The evolving burden of HIV infection compared with other chronic diseases in northern Italy.

OBJECTIVES: The aim of the study was to estimate the burden and direct costs of diseases in HIV-infected patients (either opportunistic illnesses or other chronic diseases) with respect to the HIV-uninfected population. These estimates will be useful for the projection of future direct costs of HIV care. PATIENTS AND METHODS: A population-based study was conducted in the Brescia Local Health Agency in northern Italy. An administrative database recorded diagnoses, deaths, drug prescriptions and health resource utilization for all medical and surgical patients in the region from 2003 to 2007. The study estimated the prevalence of HIV infection as well as HIV-related mortality and annual cost per patient, and compared mortality and costs related to HIV infection with those for a set of 15 other chronic diseases. The standardized hazard ratio (SHR) and standardized mortality ratio (SMR) were obtained using an indirect standardization method. RESULTS: The prevalence of HIV infection increased from 218 per 100,000 inhabitants in 2003 to 263 per 100,000 in 2007. Although mortality rates decreased markedly (from 24 per 1000 HIV-infected patients in 2003 to 16 per 1000 in 2007), the data show that mortality was still higher in HIV-infected patients compared with the general population in the most recent years (SMR 8.8 in 2007). In each year included in the study, HIV-infected patients had higher rates of care-seeking for chronic diseases, including liver diseases (SHR>8), neuropathy, oesophagus-gastro-duodenum diseases, serious psychiatric disorders and renal failure (SHR approximately 3 for each). Also, the rate of medical attendance for neoplasias, chronic pulmonary disease, diabetes, and cardiovascular disease increased over time in HIV-infected patients compared with the general population. Ranking diseases in order of their total cost to the health system, HIV infection ranked 12th, with total costs of €28.6 million in 2007. Ranking in order of cost per patient, HIV infection ranked third, with a cost per patient of €9894 in 2007. HIV-infected patients with concomitant chronic diseases had higher average costs. The cost per patient in 2007 was €8104 for HIV-infected patients without other chronic diseases, €9908 for HIV infection plus cardiovascular disease, €11,370 for HIV infection plus chronic liver disease and €12,013 for HIV infection plus neoplasias. CONCLUSIONS: The prevalence and population cost of people living with HIV are likely to increase as a result of prolonged survival, aging of HIV-infected patients and increased risk of other chronic diseases. In the near future, HIV infection will rank as one of the most costly chronic diseases. Prevention strategies need to be more widely adopted to control the growing burden of the HIV epidemic and other chronic diseases affecting HIV-infected patients.

HCV screening to enable early treatment of hepatitis C: a mathematical model to analyse costs and outcomes in two populations.

Early treatment of acute hepatitis C virus (HCV) infections reflects a new clinical paradigm and a significant option to reduce the socioeconomic burden of HCV. Therefore, this approach seems suitable as a new strategy to face HCV and prevent end stage liver diseases and premature deaths due to progressed chronic HCV-infections. The main limitation of this approach is that the majority of acute infections show an asymptomatic course and do thus not present to the health-care settings. Screening for HCV has already been extensively studied in the literature. This paper offers further insights in screening for HCV using cost effectiveness analysis for the impact of screening in two cohorts: Injecting Drug Users (IDUs) and Individuals With Surgery (IWSs). The setting of the cost effectiveness simulation is the Veneto Region in the North-east of Italy. Using a Markov model of the natural history of HCV infection we derive costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness related to screening vs. no-screening strategies. In the IDUs cohort, the screening strategy can result in a substantial difference in premature deaths and dominates (less costs better outcomes) the no-screening one. The overall outcomes of the screening strategy are mostly affected by the prevalence of HCV and of genotypes that are more relatively more difficult to treat (above 10% of prevalence for its cost effectiveness). The number of premature deaths prevented in the IWSs cohort is lower and there seems to be an unacceptable incremental cost per QALY gained, which may be unsustainable for society.

