Exploring Heterogeneity in Cost-Effectiveness Using Machine Learning Methods: A Case Study Using the FIRST-ABC Trial.

OBJECTIVE: The aim of this study was to explore heterogeneity in the cost-effectiveness of high-flow nasal cannula (HFNC) therapy compared with continuous positive airway pressure (CPAP) in children following extubation. DESIGN: Using data from the FIRST-line support for Assistance in Breathing in Children (FIRST-ABC) trial, we explore heterogeneity at the individual and subgroup levels using a causal forest approach, alongside a seemingly unrelated regression (SUR) approach for comparison. SETTINGS: FIRST-ABC is a noninferiority randomized controlled trial (ISRCTN60048867) including children in UK paediatric intensive care units, which compared HFNC with CPAP as the first-line mode of noninvasive respiratory support. PATIENTS: In the step-down FIRST-ABC, 600 children clinically assessed to require noninvasive respiratory support were randomly assigned to HFNC and CPAP groups with 1:1 treatment allocation ratio. In this analysis, 118 patients were excluded because they did not consent to accessing their medical records, did not consent to follow-up questionnaire or did not receive respiratory support. MEASUREMENTS AND MAIN RESULTS: The primary outcome of this study is the incremental net monetary benefit (INB) of HFNC compared with CPAP using a willingness-to-pay threshold of £20,000 per QALY gain. INB is calculated based on total costs and quality adjusted life years (QALYs) at 6 months. The findings suggest modest heterogeneity in cost-effectiveness of HFNC compared with CPAP at the subgroup level, while greater heterogeneity is detected at the individual level. CONCLUSIONS: The estimated overall INB of HFNC is smaller than the INB for patients with better baseline status suggesting that HFNC can be more cost-effective among less severely ill patients.

Management Reality of Female Patients with COPD: A Multicenter Cross-Sectional CAP Study in Japan.

Background: Reports from Europe and North America suggest that female chronic obstructive pulmonary disease (COPD) patients have a higher symptom burden and mortality than male patients. However, little is known about the management reality of female patients with COPD in Japan. Patients and Methods: We compared the clinical characteristics of female COPD patients with those of male using the cohort of the COPD Assessment in Practice study, which is a cross-sectional multicenter observational study. Results: Of the 1168 patients, 133 (11.4%) were female. A history of never smoking was higher in females than males (p<0.01). Although there was no difference in age or forced expiratory volume in one second (FEV1) % predicted between the groups, modified medical research council dyspnea scale (mMRC) and number of frequent exacerbators were higher in females (mMRC≥2: p<0.01; number of exacerbations≥2: p=0.011). The mean forced vital capacity and FEV1 values in females were lower than those in males (p<0.0001 and p<0.0001, respectively). Females were more likely to use long-term oxygen therapy and inhaled corticosteroids than males (p=0.016 and p<0.01, respectively). The prevalence of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) groups B, C, D (ABCD GOLD 2017 classification), and E (ABE GOLD 2023 classification) was higher in females than in males. Conclusion: The disease burden of female patients with COPD is higher than that of male patients in Japan, suggesting the importance of interventions considering female-dominant features such as lower absolute FVC and FEV1, respiratory failure, and asthma-like conditions.

Functional availability of medical oxygen for the management of hypoxaemia in Cameroon: A nationwide facility-based cross-sectional survey.

