Health utility values associated with diabetic retinopathy.

AIMS: Different estimates exist regarding the impact of diabetic retinopathy (DR) on health utility. A previously reported prospective observational study has reported much larger decrements in self-reported utility than generic utility data from the UK Prospective Diabetes Study and the Lipids in Diabetes Study. The present study was designed to estimate utility loss using multiple methods. METHODS: Detailed health state descriptions reflecting declining DR (five different visual acuity levels), neuropathy and nephropathy were validated with patients and used to elicit utility values from people with DR, people with diabetes and members of the UK general public using standard gamble. In addition, a larger sample of people with retinopathy completed different health-related quality of life measures in an interview [EuroQoL (EQ-5D), Health State Utilities Index (HUI)-3, and National Eye Institute Visual Functioning Questionnaire-25]. RESULTS: The utility scores from the standard gamble interviews were not significantly different between the three groups. There was a decline in utility from 6/6 vision to counting fingers of -0.244. The utility data derived from the generic measures revealed an equivalent decline of -0.41 on both the EQ-5D single index and the HUI-3. CONCLUSIONS: This study has re-examined the utility decrements associated with DR and has identified much larger declines in utility than previously reported. The study has also reported the utility values of patients with retinopathy as assessed by standard gamble. We believe that this may be the first study to report utility values for health states associated with vision loss which have been elicited from patients with vision loss.

The financial costs of healthcare treatment for people with Type 1 or Type 2 diabetes in the UK with particular reference to differing severity of peripheral neuropathy.

AIMS: To characterize symptom severity of diabetic peripheral neuropathy (DPN) in people with diabetes and to characterize its association with healthcare resource use. METHODS: The study was undertaken in Cardiff and the Vale of Glamorgan, UK. A postal survey was posted to subjects identified as having diabetes. Demography, quality of life (EQ-5D and SF-36) and symptoms of neuropathy (NTSS-6 and QOL-DN) data were collected. These data were linked to routine healthcare data coded into healthcare resource groups (HRGs) and subsequently costed according to UK National reference costs. RESULTS: Survey responses were received from 1298 patients, a 32% response rate. For patients with a clinically confirmed diagnosis of DPN, the mean NTSS-6-SA score was 6.16 vs. 3.19 (P < 0.001). Duration of diabetes did not change across groups defined by severity of neuropathy symptoms, but mean HbA(1c) and body mass index values did increase with symptom severity (range 7.6-8.1%, P = 0.023; and 28.0-30.9 kg/m(2), P < 0.001, respectively). General linear modelling showed that the NTSS-6-SA score was a significant predictor of both annual health resource costs and yearly prescribed drug costs. On average, each 1-point increase in NTSS-6-SA score predicted a 6% increase in primary and secondary care costs and a 3% increase in log transformed drug costs. CONCLUSION: This study demonstrated that severity of DPN symptoms was associated with increased healthcare resource use, thus costs.

Diagnosed diabetic retinopathy in France, Italy, Spain, and the United Kingdom.

AIM: The objective of this study was to describe the proportion and characteristics of patients diagnosed with diabetic retinopathy (DR) in France, Italy, Spain, and the United Kingdom (UK). METHODS: To estimate the proportion of patients with type 1 and type 2 diabetes diagnosed with DR, we conducted a cross-sectional survey of general practitioners in each country using physician records. In addition, diabetes specialists were recruited in Italy and Spain. We extracted data from the medical notes of a sample of DR patients to characterize DR severity and clinical characteristics. RESULTS: The average number of physicians per country was 41 (range: 34-49). The proportion of diagnosed DR ranged from 10.3% (95% CI, 6.7-14.0%) in Spain to 19.6% (95% CI, 16.0-23.1%) in the UK. Of 752 DR patients studied, 53.9% were male; mean age (+/-SD) was 64.2+/-12.8 years. Consistently across countries, mild non-proliferative DR was the most common severity level of diagnosed DR. Proliferative DR (PDR) ranged from 19.7% (France) to 31.5% (UK). Diabetic macular oedema was reported in approximately 10% of patients. Hypertension (73.1%), dyslipidemia (63.2%), and neuropathy (52.1%) were the most common co-morbidities. CONCLUSIONS: Country-specific prevalence of diagnosed DR may reflect clinical management of diabetes, healthcare systems, or record-keeping accuracy. Across countries, up to 30% of DR patients had a diagnosis of PDR, which could suggest that patients are diagnosed only when their disease is advanced.

