = 0.02 by repeated-measures analysis of variance). The intraclass correlation across all the indices was 0.67 (95% confidence interval 0.62-0.71). Bland-Altman plots revealed that agreement among instruments was poor at lower utility values. In this elderly RA sample, all of the global utilities mostly measured functional ability and pain.
There are significant differences in utilities obtained from different indirect methods. Agreement among the instruments was moderate but poorer at lower utilities. It is unlikely that these utility values, if used as the weightings for quality-adjusted life years, would result in comparable estimates.
Dropout and recidivism from addiction treatment has been found to be associated with individuals' readiness for change. Motivation for treatment among participants entering the North American Opiate Medication Initiative (NAOMI) randomized controlled trial, which compared heroin assisted treatment (HAT) to optimized methadone maintenance treatment (MMT), was assessed. Through multivariate regression, we aimed to determine whether baseline motivational status was predictive of four treatment outcomes: early dropout, 12-month retention, 12-month response to treatment, and time to discontinuation of treatment. Among the 251 out-of-treatment chronic opioid dependent patients recruited in Montreal, Quebec and Vancouver, British Columbia, 52% reported having a high level of motivation for treatment. HAT was statistically significantly more effective than MMT on each of the outcomes assessed. Baseline motivational status did not predict retention or time to discontinuation in either HAT or MMT. However, while patients were retained in HAT regardless of motivational status, motivated patients showed a more favourable response to treatment in terms of decreases in crime and illicit drug use. These results suggest that HAT successfully retains opioid dependent patients who otherwise may not have been attracted into existing treatment options, and may enhance the odds of successful rehabilitation among patients motivated for treatment.
To measure the association between intensive care unit (ICU) admission and both hospital and long-term mortality, separate from the effect of hospital admission alone.
Retrospective cohort study.
All hospitals in British Columbia, Canada, during 3 fiscal years, 1994 to 1996.
A total of 27,103 patients admitted to ICU and 41,308 (5% random sample) patients admitted to hospital but not to ICU.
Although ICU admission was an important factor associated with hospital mortality (odds ratio: 9.12; 95% confidence interval: 8.34-9.96), the association between ICU admission and mortality after discharge was relatively minimal (hazard ratio: 1.21; 95% confidence interval: 1.17-1.27) and was completely overshadowed by the effect of age, gender, and diagnosis.
After controlling for the effect of hospital admission, admission to ICU has minimal independent effect on mortality after discharge.
Comment In: Crit Care Med. 2002 Mar;30(3):703-511990940
Hospital discharge against medical advice, especially among substance-abusing populations, is a frustrating problem for health care providers. Because of the high prevalence of injection drug use among HIV-positive patients admitted to hospital in Vancouver, we explored the factors associated with leaving hospital against medical advice in this population.
We reviewed records for all HIV/AIDS patients admitted to St. Paul's Hospital, Vancouver, between Apr. 1, 1997, and Mar. 1, 1999. After identifying the first ("index") admission during this period, we followed the patients' records for 1 year. Multivariate models were applied to identify the determinants of discharge against medical advice and to estimate the impact of such discharge on readmission rate, readmission frequency and length of stay in hospital.
Of 981 index admissions among HIV/AIDS patients, 125 (13%) of the patients left the hospital against medical advice. Departure on the day on which welfare cheques were issued and a history of injection drug use were significant predictors of leaving against medical advice. After adjusting for sex, age, severity of illness, injection drug use and homelessness, we found that patients leaving against medical advice were readmitted more frequently than those who were formally discharged (frequency ratio 1.25, 95% confidence interval [CI] 1.11-1.42), were more likely to be readmitted with a related diagnosis within 30 days (odds ratio 5.00, 95% Cl 3.04-8.24) and had significantly longer lengths of stay in the follow-up period.
Discharge against medical advice among HIV-positive patients was associated with frequent readmissions with the same diagnosis. Preventing such discharges is likely to benefit patients (by improving their health status) and the health care system (by reducing unnecessary readmissions).
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In Ontario, Canada, the 70/90 regulations were instituted in May 1993 to establish provincial government procurement prices for generic drugs. Accordingly, the first generic entrant's price could not exceed 70% of the incumbent's branded price. Subsequent entrants' prices could not exceed 90% of the first entrant's price.
These regulations' impact on generic market competitiveness are evaluated.
