Acute Pain Management for Patients Maintained on Sublingual Buprenorphine as Medication for Opioid Use Disorder.

OBJECTIVE: The aim of this study was to compare morphine milligram equivalent (MME) requirements for acute pain management between patients admitted for medical or surgical diagnoses with opioid use disorder (OUD) who receive >12 mg of sublingual buprenorphine daily compared with those who receive ≤12 mg/d. DESIGN: This study was performed via retrospective chart review. SETTING: This study evaluated patient encounters between January 2017 and November 2021 from a single-center community teaching hospital in Lancaster, PA. METHODS: Patients were assessed according to daily dose of buprenorphine received while admitted (>12 mg/d vs ≤12 mg/d); patients who had buprenorphine held were included within the ≤12 mg/d study group. The primary outcome evaluated daily average MME requirements over the entirety of hospital length of stay. Key secondary outcomes were total MME requirements and daily average pain scores. SUBJECTS: Key inclusion criteria were sublingual buprenorphine therapy for at least 1 month prior to admission, presence of an acute pain diagnosis during hospital stay, and history of OUD. RESULTS: Seventy-eight (78) patients were included for analysis. Daily average MME requirements were similar between patients who received buprenorphine >12 mg/d and ≤12 mg/d (median, 7.5 vs 10.6; P = 0.350). Total MME and daily average pain scores were similar between study groups. CONCLUSIONS: For OUD patients in need of acute pain management, the continuation of sublingual buprenorphine throughout hospitalization at a daily dose of >12 mg/d compared with ≤12 mg/d did not confer a significant difference in daily average MME requirements.

Appropriateness of prescribed oral antibiotic duration at the time of hospital discharge.

Antibiotic stewardship initiatives usually occur in the inpatient setting and should be optimized during transitions of care. In this study, we assessed the appropriateness of oral antibiotic treatment duration at the time of discharge from our institution based on national guidelines and clinical parameters for common infections.

Treatment of Chronic Hepatitis C in Young Children Reduces Adverse Outcomes and Is Cost-Effective Compared with Deferring Treatment to Adulthood.

OBJECTIVE: To evaluate the cost-effectiveness of treating young children with chronic hepatitis C virus (HCV) with new direct-acting antivirals. STUDY DESIGN: A state-transition model of chronic HCV was developed to conduct a cost-effectiveness analysis comparing treatment at age 6 years vs delaying treatment until age 18 years. Model inputs were derived from recently conducted systematic reviews, published literature, and government statistics. Medical care costs were obtained from linked population level laboratory and administrative data (Ontario, Canada). Outcomes are expressed in expected quality-adjusted life-years and costs (CAD$). Analysis included a base-case to estimate the expected value and one-way and probabilistic sensitivity analyses to evaluate the impact of uncertainty of the model inputs. RESULTS: After 20 years, treating 10 000 children early would prevent 330 cases of cirrhosis, 18 cases of hepatocellular carcinoma, and 48 liver-related deaths. The incremental cost-effectiveness ratio of early treatment compared to delayed treatment was approximately $12 690/quality-adjusted life-years gained and considered cost-effective. Model results were robust to variation in fibrosis progression rates, disease state-based costs, treatment costs, and utilities. CONCLUSIONS: Delaying treatment until age 18 years results in an increased lifetime risk of late-stage liver complications. Early treatment in children is cost effective. Our work supports clinical and health policies that broaden HCV treatment access to young children.

Strategies to achieve population control of HCV infection: results of a multidisciplinary focus group.

Background: To meet the World Health Organization's ambitious target to eradicate hepatitis C virus (HCV) by 2030, a comprehensive strategy is needed in Canada to ensure everyone infected with HCV is identified, diagnosed, and treated. The purpose of this study was to highlight the barriers to any strategy aimed at achieving this goal. Methods: A focus group was formed (N = 11) that consisted of clinicians, patients, drug program budget managers, industry representatives, and individuals from provincial public health and federal agencies in Canada. The group met in person for a half-day focus group session. Two discussions were held: one on future barriers related to HCV treatment and one related to HCV screening. A grounded theory approach was used to elicit key themes from the day's discussion. Results: Nine themes were identified. Four themes related to HCV screening: public awareness and engagement, resource infrastructure and capacity, heterogeneity between provinces, and mechanisms of screening. Three themes related to HCV treatment: access to treatment and illicit drug use, linkage to care, and predicting post-treatment outcomes. Two overarching themes that contributed to most discussions were a focus on baby boomers versus persons who inject drugs and the need for further education and training. Conclusion: The views and findings extracted from this qualitative research complement proposals of national strategies from organizations such as the Canadian Network on Hepatitis C. This work highlights the financial, logistical, and ethical constraints that need to be tackled to make HCV elimination proposals a reality.