The health-related utility and health-related quality of life of hospital-treated subjects with type 1 or type 2 diabetes with particular reference to differing severity of peripheral neuropathy.

AIMS/HYPOTHESIS: We characterised symptom severity of diabetic peripheral neuropathy (DPN) in people with diabetes, and correlated this with health-related utility and health-related quality of life. MATERIALS AND METHODS: The study was undertaken in Cardiff and the Vale of Glamorgan, Wales. A postal survey was mailed to a random sample of subjects identified as having diabetes. Data were collected on the symptoms of neuropathy using the Neuropathic Total Symptom Score (self-administered) (NTSS-6-6A) and on quality of life using the Quality of Life in Diabetes Neuropathy Instrument (QoL-DN), EueroQoL five dimensions (EQ5D) and Short Form 36 (SF36). Other information, such as demographics and self-reported drug use, was also collected. The anonymised data were linked to routine inpatient and outpatient healthcare data. RESULTS: Responses were received from 1,298 patients. For patients with a clinically confirmed diagnosis of DPN, the mean NTSS-6-SA score was 6.16 vs 3.19 in patients without DPN (p<0.001). Four categories of severity were defined, ranging from none to severe. All quality of life measures showed a deterioration between these groups: the EQ5D(index) fell from an average of 0.81 in those without symptoms to 0.25 in those with severe symptoms, the SF36 general health profile fell from 59.9 to 25.5 (p<0.001) and the QoL-DN increased from 25.8 to 48.1 (p<0.001). Multivariate models also demonstrated that this relationship remained after controlling for other factors. CONCLUSIONS/INTERPRETATION: This study demonstrated that severity of DPN symptoms was predictive of poor health-related utility and decreased quality of life. Furthermore, it provides detailed utility data for economic evaluation of treatment of typical diabetes-related morbidity states. Reducing DPN morbidity should be a priority.

Relationship of hospital teaching status with quality of care and mortality for Medicare patients with acute MI.

CONTEXT: Issues of cost and quality are gaining importance in the delivery of medical care, and whether quality of care is better in teaching vs nonteaching hospitals is an essential question in this current national debate. OBJECTIVE: To examine the association of hospital teaching status with quality of care and mortality for fee-for-service Medicare patients with acute myocardial infarction (AMI). DESIGN, SETTING, AND PATIENTS: Analysis of Cooperative Cardiovascular Project data for 114,411 Medicare patients from 4361 hospitals (22,354 patients from 439 major teaching hospitals, 22,493 patients from 455 minor teaching hospitals, and 69,564 patients from 3467 nonteaching hospitals) who had AMI between February 1994 and July 1995. MAIN OUTCOME MEASURES: Administration of reperfusion therapy on admission, aspirin during hospitalization, and beta-blockers and angiotensin-converting enzyme inhibitors at discharge for patients meeting strict inclusion criteria; mortality at 30, 60, and 90 days and 2 years after admission. RESULTS: Among major teaching, minor teaching, and nonteaching hospitals, respectively, administration rates for aspirin were 91.2%, 86.4%, and 81.4% (P<.001); for angiotensin-converting enzyme inhibitors, 63. 7%, 60.0%, and 58.0% (P<.001); for beta-blockers, 48.8%, 40.3%, and 36.4% (P<.001); and for reperfusion therapy, 55.5%, 58.9%, and 55.2% (P =.29). Differences in unadjusted 30-day, 60-day, 90-day, and 2-year mortality among hospitals were significant at P<.001 for all time periods, with a gradient of increasing mortality from major teaching to minor teaching to nonteaching hospitals. Mortality differences were attenuated by adjustment for patient characteristics and were almost eliminated by additional adjustment for receipt of therapy. CONCLUSIONS: In this study of elderly patients with AMI, admission to a teaching hospital was associated with better quality of care based on 3 of 4 quality indicators and lower mortality. JAMA. 2000;284:1256-1262

The epidemiology of fire-related deaths in Alabama, 1992-1997.