Data on 518 drugs spanning nine therapeutic classifications were collected for the period of 04/01/1987 to 12/31/1998 from Ontario Drug Benefit formulary and IMS Canada. The period 04/01/1987 to 04/30/1993 was defined as the before period (BP) and 05/01/1993 to 12/31/1998 was the after period (AP). We compared the price ratio (P = P(G)/P(B) ) between BP and AP and performed regression analysis to assess the determinants of P.
in both the BP and AP decreased as the number of generic firms increased within these periods. However, this decrease in was significantly less in the AP (median: 0.75 --> 0.68 --> 0.67) than in BP (0.71 --> 0.61 --> 0.53) as the number of generics increased from 1 to 2 to 3, respectively. The regression analysis showed that the price ratio in the AP was higher than that in the BP by 0.05, 0.09, and 0.13 for first, second, and third generic entrant respectively.
Our findings show that the 70/90 regulations not only failed to achieve their goal of lowering the procurement price but instead the opposite occurred. The mandated procurement price became a focal point and resulted in a clustering of prices around the maximum allowable levels with little price dispersion.
To assess trends in asthma management and to identify factors associated with increasing short-acting (SA) beta-agonist utilization in British Columbia using administrative prescription data.
A retrospective cohort analysis.
All patients between 13 and 50 years of age who had received at least one prescription for a SA beta-agonist covered by BC Pharmacare between January 1, 1996, and December 31, 1998.
Cross-sectional analysis of all patients, and longitudinal analyses only of patients who had received at least one SA beta-agonist prescription in each of the 3 years. Trends in asthma medication use over time were evaluated using repeated-measures Mantel-Haenszel tests. Multiple logistic regression was used to identify factors associated with increasing SA beta-agonist use.
A total of 78,758 patients were included in the cohort. No decrease in the annual prevalence of receiving more than four canisters per year of a SA beta-agonist was identified between 1996 and 1998. A total of 12,844 patients filled at least one SA beta-agonist prescription each year. Time-trend analysis showed an overall increasing probability of not receiving an inhaled corticosteroid (ICS) agent in this population (p = 0.002). In patients exhibiting low SA beta-agonist use, > 18 years of age (adjusted odds ratio [OR], 1.5), male gender (adjusted OR, 1.7), and in receipt of social assistance (adjusted OR, 2.3) were associated with receiving increasing amounts of SA beta-agonist agents over the 3 years. In patients with a high degree of use of SA beta-agonists, only the receipt of social assistance (adjusted OR, 1.3) was significantly associated with increasing use.
Despite the development and dissemination of asthma management guidelines, there was no trend toward decreasing SA beta-agonist use. An unexpected trend toward decreasing ICS utilization was identified. Receiving social assistance was a risk factor for increasing SA beta-agonist use, independent of baseline utilization.
Rheumatoid arthritis (RA) is associated with increased frequency of and mortality from infections, which may be related to host factors, RA itself, inflammation, or medication side effects. This study was undertaken to determine the effect of nonbiologic disease-modifying antirheumatic drugs (DMARDs) on infection risk in RA.
We performed a retrospective, longitudinal study of a population-based RA cohort in British Columbia, Canada, followed from January 1996 to March 2003 using administrative data. We evaluated mild infections (requiring a physician visit or antibiotics) and serious infections (requiring or complicating hospitalization). Adjusted risk of mild and serious infections associated with DMARD exposure was estimated using generalized estimating equation extension of multivariate Poisson regression models, after adjusting for baseline covariates (age, sex, RA duration, socioeconomic status) and time-dependent covariates (corticosteroids, comorbidity, prior infections).
A total of 27,710 individuals with RA provided 162,710 person-years of followup. Of these, 25,608 (92%) had at least 1 mild infection and 4,941 (18%) had at least 1 serious infection. Use of DMARDs without corticosteroids was associated with a small decrease in mild infection risk of statistical significance but unclear clinical significance (adjusted rate ratio [RR] 0.90, 95% confidence interval [95% CI] 0.88-0.93 relative to no corticosteroid or DMARD use). Use of DMARDs without corticosteroids was not associated with increased serious infection risk (adjusted RR 0.92, 95% CI 0.85-1.0). Use of corticosteroids increased the risk of mild and serious infections.
Our results indicate that use of nonbiologic DMARDs, including methotrexate, does not increase the risk of infection in RA, whereas use of corticosteroids does. This has important implications for counseling individuals with RA concerning risks and benefits of DMARDs.