The societal burden of HIV/AIDS in Northern Italy: an analysis of costs and quality of life.

This study aims to measure the direct and indirect costs of HIV/AIDS care and quality of life (QoL) of HIV-infected patients in Northern Italy. We conducted a prospective cohort study over 12 months, enrolling a sample of 121 patients with HIV infection from two cities in Northern Italy. Patients were surveyed at baseline and were followed-up at 6 and 12 months. To assess the relationship between costs and stage of disease, patients were categorized into three groups at baseline: "No HAART" (asymptomatic and never before on highly active antiretroviral therapy (HAART)), "Stable HAART" (HAART with mild HIV infection and no prior opportunistic infections) and "HAART failure" (primary HAART regimen was altered because of severe side effects or immunological failure). Direct medical costs were based on utilization of (day) hospital admissions, diagnostic procedures, laboratory tests, clinic visits, consultations and antiretroviral drug use. Indirect costs included production losses due to absence from work, reduced productivity at work and reduced unpaid labour participation. QoL was assessed by visual analogue scale. Parametric regression was used to estimate the expected value and the standard deviation of annual costs per patient. The expected value of total annual costs was 1818 euros and 9820 euros and 12,332 euros, for groups "No HAART", "Stable HAART" and "HAART failure" respectively. We estimated annual expected earnings as 14,994 euros and 10,811 euros and 9820 euros for the same respective groups. The expected value of QoL on a scale of 0-1 in these same patient groups was 0.80, 0.78 and 0.64. We conclude that indirect costs contribute substantially to total costs and are comparable in magnitude to the direct costs excluding antiretroviral drugs. The costs of inpatient care in our cohort were almost negligible compared to total costs. Despite being in treatment, many patients were still gainfully employed and generated substantial expected annual earnings.

[Off-label antibiotic use: malpractice or good clinical practice?]. / La prescrizione off-label di antibiotici: malpractice o buona pratica clinica?

In Italy, off-label drug use has been forbidden since 1998. However, Italian law allows off-label treatment for single cases only if treatment is considered irreplaceable, and completely under physician responsibility. To assess the consequences of such regulations for the infectious diseases specialist, we listed the indications of intravenous and oral antibiotics available in our hospital pharmacy service, and discussed them in a pool of nine infectious diseases specialists. Indications were compared with the recommended treatment of major bacterial syndromes as suggested by the major guidelines and textbooks. We found that standard treatment for several bacterial infections is off-label. The pool of specialists concluded that some off-label use of antibiotics is vital to daily practice in infectious diseases. Scientific societies should promote guidelines as the standard reference for good clinical practice, which should not be based only on the respect of drug labels.

ISSQoL: a new questionnaire for evaluating the quality of life of people living with HIV in the HAART era.

OBJECTIVE: To design a Health-related Quality of Life (HRQoL) instrument for HIV-infected people in the era of highly active antiretroviral therapy (HAART). METHODS: The self-administered questionnaire was developed by an Italian network including researchers, physicians, people living with HIV, national institutions and community-based organizations (CBO) through several steps: (1) review of existing HRQoL literature and questionnaires for HIV-infected people; (2) selection of relevant domains measuring HRQoL in HIV-infected people, and identification of new domains related to new aspects of HRQoL concerning HAART-treated individuals; (3) conduction of two pre-test analyses in independent groups of Italian HIV-positive people (n approximately =100) distributed throughout the country. The objectives of the first pre-test were to verify the usefulness of the questionnaire, to construct a form easily understandable by everyone, to define the domains and their significance; the second pre-test aimed at evaluating and reshaping the questionnaire based on a statistical analysis of the outcomes of first pre-test; (4) validation analysis. A large cohort of people with HIV infection was recruited for the last step. RESULTS: The internal consistence reliability (Cronbach's alpha) was >or=0.70 for all domains. Most domains had Cronbach's coefficient >0.80. All domains demonstrated convergent and discriminant validity. The final version of ISSQoL includes two sections: HRQoL Core Evaluation Form (9 domains) and Additional Important Areas for HRQoL (6 domains). The ISSQoL was administered together with two additional forms: a Daily Impact of Symptoms Form and a Demographic Information Form. The Additional Important Areas for HRQoL include social support, interaction with medical staff, treatment impact, body changes, life planning, and motherhood/fatherhood. CONCLUSION: The data reported in the present paper provide preliminary evidence of the reliability and validity of the ISSQoL questionnaire for the measurement of HRQoL in HIV-infected people. The direct involvement of HIV-positive people in all the phases of the project was a key aspect of our work.

