Search

Background: A goal of the US Department of Health and Human Services' Ending the HIV Epidemic (EHE) in the United States initiative is to reduce the annual number of incident HIV infections in the United States by 75% within 5 years and by 90% within 10 years. We developed a resource allocation analysis to understand how these goals might be met. Methods: We estimated the current annual societal funding [$2.8 billion (B)/yr] for 14 interventions to prevent HIV and facilitate treatment of infected persons. These interventions included HIV testing for different transmission groups, HIV care continuum interventions, pre-exposure prophylaxis, and syringe services programs. We developed scenarios optimizing or reallocating this funding to minimize new infections, and we analyzed the impact of additional EHE funding over the period 2021-2030. Results: With constant current annual societal funding of $2.8 B/yr for 10 years starting in 2021, we estimated the annual incidence of 36,000 new cases in 2030. When we added annual EHE funding of $500 million (M)/yr for 2021-2022, $1.5 B/yr for 2023-2025, and $2.5 B/yr for 2026-2030, the annual incidence of infections decreased to 7600 cases (no optimization), 2900 cases (optimization beginning in 2026), and 2200 cases (optimization beginning in 2023) in 2030. Conclusions: Even without optimization, significant increases in resources could lead to an 80% decrease in the annual HIV incidence in 10 years. However, to reach both EHE targets, optimization of prevention funding early in the EHE period is necessary. Implementing these efficient allocations would require flexibility of funding across agencies, which might be difficult to achieve. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: Reducing doses of antiretroviral drugs, including stavudine (d4T), may lower toxicity, while preserving efficacy. There are substantial concerns about renal and bone toxicities of tenofovir disoproxil fumarate (TDF). Setting: HIV-1–infected treatment-naive adults in India, South Africa, and Uganda. Methods: A phase-4, 96-week, randomized, double-blind, noninferiority trial compared d4T 20 mg twice daily and TDF, taken in combination with lamivudine (3TC) and efavirenz (EFV). The primary endpoint was the proportion of participants with HIV-1 RNA <50 copies per milliliter at 48 weeks. Adverse events assessments included measures of bone density and body fat. The trial is registered on Clinicaltrials.gov (NCT02670772). Results: Between 2012 and 2014, 536 participants were recruited per arm. At week 96, trial completion rates were 75.7% with d4T/3TC/EFV (n = 406) and 82.1% with TDF/3TC/EFV (n = 440, P = 0.011). Noncompletion was largely due to virological failure [6.2% (33) with d4T/3TC/EFV versus 5.4% (29) with TDF/3TC/EFV; P = 0.60]. For the primary endpoint, d4T/3TC/EFV was noninferior to TDF/3TC/EFV (79.3%, 425/536 versus 80.8% 433/536; difference = −1.49%, 95% CI: −6.3 to 3.3; P < 0.001). Drug-related adverse event discontinuations were higher with d4T (6.7%, 36), than TDF (1.1%, 6; P < 0.001). Lipodystrophy was more common with d4T (5.6%, 30) than TDF (0.2%, 1; P < 0.001). Creatinine clearance increased in both arms, by 18.1 mL/min in the d4T arm and 14.2 mL/min with TDF (P = 0.03). Hip bone density measures, however, showed greater loss with TDF. Conclusions: Low-dose d4T combined with 3TC/EFV demonstrated noninferior virological efficacy compared with TDF/3TC/EFV, but mitochondrial toxicity remained high. Little renal toxicity occurred in either arm. Implications of bone mineral density changes with TDF warrant investigation. [ABSTRACT FROM AUTHOR]

Keywords: COVID-19; decision making; heart failure; heart transplantation; medical ethics; pandemics; resource allocation EN COVID-19 decision making heart failure heart transplantation medical ethics pandemics resource allocation 194 196 3 07/23/20 20200721 NES 200721 The coronavirus disease 2019 (COVID-19) pandemic has dramatically changed the healthcare landscape. Cardiologists must tell some patients who would normally be evaluated in-person to stay home; we must also implore some fearful patients to seek care.[2] The importance of the latter is illustrated by concerning observations of underpresentation of critical cardiovascular diseases like acute coronary syndrome. [Extracted from the article]

Keywords: heart failure; heart transplantation; resource allocation; treatment outcomes EN heart failure heart transplantation resource allocation treatment outcomes 1662 1664 3 05/21/20 20200519 NES 200519 Heart allocation policy was changed on October 18, 2018, to address several concerns with the previous system.[1] We reviewed adult heart transplants performed in the United States between January 1, 2018, and March 31, 2019, and stratified patients based on date of waitlist registration and transplantation, with follow-up data through June 6, 2019. Higher rates of transplantation coupled with lower rates of waitlist mortality or deterioration and lower posttransplant survival after the policy change. Heart failure, heart transplantation, resource allocation, treatment outcomes. [Extracted from the article]

Thus, the new heart allocation system is still based on subjective physician decision making, allowing bias as well as center-specific and regional variations in practice patterns to influence which patients receive heart transplants. Likewise, physicians at large programs are more willing to transplant high-risk patients, not only offering hope to patients who otherwise may not be deemed suitable for transplant but also enhancing the reputation of their program. Moreover, if transplant physicians interpret the rules too strictly, they are at risk of disadvantaging their patients as other physicians make alternative choices to improve the chances of an organ allocation to the patients at their center. [Extracted from the article]

The authors reflect on the cardiovascular epidemiological research projects by the National Heart, Lung, and Blood Institute (NHLBI). Topics include the strategies to optimize the allocation of research funds, role of U.S. National Institutes of Health (NIH) as the largest funding agency for medical research in the world, and costs for long follow-up periods.

