Medicare and Medicaid insurance claims data for Californians living with HIV are analyzed in order to determine: (1)The prevalence of treatment for particular mental health diagnoses among people ...living with HIV (PLWH) with Medicare or Medicaid insurance in 2010; (2)The relationship between individual mental health conditions and total medical care expenditures; (3)The impact of individual mental health diagnoses on the cost of treating non-mental health conditions; and (4)The implications of the cost of mental health diagnoses for setting managed care capitation payments. We find that the prevalence of mental health conditions among PLWH is high (23% among Medicare and 28% among Medicaid enrollees). PLWH with mental health conditions have significantly higher treatment costs for both mental health and non-mental health conditions. Setting managed care capitations that account for these greater expenditures is necessary to preserve access to both mental health and physical health services for PLWH and mental health conditions.
Individuals who are immunocompromised (IC) due to therapy or underlying disease are at increased risk of herpes zoster (HZ). This study evaluates the public health impact of recombinant zoster ...vaccine (RZV) relative to no HZ vaccination for the prevention of HZ among adults aged ≥18 years diagnosed with selected cancers in the United States (US). A static Markov model was used to simulate three cohorts of individuals who are IC with cancer (time horizon of 30 years; one-year cycle length): hematopoietic stem cell transplant (HSCT) recipients, patients with breast cancer (BC; a solid tumor example), and patients with Hodgkin's lymphoma (HL; a hematological malignancy example). Cohort sizes reflect the estimated annual incidence of each condition in the US population (19,671 HSCT recipients, 279,100 patients with BC, and 8,480 patients with HL). Vaccination with RZV resulted in 2,297; 38,068; and 848 fewer HZ cases for HSCT recipients, patients with BC, and patients with HL, respectively (each versus no vaccine). Vaccination with RZV also resulted in 422; 3,184; and 93 fewer postherpetic neuralgia cases for HSCT, BC, and HL, respectively. Analyses estimated the quality-adjusted life years gained to be 109, 506, and 17 for HSCT, BC, and HL, respectively. To prevent one HZ case, the number needed to vaccinate was 9, 8, and 10, for HSCT, BC, and HL, respectively. These results suggest RZV vaccination may be an effective option to significantly reduce HZ disease burden among patients diagnosed with selected cancers in the US.
Shingles cases can be prevented by recombinant zoster vaccine (RZV). People who have a weakened immune system (immunocompromised) due to disease or therapy are more likely to develop shingles. For example, shingles occurs in nearly a quarter of patients receiving immunosuppressive treatment for blood cancers. To estimate the public health impact of vaccination against shingles in people who are immunocompromised due to cancer in the United States (US), we used a model to simulate groups with selected types of cancer. The results indicate vaccination with RZV can significantly reduce shingles cases and related complications among these groups in the US.
A longitudinal study was designed to evaluate the prevalence, persistence, and predictors of posttreatment fatigue in breast carcinoma survivors.
A sample of 763 breast carcinoma survivors completed ...questionnaires at 1-5 and 5-10 years after diagnosis, including the RAND 36-item Health Survey, Center for Epidemiological Studies - Depression scale (CES-D), Breast Cancer Prevention Trial Symptom Checklist, and demographic and treatment-related measures.
Approximately 34% of study participants reported significant fatigue at 5-10 years after diagnosis, which is consistent with prevalence estimates obtained at 1-5 years after diagnosis. Approximately 21% reported fatigue at both assessment points, indicating a more persistent symptom profile. Longitudinal predictors of fatigue included depression, cardiovascular problems, and type of treatment received. Women treated with either radiation or chemotherapy alone showed a small improvement in fatigue compared with those treated with both radiation and chemotherapy.
Fatigue continues to be a problem for breast carcinoma survivors many years after cancer diagnosis, with 21% reporting persistent problems with fatigue. Several factors that may contribute to long-term fatigue are amenable to intervention, including depression and comorbid medical conditions.
COVID-19 has created an enormous health crisis and this spring New York City had a severe outbreak that pushed health and critical care resources to the limit. A lack of adequate space for ...mechanically ventilated patients induced our hospital to convert operating rooms into critical care areas (OR-ICU). A large number of COVID-19 will develop acute kidney injury that requires renal replacement therapy (RRT). We included 116 patients with COVID-19 who required mechanical ventilation and were cared for in our OR-ICU. At 90 days and at discharge 35 patients died (30.2%). RRT was required by 45 of the 116 patients (38.8%) and 18 of these 45 patients (40%) compared to 17 with no RRT (23.9%, ns) died during hospitalization and after 90 days. Only two of the 27 patients who required RRT and survived required RRT at discharge and 90 days. When defining renal recovery as a discharge serum creatinine within 150% of baseline, 68 of 78 survivors showed renal recovery (87.2%). Survival was similar to previous reports of patients with severe COVID-19 for patients cared for in provisional ICUs compared to standard ICUs. Most patients with severe COVID-19 and AKI are likely to recover full renal function.