Impact of liver steatosis on virological response in [corrected] Italian patients with chronic hepatitis C treated with peg-interferon alpha-2b plus ribavarin.

BACKGROUND: Whether liver steatosis affects sustained virological response in patients with chronic hepatitis C is still under discussion. AIM: To evaluate the impact of liver steatosis in patients treated (for chronic hepatitis C) with combination therapy. METHODS: We evaluated 97 (male/female 82/15, mean age 41.1 years) consecutive naive patients treated with pegylated interferon alpha-2b plus ribavirin. RESULTS: Prevalence and severity of liver steatosis were significantly associated with genotype 3a [grade 3-4 in 14 of 32 patients (44%) vs. 8 of 65 patients (12%) with other genotypes; P = 0.001], while steatosis grade 1 (<10% of hepatocytes affected) was more frequently associated with genotype 1a/1b [9/39 (23%) vs. 4/57 (7%); P = 0.02]. Overall, sustained virological response was 62.8%, and was statistically uninfluenced by the presence/absence of liver steatosis. On the contrary, the following variables were independently associated with sustained virological response at logistic regression analysis: genotype other than 1a/1b, positive association, (odds ratio 3.4, P < 0.04), and low-grade liver steatosis, negative association, (odds ratio 9.0, P = 0.009), whereas sustained virological response was unaffected by severe liver steatosis, which was mainly associated with genotypes 2 and 3 [steatosis grade 2, 18/29 (62%); grade 3, 10/12 (83%); grade 4, 7/10 (70%)]. CONCLUSIONS: Only low-grade liver steatosis negatively affects the outcome of combination therapy, with peginterferon alpha-2b plus ribavirin, while severe steatosis (which is virus-related in most cases) has no impact on virological response.

Attitudinal classification of patients receiving antibiotic treatment for mild respiratory tract infections.

The aim of this study was to determine patients' perceptions of antibiotic therapy and the doctor's skill in the management of ambulatory respiratory tract infections. Standardized face-to-face interviews were used with more than 3000 randomized patients or parents from four European countries. Attitudinal dimensions relating to their doctor identified four patient types: Involved (30%), Deferent (23%), Ignored (13%) and Critical (17%). Involved and Deferent patients were the most satisfied by the information received from their doctor (43%/39% compared with 17%/16% for Ignored/Critical, respectively, P < 0.01). They also scored more highly on the accurate use of antibiotics, with 80%/80% vs. 38%/62%, respectively (P < 0.01), understanding dosing intervals and 77%/77% vs. 36%/60% (P < 0.01), understanding the course length. Involved and Deferent patients showed better compliant behaviour, with 91% of both groups vs. 86% of the Ignored and Critical claiming to have taken every dose (P < 0.001) and 92%/87% vs. 84%/85% claiming to have finished the course (P < 0.001 for Involved only). Involved and Deferent patients were less prone to save part of a course of antibiotics than the Ignored and Critical (46%/41% vs. 20%/31%, P < 0.001), and they perceived the antibiotics prescribed to be more effective (36%/31% vs. 21%/15%, P < 0.001). By analysing patient perceptions, this study identifies an important mirror effect, whereby a more sympathetic attitude from the doctor should increase the patient's involvement in disease management, for a more appropriate use of antibiotics in common infections.

The application of cost effectiveness analysis to derive a formulary for urinary tract infections.

