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1.
EClinicalMedicine ; 69: 102457, 2024 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-38361989

RESUMO

Background: Treatment-simplification strategies are important tools for patient-centred management. We evaluated long-term outcomes from a PI monotherapy switch strategy. Methods: Eligible participants attending 43 UK treatment centres had a viral load (VL) below 50 copies/ml for at least 24 weeks on combination ART. Participants were randomised to maintain ongoing triple therapy (OT) or switch to a strategy of physician-selected PI monotherapy (PI-mono) with prompt return to combination therapy if VL rebounded. The primary outcome, previously reported, was loss of future drug options after 3 years, defined as new intermediate/high level resistance to at least one drug to which the participant's virus was considered sensitive at trial entry. Here we report resistance and disease outcomes after further extended follow-up in routine care. The study was registered as ISRCTN04857074. Findings: We randomised 587 participants to OT (291) or PI-mono (296) between Nov 4, 2008, and July 28, 2010 and followed them for a median of more than 8 years (100 months) until 2018. At the end of this follow-up time, one or more future drug options had been lost in 7 participants in the OT group and 6 in the PI-mono group; estimated cumulative risk by 8 years of 2.7% and 2.1% respectively (difference -0.6%, 95% CI -3.2% to 2.0%). Only one PI-mono participant developed resistance to the protease inhibitor they were taking (atazanavir). Serious clinical events (death, serious AIDS, and serious non-AIDS) were infrequent; reported in a total of 12 (4.1%) participants in the OT group and 23 (7.8%) in the PI-mono group (P = 0.08) over the entire follow-up period. Interpretation: A strategy of PI monotherapy, with regular VL monitoring and prompt reintroduction of combination treatment following rebound, preserved future treatment options. Findings confirm the high genetic barrier to resistance of the PI drug class that makes them well suited for creative, patient-centred, treatment-simplification approaches. The possibility of a small excess risk of serious clinical events with the PI monotherapy strategy cannot be excluded. Funding: The National Institute for Health Research Health Technology Assessment programme.

2.
J Environ Manage ; 325(Pt A): 116254, 2023 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-36265233

RESUMO

Mechanical solid-liquid separation is an emerging closed-loop technology to recover and recycle carbon, nutrients and water from dilute livestock manure. This closed-loop concept is tested using a modular separation technology (Z-Filter) applied at full-scale for the first time to treat effluent from a pasture-based dairy. Effluent flow rates were 200-400 L min-1 at a total solids (TS) content of 0.52% (pH 7.2). Separation efficiency and composition of the separated solid fraction were determined, and chemically-assisted separation with cationic polymer flocculant with/without hydrated lime was also tested. Without flocculant and lime, 25.9% of TS and 33.4% of volatile solids (VS) ended up in the solid fraction, but total Kjeldahl nitrogen (TKN), phosphorus (P) and potassium recovery was not significant, likely being in poorly separable fine particle or soluble fractions. With a 5% flow-based dosage of flocculant, most of the TS (69%) and VS (85%), and notable amounts of TKN (52-56%) and P (40%) ended up in the solid fraction. Phosphorus recovery was further increased to 91% when both flocculant and hydrated lime was added up to pH 9.2. The solid fraction was stackable with 16-20% TS, making transport more economical to enable further processing and beneficial reuse of nutrients and organic matter. Removal of VS also reduces fugitive methane emissions from uncovered anaerobic effluent ponds. Overall, the results indicated that solid-liquid separation could provide improved environmental management options for dairy farmers with dilute manure effluent to beneficially utilise organic matter and nutrients.


Assuntos
Gado , Esterco , Animais , Conservação dos Recursos Naturais , Fósforo , Nitrogênio , Anaerobiose
3.
Ann Vasc Surg ; 94: 38-44, 2023 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-36306973