Background: The importance of morbid obesity as a risk factor for complications after total knee arthroplasty (TKA) continues to be debated. Obesity is rarely an isolated diagnosis and tends to cluster with other comorbidities that may independently lead to increased risk and confound outcomes. It is unknown whether morbid obesity independently affects postoperative complications and resource use after TKA. Questions/purposes: The purpose of this study was to determine whether morbid obesity is an independent risk factor for inpatient postoperative complications, mortality, and increased resource use in patients undergoing primary TKA. Methods: The Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) database was used to identify patients undergoing primary TKA from October 2005 to December 2008. Morbid obesity (body mass index ≥ 40 kg/m) was determined using International Classification of Diseases, 9 Revision, Clinical Modification codes. In-hospital postoperative complications, mortality, costs, and disposition for morbidly obese patients were compared with nonobese patients. To control for potential confounders and comorbid conditions, each morbidly obese patient was matched to a nonobese patient using age, sex, and all 28 comorbid-defined elements in the NIS database based on the Elixhauser Comorbidity Index. Of 1,777,068 primary TKAs, 98,410 (5.5%) patients were categorized as morbidly obese. Of these, 90,045 patients (91%) were able to be matched one-to-one to a nonobese patient for the adjusted analysis. Results: Morbidly obese patients had a higher risk of postoperative in-hospital infection (0.24% versus 0.17%; odds ratio [OR], 1.3; 95% confidence interval [CI], 1.1-1.7; p = 0.001), wound dehiscence (0.11% versus 0.08%; OR, 1.3; 95% CI, 1.0-1.7; p = 0.28), and genitourinary-related complications (0.60% versus 0.44%; OR, 1.3; 95% CI, 1.1-1.5; p < 0.001). There was no increase in the prevalence of cardiovascular or thromboembolic-related complications. Morbidly obese patients were at higher risk of in-hospital death after primary TKA compared with nonobese patients (0.08% versus 0.02%; OR, 3.2; 95% CI, 2.0-5.2; p < 0.001). Total hospital costs (USD 15,174 versus USD 14,715, p < 0.001), length of stay (3.6 days versus 3.5 days, p < 0.001), and rate of discharge to a facility (40% versus 30%, p < 0.001) were all higher in morbidly obese patients. Conclusions: Morbid obesity appears to be independently associated with a higher risk for a small number of select in-hospital postoperative complications and mortality after matching for comorbid medical conditions linked to obesity. However, the independent impact of morbid obesity appears to be fairly modest, and morbid obesity did not appear to be an independent risk factor for many systemic complications. Continued research is necessary to identify the influence of associated comorbidities on early postoperative complications in morbidly obese patients after TKA. Level of Evidence: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Over a 3-year period, the Centers for Disease Control and Prevention invested $102.3 million in a large-scale HIV testing program, the Expanded HIV Testing Initiative for populations disproportionally affected by HIV. Policy makers, who must optimize public health given a set budget, are interested in the financial return on investment (ROI) of large-scale HIV testing.We conducted an ROI analysis using expenditure and outcome data from the program. A health system perspective was used that included all program expenditures including medical costs of treating newly diagnosed patients. We incorporated benefits of HIV transmissions averted from persons diagnosed of their infection through the Initiative compared with when, on average, those persons would have been diagnosed without the Initiative (3 years later in the base case). HIV transmissions were derived from a published mathematical model of HIV transmission. In sensitivity analysis, we tested the effect of 1-year to 5-year alternate testing intervals and differences in the prevalence of undiagnosed HIV infection.Under the Initiative, 2.7 million persons were tested for HIV, there was a newly diagnosed HIV positivity rate of 0.7%, and an estimated 3381 HIV infections were averted. It achieved a return of $1.95 for every dollar invested. ROI ranged from $1.46 to $2.01 for alternative testing intervals of 1-5 years and remained above $1 (positive return on investment) with a prevalence of undiagnosed HIV infection as low as 0.12%.The expanded testing Initiative yielded ROI values of >$1 under a broad range of sensitivity analyses and provides further support for large-scale HIV testing programs. [ABSTRACT FROM AUTHOR]