According to economic principles an inappropriate prescription is the choice of an antimicrobial with higher/equivalent cost and lower effectiveness (or higher cost and equivalent/lower efficacy) than an alternative (in this case, the former is specified as a "dominated" drug). To identify cost-effective antibiotics we applied the principles of incremental cost-effectiveness analysis (ICEA) to microbiological data of San Bortolo Hospital. Its 27 wards were grouped in 9 functional areas. The resistance patterns of 8 urinary pathogens in the 1997 microbiology data base were assessed. The measure of antibiotic effectiveness was expressed as the percentage of isolates susceptible to each antibiotic tested. The difference in cost (i.e. the incremental change) between each antibiotic and the next more expensive alternative was calculated, and compared with the incremental change in effectiveness. Calculations were made for each pathogen. The antibiotics remaining after exclusion of all "dominated" antibiotics were pooled on a list defined as "Specific Area Formulary". The implications of the use of economic principles within a general antimicrobial policy are discussed.

Three-times weekly teicoplanin in the outpatient treatment of acute methicillin-resistant staphylococcal osteomyelitis: a pilot study.

Treatment of osteomyelitis requires prolonged hospital stay, lengthy antibiotic therapy and adequate surgical debridement. Outpatient parenteral antibiotic therapy (OPAT) is a new approach to reduce patient discomfort and hospital costs. Teicoplanin, a glycopeptide antibiotic with a long half-life (72 hours), is one of the most useful drugs for OPAT. We performed a pilot study to assess the safety and efficacy of three-times weekly teicoplanin in the treatment of methicillin-resistant (MR) acute staphylococcal osteomyelitis. Ten patients with acute post-traumatic osteomyelitis were enrolled. Pathogens were MR Staphylococcus aureus (5 patients) and MR coagulase-negative staphylococci (5 patients). After a loading dose of 400 mg b.i.d. for 3 days, patients were treated with an intravenous dose of 1000 mg on Mondays and Wednesdays and with a 1200 mg dose on Fridays. Teicoplanin trough levels were maintained within a 10 to 20 mg/L range. If hardware removal had been possible at enrollment, treatment was carried out for at least 4 weeks. If, on the contrary, hardware removal had not been possible, teicoplanin was administered as suppressive therapy until hardware removal. Treatment was successfully performed in 9 out of 10 patients, whereas in one patient only improvement was achieved. Side effects were not recorded. Three times weekly teicoplanin seems to be a valuable option in the treatment of acute MR staphylococcal osteomyelitis. Further studies are warranted in order to better define the role of this new administration schedule in this field.

Regional prophylaxis with teicoplanin in monolateral or bilateral total knee replacement: an open study.

From January 1991 to June 1997, patients undergoing primary elective monolateral or bilateral total knee replacement (TKR) were consecutively enrolled in a prospective, open clinical study on the efficacy and safety of regional prophylaxis with teicoplanin (TEC). Those scheduled for monolateral TKR (115 patients) received 400 mg of TEC in 100 ml of saline as a 5-min infusion into a foot vein of the leg to be operated on immediately after the tourniquet was inflated to 400 mm Hg (ca. 50 kPa). For patients undergoing bilateral surgery (45 patients), regional administration of TEC was also repeated for the second knee operation. Follow-up ranged from a minimum of 2 years to 8 years. None of the patients experienced local or systemic adverse effects following regional administration of TEC. In the immediate postoperative and 2-year follow-up periods, only one superficial infection of the primary site attributable to intraoperative contamination (prophylaxis failure) out of the 205 prostheses implanted was observed. Deep infections involving the prosthesis did not occur. Infectious complications at distant sites were observed in nine cases (urinary tract infection due to Escherichia coli in eight cases, and Salmonella enteritidis gastroenteritis in one case) in the immediate postoperative period; they all were rapidly cured after antibiotic treatment. A delayed prosthetic infection, related to hematogenous spread of the etiological agent and therefore not considered a prophylactic failure, was observed in a patient who had undergone TKR 5 years before. Regional administration of TEC in monolateral and bilateral TKR appears to be a safe and valuable prophylactic technique.

