To describe hospitalisations for kidney disease (KD) among people living with HIV (PLHIV) in France and to identify the factors associated with such hospitalisations since data on the epidemiology of KD leading to hospitalisation are globally scarce.
Observational nationwide study using the French Programme de Médicalisation des Systèmes d’Information database.
Around 10 862 PLHIV out of a mean of 5 210 856 patients hospitalised each year. All hospital admissions with a main diagnosis code indicating KD (International Classification of Diseases, 10th revision codes, N00 to –N39) were collected.
The prevalence and incidence of KD leading to hospital admission in PLHIV and the associated risk factors.
The prevalence of patients hospitalised for KD was 1.5 higher in PLHIV than in the general population, and increased significantly from 3.0% in 2008 to 3.7% in 2013 (p
The 5-year cumulative incidence of KD requiring hospitalisation was 5.9% in HIV patients newly diagnosed for HIV in 2009. Factors associated with a higher risk of incident KD requiring hospitalisation were cardiovascular disease (HR 3.30, 95% CI 1.46 to 7.49), and, for female patients, AIDS (HR 2.45, 95% CI 1.07 to 5.58). Two-thirds of hospitalisations for incident ARF occurred in the first 2 years of follow-up.
Hospital admission for KD is more frequent in PLHIV than in the general population and increases over time. ARF remains the leading cause. Glomerular diseases are infrequently documented by renal biopsies. Older patients and those with cardiovascular disease are particularly concerned.
Inflammatory bowel disease (IBD) is a chronic, autoimmune, gastrointestinal disorder. Canada has one of the highest prevalence and incidence rates of IBD in the world. Diagnosis is challenging due to the similarity of symptoms to functional gastrointestinal disorders. Faecalcalprotectin (FC) is a biomarker for active mucosal inflammation and has proven effective in the diagnosis of IBD. Our study objective was to assess the cost-effectiveness of adding an FC test compared with standard practice (blood test) in primary care among adult patients presenting with gastrointestinal symptoms.
We constructed a decision analytic tree with a 1-year time horizon. The cut-off level of 100 µg/g was used for FC testing. Probabilistic analyses were conducted for the base case and all scenarios.
Canadian health sector perspective.
A hypothetical cohort of adult patients presenting with gastrointestinal symptoms in the primary care setting.
FC test compared with blood test.
Costs, quality-adjusted life years (QALYs), incremental cost-effectiveness ratio (ICER) of FC test expressed as cost per QALY gained compared with blood test and time to IBD diagnosis.
FC testing is expected to cost more ($C295.1 vs $C273.9) than standard practice but yield little higher QALY (0.751vs0.750). The ICER of FC test was $C20 323 per QALY. Probabilistic analysis demonstrated that at a willingness-to-pay threshold of $C50 000 per QALY, there was 81.3% probability of FC test being cost-effective. The use of FC test in primary care reduced the time to IBD diagnosis by 40.0 days (95% CI 16.3 to 65.3 days), compared with blood testing alone.
Based on this analysis of short-term outcomes, screening adult patients in primary care using FC test at a cut-off level of 100 µg/g is expected to be cost-effective in Canada.
Management of type 2 diabetes mellitus (T2DM) requires frequent monitoring of patients. Within a collective care group setting, doubts on the clinical effects of registration are a barrier for full adoption of T2DM registration in general practice. We explored whether full monitoring of biomedical and lifestyle-related target indicators within a care group approach is associated with lower HbA1c levels.
Observational, real-life cohort study.
Primary care data registry from the Hadoks (EerstelijnsZorggroepHaaglanden) care group.
The care group provides general practitioners collectively with organisational support to facilitate structured T2DM primary care. Patients are offered quarterly medical and lifestyle-related consultation.
Full monitoring of each target indicator in patients with T2DM which includes minimally one measure of HbA1c level, systolic blood pressure, LDL, BMI, smoking behaviour and physical exercise between January and December 2014; otherwise, patients were defined as ’incompletely monitored'. HbA1c levels of 8137 fully monitored and 3958 incompletely monitored patients were compared, adjusted for the confounders diabetes duration, age and gender. Since recommended HbA1c values depend on age, medication use and diabetes duration, analyses were stratified into three HbA1c profile groups. Linear multilevel analyses enabled adjustment for general practice.
Compared with incompletely monitored patients, fully monitored patients had significantly lower HbA1c levels (95% CI) in the first (–2.03 [–2.53 to –1.52] mmol/mol) (–0.19% [–0.23% to –0.14%]), second (–3.36 [–5.28 to –1.43] mmol/mol) (–0.31% [–0.48% to –0.13%]) and third HbA1c profile group (–1.89 [–3.76 to –0.01] mmol/mol) (–0.17% [–0.34% to 0.00%]).
This study shows that in a care group setting, fully monitored patients had significantly lower HbA1c levels compared with incompletely monitored patients. Since this difference might have considerable clinical impact in terms of T2DM-related risks, this might help general practices in care group settings to overcome barriers on adequate registration and thus improve structured T2DM primary care. From population health management perspective, we recommend a systematic approach to adjust the structured care protocol for incompletely monitored subgroups.
Emergency intubation of children with abnormal respiratory or cardiac physiology is a high-risk procedure and associated with a high incidence of adverse events including hypoxemia. Successful emergency intubation is dependent on inter-related patient and operator factors. Preoxygenation has been used to maximise oxygen reserves in the patient and to prolong the safe apnoeic time during the intubation phase. Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) prolongs the safe apnoeic window for a safe intubation during elective intubation. We designed a clinical trial to test the hypothesis that THRIVE reduces the frequency of adverse and hypoxemic events during emergency intubation in children and to test the hypothesis that this treatment is cost-effective compared with standard care.
The Kids THRIVE trial is a multicentre randomised controlled trial performed in participating emergency departments and paediatric intensive care units. 960 infants and children aged 0–16 years requiring emergency intubation for all reasons will be enrolled and allocated to THRIVE or control in a 1:1 allocation with stratification by site, age (7 years) and operator (junior and senior). Children allocated to THRIVE will receive weight appropriate transnasal flow rates with 100% oxygen, whereas children in the control arm will not receive any transnasal oxygen insufflation. The primary outcomes are defined as follows: (1) hypoxemic event during the intubation phase defined as SpO2
Ethics approval for the protocol and consent process has been obtained (HREC/16/QRCH/81). The trial has been actively recruiting since May 2017. The study findings will be submitted for publication in a peer-reviewed journal.