Background: Medical oxygen is essential for managing hypoxaemia, which has a multifactorial origin, including acute and chronic lung diseases such as pneumonia, asthma, and severe malaria. The coronavirus disease 2019 (COVID-19) revealed substantial gaps in the availability and accessibility of safe medical oxygen, especially in low- and middle-income countries (LMICs). This study aimed to assess the availability and sources, as well as the barriers to the availability of functional medical oxygen in hospitals in Cameroon. Methods: This was a nationwide cross-sectional descriptive study conducted from 26 March to 1 June 2021. Using a convenient sampling technique, we sampled accredited public and private COVID-19 treatment centres in all ten regions in Cameroon. Representatives from the selected hospitals were provided with a pre-designed questionnaire assessing the availability, type, and state of medical oxygen in their facilities. All analyses were performed using R. Results: In total, 114 hospitals were included in this study, with functional medical oxygen available in 65% (74/114) of the hospitals. About 85% (23/27) of the reference hospitals and only 59% (51/87) of the district hospitals had available functional medical oxygen. Compared to district hospitals, reference hospitals were more likely to have central oxygen units (reference vs. district: 10 vs. 0%), oxygen cylinders (74 vs. 42%), and oxygen concentrators (79 vs. 51%). The most common barriers to the availability of medical oxygen were inadequate oxygen supply to meet needs (district vs. reference hospitals: 55 vs. 30%), long delays in oxygen bottle refills (51 vs. 49%), and long distances from oxygen suppliers (57 vs. 49%). Conclusions: The availability of medical oxygen in hospitals in Cameroon is suboptimal and more limited in districts compared to reference hospitals. The cost of medical oxygen, delays related to refills and supplies, and long distances from medical sources were the most common barriers to availability in Cameroon.

High-flow nasal cannula use in pediatric patients for other indications than acute bronchiolitis-a scoping review of randomized controlled trials.

The objective of the study is to summarize current literature on high-flow nasal cannula (HFNC) use for different indications in pediatric patient excluding acute bronchiolitis and neonatal care. The study design is a systematic scoping review. Pubmed, Scopus, and Web of Science databases were searched in February, 2023. All abstracts and full texts were screened by two independent reviewers. Randomized controlled trials focusing on HFNC use in pediatric patients (age < 18 years) were included. Studies focusing on acute bronchiolitis and neonatal respiratory conditions were excluded. Study quality was assessed by Cochrane risk of bias 2.0 tool. The main outcomes are patient groups and indications, key outcomes, and risk of bias. After screening 1276 abstracts, we included 22 full reports. Risk of bias was low in 11 and high in 5 studies. We identified three patient groups where HFNC has been studied: first, children requiring primary respiratory support for acute respiratory failure; second, perioperative use for either intraprocedural oxygenation or postoperative respiratory support; and third, post-extubation care in pediatric intensive care for other than postoperative patients. Clinical and laboratory parameters were assessed as key outcomes. None of the studies analyzed cost-effectiveness.Conclusion: This systematic scoping review provides an overview of current evidence for HFNC use in pediatric patients. Future studies should aim for better quality and include economic evaluation with cost-effectiveness analysis.Protocol registration: Protocol has been published https://osf.io/a3y46/ .

Rapid implementation of home oxygen treatment and remote monitoring for COVID-19 patients at the verge of the Omicron wave in Turku, Finland.

BACKGROUND: In Turku, Finland, we introduced a home oxygen treatment and app-based monitoring program for hospitalized COVID-19 patients to facilitate an early discharge during the Omicron wave. In this case series we explore the clinical parameters of patients enrolled in the program and evaluate the cost-benefit and safety issues of the program. METHODS: Hospitalized COVID-19 patients with marked hypoxemia but otherwise in stable condition were screened from Turku City Hospital and Turku University Hospital by treating doctors for eligibility in the program. Peripheral oxygen saturation of > 92% and breathing frequency < 30/min in rest with oxygen supplementation were among the criteria. All patients actively participating in the program between 10th of January 2022 and 30th of September 2022 were included in this case series. Clinical data of hospitalization and monitoring were analysed, and cost-benefit evaluation was based on the number of saved hospitalization days. RESULTS: Nineteen COVID-19 patients were included in this case series and recruited from three different hospital departments in the Turku city region, South-West Finland. All patients were male, the median age was 59 years and the median duration of hospitalization before enrolment in the program was 6 days (range 3-20 days). The median duration of home oxygen treatment was 13 days (range 3-72 days) and the median duration of home monitoring was 18 days (range 7-41 days). A total of 210,5 hospital days were prevented, resulting in savings of €144,490 of healthcare expenditure (on average 9 days and €7,605 per patient). No major safety issues were reported during the program. CONCLUSIONS: In our case series, home oxygen treatment combined with home monitoring was safe and economically beneficial. Application based monitoring could be considered in other post-acute pulmonary conditions to reduce hospitalization and healthcare costs.

