Ulinastatin Add-on to Standard of Care in Critically Ill COVID-19 Patients: A Multicenter, Retrospective Study.

AIM: To assess the impact on 30-day mortality with ulinastatin (ULI) used as add-on to standard of care (SOC) compared to SOC alone in coronavirus disease (COVID-19) patients requiring admission to the intensive care unit (ICU). MATERIALS AND METHODS: In this multicentric, retrospective study, we collected data on clinical, laboratory, and outcome parameters in patients with COVID-19. Thirty-day mortality outcome was compared among patients treated with SOC alone and ULI used as add-on to SOC. Odds ratio (OR) and 95% confidence intervals (CI) were determined to identify the predictors of 30-day mortality. RESULTS: Ninety-four patients were identified and enrolled in both groups with comparable baseline parameters. On univariate analysis, 30-day mortality was significantly lower in ULI plus SOC group than SOC alone group (36.2 vs 51.1%, OR 0.54, 95% CI 0.30-0.97, p = 0.040). The effect on mortality was more pronounced in patients who did not require intubation (10.9 vs 34.0%, OR 0.24, 95% CI 0.09-0.66, p = 0.006) and with early administration (within 72 hours of admission) of ULI (30.7 vs 57.9%, OR 0.32, 95% CI 0.11-0.91, p = 0.032). On multivariate analysis, only intubation predicted mortality (adjusted OR 10.13, 95% CI 3.77-27.25, p<0.0001) and the effect of ULI on survival was not significant (adjusted OR 0.58, 95% CI 0.22-1.52, p = 0.270). CONCLUSION: Given the limited options for COVID-19 patients treated in ICU, early administration of ULI may be helpful, especially in patients not requiring intubation to improve the outcomes. Further, a large, randomized study is warranted to confirm these findings.

Congenital syphilis presenting as fulminant early-onset sepsis.

Congenital syphilis (CS) is a rare entity and one of the most well-known congenital infections. A case of early CS presenting with fulminant sepsis is reported. A high index of suspicion is needed by the clinician to diagnose and treat this potentially life-threatening disease.

Evidence that value-based insurance can be effective.

Value-based insurance design reduces patient copayments to encourage the use of health care services of high clinical value. As employers face constant pressure to control health care costs, this type of coverage has received much attention as a cost-savings device. This paper's examination of one value-based insurance design program found that the program led to reduced use of nondrug health care services, offsetting the costs associated with additional use of drugs encouraged by the program. The findings suggest that value-based insurance design programs do not increase total systemwide medical spending.

"Dial-an-ROI?" changing basic variables impacts cost trends in single-population pre-post ("DMAA type") savings analysis.

Disease management (DM) programs claim to achieve cost savings by reducing clinical adverse events. While measuring changes in adverse events is straightforward, plausibly demonstrating savings has been contentious, especially absent an external comparison population. In this situation, a single-population methodology is often used, in which the cost trend for those with no program conditions ("non-chronics"--NC) forms the expected trend for those who have at least 1 program condition ("chronics"--C). The methodology's fundamental assumption is that--absent DM--C and NC trends would be identical (or bear a constant relationship over time). We assessed this assumption by altering the values of key variables used to identify C and NC, and to calculate trend. We compared C and NC baseline trends for a 23-condition telephonic DM multiemployer program representing nearly 300,000 members. Trends were calculated for 16 combinations of values for 4 key variables: identification look-back frame (12 vs. 24 months); identification threshold (high vs. lower specificity); claims runout (3 vs. 6 months); and minimum required insurance eligibility (any 6 months vs. 12 months continuous eligibility in the measurement year). Identification was performed by annual qualification. Changes in values for the 4 key variables markedly impacted baseline C and NC trends. C trends varied between 10.1% and 13.1%; NC trends between 5.2% and 12.8%. C-NC trend differences ranged between -1.9% and +7.0%. The combination of 24 months identification look-back, high identification threshold, 6 months runout, and any-6-months eligibility gave the most convergent C and NC trends (10.4% and 10.7%). Seemingly minor changes in key variables impact C and NC trends in single-population pre-post DM savings methodologies. When a suitable comparison population is not available, at least 1 year of baseline C and NC trends should be reported-as recommended by the DMAA--and values of key variables used should be specified. Plausibility metrics (eg, hospitalizations) should be reported.

Impact of decreasing copayments on medication adherence within a disease management environment.

This paper estimates the effects of a large employer's value-based insurance initiative designed to improve adherence to recommended treatment regimens. The intervention reduced copayments for five chronic medication classes in the context of a disease management (DM) program. Compared to a control employer that used the same DM program, adherence to medications in the value-based intervention increased for four of five medication classes, reducing nonadherence by 7-14 percent. The results demonstrate the potential for copayment reductions for highly valued services to increase medication adherence above the effects of existing DM programs.