RESUMO
BACKGROUND: Comprehensive US epidemiologic data for adult pleural disease are not available. RESEARCH QUESTION: What are the epidemiologic measures related to adult pleural disease in the United States? STUDY DESIGN AND METHODS: Retrospective cohort study using Healthcare Utilization Project databases (2007-2016). Adults (≥ 18 years of age) with malignant pleural mesothelioma, malignant pleural effusion, nonmalignant pleural effusion, empyema, primary and secondary spontaneous pneumothorax, iatrogenic pneumothorax, and pleural TB were studied. RESULTS: In 2016, ED treat-and-discharge (T&D) visits totaled 42,215, accounting for charges of $286.7 million. In 2016, a total of 361,270 hospitalizations occurred, resulting in national costs of $10.1 billion. A total of 64,174 readmissions contributed $1.16 billion in additional national costs. Nonmalignant pleural effusion constituted 85.5% of ED T&D visits, 63.5% of hospitalizations, and 66.3% of 30-day readmissions. Contemporary sex distribution (male to female ratio) in primary spontaneous pneumothorax (2.1:1) differs from older estimates (6.2:1). Decadal analyses of annual hospitalization rates/100,000 adult population (2007 vs 2016) showed a significant (P < .001) decrease for malignant pleural mesothelioma (1.3 vs 1.09, respectively), malignant pleural effusion (33.4 vs 31.9, respectively), iatrogenic pneumothorax (17.9 vs 13.9, respectively), and pleural TB (0.20 vs 0.09, respectively) and an increase for empyema (8.1 vs 11.1, respectively) and nonmalignant pleural effusion (78.1 vs 100.1, respectively). Empyema hospitalizations have high costs per case ($38,591) and length of stay (13.8 days). The mean proportion of readmissions attributed to a pleural cause varied widely: malignant pleural mesothelioma, 49%; malignant pleural effusion, 45%; nonmalignant pleural effusion, 31%; empyema, 27%; primary spontaneous pneumothorax, 27%; secondary spontaneous pneumothorax, 27%; and iatrogenic pneumothorax, 20%. Secondary spontaneous pneumothorax had the shortest time to readmission in 2016 (10.3 days, 95% CI, 8.8-11.8 days). INTERPRETATION: Significant epidemiologic trends and changes in various pleural diseases were observed. The analysis identifies multiple opportunities for improvement in management of pleural diseases.
Assuntos
Doenças Pleurais/epidemiologia , Adolescente , Adulto , Idoso , Empiema/economia , Empiema/epidemiologia , Feminino , Coalizão em Cuidados de Saúde , Gastos em Saúde , Hospitalização/economia , Humanos , Incidência , Masculino , Mesotelioma Maligno/economia , Mesotelioma Maligno/epidemiologia , Pessoa de Meia-Idade , Readmissão do Paciente/economia , Doenças Pleurais/economia , Derrame Pleural/economia , Derrame Pleural/epidemiologia , Derrame Pleural Maligno , Neoplasias Pleurais/economia , Neoplasias Pleurais/epidemiologia , Pneumotórax/economia , Pneumotórax/epidemiologia , Tuberculose Pleural/economia , Tuberculose Pleural/epidemiologia , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Medical students acquire latent tuberculosis (TB) infection at a rate of 23 cases/100 person-years. The frequency and impact of occupational TB disease in this population are unknown. METHODS: A self-administered questionnaire was distributed via email and social media to current medical students and recently graduated doctors (2010 - 2015) at two medical schools in Cape Town. Individuals who had developed TB disease as undergraduate students were eligible to participate. Quantitative and qualitative data collected from the questionnaire and semi-structured interviews were analysed with descriptive statistics and a framework approach to identify emerging themes. RESULTS: Twelve individuals (10 female) reported a diagnosis of TB: pulmonary TB (n=6), pleural TB (n=3), TB lymphadenitis (n=2) and TB spine (n=1); 2/12 (17%) had drug-resistant disease (DR-TB). Mean diagnostic delay post consultation was 8.1 weeks, with only 42% of initial diagnoses being correct. Most consulted private healthcare providers (general practitioners (n=7); pulmonologists (n=4)), and nine underwent invasive procedures (bronchoscopy, pleural fluid aspiration and tissue biopsy). Substantial healthcare costs were incurred (mean ZAR25 000 for drug-sensitive TB, up to ZAR104 000 for DR-TB). Students struggled to obtain treatment, incurred high transport costs and missed academic time. Students with DR-TB interrupted their studies and experienced severe side-effects (hepatotoxicity, depression and permanent ototoxicity). Most participants cited poor TB infection-control practices at their training hospitals as a major risk factor for occupational TB. CONCLUSIONS: Undergraduate medical students in Cape Town are at high risk of occupationally acquired TB, with an unmet need for comprehensive occupational health services and support.