RESUMO

BACKGROUND: Aortic dissection (AD) is a life-threatening medical emergency that affects an estimated 3-4 people per 100,000 annually, with 40% of cases classified as type B AD (TBAD). TBAD can be further classified as being complicated (co-TBAD) or uncomplicated (un-TBAD) based on the presence or absence of certain features such as malperfusion and rupture. TBAD can be managed conservatively with optimal medical therapy (OMT), or invasively with open surgical repair (OSR) or thoracic endovascular aortic repair (TEVAR), depending on several factors such as type of TBAD and its clinical acuity. The cost-effectiveness, or cost-benefit profile, of these strategies must be given equal consideration. However, TBAD studies featuring cost analyses are limited within the literature. This narrative review aims to address the gap in the literature on cost-effectiveness of TBAD treatments by providing an overview of cost analyses comparing OMT with TEVAR in un-TBAD and TEVAR with OSR in co-TBAD. Another aim is to provide a market analysis of the commercially available TEVAR devices. METHODS: A comprehensive literature search was performed using several search engines including PubMed, Ovid, Google Scholar, Scopus, and Embase to identify and extract relevant studies. RESULTS: Several TEVAR devices are available commercially on the global market costing $12,000-19,495. Nevertheless, the Terumo Aortic RELAY® stent graft seems to be the most cost-effective, yielding highly favourable clinical outcomes. Despite the higher initial cost of TEVAR, evidence in the literature strongly suggest that it is superior to OMT for un-TBAD on the long-term. In addition, TEVAR is well established in the literature as being gold-standard repair technique for co-TBAD, replacing OSR by offering a more optimal cost-benefit profile through lower costs and improved results. CONCLUSIONS: The introduction of TEVAR has revolutionized the field of aortovascular surgery by offering a highly efficacious and long-term cost-effective treatment for TBAD.


Assuntos
Aneurisma da Aorta Torácica , Dissecção Aórtica , Implante de Prótese Vascular , Procedimentos Endovasculares , Humanos , Correção Endovascular de Aneurisma , Procedimentos Endovasculares/efeitos adversos , Fatores de Risco , Resultado do Tratamento , Dissecção Aórtica/diagnóstico por imagem , Dissecção Aórtica/cirurgia , Implante de Prótese Vascular/efeitos adversos , Análise Custo-Benefício , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/cirurgia , Estudos Retrospectivos
4.
Waste Manag ; 155: 19-28, 2023 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-36335772

RESUMO

The orbital debris population is rapidly growing, increasing the chance of a Kessler-style collision event. We report a novel method for the production of estimates for the total monetary value of all debris objects and total mass of all objects currently in orbit. The method was devised using debris object data from the European Space Agency's DISCOS dataset, classified via a decision tree. 'Reuse' and 'scrap material' scenarios were developed. A high-end estimate for reuse shows a net value of $1.2 trillion. Median and low-end net value estimates of $600 billion and $570 billion, respectively, are probably judicious. A scrap material scenario produced a high mass estimate of 19,124 tonnes, a median of 6,978 tonnes and a low estimate of 5,312 tonnes. Development of in-orbit services will be crucial to solve the orbital debris problem. A future circular economy for space may be financially viable, with potentially beneficial consequences for risk reduction; resource efficiency; additional high-value employment; and climate-change knowledge, science, monitoring and early warning data.


Assuntos
Meio Ambiente Extraterreno , Reciclagem , Gerenciamento de Resíduos , Reciclagem/economia , Reciclagem/estatística & dados numéricos , Gerenciamento de Resíduos/economia , Gerenciamento de Resíduos/estatística & dados numéricos
5.
Sci Total Environ ; 858(Pt 3): 159987, 2023 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-36372167

RESUMO

The automotive industry is one of the most significant and increasing sources of pollution worldwide. Previous studies examining its impacts focus on the post-1950 era as data available before this period is scarce. This study carefully reconstructs six datasets from the early 20th century to 2019 for the UK: annual number of motor cars, road lengths, road fatalities, NOx and CO emissions, and fuel consumption. Interpolation was prudently used to fill gaps in the data sets. Results highlight changing health, social and environmental effects throughout the growth of the automotive sector. Ratios of fatalities to cars indicate social ingraining of the car and rapid response to legislation. Significant emissions resulted from the early industry. Successful remediation of emissions occurred in the late 20th century. All variables studied were interrelated, but expansion of road networks particularly contributed to a range of both positive and (unintended) negative consequences. World War 2 appears to have been a landmark for the automotive industry, producing capacity for mass production, personal mobility and research and therefore a struggle between impacts and social policies. We have demonstrated that technological developments and regulatory interventions relating to the motor industry, alongside events that have catalysed societal change, have been crucial in terms of subsequently providing benefits to society whilst also acting to mitigate (but not prevent) the adverse and frequently devastating impacts of motor vehicles on human health and the environment. A periodic, regular, overarching, independent review (~ every 5 years) of the collective positive and negative impacts of the motor vehicle industry and appropriate interventions are essential to maintain and improve social benefits and public and environmental health, as well as supporting delivery of the United Nations' Sustainable Development Goals by 2030 and beyond.


