Carbapenem resistance and mortality in patients with Acinetobacter baumannii infection: systematic review and meta-analysis.

Acinetobacter baumannii has emerged as a major cause of healthcare-associated infections. Controversy exists as to whether antimicrobial resistance increases the risk of mortality. We conducted a systematic review and meta-analysis to examine this association. We searched MEDLINE and EMBASE databases up to May 2013 to identify studies comparing mortality in patients with carbapenem-resistant A. baumannii (CRAB) vs. carbapenem-susceptible A. baumannii (CSAB). A random-effects model was used to pool Odds Ratios (OR). Heterogeneity was examined using I(2). We included 16 observational studies. There were 850 reported deaths (33%) among the 2546 patients. Patients with CRAB had a significantly higher risk of mortality than patients with CSAB in the pooled analysis of crude effect estimates (crude OR = 2.22; 95% CI = 1.66, 2.98), although substantial heterogeneity was evident (heterogeneity I(2) = 55%). The association remained significant in the pooled adjusted OR of 10 studies. Studies reported that patients with CRAB compared to patients with CSAB were more likely to have severe underlying illness and also to receive inappropriate empirical antimicrobial treatment, which increases the risk of mortality. Our study suggests that carbapenem resistance may increase the risk of mortality in patients with A. baumannii infection. However, cautious interpretation is required because of the residual confounding factors and inadequate sample size in most studies.

Cost effectiveness and quality of life considerations in the treatment of patients with overactive bladder.

This article summarizes the quality of life (QOL), cost of illness, and cost-effectiveness considerations in the treatment and management of patients with overactive bladder (OAB). Most cost studies have focused primarily on urinary incontinence, which is only one possible symptom of OAB. Prevalence rates of urge and mixed incontinence in the United States ranged from 3% to 8% and 5% to 37%, respectively. The highest prevalence was found in geriatric and psychogeriatric populations, where 40% and 90%, respectively, were classified as incontinent. In patients with OAB, all aspects of QOL can be compromised including physical, social, occupational, domestic, and sexual activities, and associated costs can be substantial. Oxybutynin has been the mainstay of pharmacotherapy for OAB but its more frequent side effects (including dry mouth) may deter patients from full compliance with treatment. Tolterodine, a newer antimuscarinic drug, has proven safe and effective in the treatment of OAB, with fewer side effects and better tolerability than existing agents. Cost effectiveness reports are reviewed. Further research on OAB is needed to characterize the disease process and identify risk factors.

Preferences for treatment outcomes in patients with heart failure: symptoms versus survival.

BACKGROUND: Patient preferences for congestive heart failure therapy outcomes may vary depending on the goals of improving symptoms versus survival, but this has not been extensively investigated. Our objective was to analyze patient preferences for congestive heart failure therapy outcomes based on the goals of symptom versus survival improvement. METHODS AND RESULTS: This was a prospective, full-profile conjoint analysis study of individual preferences for congestive heart failure treatment outcomes. Conjoint analysis was based on ratings of 16 treatment-outcome profiles, each consisting of 4 attributes (tiredness, shortness of breath, depression, and survival) varied across 4 severity levels. Part-worths (utilities) and importance weights were calculated for each attribute to determine their relative contribution to the full-profile rating decision using standard full-profile conjoint analysis techniques. Fifty-one patients with congestive heart failure from our medical center (University of Pennsylvania Medical Center, Philadelphia, PA) and 47 age-, gender-, and race-matched control subjects were studied. Part-worths and importance weights were significantly different for shortness of breath and depression between patients and control subjects. Symptom-sensitive (n = 33) and survival-sensitive (n = 17) treatment outcome preference segments were identified within the patient group. Importance weights for symptom-sensitive versus survival-sensitive patients were as follows: tiredness 0.30+/-0.10 versus 0.16+/-0.09 (P < .01); shortness of breath 0.26+/-0.08 versus 0.21+/-0.08 (P = .07); depression 0.26+/-0.09 versus 0.19+/-0.09 (P = .01); and survival 0.18+/-0.07 versus 0.43+/-0.11 (P < .01). There were no significant predictors of which treatment outcome preference segment a patient belonged. Control subjects did not display similar preference segmentation. CONCLUSIONS: Symptomatic congestive heart-failure patients were clustered into symptom-sensitive and survival-sensitive segments in a manner suggesting that treatment outcomes of improved symptoms were of greater importance to the majority than longer survival. A full understanding of these individual preferences may have important implications for the design of therapy for heart-failure patients.

Comorbidities associated with overactive bladder.

Overactive bladder (OAB), defined as symptoms of frequency, urgency, and urge incontinence, that occur singly or in any combination in the absence of local pathologic or metabolic factors, is a highly prevalent disorder with an unknown etiology. Few risk factors for OAB have been elucidated through epidemiologic studies, and even less is known about the contribution of OAB to other morbidities. An overview is provided of the impact of OAB on other problems now known to coexist with OAB including falls and fractures, urinary tract and skin infections, sleep disturbances, and depression.

Employer and consumer perspectives.

This paper reviews various published reports from surveys on employer opinion, perception of needs, and trends with regard to healthcare benefits; the consumer perspective regarding healthcare is also discussed. Surveys indicate that businesses want continuous evidence that high-quality healthcare can positively impact company profits. Employers and labor unions are demanding more cost-effective healthcare. At both employer and consumer levels, greater patient education is needed, as well as traditional educational media. Direct-to-consumer advertising and use of the World Wide Web are increasingly important in enabling consumers to participate more fully in their own lipid-related decision-making. Finally, the transition of lipid-lowering drugs to over-the-counter accessibility has great implications with respect to issues of patient preferences and willingness to pay in the evolving healthcare environment. Groups in the United States, such as the National Committee on Quality Assurance and the Foundation for Accountability, are setting standards and beginning to assess both process and outcomes in patient care. Further collaborative efforts are needed that raise standards of care and stimulate more cost-effective healthcare. The pharmacoeconomics and outcomes data gathered will, one hopes, also demonstrate to global businesses the positive financial impact of high-quality healthcare and appropriate lipid therapy.