Assuntos
Doenças Profissionais/epidemiologia , Estudantes de Medicina/estatística & dados numéricos , Tuberculose/epidemiologia , Adulto , Antituberculosos/efeitos adversos , Broncoscopia , Doença Hepática Induzida por Substâncias e Drogas/etiologia , Diagnóstico Tardio , Depressão/induzido quimicamente , Feminino , Custos de Cuidados de Saúde , Transtornos da Audição/induzido quimicamente , Humanos , Masculino , Doenças Profissionais/diagnóstico , Doenças Profissionais/tratamento farmacológico , Doenças Profissionais/economia , Licença Médica , África do Sul/epidemiologia , Inquéritos e Questionários , Toracentese , Tuberculose/diagnóstico , Tuberculose/tratamento farmacológico , Tuberculose/economia , Tuberculose dos Linfonodos/diagnóstico , Tuberculose dos Linfonodos/tratamento farmacológico , Tuberculose dos Linfonodos/economia , Tuberculose dos Linfonodos/epidemiologia , Tuberculose Resistente a Múltiplos Medicamentos/diagnóstico , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/economia , Tuberculose Resistente a Múltiplos Medicamentos/epidemiologia , Tuberculose Pleural/diagnóstico , Tuberculose Pleural/tratamento farmacológico , Tuberculose Pleural/economia , Tuberculose Pleural/epidemiologia , Tuberculose Pulmonar/diagnóstico , Tuberculose Pulmonar/tratamento farmacológico , Tuberculose Pulmonar/economia , Tuberculose Pulmonar/epidemiologia , Tuberculose da Coluna Vertebral/diagnóstico , Tuberculose da Coluna Vertebral/tratamento farmacológico , Tuberculose da Coluna Vertebral/economia , Tuberculose da Coluna Vertebral/epidemiologia , Adulto JovemAssuntos
Antituberculosos/economia , Custos de Medicamentos , Custos de Cuidados de Saúde , Tuberculose dos Linfonodos/economia , Tuberculose Resistente a Múltiplos Medicamentos/economia , Tuberculose Pleural/economia , Tuberculose Pulmonar/economia , Adulto , Amicacina/economia , Amicacina/uso terapêutico , Ácido Aminossalicílico/economia , Ácido Aminossalicílico/uso terapêutico , Antibacterianos/economia , Antibacterianos/uso terapêutico , Antituberculosos/uso terapêutico , Broncoscopia , Clofazimina/economia , Clofazimina/uso terapêutico , Depressão/complicações , Depressão/diagnóstico , Depressão/tratamento farmacológico , Depressão/psicologia , Emigrantes e Imigrantes , Etambutol/economia , Etambutol/uso terapêutico , Tuberculose Extensivamente Resistente a Medicamentos , Fluoroquinolonas/economia , Fluoroquinolonas/uso terapêutico , Humanos , Índia/etnologia , Isoniazida/economia , Isoniazida/uso terapêutico , Linezolida/economia , Linezolida/uso terapêutico , Masculino , Mediastino , Testes de Sensibilidade Microbiana , Moxifloxacina , Nova Zelândia , Pirazinamida/economia , Pirazinamida/uso terapêutico , Radiografia Torácica , Rifampina/economia , Rifampina/uso terapêutico , Esquizofrenia Paranoide/complicações , Esquizofrenia Paranoide/diagnóstico , Esquizofrenia Paranoide/tratamento farmacológico , Esquizofrenia Paranoide/psicologia , Tuberculose dos Linfonodos/tratamento farmacológico , Tuberculose Resistente a Múltiplos Medicamentos/complicações , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico , Tuberculose Pleural/tratamento farmacológico , Tuberculose Pulmonar/tratamento farmacológicoRESUMO
Pleural fluid levels of interferon-gamma (IFN-gamma) and adenosine deaminase (ADA) have been found to be high in patients with tuberculosis (TB). The present study was carried out to compare the diagnostic utility of these two markers and to carry out a cost-effectiveness analysis of performing IFN-gamma estimation in comparison to ADA. A total of 52 patients with pleural effusion, 35 of which were found to have TB etiology, were prospectively included for estimation of ADA and IFN-gamma levels. The difference in the cost of performing the two diagnostic tests was compared with the cost of the treatment for a patient with TB. Pleural fluid IFN-gamma (median [range]: 2,100 [70-14,000] vs. 3 [0-160]; P<0.001) as well as ADA levels (mean [SD]: 93.1 [62.3] vs 15.4 [8.7]; P<0.001) were significantly higher in patients with TB effusion. Even though IFN-gamma estimation was more sensitive (97.1 vs. 91.4%), the extra cost of IFN-gamma estimation for detecting one patient with TB was found to be equivalent to the cost of a complete course of antituberculosis treatment for six patients. In developing countries, where TB is rampant and cost is a major concern, pleural fluid IFN-gamma estimation does not seem to be a cost-effective investigation method for differentiating TB from non-TB pleural effusion.
Assuntos
Adenosina Desaminase/análise , Interferon gama/análise , Derrame Pleural/química , Tuberculose Pleural/diagnóstico , Adulto , Análise Custo-Benefício , Feminino , Humanos , Masculino , Derrame Pleural/etiologia , Tuberculose Pleural/complicações , Tuberculose Pleural/economiaAssuntos
Adenosina Desaminase/metabolismo , Isoenzimas/metabolismo , Tuberculose Pleural/enzimologia , Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Infecções Oportunistas Relacionadas com a AIDS/enzimologia , Ensaios Enzimáticos Clínicos/economia , Custos e Análise de Custo , Humanos , Derrame Pleural/enzimologia , Reação em Cadeia da Polimerase/economia , Tuberculose Pleural/diagnóstico , Tuberculose Pleural/economiaRESUMO
The purpose of this study was to observe routine practice in the care of tuberculosis cases treated in the Seine Saint-Denis department in 1984, with reference to the recent recommendations of the French Pneumology Society. The pathway of each patient through the care network was established for 336 adult cases being treated for respiratory tuberculosis for the first time. The social and economic cost of each pathway was evaluated. The results show the multiplicity of health services intervening in the care of these patients, the persistence of hospitalization, sanatorium care, and long sick-leaves from work, together with major differences in the care pathways according to the nationality, sex, and socio-economic group of the patients. The cost of tuberculosis treatment is shown to be high for both patients and the community.