Assuntos
Automóveis , Indústria Manufatureira , Política Pública , Humanos , Emissões de Veículos , Poluição Ambiental , Reino Unido , Acidentes de Trânsito
6.
J Card Surg ; 37(8): 2258-2265, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35485597

RESUMO

BACKGROUND: Initial clinical evaluation (ICE) is traditionally considered a useful screening tool to identify frail patients during the preoperative assessment. However, emerging evidence supports the more objective assessment of cardiorespiratory fitness (CRF) via cardiopulmonary exercise testing (CPET) to improve surgical risk stratification. Herein, we compared both subjective and objective assessment approaches to highlight the interpretive idiosyncrasies. METHODS: As part of routine preoperative patient contact, patients scheduled for major surgery were prospectively "eyeballed" (ICE) by two experienced clinicians before more detailed history taking that also included the American Society of Anesthesiologists score classification. Each patient was subjectively judged to be either "frail" or "not frail" by ICE and "fit" or "unfit" from a thorough review of the medical notes. Subjective data were compared against the more objective validated assessment of postoperative outcomes using established CPET "cut-off" metrics incorporating peak pulmonary oxygen uptake, V̇O2PEAK at the anaerobic threshold (V̇O2 -AT), and ventilatory equivalent for carbon dioxide that collectively informed risk stratification. These data were retrospectively extracted from a single-center prospective National Health Service database. Data were analyzed using the Chi-square automatic interaction detection decision tree method. RESULTS: A total of 127 patients were examined that comprised 58% male and 42% female patients aged 69 ± 10 years with a body mass index of 29 ± 7 kg/m2 . Patients were poorly conditioned with a V̇O2PEAK almost 20% lower than predicted for age, sex-matched healthy controls with 35% exhibiting a V̇O2 -AT < 11 ml/kg/min. Disagreement existed between the subjective assessments of risk with ∼34% of patients classified as not frail on ICE were considered unfit by notes review (p < .0001). Furthermore, ∼35% of patients considered not frail on ICE and ∼31% of patients considered fit by notes review exhibited a V̇O2 -AT < 11 ml/kg/min, and of these, ∼28% and ∼19% were classified as intermediate to high risk. CONCLUSIONS: These findings highlight the interpretive limitations associated with the subjective assessment of patient frailty with surgical risk classification underestimated in up to a third of patients compared to the validated assessment of CRF. They reinforce the benefits of a more objective and integrated approach offered by CPET that may help us to improve perioperative risk assessment and better direct critical care provision in patients scheduled for "high-stakes" surgery including open thoracoabdominal aortic aneurysm repair.


Assuntos
Teste de Esforço , Medicina Estatal , Limiar Anaeróbio , Teste de Esforço/métodos , Feminino , Humanos , Masculino , Consumo de Oxigênio , Estudos Prospectivos , Estudos Retrospectivos , Medição de Risco
7.
Med J Aust ; 214(5): 212-217, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33580553

RESUMO

OBJECTIVE: To investigate whether integrating pharmacists into general practices reduces the number of unplanned re-admissions of patients recently discharged from hospital. DESIGN, SETTING: Stepped wedge, cluster randomised trial in 14 general practices in southeast Queensland. PARTICIPANTS: Adults discharged from one of seven study hospitals during the seven days preceding recruitment (22 May 2017 - 14 March 2018) and prescribed five or more long term medicines, or having a primary discharge diagnosis of congestive heart failure or exacerbation of chronic obstructive pulmonary disease. INTERVENTION: Comprehensive face-to-face medicine management consultation with an integrated practice pharmacist within seven days of discharge, followed by a consultation with their general practitioner and further pharmacist consultations as needed. MAJOR OUTCOMES: Rates of unplanned, all-cause hospital re-admissions and emergency department (ED) presentations 12 months after hospital discharge; incremental net difference in overall costs. RESULTS: By 12 months, there had been 282 re-admissions among 177 control patients (incidence rate [IR], 1.65 per person-year) and 136 among 129 intervention patients (IR, 1.09 per person-year; fully adjusted IR ratio [IRR], 0.79; 95% CI, 0.52-1.18). ED presentation incidence (fully adjusted IRR, 0.46; 95% CI, 0.22-0.94) and combined re-admission and ED presentation incidence (fully adjusted IRR, 0.69; 95% CI, 0.48-0.99) were significantly lower for intervention patients. The estimated incremental net cost benefit of the intervention was $5072 per patient, with a benefit-cost ratio of 31:1. CONCLUSION: A collaborative pharmacist-GP model of post-hospital discharge medicines management can reduce the incidence of hospital re-admissions and ED presentations, achieving substantial cost savings to the health system. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12616001627448 (prospective).