Supplemental Oxygen Therapy in Interstitial Lung Disease: A Narrative Review.

Patients with interstitial lung diseases (ILD) often have hypoxemia at rest and/or with exertion, for which supplemental oxygen is commonly prescribed. The number of patients with ILD who require supplemental oxygen is unknown, although estimates suggest it could be as much as 40%; many of these patients may require high-flow support (>4 L/min). Despite its frequent use, there is limited evidence for the impact of supplemental oxygen on clinical outcomes in ILD, with recommendations for its use primarily based on older studies in patients with chronic obstructive pulmonary disease. Oxygen use in ILD is rarely included as an outcome in clinical trials. Available evidence suggests that supplemental oxygen in ILD may improve quality of life and some exercise parameters in patients whose hypoxemia is a limiting factor; however, oxygen therapy also places new burdens and barriers on some patients that may counter its beneficial effects. The cost of supplemental oxygen in ILD is also unknown but likely represents a significant portion of overall healthcare costs in these patients. Current Centers for Medicare and Medicaid reimbursement policies provide only a modest increase in payment for high oxygen flows, which may negatively impact access to oxygen services and equipment for some patients with ILD. Future studies should examine clinical and quality-of-life outcomes for oxygen use in ILD. In the meantime, given the current limited evidence for supplemental oxygen and considering cost factors and other barriers, providers should take a patient-focused approach when considering supplemental oxygen prescriptions in patients with ILD.

Sleep Assessment in Critically Ill Patients With Acute Hypoxemic Respiratory Failure.

BACKGROUND: Sleep deprivation alters respiratory muscle performance and may precipitate respiratory failure. This study aimed to assess sleep in subjects admitted to ICU for acute hypoxemic respiratory failure and its role in the risk of intubation. METHODS: This was a prospective observational single-center cohort study including subjects admitted to ICU for de novo acute hypoxemic respiratory failure defined as breathing frequency ≥ 25 breaths/min or clinical signs of respiratory distress and PaO2 /FIO2 < 300 mm Hg while receiving high-flow nasal oxygen. Subjects with altered consciousness, central nervous or psychiatric disorders, continuous sedation or neuroleptic medication, or were uncooperative were excluded. Sleep was assessed by complete polysomnography (PSG) the night following ICU admission. The main outcome was to assess sleep among subjects with acute hypoxemic respiratory failure and to compare sleep between subjects who eventually required intubation to those who did not. RESULTS: Over a 24-month inclusion period, 34 subjects had complete PSG, among whom 5 (15%) required intubation in the ICU. Total sleep time was 4.2 h in median (interquartile range 2.9-6.8); deep-sleep duration was 70 min (34-127), and rapid eye movement (REM) sleep duration was 9 min (0-28). Among them, 13 subjects (38%) had no REM sleep. Total sleep time and duration of deep and REM sleep stages did not differ between subjects who required intubation and those successfully treated with high-flow nasal oxygen. CONCLUSIONS: Whereas total sleep time remained relatively preserved in critically ill subjects with acute hypoxemic respiratory failure, REM sleep time was uncommon or completely absent in a large number of subjects. Sleep did not differ between subjects who required intubation and those who did not. However, given a trend toward an increased risk of intubation in subjects with a complete absence of REM sleep, further studies are needed to better explore the impact of REM sleep on the risk of intubation.

