Risk factors and prognosis of complicated urinary tract infections caused by Pseudomonas aeruginosa in hospitalized patients: a retrospective multicenter cohort study.

PURPOSE: Complicated urinary tract infections (cUTIs) are among the most frequent health-care-associated infections. In patients with cUTI, Pseudomonas aeruginosa deserves special attention, since it can affect patients with serious underlying conditions. Our aim was to gain insight into the risk factors and prognosis of P. aeruginosa cUTIs in a scenario of increasing multidrug resistance (MDR). METHODS: This was a multinational, retrospective, observational study at 20 hospitals in south and southeastern Europe, Turkey, and Israel including consecutive patients with cUTI hospitalized between January 2013 and December 2014. A mixed-effect logistic regression model was performed to assess risk factors for P. aeruginosa and MDR P. aeruginosa cUTI. RESULTS: Of 1,007 episodes of cUTI, 97 (9.6%) were due to P. aeruginosa. Resistance rates of P. aeruginosa were: antipseudomonal cephalosporins 35 of 97 (36.1%), aminoglycosides 30 of 97 (30.9%), piperacillin-tazobactam 21 of 97 (21.6%), fluoroquinolones 43 of 97 (44.3%), and carbapenems 28 of 97 (28.8%). The MDR rate was 28 of 97 (28.8%). Independent risk factors for P. aeruginosa cUTI were male sex (OR 2.61, 95% CI 1.60-4.27), steroid therapy (OR 2.40, 95% CI 1.10-5.27), bedridden functional status (OR 1.79, 95% CI 0.99-3.25), antibiotic treatment within the previous 30 days (OR 2.34, 95% CI 1.38-3.94), indwelling urinary catheter (OR 2.41, 95% CI 1.43-4.08), and procedures that anatomically modified the urinary tract (OR 2.01, 95% CI 1.04-3.87). Independent risk factors for MDR P. aeruginosa cUTI were age (OR 0.96, 95% CI 0.93-0.99) and anatomical urinary tract modification (OR 4.75, 95% CI 1.06-21.26). Readmission was higher in P. aeruginosa cUTI patients than in other etiologies (23 of 97 [23.7%] vs 144 of 910 [15.8%], P=0.04), while 30-day mortality was not significantly different (seven of 97 [7.2%] vs 77 of 910 [8.5%], P=0.6). CONCLUSION: Patients with P. aeruginosa cUTI had characteristically a serious baseline condition and manipulation of the urinary tract, although their mortality was not higher than that of patients with cUTI caused by other etiologies.

Discrete-choice experiment to analyse preferences for centralizing specialist cancer surgery services.

BACKGROUND: Centralizing specialist cancer surgery services aims to reduce variations in quality of care and improve patient outcomes, but increases travel demands on patients and families. This study aimed to evaluate preferences of patients, health professionals and members of the public for the characteristics associated with centralization. METHODS: A discrete-choice experiment was conducted, using paper and electronic surveys. Participants comprised: former and current patients (at any stage of treatment) with prostate, bladder, kidney or oesophagogastric cancer who previously participated in the National Cancer Patient Experience Survey; health professionals with experience of cancer care (11 types including surgeons, nurses and oncologists); and members of the public. Choice scenarios were based on the following attributes: travel time to hospital, risk of serious complications, risk of death, annual number of operations at the centre, access to a specialist multidisciplinary team (MDT) and specialist surgeon cover after surgery. RESULTS: Responses were obtained from 444 individuals (206 patients, 111 health professionals and 127 members of the public). The response rate was 52·8 per cent for the patient sample; it was unknown for the other groups as the survey was distributed via multiple overlapping methods. Preferences were particularly influenced by risk of complications, risk of death and access to a specialist MDT. Participants were willing to travel, on average, 75 min longer in order to reduce their risk of complications by 1 per cent, and over 5 h longer to reduce risk of death by 1 per cent. Findings were similar across groups. CONCLUSION: Respondents' preferences in this selected sample were consistent with centralization.

Cost-Effectiveness Methods and Newborn Screening Assessment.