•We retrospectively assessed renal outcomes and mortality in 116 patients with severe COVID-19 who were cared for in a provisional OR ICU.•A large number of these patients will develop acute kidney injury: Stage 1 AKI: 20.9%, Stage 2 AKI: 14.8, Stage 3 AKI: 31.9%.•The overall mortality was 30.2%.•38.8% required renal replacement therapy but only 2 of the survivors required renal replacement therapy at discharge and at 90 day after admission and 68 of 78 survivors showed renal recovery (87.2%).•Acute kidney injury is common with severe COVID-19 but most survivors are likely to recover full renal function.
Background: Women with breast cancer are the largest group of female survivors of cancer. There is limited information about the long-term quality of life (QOL) in disease-free breast cancer ...survivors. Methods: Letters of invitation were mailed to 1336 breast cancer survivors who had participated in an earlier survey and now were between 5 and 10 years after their initial diagnosis. The 914 respondents interested in participating were then sent a survey booklet that assessed a broad range of QOL and survivorship concerns. All P values were two-sided. Results: A total of 817 women completed the follow-up survey (61% response rate), and the 763 disease-free survivors in that group, who had been diagnosed an average of 6.3 years earlier, are the focus of this article. Physical well-being and emotional well-being were excellent; the minimal changes between the baseline and follow-up assessments reflected expected age-related changes. Energy level and social functioning were unchanged. Hot flashes, night sweats, vaginal discharge, and breast sensitivity were less frequent. Symptoms of vaginal dryness and urinary incontinence were increased. Sexual activity with a partner declined statistically significantly between the two assessments (from 65% to 55%, P = .001). Survivors with no past systemic adjuvant therapy had a better QOL than those who had received systemic adjuvant therapy (chemotherapy, tamoxifen, or both together) (physical functioning, P = .003; physical role function, P = .02; bodily pain, P = .01; social functioning, P = .02; and general health, P = .03). In a multivariate analysis, past chemotherapy was a statistically significant predictor of a poorer current QOL (P = .003). Conclusions: Long-term, disease-free breast cancer survivors reported high levels of functioning and QOL many years after primary treatment. However, past systemic adjuvant treatment was associated with poorer functioning on several dimensions of QOL. This information may be useful to patients and physicians who are engaging in discussion of the risks and benefits of systemic adjuvant therapy.
The role of HIV specialists in providing primary care to persons living with HIV/AIDS is evolving, given their increased incidence of comorbidities. Multivariate logit analysis compared compliance ...with sentinel preventive screening tests and interventions among publicly insured Californians with and without access to HIV specialists in 2010. Quality-of-care indicators visit frequency, CD4 and viral load (VL) assessments, influenza vaccine, tuberculosis (TB) testing, lipid profile, glucose blood test, and Pap smears for women were related to patient characteristics and provider HIV caseload. There were 9377 adult Medicare enrollees (71% also had Medicaid coverage) and 2076 enrollees with only Medicaid coverage. Adjusted for patient characteristics, patients seeing providers with greater HIV caseloads (>50 HIV patients) were more likely to meet visit frequency guidelines in both Medicare 98%; confidence interval (CI 97.5-98.2) and Medicaid (97%; CI 96.2-98.0), compared to 60% (CI 57.1-62.3) and 45% (CI 38.3-50.4), respectively, seeing providers without large HIV caseloads (p < 0.001). Patients seeing providers with larger caseloads were significantly more likely to have CD4 (p < 0.001), VL (p < 0.001), and TB testing (p < 0.05). A larger percentage of patients seeing large-volume Medicare providers received influenza vaccinations. Provider caseload was unrelated to lipid or glucose assessments or Pap Smears for women. Patients with access to large-volume providers were more likely to meet clinical guidelines for visits, CD4, VL, tuberculosis testing, and influenza vaccinations, and were not less likely to receive primary preventive care. Substantial insufficiencies remain in both monitoring to assess viral suppression and in preventive care.
To describe the occurrence of fatigue in a large sample of breast cancer survivors relative to general population norms and to identify demographic, medical, and psychosocial characteristics of ...fatigued survivors.
Breast cancer survivors in two large metropolitan areas completed standardized questionnaires as part of a survey study, including the RAND 36-item Health Survey, Center for Epidemiological Studies-Depression Scale, Breast Cancer Prevention Trial Symptom Checklist, Medical Outcomes Study Sleep Scale, and demographic and treatment-related measures.