The state of Alabama has one of the highest fire-related fatality rates in the nation. The goal of this study was to present the epidemiology of fire-related deaths in the state of Alabama. Fatality reports for all fire-related deaths in the state of Alabama from 1992 to 1997 were obtained from the State Fire Marshall's Office. Fatality rates were calculated and compared according to age, sex, and race. Descriptive statistics were generated for population and fire characteristics. Fatality rates were higher among black people, men, children, and older people. Approximately half (48.8%) of the deaths occurred between the months of November and March; July had the lowest proportion of deaths (5.0%). Residential fires accounted for the largest proportion of deaths. Fatality rates were higher for mobile home residents. Overall, smoke detectors were present in only 32.5% of the residential fires. The presence of smoke detectors was more common with deaths in urban locations (41.8%) than with deaths in rural locations (20.8%). The most frequently reported cause of fatal fires was misuse of cigarettes. More than half of the victims aged 18 years and older tested positive for alcohol. Fire prevention efforts should focus on smoke detectors, fire-safe cigarettes, and alcohol. Mobile home residents should also be targeted for fire prevention initiatives.

Fire fatalities in older people.

OBJECTIVE: To compare the epidemiology of fire-related fatalities among older, middle-aged, and young people. DESIGN: Retrospective case series. SETTING: Alabama, 1992-1997. PARTICIPANTS: All persons fatally injured in fire-related incidents in the state of Alabama from 1992 to 1997. MEASUREMENTS: The State Fire Marshal's Office provided both demographic and autopsy information about the victim. In addition, information regarding the nature and circumstances of the fire was also obtained. RESULTS: Between 1992 and 1997, there were 674 fire-related deaths in the state of Alabama. The fire-related fatality rate was highest among older persons. The fatality rate was particularly high among older black people. The rate of fatal fires caused by heating devices was higher (15.0%) among older people compared with their young and middle-aged counterparts (6.3% and 4.5%, respectively). Fatalities among older people were least likely (26.0%) to occur if smoke detectors were present, compared with deaths among young and middle-aged persons (38.3% and 33.5%, respectively). There were fewer smoke detectors present in the fatal fires of older rural black adults and white adults (0.0% and 29.0%, respectively) compared with their urban counterparts (25.0% and 47.0%, respectively). Alcohol was not a factor in fatal fires involving older adults (29.0%) compared with those involving the young (52.0%) and middle-aged adults (73.9%). CONCLUSIONS: With the growth of the percentage of older people in the population, the problem of fire-related deaths in this age group is likely to increase. Interventions focused on this age group are necessary for the state of Alabama to meet the National Health Objectives for the year 2000.

Pediatric pedestrian injuries: a community assessment using a hospital surveillance system.

OBJECTIVE: To provide a descriptive demographic and environmental account of pedestrian injuries among children aged < or =15 years in Jefferson County, Alabama. METHODS: This was a retrospective study with a case definition for inclusion of individuals, aged < or =15 years, who suffered a pedestrian injury and sought care at The Children's Hospital of Alabama between 1989 and 1991. Demographic and injury-related information was obtained from the medical record and analyses were performed using t-test and a simple correlation. RESULTS: The majority of the cases were nonwhite, and nearly half had Medicaid or were uninsured. The most common injuries were fractures and closed head trauma. The geographic locations of injury events were not uniformly distributed: a comparison of areas wherein an injury occurred with those that were injury-free revealed a number of significant differences with regard to specific demographic, socioeconomic, and ecological factors. CONCLUSIONS: Some of the possible manageable environmental risk factors identified in this study were relatively high posted speed limits; sidewalks that were narrow, absent, or in a state of disrepair; vehicular parking on both sides of the street; and the absence of a divided highway. In this community, the most cost-effective educational intervention may best be targeted to elementary-aged schoolchildren living in areas with low-income families and that have a high density of children.