Cost Effectiveness of Advanced Pharmacy Services Provided in the Community and Primary Care Settings: A Systematic Review.

BACKGROUND: Pharmacists working in community and primary care are increasingly developing advanced skills to provide enhanced services, particularly in dealing with minor acute illness. These services can potentially free-up primary care physicians' time; however, it is not clear whether they are sufficiently cost effective to be recommended for wider provision in the UK. OBJECTIVE: The aim of this study was to review published economic evaluations of enhanced pharmacy services in the community and primary care settings. METHODS: We undertook a systematic review of economic evaluations of enhanced pharmacy services to inform NICE guidelines for emergency and acute care. The review protocol was developed and agreed with the guideline committee. The National Health Service Economic Evaluation Database, Health Technology Assessment Database, Health Economic Evaluations Database, MEDLINE and EMBASE were searched in December 2016 and the search was updated in March 2018. Studies were assessed for applicability and methodological quality using the NICE Economic Evaluation Checklist. RESULTS: Of 3124 records, 13 studies published in 14 papers were included. The studies were conducted in the UK, Spain, The Netherlands, Australia, Italy and Canada. Settings included community pharmacies, primary care/general practice surgeries and patients' homes. Most of the studies were assessed as partially applicable with potentially serious limitations. Services provided in community and primary care settings were found to be either dominant or cost effective, at a £20,000 per quality-adjusted life-year threshold, compared with usual care. Those delivered in the patient's home were not found to be cost effective. CONCLUSIONS: Advanced pharmacy services appear to be cost effective when delivered in community and primary care settings, but not in domiciliary settings. Expansion in the provision of these services in community and primary care can be recommended for wider implementation.

An economic evaluation of vector control in the age of a dengue vaccine.

INTRODUCTION: Dengue is a rapidly emerging vector-borne Neglected Tropical Disease, with a 30-fold increase in the number of cases reported since 1960. The economic cost of the illness is measured in the billions of dollars annually. Environmental change and unplanned urbanization are conspiring to raise the health and economic cost even further beyond the reach of health systems and households. The health-sector response has depended in large part on control of the Aedes aegypti and Ae. albopictus (mosquito) vectors. The cost-effectiveness of the first-ever dengue vaccine remains to be evaluated in the field. In this paper, we examine how it might affect the cost-effectiveness of sustained vector control. METHODS: We employ a dynamic Markov model of the effects of vector control on dengue in both vectors and humans over a 15-year period, in six countries: Brazil, Columbia, Malaysia, Mexico, the Philippines, and Thailand. We evaluate the cost (direct medical costs and control programme costs) and cost-effectiveness of sustained vector control, outbreak response and/or medical case management, in the presence of a (hypothetical) highly targeted and low cost immunization strategy using a (non-hypothetical) medium-efficacy vaccine. RESULTS: Sustained vector control using existing technologies would cost little more than outbreak response, given the associated costs of medical case management. If sustained use of existing or upcoming technologies (of similar price) reduce vector populations by 70-90%, the cost per disability-adjusted life year averted is 2013 US$ 679-1331 (best estimates) relative to no intervention. Sustained vector control could be highly cost-effective even with less effective technologies (50-70% reduction in vector populations) and in the presence of a highly targeted and low cost immunization strategy using a medium-efficacy vaccine. DISCUSSION: Economic evaluation of the first-ever dengue vaccine is ongoing. However, even under very optimistic assumptions about a highly targeted and low cost immunization strategy, our results suggest that sustained vector control will continue to play an important role in mitigating the impact of environmental change and urbanization on human health. If additional benefits for the control of other Aedes borne diseases, such as Chikungunya, yellow fever and Zika fever are taken into account, the investment case is even stronger. High-burden endemic countries should proceed to map populations to be covered by sustained vector control.