Assuntos
Clínicos Gerais , Modelos Organizacionais , Readmissão do Paciente/estatística & dados numéricos , Farmacêuticos , Corporações Profissionais/organização & administração , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde , Insuficiência Cardíaca/epidemiologia , Humanos , Masculino , Reconciliação de Medicamentos , Pessoa de Meia-Idade , Atenção Primária à Saúde/normas , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Qualidade de Vida , Queensland
8.
Sci Total Environ ; 775: 145815, 2021 Jun 25.
Artigo em Inglês | MEDLINE | ID: mdl-33631586

RESUMO

Accurate assessment of carbon stocks remains a global challenge. High levels of uncertainty in Land Use, Land Use Change and Forestry reporting has hindered decision-makers and investors worldwide to support sustainable soil and vegetation management. Potential mitigation-driven activities and effects are likely to be locally/regionally unique. A spatially-targeted approach is thus required to optimise strategic carbon management. This study provides a new regional carbon assessment (tier 3) approach using biophysical-process modelling of high-resolution Land Cover (LC) data within a UK National Park (NFNP) to provide higher accuracy. Future Land Cover Change (LCC) scenarios were simulated. Vegetation-driven carbon dynamics were modelled by coupling two widely-used models, LPJ-GUESS and RothC-26.3. Transition and persistence analysis was conducted using Terrset's Land Change Modeller to predict likely future LCC for 2040 using Multi-Layer Perceptron Markov-Chain Analysis. Current total carbon in the NFNP is 7.32-8.73 Mt C, with current trajectories of LCC leading to minor losses of up to 0.39 Mt C. Alternative LCC scenarios indicated possible gains or losses of 1.27 Mt C, or 136.7 t C ha-1. The importance of vegetation-driven carbon storage was greater than the national average, with a VegC pool 12-14% of the soil organic C pool, placing greater significance on local/regional LC and management policy. The potential storage capacity of each LC class was ranked (highest to lowest): Coniferous > Broadleaved/Mixed > Coastal > Semi-natural Grassland > Heath > Improved Grassland > Arable (Cropland). Opportunities were prioritised to inform landscape-scale management to reduce future carbon losses and/or to enhance gains through LCC. Balancing the carbon budget relies upon maintaining existing LC. The more detailed LC classification facilitated accounting of management through stock change factors and disaggregation of classes, achieving greater detail and accuracy. Forthcoming policy decisions must optimise carbon storage at a local/regional landscape-scale.

9.
Health Soc Care Community ; 28(2): 347-356, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31568627

RESUMO

Medical advances have led to many of the severe consequences of stroke being averted. Consequently, more people are being discharged from hospital following treatment for what is classed as minor stroke. The needs of people with minor stroke have received little research attention. The aim of the current study was to conduct an exploratory prospective needs analysis to document the unmet health, rehabilitation and psychosocial needs of a recently hospitalised minor stroke cohort approximately 2 weeks (T1) and 2 months (T2) post-hospital discharge. An exploratory cohort design was used to explore the unmet health, service and social needs of 20 patients with minor stroke. Participants completed questionnaires (Survey of Unmet Needs and Service Use, Mayo-Portland Adaptability Inventory-4, Exeter Identity Transition Scales, RAND 36-Item Health Survey 1.0) at T1 and T2. Nine participants reported unmet needs at T1 and seven participants reported unmet needs at T2. Between T1 and T2, there was a significant improvement in perceived role limitations due to physical health. Participation in society was significantly better at T2. In conclusion, patients with minor stroke report health, service and social needs that are unmet by existing services. This patient cohort urgently requires co-ordinated services to detect and manage these unmet needs.