A covid-19 como um analisador do sofrimento de enfermeiras: um ensaio teórico / Covid-19 as a suffering analyzer for female nurses: a theoretical essay / El covid-19 como analizador de sufrimiento de enfermeras: un ensayo teórico

Este ensaio propõe que a Covid-19 pode operar como um analisador, dentro da perspectiva da análise institucional, iluminando um determinado modo de organização social que promove profundas desigualdades e ameaça a vida em diversos níveis e revelando as condições sociais, institucionais e políticas de produção de sofrimento no corpo profissional de Enfermagem. A pandemia desvelou um conjunto de marcas relacionadas à profissão, agravadas pela crise sanitária, reforçando a naturalização das relações de cuidado atribuídas ao feminino, bem como um conjunto de clivagens e hierarquias internas à profissão a partir da sinergia de marcadores da diferença, como gênero, cor/raça, classe e geração. Além disso, este trabalho mostra a presença de uma necropolítica nas respostas à pandemia que banaliza a vida e permite morrer determinados grupos sociais. A ideia de "profissionais de linha de frente" é criticada em suas metáforas bélicas, mas tomada como figura de linguagem em sua potência para afirmar que existem corpos que, pelas marcas sociais e históricas e pela interdependência do cuidado, são mais presentes e exigidos e, portanto, mais vulneráveis à doença e ao sofrimento dela decorrente.(AU)

The essay proposes that Covid-19 can operate as an analyzer, within the perspective of institutional analysis, illuminating a certain mode of social organization that promotes profound inequalities and threatens life at various levels, revealing the social, institutional and political conditions for the production of suffering in the professional nursing body. The pandemic would unveil a set of marks related to the profession, aggravated by the sanitary crisis, reinforcing the naturalization of the care relations attributed to the feminine, as well as a set of cleavages and internal hierarchies to the profession from the synergy of markers of difference as gender, color/race, class and generation. The work shows the presence of necropolitics in responses to the pandemic, which trivializes life and allows certain social groups to die. The idea of "front-line professionals" is criticized in its war metaphors, but taken as a figure of speech in its potency to affirm that there are bodies that by social and historical marks, and by the interdependence of care, are more present and demanded, and therefore more vulnerable to disease and the resulting suffering.(AU)

El ensayo propone que el Covid-19 puede funcionar como analizador, desde la perspectiva del análisis institucional, revelando las condiciones sociales, institucionales y políticas de producción de sufrimiento de enfermeras. La pandemia revela algunas marcas relacionadas con la profesión, agravadas por la crisis de salud, reforzando la naturalización de la atribución del cuidado a lo femenino y un conjunto de jerarquías internas de la profesión. El trabajo también muestra la presencia de una necropolítica en las respuestas a la pandemia. La idea de "profesionales de primera línea" es criticada, pero tomada como una figura del lenguaje en su potencia para afirmar que hay cuerpos que, por las marcas sociales e históricas y por la interdependencia del cuidado, están más presentes y demandados, y por lo tanto más vulnerables a la enfermedad.(AU)

Systematic review and cost-utility of high flow nasal cannula versus continuous positive airway pressure in children with acute severe or moderate bronchiolitis in Colombia.

BACKGROUND: Nasal Continuous Positive Airway Pressure (CPAP) and High-Flow Nasal Cannula (HFNC) have emerged as alternatives to orotracheal intubation and conventional invasive ventilation in patients with moderate to severe bronchiolitis. This study aims to evaluate the evidence and the cost-utility of HFNC compared to CPAP in infants with moderate-severe bronchiolitis in Colombia. METHODS: The search includes electronic databases such as Pubmed, ScienceDirect, and Embase. Through inclusion and exclusion criteria, screen randomized controlled trials. A decision tree model was used to estimate the cost-utility of CPAP compared with HFNC in infants with moderate-severe bronchiolitis. Sensitivity analysis of transition probabilities, utilities, and cost was carried out. RESULTS: Incorporate five studies that meet the criteria. The risk of intubation rate in the patients with CPAP is lower than HFNC (relative risk 0.62; 95% confidence interval 0.46-0.84; I2 = 0%) The base-case analysis showed that compared with HFNC, CPAP was associated with lower costs and higher quality-adjusted life years (QALYs). The expected annual cost per patient with CPAP was US$17,574 and with HFNC was US$29,421. The QALYs per person estimated with CPAP were 0.92 and with HFNC was 0.91. This position of absolute dominance of CPAP (CPAP has lower costs and higher QALYs than HFNI) makes it unnecessary to estimate the incremental cost-utility ratio. CONCLUSIONS: CPAP is cost-effective, over the HFNC, in infants with severe-moderate bronchiolitis in Colombia. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines and should be replicated to validate their results in other countries.

