Is it still worthwhile to perform quarterly cd4+ t lymphocyte cell counts on hiv-1 infected stable patients?

BACKGROUND: In the last 20 years routine T CD4+ lymphocyte (CD4+) cell count has proved to be a key factor to determine the stage of HIV infection and start or discontinue of prophylaxis for opportunistic infections. However, several studies recently showed that in stable patients on cART a quarterly CD4+ cell count monitoring results in limited (or null) clinical relevance. The research is intended to investigate whether performing quarterly CD4+ cell counts in stable HIV-1 patients is still recommendable and to provide a forecast of the cost saving that could be achieved by reducing CD4+ monitoring in such a category of patients. METHODS: The study is based on data referring to all HIV-infected patients > 18 years of age being treated at two large infectious diseases units located in the metropolitan area of Genoa, Italy. The probability of CD4+ cell counts dropping below a threshold value set at 350 cells/mm3 is assessed using confidence intervals and Kaplan-Meier survival estimates, whereas multivariate Cox analysis and logistic regression are implemented in order to identify factors associated with CD4+ cell count falls below 350 cells/mm3. RESULTS: Statistical analysis reveals that among stable patients the probability of maintaining CD4+ >350 cell/mm3 is more than 98%. Econometric models indicate that HCV co-infection and HIV-RNA values >50 copies/mL in previous examinations are associated with CD4+ falls below 350 cells/mm3. Moreover, results suggest that the cost saving that could be obtained by reducing CD4+ examinations ranges from 33 to 67%. CONCLUSIONS: Empirical findings shows that patients defined as stable at enrollment are highly unlikely to experience a CD4+ value <350 cell/mm3 in the space/arc of a year. The research supports a recommendation for annual CD4+ monitoring in stable HIV-1 patients.

Targeting frequent users of emergency departments: Prominent risk factors and policy implications.

This study investigates the characteristics of frequent users of accident and emergency departments (AEDs) and recommends alternative medical services for such patients. Prominent demographic and clinical risk factors for individuals accessing seven AEDs located in the metropolitan area of Genoa, Italy are identified and analysed. A truncated count data model is implemented to establish the determinants of access, while a multinomial logistic regression is used to highlight potential differences among different user categories. According to previous studies, empirical findings suggest that despite the relevance of demographic drivers, vulnerability conditions (e.g. abuse of alcohol and drugs, chronic conditions, and psychological distress) are the main reasons behind frequent AED use; the analysis seems to confirm an association between AED frequent use and lower level of urgency. Since frequent and highly frequent users are found responsible for disproportionate resource absorption with respect to total amount of AED costs (they represent roughly 10% of the total number of patients, but contribute to more than 19% of the total annual AED cost), policies aiming to reduce frequent use of AEDs could bring significant savings in economic resources. Thus, efficient actions could be oriented toward extending primary care services outside AED and toward instituting local aid services specifically addressed to people under the influence of substances or in conditions of mental distress.

IANUA: a regional project for the determination of costs in HIV-infected patients.

HIV treatment is based on combined antiretroviral therapy (cART) which has substantially improved survival, thus resulting in an increase in patient life expectancy as well as in the cost of HIV-related medical care. Therefore, several cost effectiveness studies were implemented worldwide, with one specifically in the Liguria region (Italy), to compare the annual economic expense in this area for HIV services, and the related improvement in patients' health. The IANUA project is intended to implement both cost-effectiveness and cost-utility analysis, therefore data related to clinical indicators and perceived health status were collected, the latter using a questionnaire based on the EQ-5D-3L. Information about the antiretroviral drugs and the relative quantity that a patient withdraws from the hospital pharmacy every month were extracted from the regional "F-file". All data gathered were stored in the Ligurian HIV Network, a web platform developed by the DIBRIS - Medinfo laboratory. More than eight hundred questionnaires were collected, and data will be elaborated by economists and psychologists. The first statistical elaborations showed that, as expected, costs increased as the number of therapeutic lines increased. Moreover, the average annual costs for patients whose last CD4 values were below 200 cells/mmc corresponded to the maximum expense recorded, however, the cost for patients with final CD4 counts above 500 cells/mmc was not, as expected, the lowest found. This can be explained by the fact that stabilized patients, who had CD4 values below 500 cells/mmc, did not need very expensive care, while patients with CD4 counts above 500 cells/mmc improved their health status thanks to cART.