Goal: The goal was to determine the optimal strategy for screening coverage, test selection, and treatment for infection in asymptomatic women for a given family-planning-program budget.Study Design: We developed a resource allocation model to determine the optimal strategy using data from 5078 visits by women universally screened for infection in a publicly funded family planning clinic system in Philadelphia. We maximized the number of infected women cured from the clinic perspective and maximized the cost-savings from the healthcare system perspective. The model incorporated the following age distributions: <20 years (27%), 20 to 24 years (30%), and >24 years (43%), with prevalences of 10.6%, 6.9%, and 2.3%, respectively. We modeled two screening test assays (DNA probe and ligase chain reaction [LCR] for cervical specimens) and two treatments (doxycycline and azithromycin). The model allowed for different test and treatment choices by age group.Results: At the baseline annual budget of $6 per visit, the strategy that maximized both the number of infected women cured and cost savings would be to screen all women with DNA probe and to treat all women with positive tests with azithromycin. This strategy would result in 183 women cured at a cost-savings of $140,176. Sensitivity analysis showed that the total budget had a great impact on the optimal strategy, incorporating screening coverage, test selection, and treatment.Conclusions: Using resource allocation models enables clinic managers operating with a fixed budget to identify a strategy that maximizes the number of asymptomatic women cured and cost savings when the clinic age distribution and age-specific prevalences are known. [ABSTRACT FROM AUTHOR]

Introduction: Utilization of emergent transthoracic echocardiograms (STAT TTEs) increased tremendously due to its cost-effectiveness, benign safety risk profile, ease of use and ability to quickly provide information that can immediately impact patient care. It remains unclear whether this modality is utilized per guidelines established by American Society of Echocardiography (ASE). We aim to assess appropriateness of STAT TTEs and determine if patient management is affected. Methods: Retrospective review of STAT TTEs from Dec 1, 2017 to Feb 28, 2018 performed at Memorial Hermann Hospital - Texas Medical Center, Houston, TX. Data points included time to perform/report, hospital unit, indication and TTE finding. Chart review was done to determine if the TTE answered the clinical question and changed acute management. Results: Out of 736 STAT TTEs, an average of 8 were performed daily of which only 3 (37.5%) were truly emergent per guidelines. Median time from ordering to performing a TTE was 3h:07m for true STATs vs 2h:78m for non-true STATs (p<0.85). Median ordering to reporting time was 8h:23m for true STATs vs 8h:17m for non-true STATs (p<0.687). Top utilizer of true STATs was the heart failure intensive care unit 39 (13.5%) vs the emergency department 86 (19.2%) for non-true STATs. Most common indication for true STATs was acute heart failure 127 (44.1%) vs ECG abnormalities 95 (21.2%) for non-true STATs. TTE answered the clinical question in 158 (54.7%) true STATs vs 199 (44.4%) non-true STATs (p<0.006). Most common finding in true and non-true STATs was a normal study, 80 (27.9%) vs 184 (41.2%). Acute management change occurred in 54 (18.7%) true STATs vs 62 (13.8%) non-true STATs (p<0.085). Most common changes were a Cardiology or Advanced Heart Failure consult, emergent surgical evaluation or surgery, or percutaneous intervention, 12 (22.2%) each. Conclusions: Our study indicates that overutilization of STAT TTEs may lead to a delay in performance time and findings do not usually affect acute management. When ordered appropriately within established guidelines, clinical questions were answered at a significantly higher rate. Adherence to appropriate use criteria for STAT TTEs can improve allocation of available resources and performance efficiency. [ABSTRACT FROM AUTHOR]

Introduction: Gender disparities in PCI are well recognized. Global Lumen Organization for Women (GLOW), has previously reported these inequalities in a meta-analysis of >750,000 patients. Telemedicine eliminates some process barriers that women traditionally face when confronted with an acute myocardial infarction. Research regarding gender and telemedicine, however, is altogether lacking. Hypothesis: We explored the Latin American Telemedicine Infarct Network (LATIN) database to investigate the prevalence of gender disparities and their impact on STEMI interventions Methods: As a program for managing population-based AMI care, LATIN has utilized an innovative hub and spoke strategy and remote guidance to expand access in remote regions of Brazil, Colombia and Mexico. A two-part strategy was diligently constructed for LATIN - telemedicine was first deployed as a screening tool to accurately diagnose AMI. Next, based upon the duration of chest pain and transfer time to a PCI-capable facility, the AMI patients were triaged into guidelines-based pathways of thrombolysis, pharmaco-invasive management or Primary PCI. Along the entire LATIN pathway of AMI diagnosis and its management, resource allocation was identical for both men and women Results: Data from 610,427 screened patients in LATIN reveals broad gender disparities were that were most revealing for prevalence of STEMI diagnosed (p<0.0001), STEMI treated (p<0.0001), PCI as the preferred reperfusion strategy (p<0.0001), pharmaco-invasive management (p<0.0001), use of CABG (p<0.001) and in-hospital mortality (<0.001). These findings assume even greater relevance with the detection that more women were screened through the Telemedicine pathway (p<0.0001). Conclusions: LATIN gender data signals the urgency to decree better STEMI care for women. [ABSTRACT FROM AUTHOR]