[Setting priorities in the prevention and control of nosocomial infections: an economic perspective] / Definizione delle priorita e degli obiettivi nei programmi di prevenzione e controllo delle infezioni ospedaliere: il punto di vista economico.

Nosocomial infections are a good indicator of the quality of health care provided by hospitals. Despite their cost-effectiveness, nosocomial infection programs are rarely applied in Italy. Epidemiological surveillance is the simplest measure to adopt because it allows us to monitor the baseline endemic rates, identify new epidemics and assess the improvements achieved by interventions provided. The presence of continuous epidemiological surveillance must be considered the exception rather than the rule in Italy. In this paper, the prevention of nosocomial infections was analysed through two economic evaluation techniques (i.e. cost-benefit and cost effectiveness). A hierarchy of intervention based on cost effectiveness, hospital size and organisational setting was also provided. The main conclusions are the following: 1. Benefits associated to prevention of nosocomial infections are considered small because of the uncertainty associated to the future. Therefore a discount factor must be applied. 2. Local factors and specific reasons are usually advocated to explain the simple fact that infection control programs are only formally implemented and usually limited to the constitution of a nosocomial infections committee. 3. The prevention of nosocomial infections must be provided for under specific laws which take into account the various organisations and structures found in different hospitals.

HIV-associated dementia: clinical, epidemiological and resource utilization issues.

Among mental disorders associated with HIV infection, dementia is the one most likely to have a major impact on public health, both as a result of the high levels of individual disability, and the greater demand of health care resource utilization. Epidemiologic and economic impact of HIV-associated dementia needs to be estimated, in order to provide policy makers and health managers with the information required for decision making and resource allocation. An increase in HIV encephalopathy prevalence rates may be expected as a consequence of longer survival time in dementia patients and in patients with other AIDS defining disease (longer survival increases the risk of developing HIV encephalopathy). A resource utilization study shows that, in the chronic stage of the disease, in-patient days per person-year are almost double in AIDS subjects with neurological complications as compared with those without neurological complications; no major difference appears when considering out-patients consultations and day-care treatments. In conclusion, a significant rise in resource utilization and in related costs may be anticipated as a consequence of the increasing prevalence of HIV encephalopathy. Further studies seem necessary to compare different approaches in the management of this debilitating disease, in view of a more rational utilization and allocation of resources.

The influence of socioeconomic status on health service utilisation by patients with AIDS in north Italy. The North-East Italian Group for Planning of AIDS Health Care.

Evidence for an association between socioeconomic status (SES) and health service utilisation (HSU) by patients with AIDS is examined using data for an Italian AIDS study population. A composite measure of SES which takes into account several key variables was developed using Multiple Correspondence Analysis. A classification of SES categories (high, medium-high, medium-low, low) was constructed and resource utilisation across the categories compared. The study population were patients with AIDS referred to 10 AIDS clinics in the study area in North-East Italy. A questionnaire survey was undertaken over the period January to June 1994, and was completed by 555 patients. Statistical analysis was conducted, using log-linear modelling, of health service utilisation (covering inpatient and day care) by SES categories, illness severity and HIV transmission route group. The analysis demonstrated that SES has a statistically significant association with variation in HSU, secondary in importance to severity of illness. This finding has important implications for future care planning for HIV/ AIDS in Italy, and potentially to other countries. Further research is needed to examine the relationship between SES and health service utilisation and costs in Italy and in other European countries.

Hospital care for persons with AIDS in the European Union.