Prevalence of high flow nasal cannula therapy use for management of infants with bronchiolitis in Australia and New Zealand.

AIM: To determine the prevalence of high flow nasal cannula (HFNC) therapy in infants presenting to hospital in Australia and New Zealand with bronchiolitis over four bronchiolitis seasons. Secondary aims were to determine temporal trends in HFNC use, and associations between HFNC, hospital length of stay (LOS) and intensive care unit (ICU) admission. METHODS: A planned sub-study of a multi-centre international cluster randomised controlled trial investigating knowledge translation strategies for a bi-national bronchiolitis guideline. Demographics, management and outcomes data were collected retrospectively for infants presenting with bronchiolitis to 26 hospitals between 1 May 2014 and 30 November 2017. Prevalence data are presented as absolute frequencies (95% confidence interval (CI)) with differences between groups for continuous and categorical variables analysed using linear and logistic regression, respectively. RESULTS: 11 715 infants were included with 3392 (29.0%, 95% CI (28.1-29.8%)) receiving oxygen therapy; of whom 1817 (53.6%, 95% CI (51.9-55.3%)) received HFNC. Use of oxygen therapy did not change over the four bronchiolitis seasons (P = 0.12), while the proportion receiving HFNC increased (2014, 336/2587 (43.2%); 2017, 609/3720 (57.8%); P ≤ 0.001). Infants who received HFNC therapy were not substantially different to infants who received oxygen therapy without HFNC. HFNC use was associated with increases in both hospital LOS (P < 0.001) and ICU admissions (P < 0.001). CONCLUSION: Use of HFNC therapy for infants with bronchiolitis increased over 4 years. Of those who received oxygen therapy, the majority received HFNC therapy without improvement in hospital LOS or ICU admissions. Strategies to guide appropriate HFNC use in infants with bronchiolitis are required.

Assessment of Racial and Ethnic Differences in Oxygen Supplementation Among Patients in the Intensive Care Unit.

Importance: Pulse oximetry (SpO2) is routinely used for transcutaneous monitoring of blood oxygenation, but it can overestimate actual oxygenation. This is more common in patients of racial and ethnic minority groups. The extent to which these discrepancies are associated with variations in treatment is not known. Objective: To determine if there are racial and ethnic disparities in supplemental oxygen administration associated with inconsistent pulse oximeter performance. Design, Setting, and Participants: This retrospective cohort study was based on the Medical Information Mart for Intensive Care (MIMIC)-IV critical care data set. Included patients were documented with a race and ethnicity as Asian, Black, Hispanic, or White and were admitted to the intensive care unit (ICU) for at least 12 hours before needing advanced respiratory support, if any. Oxygenation levels and nasal cannula flow rates for up to 5 days from ICU admission or until the time of intubation, noninvasive positive pressure ventilation, high-flow nasal cannula, or tracheostomy were analyzed. Main Outcomes and Measures: The primary outcome was time-weighted average supplemental oxygen rate. Covariates included race and ethnicity, sex, SpO2-hemoglobin oxygen saturation discrepancy, data duration, number and timing of blood gas tests on ICU days 1 to 3, partial pressure of carbon dioxide, hemoglobin level, average respiratory rate, Elixhauser comorbidity scores, and need for vasopressors or inotropes. Results: This cohort included 3069 patients (mean [SD] age, 66.9 [13.5] years; 83 were Asian, 207 were Black, 112 were Hispanic, 2667 were White). In a multivariable linear regression, Asian (coefficient, 0.602; 95% CI, 0.263 to 0.941; P = .001), Black (coefficient, 0.919; 95% CI, 0.698 to 1.140; P < .001), and Hispanic (coefficient, 0.622; 95% CI, 0.329 to 0.915; P < .001) race and ethnicity were all associated with a higher SpO2 for a given hemoglobin oxygen saturation. Asian (coefficient, -0.291; 95% CI, -0.546 to -0.035; P = .03), Black (coefficient, -0.294; 95% CI, -0.460 to -0.128; P = .001), and Hispanic (coefficient, -0.242; 95% CI, -0.463 to -0.020; P = .03) race and ethnicity were associated with lower average oxygen delivery rates. When controlling for the discrepancy between average SpO2 and average hemoglobin oxygen saturation, race and ethnicity were not associated with oxygen delivery rate. This discrepancy mediated the effect of race and ethnicity (-0.157; 95% CI, -0.250 to -0.057; P = .002). Conclusions and Relevance: In this cohort study, Asian, Black, and Hispanic patients received less supplemental oxygen than White patients, and this was associated with differences in pulse oximeter performance, which may contribute to known race and ethnicity-based disparities in care.