Assuntos
Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Reabilitação do Acidente Vascular Cerebral/enfermagem , Acidente Vascular Cerebral/enfermagem , Atividades Cotidianas , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação das Necessidades/estatística & dados numéricos , Alta do Paciente , Estudos Prospectivos , Inquéritos e Questionários
10.
BMJ Open ; 7(4): e015301, 2017 04 13.
Artigo em Inglês | MEDLINE | ID: mdl-28408545

RESUMO

INTRODUCTION: A model of general practitioner (GP) and pharmacist collaboration in primary care may be an effective strategy to reduce medication-related problems and provide better support to patients after discharge. The aim of this study is to investigate whether a model of structured pharmacist and GP care reduces hospital readmissions in high-risk patients. METHODS AND ANALYSIS: This protocol details a stepped-wedge, cluster-randomised trial that will recruit participants over 9 months with a 12-month follow-up. There will be 14 clusters each representing a different general practice medical centre. A total of 2240 participants will be recruited from hospital who attend an enrolled medical centre, take five or more long-term medicines or whose reason for admission was related to heart failure or chronic obstructive pulmonary disease.The intervention is a multifaceted service, involving a pharmacist integrated into a medical centre to assist patients after hospitalisation. Participants will meet with the practice pharmacist and their GP after discharge to review and reconcile their medicines and discuss changes made in hospital. The pharmacist will follow-up with the participant and liaise with other health professionals involved in the participant's care. The control will be usual care, which usually involves a patient self-organising a visit to their GP after hospital discharge.The primary outcome is the rate of unplanned, all-cause hospital readmissions over 12 months, which will be analysed using a mixed effects Poisson regression model with a random effect for cluster and a fixed effect to account for any temporal trend. A cost analysis will be undertaken to compare the healthcare costs associated with the intervention to those of usual care. ETHICS AND DISSEMINATION: The study has received ethical approval (HREC/16/QRBW/410). The study findings will be disseminated through peer-reviewed publications, conferences and reports to key stakeholders. TRIAL REGISTRATION NUMBER: ACTRN12616001627448.


Assuntos
Clínicos Gerais , Readmissão do Paciente , Farmacêuticos , Corporações Profissionais/organização & administração , Custos de Cuidados de Saúde , Insuficiência Cardíaca/epidemiologia , Humanos , Reconciliação de Medicamentos , Atenção Primária à Saúde/normas , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Qualidade de Vida , Projetos de Pesquisa
11.
Aust Fam Physician ; 44(5): 323-6, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-26042406

RESUMO

BACKGROUND: Healthcare services are complex and prone to accidents. Most medical incidents are the result of human error. Examination of these incidents can reveal contributing factors that can be addressed to prevent recurrence. OBJECTIVE: The aim of this paper is to describe the development and institution of an incident review committee (IRC) in the setting of a large general practice. DISCUSSION: Two hundred incident reports were reviewed, resulting in meaningful clinical and business alterations to the practice. The design and running of the committee was open and collaborative. A satisfaction survey showed high acceptance among staff. The instigation of an IRC in general practice is new and unique, and this paper offers a template for other general practices to replicate.


Assuntos
Medicina de Família e Comunidade/organização & administração , Erros Médicos/prevenção & controle , Gestão de Riscos/organização & administração , Comportamento de Redução do Risco , Austrália , Humanos
12.
Nat Commun ; 4: 2555, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-24084759

RESUMO

Confining a system in a small volume profoundly alters its behaviour. Hitherto, attention has focused on static confinement where the confining wall is fixed such as in porous media. However, adaptive confinement where the wall responds to the interior has clear relevance in biological systems. Here we investigate this phenomenon with a colloidal system of quasi hard discs confined by a ring of particles trapped in holographic optical tweezers, which form a flexible elastic wall. This elasticity leads to quasi-isobaric conditions within the confined region. By measuring the displacement of the tweezed particles, we obtain the radial osmotic pressure. We further find a novel bistable state of a hexagonal structure and concentrically layered fluid mimicking the shape of the confinement. The hexagonal configurations are found at lower pressure than those of the fluid, thus the bistability is driven by the higher entropy of disordered arrangements, unlike bulk hard systems.