This study estimates the current and future hospital resources for AIDS patients in the European Union (EU), using multinational scenario analysis (EU Concerted Action BMH1-CT-941723). In collaboration with another EU-project ('Managing the Costs of HIV Infection'), six national European studies on the utilization of hospital care for AIDS have been selected to provide the data for our analysis. The selection criteria involve recentness, quality, comparability, accessibility and representativeness. Baseline hospital resource utilization is estimated for hospital inpatient days and outpatient contracts, using a standardized approach controlling for two severity stages of AIDS (chronic stage and late stage). The epidemiological part of the study is based on standard models for backcalculating HIV incidence and projecting AIDS incidence, prevalence and mortality. In the next step, baseline resource utilization is linked to epidemiological information in a mixed prevalence and mortality-based approach. Several scenarios render different future epidemiological developments and hospital resource needs. For the year 1999, hospital bed needs of 10,000-12,700 in the EU are indicated, representing an increase of 20-60% compared to the estimated current (1995) level. The projected range for 1999 corresponds to a maximum of 0.65% of all hospital beds available in the EU. The growth in the number of outpatient hospital contacts is projected to possibly exceed that of inpatient days up to 1.82 million in 1999. Our methodology illustrates that estimation of current and future hospital care for AIDS has to be controlled for severity stages, to prevent biases. Further application of the multinational approach is demonstrated through a 'what-if' analysis of the potential impact of combination triple therapy for HIV/AIDS. Estimation of the economic impact of other diseases could as well benefit from the severity-stages approach.

Efficiency and rationality in the planning of health care for people with AIDS: an application of the balance of care approach. North-East Italian Group for Planning of AIDS Health Care.

OBJECTIVE: To demonstrate the application of an approach for assessing efficiency and rationality in the use of resources for the care of patients with AIDS (PWA), using data for north-east Italy. DESIGN: An economic methodology, the balance of care (BoC) approach, enabled identification of scenarios for the current, planned and recommended provision of care in the study region. METHODS: Data on the supply and utilization of care by PWA across four locations (inpatient care, day care, home care and sheltered accommodation) was collected for a 6-month period during 1994. The current BoC measured in care contacts across the locations was compared with a planned BoC scenario, derived from the Italian AIDS Health Plan, and a recommended BoC scenario based on a delphi expert panel judgement of the appropriate care location according to sets of hypothetical clinical and social characteristics of PWA. The cost consequences of reallocating patient contacts between the current BoC to the recommended BoC was assessed for inpatient and day care contacts. RESULTS: There is an overprovision of home care in the planned BoC scenario if applied to the study region. The cost consequences of a shift of care contacts according to the recommended scenario results in a potential cost reduction of 9.2% compared with the current scenario, and hence an expected efficiency improvement. CONCLUSION: The BoC approach can be applied to improve the efficiency and rationality of resource use in planning care provision for PWA.

Investigation of a Q-fever outbreak in northern Italy.

OBJECTIVES: A study was conducted to evaluate the extent of a Q-fever epidemic through active case finding in the area of Vicenza (north-eastern Italy), and to identify risk factors for Q-fever in this outbreak. METHODS: 1) Descriptive epidemiology; 2) Seroepidemiological survey; 3) Case-control study. 1) Epidemic curve and maps with the location of cases. Identification of the road followed by the flocks of sheep. 2) Cross-sectional study on humans and flocks of sheep tested for anti-Coxiella burnetii antibodies. 3) Cases were defined by the presence of fever > 38 degrees C plus serological confirmation. Controls were 94 apparently healthy individuals attending outpatient facilities for control visits or certification, group-matched by geographical area, age and gender. A standardized questionnaire was administered by trained interviewers. Odds ratio and 95% confidence intervals (CI) were used to evaluate risk factors for Q-fever. RESULTS: A total 58 cases were identified in a 5-month period. Male to female ratio was 2.8:1; mean age was 42 years (range: 20-65 years). Twenty-eight patients (48%) were hospitalized. Fever was accompanied by asthenia (81%), headache (76%), chills (72%), and myalgia and arthralgia (53%); cough was present in 47% of patients. Rx abnormalities were found in 81% of the patients undergoing chest X-ray. Among 111 apparently healthy family members who underwent serological testing, four (3.6%) had antibodies to Coxiella burnetii. Three flocks which passed through the outbreak area between late May and early June were shown to be infected, with prevalence of antibodies ranging between 45 and 53%. The case-control study showed a significant association with exposure to flocks of sheep (Odds ratio = 6.1; 95% CI 2.5, 16.3). Other potential risk factors were not more commonly reported by cases with respect to controls. CONCLUSIONS: Indirect exposure to flocks of sheep was a determinant of this outbreak of Q-fever. This finding suggests that transmission occurred through inhalation of contaminated airborne particles. The importance of control measures should be stressed in areas traversed by flocks of sheep.