An On-Demand Oxygen Flow Meter for Enhanced Patient Comfort and Reduced Oxygen Cost in Hospitals.

Background: Hypoxemia is currently treated in hospital wards with oxygen, released continuously by "conventional" flow meters. A new type of hybrid flow meter allows to switch between on-demand and continuous mode. The aim of this observational study was to assess whether this new device reduces oxygen expenditure, is well accepted in a hospital setting and improves patient comfort during oxygen therapy. Methods: Oxygen was administered in hypoxemic patients with conventional or hybrid flow meters to maintain an oxygen saturation of ≥ 92% over a 12-week period. Every two weeks conventional and hybrid flow meters were switched. The overall oxygen delivery to the ward was continuously measured with a data logging device installed in the main oxygen pipeline and corrected for multiple confounding factors. Humidity measurements, for which a sensor placed in front of one of the nostrils, and patient questionnaires, were used to assess patient comfort during continuous and on-demand flow. Results: Overall oxygen delivery decreased by 39% when switching from continuous flow to on-demand therapy after correction for confounding factors. Continuous flows significantly decreased relative humidity more than equivalent on-demand settings and the latter tended to increase comfort. Conclusions: Hybrid flow meters cause a significant reduction in oxygen delivery in a hospital ward, which may lead to financial savings. Using the on-demand technology also lowers the dryness of the upper airways (and may increase patient comfort), while maintaining an adequate oxygenation.

Hospital Cost Savings for Sequential COPD Patients Receiving Domiciliary Nasal High Flow Therapy.

Purpose: To estimate the 5-year budget impact to Aotearoa New Zealand (NZ) hospitals of domiciliary nasal high flow (NHF) therapy to patients with chronic obstructive pulmonary disease (COPD) who require long term oxygen therapy. Methods: Hospital admission counts along with length of stay were obtained from hospital records of 200 COPD patients enrolled in a 12-month randomized clinical trial of NHF in Denmark, both over a 12-month baseline and then in the study period while on randomized treatment (control or NHF). NZ costings from similar COPD patients were estimated using data from Middlemore Hospital, Auckland and were applied to the Danish trial. The budget impact of NHF was estimated over the predicted 5-year lifetime of the device when used by patients sequentially. Results: Fifty-five of 100 patients in the NHF group and 44 of 100 patients in the control group were admitted to hospital with a respiratory diagnosis during the baseline year. They had 108 admissions in the treatment group vs 89 in the control group, with 632 vs 438 days in hospital, and modeled annual costs of $9443 vs $6512 per patient, respectively. During the study period there were 38 vs 44 patients with 67 vs 80 admissions and 302 vs 526 days in hospital, at a modeled annual cost of $6961 vs $9565 per patient respectively. Taking into account capital expenditure and running costs, this resulted in cost savings of $5535 per patient-year (95% CI, -$36 to -$11,034). With 90% usage over the estimated five-year lifetime of the NHF device, amortized capital costs of $594 per year and annual running costs of $662, we estimate a 5-year undiscounted cost saving per NHF device of $18,626 ($16,934 when discounted to net present value at 5% per annum). There would still be annual cost savings over a wide range of assumptions. Conclusion: Domiciliary NHF therapy for patients with severe COPD has the potential to provide substantial hospital cost savings over the five-year lifetime of the NHF device.