Assuntos
Técnicas de Química Analítica , Etanol/química , Pressão Osmótica , Poliestirenos/química , Água/química , Coloides , Simulação por Computador , Elasticidade , Entropia , Modelos Químicos , Método de Monte Carlo , Pinças Ópticas , Porosidade , Pressão
13.
Aust Fam Physician ; 41(12): 973-7, 2012 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-23210123

RESUMO

BACKGROUND: Chronic disease is responsible for 80% of the burden of disease in Australia. The Australian Government Medicare Benefits Schedule (MBS) provides incentives through specific Medicare items to optimise chronic disease management (CDM), yet little is known about factors that influence their uptake. METHODS: Exploratory qualitative research was used, which incorporated focus groups and interviews with 26 staff from nine general practices in southeast Queensland, together with review of practice-specific data on CDM income. Content analysis of qualitative data was undertaken to identify barriers, enablers and service models associated with MBS CDM item uptake. Triangulation of methods and data sources facilitated confirmation of findings. RESULTS: Time pressures and unreliable MBS information were common barriers to uptake for general practitioners. Employing a nurse, team-based approaches, recall systems and using only selected MBS CDM item numbers were associated with best uptake. CONCLUSION: Improved systems within general practice and Medicare may increase the uptake of MBS CDM item numbers.


Assuntos
Atitude do Pessoal de Saúde , Doença Crônica/economia , Medicina Geral/economia , Reembolso de Incentivo/estatística & dados numéricos , Adulto , Austrália , Doença Crônica/terapia , Feminino , Medicina Geral/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde , Pesquisa Qualitativa , Reembolso de Incentivo/economia
14.
Int J Pharm Pract ; 20(6): 395-401, 2012 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-23134099

RESUMO

OBJECTIVE: To describe the effect of integrating a pharmacist into the general practice team on the timeliness and completion of pharmacist-conducted medication reviews. METHOD: A pharmacist was integrated into an Australian inner-city suburb general practice medical centre to provide medication reviews for practice patients. A retrospective analysis of medication reviews with two time periods was conducted: pre-integration of the practice pharmacist and post-integration of the practice pharmacist. In an effort to obtain a measure of external validity the data were compared to data from the Division of General Practice in which the medical centre is located. KEY FINDINGS: There were 70 patients referred for medication review in the pre-integration phase and 314 patients referred in the post-integration phase. The time to complete the medication review process was significantly reduced from a median of 56 days to 20 days with a practice pharmacist. Prior to having a practice pharmacist 52% of patients did not have the service billed by the general practitioner, which was reduced to 6% during the post-integration phase. CONCLUSION: The results from this trial show that the integration of a pharmacist into the general practice team was associated with an increase in the timeliness and completion rate of medication reviews.


Assuntos
Revisão de Uso de Medicamentos/organização & administração , Assistência Farmacêutica/organização & administração , Farmacêuticos/organização & administração , Atenção Primária à Saúde/organização & administração , Idoso , Idoso de 80 Anos ou mais , Austrália , Feminino , Humanos , Masculino , Equipe de Assistência ao Paciente/organização & administração , Papel Profissional , Encaminhamento e Consulta , Estudos Retrospectivos , Serviços de Saúde Suburbana/organização & administração , Fatores de Tempo
15.
PLoS One ; 7(10): e47376, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-23118869

RESUMO

AIM: Investigate the cost and effects of a single-pill versus two- or three pill first-line antiretroviral combinations in reducing viral load, increasing CD4 counts, and first-line failure rate associated with respective regimens at 6 and 12 months. METHODS: Patients on first-line TDF+3TC+EFV, TDF+FTC+EFV, Truvada®+EFV or Atripla® between 1996-2008 were identified and viral load and CD4 counts measured at baseline, six and twelve months respectively. Factors that independently predicted treatment failure at six and twelve months were derived using multivariate Cox's proportional hazard regression analyses. Use and cost of hospital services were calculated at six and twelve months respectively. RESULTS: All regimens reduced viral load to below the limit of detection and CD4 counts increased to similar levels at six and twelve months for all treatment regimens. No statistically significant differences were observed for rate of treatment failure at six and twelve months. People on Atripla® generated lower healthcare costs for non-AIDS patients at £5,340 (£5,254 to £5,426) per patient-semester and £9,821 (£9,719 to £9,924) per patient-year that was £1,344 (95%CI £1,222 to £1,465) less per patient-semester and £1,954 (95%CI £1,801 to £2,107) less per patient-year compared with Truvada®+EFV; healthcare costs for AIDS patients were similar across all regimens. CONCLUSION: The single pill regimen is as effective as the two- and three-pill regimens of the same drugs, but if started as first-line induction therapy there would be a 20% savings on healthcare costs at six and 17% of costs at twelve months compared with Truvada®+EFV, that generated the next lowest costs.