A risk-benefit assessment of teicoplanin in the treatment of infections.

Teicoplanin is a glycopeptide antibiotic whose activity is selectively oriented against Gram-positive aerobic and anaerobic bacteria, including Staphylococcus aureus, coagulase-negative staphylococci, Clostridium difficile, Peptostreptococcus spp. and Corynebacterium jeikeium; such activity is affected by neither methicillin resistance nor beta-lactamase production. Teicoplanin is not significantly absorbed from the gastrointestinal tract; consequently, it has to be administered intravenously (either by infusion or by rapid injection) or intramuscularly. Its long half-life allows regimens based upon once daily administration. The adverse effects most frequently associated with teicoplanin treatment are local and hypersensitivity reactions, such as itching and drug fever; anaphylactoid reactions (the 'red man syndrome') are seldom observed. Teicoplanin also has less potential than vancomycin to cause nephrotoxicity, especially when administered in combination with an aminoglycoside. Teicoplanin has been proven to be effective in the treatment of microbiologically documented Gram-positive infections, including 'difficult to treat infections' such as endocarditis and prosthetic infections. Furthermore, recent trials in patients with haematological malignancies or other cancers have clearly demonstrated that teicoplanin is at least as efficacious as vancomycin in the empirical initial antibiotic regimen for febrile neutropenic patients, and is associated with fewer adverse effects. Finally, owing to its good tolerability profile and the advantage of once daily administration by both intravenous and intramuscular routes, teicoplanin has proven to be very useful for the outpatient treatment of serious Gram-positive infections. In conclusion, teicoplanin is potentially an effective alternative to vancomycin both in immunocompetent and immunocompromised patients, with the advantage over vancomycin of single daily dose administration and lower toxicity. Further comparative studies with vancomycin are, however, required to better define the therapeutic role of teicoplanin for particular infections (i.e. infective endocarditis).

An economic evaluation of home-care assistance for AIDS patients: a pilot study in a town in northern Italy.

OBJECTIVE: To evaluate the costs and cost-effectiveness of home-care assistance (HCA) as an alternative to hospital-based care only for patients with AIDS (PWA). DESIGN: A 6-month prospective study. Use of resources by a control group of PWA receiving ordinary hospital-based care (OC group) was compared with that by a random group of PWA who, in addition to hospital care, were also receiving home care (HC group). SETTING: Home- and hospital-based care for PWA in Vicenza, Italy. PATIENTS: HC group selection was based on eligibility criteria for severity of illness, home location and economic and family support. Ten of the PWA satisfying all eligibility criteria were randomly allocated to the HC group. The control group consisted of 32 PWA lacking one or more of the eligibility criteria. INTERVENTION: HCA involved the provision of palliative care for PWA by a multidisciplinary team of caregivers. Hospital-based services covered inpatient and outpatient services. MAIN OUTCOME MEASURE: The health benefits for HC and OC groups using a quantitative quality of life measure (the Quality of Well-Being Scale). RESULTS: Overall health-care cost savings of 6-7%, relative to the OC group, were predicted for the HC group. Costs per well week were estimated at US$482 for the HC group and US$791 for the OC group. CONCLUSION: Home-care assistance appears to be a cost-effective strategy for the treatment and care of PWA if strict eligibility criteria are adhered to.