Epidemiology, healthcare utilization, and related costs among patients with IPF: results from a German claims database analysis.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a progressive form of fibrosing interstitial pneumonia with poor survival. This study provides insight into the epidemiology, cost, and disease course of IPF in Germany. METHODS: A cohort of incident patients with IPF (n = 1737) was identified from German claims data (2014-2019). Incidence and prevalence rates were calculated and adjusted for age differences compared with the overall German population. All-cause and IPF-related healthcare resource utilization as well as associated costs were evaluated per observed person-year (PY) following the initial IPF diagnosis. Finally, Kaplan-Meier analyses were performed to assess time from initial diagnosis to disease deterioration (using three proxy measures: non-elective hospitalization, IPF-related hospitalization, long-term oxygen therapy [LTOT]); antifibrotic therapy initiation; and all-cause death. RESULTS: The cumulative incidence of IPF was estimated at 10.7 per 100,000 individuals in 2016, 10.9 in 2017, 10.5 in 2018, and 9.6 in 2019. The point prevalence rates per 100,000 individuals for the respective years were 21.7, 23.5, 24.1, and 24.1. On average, ≥ 14 physician visits and nearly two hospitalizations per PY were observed after the initial IPF diagnosis. Of total all-cause direct costs (€15,721/PY), 55.7% (€8754/PY) were due to hospitalizations and 29.1% (€4572/PY) were due to medication. Medication accounted for 49.4% (€1470/PY) and hospitalizations for 34.8% (€1034/PY) of total IPF-related direct costs (€2973/PY). Within 2 years of the initial IPF diagnosis (23.6 months), 25% of patients died. Within 5 years of diagnosis, 53.1% of patients had initiated LTOT; only 11.6% were treated with antifibrotic agents. The median time from the initial diagnosis to the first non-elective hospitalization was 5.5 months. CONCLUSION: The incidence and prevalence of IPF in Germany are at the higher end of the range reported in the literature. The main driver for all-cause cost was hospitalization. IPF-related costs were mainly driven by medication, with antifibrotic agents accounting for around one-third of the total medication costs even if not frequently prescribed. Most patients with IPF do not receive pharmacological treatment, highlighting the existing unmet medical need for effective and well-tolerated therapies.

Baricitinibe para tratamento de pacientes adultos com Covid-19 hospitalizados que necessitam de oxigênio por máscara ou cateter nasal, ou que necessitam de alto fluxo de oxigênio ou ventilação não invasiva / Baricitinib for the treatment of hospitalized adult patients with Covid-19 who require oxygen by mask or nasal catheter, or who require high flow oxygen or non-invasive ventilation

INTRODUÇÃO: O baricitinbe, um imunomodulador que atua sobre a atividade da IL-6 (citocina pró-inflamatória), pode representar uma estratégia para o tratamento de pacientes com COVID-19 que tiveram comprometimento pulmonar devido a resposta hiperinflamátoria desencadeada pela tempestade de citocinas característica na infecção causada pelo vírus SARS-COV2. TECNOLOGIA: Baricitinibe (Olumiant®). EVIDÊNCIAS CLÍNICAS: Para seleção das evidências clínicas foi conduzida uma revisão sistemática da literatura em busca de ensaios clínicos randomizados (ECR), estudos observacionais (mundo real) e revisões sistemáticas que avaliassem os efeitos do baricitinibe como monoterapia ou associado aos cuidados usuais - definidos aqui como 'terapia padrão' (corticoesteróides sistêmicos, anticoagulantes, antimicrobianos/antivirais) no tratamento de pacientes adultos com COVID-19, hospitalizados e que necessitam de suplementação de oxigênio (máscara ou cateter nasal, alto fluxo de oxigênio ou ventilação não invasiva). As buscas eletrônicas foram realizadas nas bases de dados: the Cochrane Library, MEDLINE via Pubmed, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), EMBASE e Centre for Reviews and Dissemination (CRD). O risco de viés dos estudos primários incluídos foi avaliado pelas ferramentas Risk of Bias versão 2 da Cochrane (para ECR) ou ROBINS-I (para estudos observacionais), e a qualidade metodológica das revisões sistemáticas foi avaliada pela ferramenta AMSTAR-2. A qualidade da evidência foi avaliada pelo sistema GRADE. Seis artigos foram incluídos na presente revisão, sendo dois deles referentes a um ensaio clínico randomizado (ECR), um estudo observacional e três revisões sistemáticas com meta-análise (RSMA), sendo uma