Assuntos
Antirretrovirais/administração & dosagem , Combinação de Medicamentos , Infecções por HIV , Custos de Cuidados de Saúde , Adenina/administração & dosagem , Adenina/análogos & derivados , Adulto , Contagem de Linfócito CD4 , Desoxicitidina/administração & dosagem , Desoxicitidina/análogos & derivados , Combinação Efavirenz, Emtricitabina, Fumarato de Tenofovir Desoproxila , Combinação Emtricitabina e Fumarato de Tenofovir Desoproxila , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/economia , Infecções por HIV/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Organofosfonatos/administração & dosagem , Compostos Organofosforados/administração & dosagem , Oxazinas/administração & dosagem , Modelos de Riscos Proporcionais , Reino Unido , Carga Viral
17.
PLoS One ; 6(12): e27830, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-22194795

RESUMO

AIM: To calculate use, cost and cost-effectiveness of people living with HIV (PLHIV) starting routine treatment and care before starting combination antiretroviral therapy (cART) and PLHIV starting first-line 2NRTIs+NNRTI or 2NRTIs+PI(boosted), comparing PLHIV with CD4≤200 cells/mm3 and CD4>200 cells/mm3. Few studies have calculated the use, cost and cost-effectiveness of routine treatment and care before starting cART and starting cART above and below CD4 200 cells/mm3. METHODS: Use, costs and cost-effectiveness were calculated for PLHIV in routine pre-cART and starting first-line cART, comparing CD4≤200 cells/mm3 with CD4>200 cells/mm3 (2008 UK prices). RESULTS: cART naïve patients CD4≤200 cells/mm3 had an annual cost of £6,407 (95%CI £6,382 to £6,425) PPY compared with £2,758 (95%CI £2,752 to £2,761) PPY for those with CD4>200 cells/mm3; cost per life year gained of pre-cART treatment and care for those with CD4>200 cells/mm3 was £1,776 (cost-saving to £2,752). Annual cost for starting 2NRTIs+NNRTI or 2NRTIs+PI(boosted) with CD4≤200 cells/mm3 was £12,812 (95%CI £12,685-£12,937) compared with £10,478 (95%CI £10,376-£10,581) for PLHIV with CD4>200 cells/mm3. Cost per additional life-year gained on first-line therapy for those with CD4>200 cells/mm3 was £4639 (£3,967 to £2,960). CONCLUSION: PLHIV starting to use HIV services before CD4≤200 cells/mm3 is cost-effective and enables them to be monitored so they start cART with a CD4>200 cells/mm3, which results in better outcomes and is cost-effective. However, 25% of PLHIV accessing services continue to present with CD4≤200 cells/mm3. This highlights the need to investigate the cost-effectiveness of testing and early treatment programs for key populations in the UK.


Assuntos
Terapia Antirretroviral de Alta Atividade/economia , Infecções por HIV/tratamento farmacológico , Infecções por HIV/economia , Acessibilidade aos Serviços de Saúde/economia , Adulto , Análise Custo-Benefício , Demografia , Quimioterapia Combinada , Feminino , Humanos , Masculino , Análise Multivariada , Modelos de Riscos Proporcionais , Reino Unido
18.
PLoS One ; 6(5): e20200, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21633514