Nowadays, health funding decisions must be supported by sound arguments in terms of both effectiveness and economic criteria. After more than half a century of newborn screening for rare diseases, the appropriate economic evaluation framework for these interventions is still challenging. The validity of standard methods for economic evaluation heavily relies on the availability of robust evidence, but collection of such evidence is precluded by the rareness of the conditions that may benefit from screening. Furthermore, there are a series of conceptual and methodological limitations that warrant further careful consideration when assessing the cost-effectiveness of newborn screening programs. In this chapter we provide a general overview of current economic evaluation methods and the challenges for their application to newborn screening programs.

Cost-effectiveness of electroconvulsive therapy compared to repetitive transcranial magnetic stimulation for treatment-resistant severe depression: a decision model.

BACKGROUND: Electroconvulsive therapy (ECT) is widely applied to treat severe depression resistant to standard treatment. Results from previous studies comparing the cost-effectiveness of this technique with treatment alternatives such as repetitive transcranial magnetic stimulation (rTMS) are conflicting. METHOD: We conducted a cost-effectiveness analysis comparing ECT alone, rTMS alone and rTMS followed by ECT when rTMS fails under the perspective of the Spanish National Health Service. The analysis is based on a Markov model which simulates the costs and health outcomes of individuals treated under these alternatives over a 12-month period. Data to populate this model were extracted and synthesized from a series of randomized controlled trials and other studies that have compared these techniques on the patient group of interest. We measure effectiveness using quality-adjusted life years (QALYs) and characterize the uncertainty using probabilistic sensitivity analyses. RESULTS: ECT alone was found to be less costly and more effective than rTMS alone, while the strategy of providing rTMS followed by ECT when rTMS fails is the most expensive and effective option. The incremental cost per QALY gained of this latter strategy was found to be above the reference willingness-to-pay threshold used in these types of studies in Spain and other countries. The probability that ECT alone is the most cost-effective alternative was estimated to be around 70%. CONCLUSIONS: ECT is likely to be the most cost-effective option in the treatment of resistant severe depression for a willingness to pay of €30,000 per QALY.

Ethnic variations in overweight and obesity among children over time: findings from analyses of the Health Surveys for England 1998-2009.

BACKGROUND: The increase in the prevalence of obesity among children and adolescents in England since the mid-1990s has been dramatic. Cross-sectional evidence suggests ethnic variations in childhood obesity prevalence. OBJECTIVES: The objective of the study was to examine whether and how ethnic variations in childhood overweight/obesity have changed over time, and are affected by socioeconomic factors. METHOD: This study uses logistic regression to analyse ethnic differences in the relative likelihood of being at or above the age- and gender-specific thresholds for overweight and obesity developed by the International Obesity Task Force among children aged between 2 and 15 from 11 ethnic groups included in the Health Surveys for England between 1998 and 2009, adjusting for age, gender, year of data collection and equivalized household income. We separately analyse the likelihood of being at or above the thresholds for overweight (but below those for obesity) and obesity. RESULTS: Trends in overweight/obesity over time among ethnic minority groups do not follow those of white English children. Black African children had higher rates of overweight and obesity, which appear to have peaked, and black Caribbean children had higher rates of obesity than other groups examined, which appear to continue rising. These differences were not explained by socioeconomic variations between groups. CONCLUSION: Policies are required that encourage healthy lifestyles among ethnic minority young people, while engaging with the complexities associated with these choices during childhood and adolescence.

Measuring current and future cost of skin cancer in England.

BACKGROUND: Increasing incidence of and mortality from skin cancer are posing a large financial burden on the NHS in England. Information provided by cost-of-illness (CoI) studies are used in policy making and are particularly useful for measuring the potential savings from averting a case of disease. METHODS: We estimate the cost of skin cancer in England, and model future costs up to 2020. We compare two costing approaches (top-down and bottom-up). RESULTS: We estimate that costs due to skin cancer were in the range of £106-£112 million in 2008. These figures are very closely related to those provided by the Department of Health (estimated to be £104.0 million in 2007-8 and £105.2 million 2008-9). The expected cost per case of malignant melanoma was estimated to be £2607 and £2560, using the bottom-up and top-down approaches, respectively. The mean cost per case of non-melanoma skin cancer was £889 and £1226, respectively. We estimate that the cost to the NHS due to skin cancer will amount to over £180 million in 2020. CONCLUSION: Effective prevention of skin cancer might not only reduce a significant burden of disease but it could also save considerable resources to the NHS.