Assessment of Clinical Outcomes Among Children and Adolescents Hospitalized With COVID-19 in 6 Sub-Saharan African Countries.

IMPORTANCE: Little is known about COVID-19 outcomes among children and adolescents in sub-Saharan Africa, where preexisting comorbidities are prevalent. OBJECTIVE: To assess the clinical outcomes and factors associated with outcomes among children and adolescents hospitalized with COVID-19 in 6 countries in sub-Saharan Africa. DESIGN, SETTING, AND PARTICIPANTS: This cohort study was a retrospective record review of data from 25 hospitals in the Democratic Republic of the Congo, Ghana, Kenya, Nigeria, South Africa, and Uganda from March 1 to December 31, 2020, and included 469 hospitalized patients aged 0 to 19 years with SARS-CoV-2 infection. EXPOSURES: Age, sex, preexisting comorbidities, and region of residence. MAIN OUTCOMES AND MEASURES: An ordinal primary outcome scale was used comprising 5 categories: (1) hospitalization without oxygen supplementation, (2) hospitalization with oxygen supplementation, (3) ICU admission, (4) invasive mechanical ventilation, and (5) death. The secondary outcome was length of hospital stay. RESULTS: Among 469 hospitalized children and adolescents, the median age was 5.9 years (IQR, 1.6-11.1 years); 245 patients (52.4%) were male, and 115 (24.5%) had comorbidities. A total of 39 patients (8.3%) were from central Africa, 172 (36.7%) from eastern Africa, 208 (44.3%) from southern Africa, and 50 (10.7%) from western Africa. Eighteen patients had suspected (n = 6) or confirmed (n = 12) multisystem inflammatory syndrome in children. Thirty-nine patients (8.3%) died, including 22 of 69 patients (31.9%) who required intensive care unit admission and 4 of 18 patients (22.2%) with suspected or confirmed multisystem inflammatory syndrome in children. Among 468 patients, 418 (89.3%) were discharged, and 16 (3.4%) remained hospitalized. The likelihood of outcomes with higher vs lower severity among children younger than 1 year expressed as adjusted odds ratio (aOR) was 4.89 (95% CI, 1.44-16.61) times higher than that of adolescents aged 15 to 19 years. The presence of hypertension (aOR, 5.91; 95% CI, 1.89-18.50), chronic lung disease (aOR, 2.97; 95% CI, 1.65-5.37), or a hematological disorder (aOR, 3.10; 95% CI, 1.04-9.24) was associated with severe outcomes. Age younger than 1 year (adjusted subdistribution hazard ratio [asHR], 0.48; 95% CI, 0.27-0.87), the presence of 1 comorbidity (asHR, 0.54; 95% CI, 0.40-0.72), and the presence of 2 or more comorbidities (asHR, 0.26; 95% CI, 0.18-0.38) were associated with reduced rates of hospital discharge. CONCLUSIONS AND RELEVANCE: In this cohort study of children and adolescents hospitalized with COVID-19 in sub-Saharan Africa, high rates of morbidity and mortality were observed among infants and patients with noncommunicable disease comorbidities, suggesting that COVID-19 vaccination and therapeutic interventions are needed for young populations in this region.