RESUMO

AIM: Calculate time to first-line treatment failure, annual cost and cost-effectiveness of NNRTI versus PIboosted first-line HAART regimens in the UK, 1996-2006. BACKGROUND: Population costs for HIV services are increasing in the UK and interventions need to be effective and efficient to reduce or stabilize costs. 2NRTIs + NNRTI regimens are cost-effective regimens for first-line HAART, but these regimens have not been compared with first-line PI(boosted) regimens. METHODS: Times to first-line treatment failure and annual costs were calculated for first-line HAART regimens by CD4 count when starting HAART (2006 UK prices). Cost-effectiveness of 2NRTIs+NNRTI versus 2NRTIs+PI(boosted) regimens was calculated for four CD4 strata. RESULTS: 55% of 5,541 people living with HIV (PLHIV) started HAART with CD4 count ≤ 200 cells/mm3, many of whom were Black Africans. Annual treatment cost decreased as CD4 count increased; most marked differences were observed between starting HAART with CD4 ≤ 200 cells/mm3 compared with CD4 count >200 cells/mm3. 2NRTI+PI(boosted) and 2NRTI+NNRTI regimens were the most effective regimens across the four CD4 strata; 2NRTI + NNRTI was cost-saving or cost-effective compared with 2NRTI + PI(boosted) regimens. CONCLUSION: To ensure more effective and efficient provision of HIV services, 2NRTI+NNRTI should be started as first-line HAART regimen at CD4 counts ≤ 350 cell/mm3, unless specific contra-indications exist. This will increase the number of PLHIV receiving HAART and will initially increase population costs of providing HIV services. However, starting PLHIV earlier on cost-effective regimens will maintain them in better health and use fewer health or social services, thereby generating fewer treatment and care costs, enabling them to remain socially and economically active members of society. This does raise a number of ethical issues, which will have to be acknowledged and addressed, especially in countries with limited resources.


Assuntos
Terapia Antirretroviral de Alta Atividade/métodos , Infecções por HIV/tratamento farmacológico , Infecções por HIV/economia , Inibidores da Transcriptase Reversa/uso terapêutico , Adulto , Algoritmos , Terapia Antirretroviral de Alta Atividade/estatística & dados numéricos , Contagem de Linfócito CD4 , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde/métodos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Análise de Sobrevida , Fatores de Tempo , Reino Unido
19.
Aust Fam Physician ; 39(3): 163-4, 2010 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-20369121

RESUMO

Australia continues to explore methods to restructure primary health care services to meet stressors within the health system. The primary health care strategy and its support for larger general practices and multidisciplinary team contributions, raise opportunities for re-engineering general practice services.


Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Clínicos Gerais/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Farmacêuticos/organização & administração , Austrália , Atenção à Saúde/organização & administração , Humanos , Papel Profissional , Gestão de Riscos
20.
PLoS One ; 5(12): e15677, 2010 Dec 30.
Artigo em Inglês | MEDLINE | ID: mdl-21209893

RESUMO

BACKGROUND: The number of people living with HIV (PLHIV) is increasing in the UK. This study estimated the annual population cost of providing HIV services in the UK, 1997-2006 and projected them 2007-2013. METHODS: Annual cost of HIV treatment for PLHIV by stage of HIV infection and type of ART was calculated (UK pounds, 2006 prices). Population costs were derived by multiplying the number of PLHIV by their annual cost for 1997-2006 and projected 2007-2013. RESULTS: Average annual treatment costs across all stages of HIV infection ranged from £17,034 in 1997 to £18,087 in 2006 for PLHIV on mono-therapy and from £27,649 in 1997 to £32,322 in 2006 for those on quadruple-or-more ART. The number of PLHIV using NHS services rose from 16,075 to 52,083 in 2006 and was projected to increase to 78,370 by 2013. Annual population cost rose from £104 million in 1997 to £483 million in 2006, with a projected annual cost between £721 and £758 million by 2013. When including community care costs, costs increased from £164 million in 1997, to £683 million in 2006 and between £1,019 and £1,065 million in 2013. CONCLUSIONS: Increased number of PLHIV using NHS services resulted in rising UK population costs. Population costs are expected to continue to increase, partly due to PLHIV's longer survival on ART and the relative lack of success of HIV preventing programs. Where possible, the cost of HIV treatment and care needs to be reduced without reducing the quality of services, and prevention programs need to become more effective. While high income countries are struggling to meet these increasing costs, middle- and lower-income countries with larger epidemics are likely to find it even more difficult to meet these increasing demands, given that they have fewer resources.


Assuntos
Infecções por HIV/economia , Infecções por HIV/terapia , Algoritmos , Fármacos Anti-HIV/economia , Terapia Antirretroviral de Alta Atividade/economia , Custos e Análise de Custo , Economia Médica , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Modelos Estatísticos , Estudos Prospectivos , Análise de Regressão , Reino Unido
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