Are newspapers a viable source for intentional injury surveillance data?

BACKGROUND: Previous researchers have reported that newspapers were useful adjuncts to unintentional injury surveillance efforts in a nearby southern state. The current study sought to determine whether newspaper accounts of intentional injuries could provide a reliable source of primary or secondary surveillance data. METHODS: Newspaper accounts of assaults, homicides, suicides, and rapes occurring in Jefferson County, Alabama, between January 1, 1991, and December 31, 1991, were compared with similar data from official governmental agencies whose responsibility it is to investigate and/or document the occurrence, details, and characteristics of violent events resulting in death or injury. RESULTS: Newspapers greatly underreported suicides, rapes, and assaults, and reported firearms-related incidents in numbers that substantially exceeded their actual occurrence. CONCLUSIONS: Much information of potential value for injury surveillance purposes appears to be excluded from newspapers by editorial process and policy. Thus, newspapers are neither a valid nor reliable source for intentional injury surveillance purposes.

Surfactant protein A-directed toxin gene kills lung cancer cells in vitro.

Human surfactant protein A (SPA) expression is considered a marker of respiratory epithelial differentiation. Non-small cell lung cancers (NSCLC) are respiratory epithelial derivatives, and it was previously shown that a minority of these cancers expressed SPA, presumably a consequence of their respiratory epithelial origin. In the studies reported here, SPA-I gene transcriptional regulatory sequences were localized to a 2.75-kb genomic 5'-flanking region fragment obtained by screening a human genomic library. The 2.75-kb fragment was used to direct a luciferase coding sequence transcriptionally within a plasmid construct. In plasmid transduction experiments, the SPA-directed luciferase plasmid produced significant luciferase activity in the SPA-expressing NSCLC cell line, H441, but only background levels in the non-SPA-expressing A549 cells. Because Northern blot analysis of resected NSCLC showed that the majority expressed SPA, an SPA-transcriptional targeting strategy was investigated using chimeric toxin genes comprising the coding sequence for herpes simplex virus thymidine kinase (HSV-TK) under transcriptional control of SPA or SV40 regulatory sequences. As expected, transduction of the constitutive, SV40-directed plasmid followed by ganciclovir treatment reduced numbers of both the A549 and H441 cells. In contrast, the SPA-directed plasmid reduced only the SPA-expressing H441 cells and had no significant effect on the A549 cells. The results of these in vivo experiments suggest the concept of transcriptionally directing toxin genes with SPA can produce targeted toxicity in NSCLC.

Quantitative evaluation of retroviral gene transduction efficiency in human lung cancer cells.

Gene therapy may serve as a valuable therapeutic modality for malignancies, such as lung cancer, that are poorly responsive to conventional therapies. Although many methods for transducing new genes into cells have been described, little is known about gene transduction into lung cancer, especially under conditions that might be encountered in clinical use. As a first step in addressing this important issue, the study presented here examined the ability of a recombinant retrovirus to add a selectable marker gene to the A549 non-small cell lung cancer (NSCLC) cell line under a variety of conditions. Examination of viral exposure times ranging from 30 sec to 4 hr revealed that the number of infected cells increased with every increment in time. By increasing the multiplicity of infection to 1.0 and including a polycation, Polybrene, as an infection facilitator, 0.8% of the NSCLC cells were infected with only a 30-sec viral exposure. Nebulization, a potentially attractive route of administration for pulmonary malignancies, had no significant effect on viral titer, proviral structure, or proviral transcripts. A single lyophilization did reduce viral titer by 58 +/- 6%, but did not affect the proviral structure or transcripts produced by the surviving viruses. These results suggest that recombinant retroviruses have the potential to add new genes to malignancies accessible by the airways under conditions likely required for clinical use.