On average, the level of fatigue reported by the breast cancer survivors surveyed (N = 1,957) was comparable to that of age-matched women in the general population, although the breast cancer survivors were somewhat more fatigued than a more demographically similar reference group. Approximately one third of the breast cancer survivors assessed reported more severe fatigue, which was associated with significantly higher levels of depression, pain, and sleep disturbance. In addition, fatigued women were more bothered by menopausal symptoms and were somewhat more likely to have received chemotherapy (with or without radiation therapy) than nonfatigued women. In multivariate analyses, depression and pain emerged as the strongest predictors of fatigue.
Although the majority of breast cancer survivors in this large and diverse sample did not experience heightened levels of fatigue relative to women in the general population, there was a subgroup of survivors who did report more severe and persistent fatigue. We identified characteristics of these women that may be helpful in elucidating the mechanisms underlying fatigue in this population, as well as directing intervention efforts.
Only 43% of Americans with HIV are virally suppressed; the rate is lower for African Americans, even among insured populations. This study uses 2010 Medicare and Medicaid data for HIV-positive ...Californians to examine how antiretroviral treatment (ART) relates to patient and provider characteristics. Logistic regressions isolated the effect of race/ethnicity on receipt of ART. Over 90% of the full sample received any ART. Nearly 80% of ART users received a recommended combination for at least half the year; half had a recommended combination for 90% of the year. Lacking evaluation and management visits, or seeing only providers with low HIV patient volume lowered the odds of receiving ART. Controlling for other factors, African Americans remained less likely to receive ART at all, or to be covered for 90% of the year with a recommended regimen. The observed racial treatment differentials may lead to important health disparities.
Background. COVID-19 may result in multiorgan failure and death. Early detection of patients at risk may allow triage and more intense monitoring. The aim of this study was to develop a simple, ...objective admission score, based on laboratory tests, that identifies patients who are likely going to deteriorate. Methods. This is a retrospective cohort study of all COVID-19 patients admitted to a tertiary academic medical center in New York City during the COVID-19 crisis in spring 2020. The primary combined endpoint included intubation, stage 3 acute kidney injury (AKI), or death. Laboratory tests available on admission in at least 70% of patients (and age) were included for univariate analysis. Tests that were statistically or clinically significant were then included in a multivariate binary logistic regression model using stepwise exclusion. 70% of all patients were used to train the model, and 30% were used as an internal validation cohort. The aim of this study was to develop and validate a model for COVID-19 severity based on biomarkers. Results. Out of 2545 patients, 833 (32.7%) experienced the primary endpoint. 53 laboratory tests were analyzed, and of these, 47 tests (and age) were significantly different between patients with and without the endpoint. The final multivariate model included age, albumin, creatinine, C-reactive protein, and lactate dehydrogenase. The area under the ROC curve was 0.850 (CI 95%: 0.813, 0.889), with a sensitivity of 0.800 and specificity of 0.761. The probability of experiencing the primary endpoint can be calculated as p=e−2.4475+0.02492age−0.6503albumin+0.81926creat+0.00388CRP+0.00143LDH/1+e−2.4475+ 0.02492age−0.6503albumin+0.81926creat+0.00388CRP+0.00143LDH. Conclusions. Our study demonstrated that poor outcome in COVID-19 patients can be predicted with good sensitivity and specificity using a few laboratory tests. This is useful for identifying patients at risk during admission.
Child and infant malnourishment is a significant and growing problem in the developing world. Malnourished children are at high risk for negative health outcomes over their lifespans. Philani, a ...paraprofessional home visiting program, was developed to improve childhood nourishment. The objective of this study is to evaluate whether the Philani program can rehabilitate malnourished children in a timely manner.
Mentor Mothers were trained to conduct home visits. Mentor Mothers went from house to house in assigned neighborhoods, weighed children age 5 and younger, and recruited mother-child dyads where there was an underweight child. Participating dyads were assigned in a 2:1 random sequence to the Philani intervention condition (n = 536) or a control condition (n = 252). Mentor Mothers visited dyads in the intervention condition for one year, supporting mothers' problem-solving around nutrition. All children were weighed by Mentor Mothers at baseline and three, six, nine and twelve month follow-ups.
By three months, children in the intervention condition were five times more likely to rehabilitate (reach a healthy weight for their ages) than children in the control condition. Throughout the course of the study, 43% (n = 233 of 536) of children in the intervention condition were rehabilitated while 31% (n = 78 of 252) of children in the control condition were rehabilitated.
Paraprofessional Mentor Mothers are an effective strategy for delivering home visiting programs by providing the knowledge and support necessary to change the behavior of families at risk.
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