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In This Issue of Archives of Internal Medicine
Arch Intern Med. 2002;162:127.
Health and Economic Outcomes of the Emergence of Third-Generation Cephalosporin
Resistance in Enterobacter Species
Third-generation cephalosporin resistance often emerges in Enterobacter species during antimicrobial therapy. This article assesses
the clinical and economic impact of emergence of resistance in hospitalized
patients. In a matched cohort study, emergence of resistance was associated
with a significant increase in mortality and a 50% increase in length of hospital
stay and hospital charge. The authors conclude that minimization and early
detection of the development of resistance in Enterobacter species should be priorities.
(SEE ARTICLE)
Daytime Sleepiness and Cognitive Impairment in the Elderly Population
This article demonstrates that excessive daytime sleepiness can be an
early sign of cognitive decline in a healthy elderly population. The study
was done using 1026 subjects 60 years or older, who are representative of
the general population living in the metropolitan area of Paris, France. In
contrast to other studies, this study made the distinction between intentional
and nonintentional naps and excessive daytime sleepiness. This distinction
showed that intentional napping is not harmful and not associated with cognitive
impairments, while excessive daytime sleepiness is a good predictor of cognitive
impairments even after controlling for factors known to be responsible for
cognitive impairments.
(SEE ARTICLE)
Cost-effectiveness of Gemfibrozil for Coronary Heart Disease Patients
With Low Levels of High-Density Lipoprotein Cholesterol: The Department of
Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial
Although a number of clinical trials have investigated the efficacy
and cost-effectiveness of agents used to lower low-density lipoprotein cholesterol
levels, the Veterans Affairs High-Density Lipoprotein Cholesterol Intervention
Trial investigated the effect of gemfibrozil in raising high-density lipoprotein
cholesterol levels in older male patients with coronary heart disease for
whom a low level of high-density lipoprotein cholesterol is the primary lipid
abnormality. This study reports the cost-effectiveness results from that trial.
Using a Markov analysis, the authors found that at annual treatment costs
experienced by the US Department of Veterans Affairs, gemfibrozil is cost-saving,
and at annual treatment costs found more generally in the economy, this therapy
costs between $6300 and $17 100 per life-year saved. These cost-effectiveness
levels place gemfibrozil well within the range of therapies deemed to be cost-effective.
Table 5. Break-even Costs and Average Age at First Event
(SEE ARTICLE)
Use of Oral Antithrombotic Agents Among Health Maintenance Organization
Members With Atherosclerotic Cardiovascular Disease
Although several US studies report disappointingly low use rates of
prophylactic antithrombotic therapy, a rate of 85% has been achieved in a
large unselected population with cardiovascular disease. That fortunate population
were members of the Oregon–southwest Washington region of Kaiser Permanente
Northwest, a long-established not-for-profit, group-model health maintenance
organization. As of mid-1999, aspirin was used by 72% of the subjects, and
prescription agents (largely warfarin) by an additional 12%. Over 90% of the
subjects recalled receiving education about aspirin and medical advice to
use it. Participation in an integrated, prevention-oriented, computer-linked
medical care system seems to facilitate the promotion of aspirin use. The
steps that Kaiser Permanente Northwest took included developing and publicizing
a guideline, maintaining a single comprehensive medical record, ensuring that
hospitalized patients with cardiovascular disease were discharged with a prescription
for aspirin, having nurse- and pharmacist-care managers promote aspirin use,
and sending e-mail and letter messages to clinicians. After the study was
completed, the health maintenance organization successfully promoted aspirin
use in diabetes with a direct mailing to patients and dramatically increased
medical documentation of aspirin use through alerts and routines embedded
in its electronic medical record.
(SEE ARTICLE)
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