Comparative safety of filgrastim versus sargramostim in patients receiving myelosuppressive chemotherapy.

STUDY OBJECTIVE: To compare rates of adverse events with filgrastim versus sargramostim when given prophylactically to patients receiving myelosuppressive chemotherapy. DESIGN: Retrospective review with center crossover. SETTING: Ten United States outpatient chemotherapy centers. PATIENTS: Four hundred ninety patients treated for lung, breast, lymphatic system, or ovarian tumors. INTERVENTION: Prophylactic use of filgrastim or sargramostim, with dosages at investigator discretion. MEASUREMENTS AND MAIN RESULTS: The frequency and severity of adverse events and the frequency of switching to the alternative CSF were assessed. There was no difference in infectious fever. Fever unexplained by infection was more common with sargramostim (7% vs 1%, p<0.001), as were fatigue, diarrhea, injection site reactions, other dermatologic disorders, and edema (all p<0.05). Skeletal pain was more frequent with filgrastim (p=0.06). Patients treated with sargramostim switched to the alternative agent more often (p<0.001). CONCLUSION: Adverse events were less frequent with filgrastim than with sargramostim, suggesting that quality of life and treatment costs also may differ.

A cost-effectiveness analysis of OKT3 induction therapy in cadaveric kidney transplantation.

We evaluated the cost-effectiveness of a standard immunosuppressive regimen versus an OKT3 induction regimen in cadaveric kidney transplant recipients. Cost estimates were based on results from a five-center randomized trial comparing the safety and efficacy of OKT3 induction with a conventional triple-drug regimen and financial data from the National Cooperative Transplantation Study, the Medicare Provider and Analysis Review database, and other sources. Patients received OKT3 (5 mg/day) by intravenous (IV) bolus injection for 10 to 14 consecutive days in conjunction with azathioprine, prednisone, and the delayed addition of cyclosporine (CsA) on day 11 (n = 105) or a conventional immunosuppressive regimen consisting of CsA, azathioprine, and prednisone (n = 102). The following measures were used to evaluate the two regimens: costs incurred between transplantation and graft failure; the effectiveness of the two regimens as defined by length of graft survival; and cost-effectiveness ratios through 5 years of observed follow-up and modeled through the expected duration of graft survival. Results showed that OKT3 induction uniformly adds $8,219 to the cost of the transplant hospitalization. However, most of this cost is offset by a reduction in the cost of treating rejection episodes in the OKT3 group (P = 0.002). A trend toward improved graft survival was detected in the OKT3 group (P = 0.158). Through 5 years of observed follow-up, costs per year of graft survival are $30,474 with OKT3 versus $32,687 with the conventional regimen. Modeled through the expected duration of graft survival, OKT3 induction costs $8,335 for each additional year of graft survival. Results are fairly insensitive to wide variations in baseline assumptions. We conclude that OKT3 induction improves the cost-effectiveness of kidney transplantation.

The changing role of volunteerism.

As the number of Americans who volunteer grows, the definition of "volunteer" is becoming more broad. In addition to the traditional volunteer opportunity, there are community service, student internship, and court-ordered service programs, all of which pose a set of complicated managerial questions for those charged with designing and running volunteer programs. Today, volunteers' motives may extend further than the simple desire to help their neighbor. For example, given the tough job market, some individuals are volunteering as a possible bridge to employment, and are eager to learn skills and gain experience that they might transfer to a new work setting. The growth in the number of volunteers is not without its down side, however. As governments have cut back on service programs, some responsibilities traditionally assumed by government are being shunted to volunteer organizations, an inappropriate solution. Although volunteer programs deserve support, governments cannot be let off the hook. Volunteers cannot and should not replace paid staff. There are a number of exciting and innovative approaches to recruiting, managing, and motivating volunteers. Some programs are responding to the new kinds of volunteers by restructuring the volunteer opportunity to make it more accessible to those who work from 9 to 5. Others are responding to the diversity of the communities they serve by seeking training in cultural sensitivity and recruiting volunteers from the community. Whatever the volunteer opportunity, the screening and placement interview is a crucial first step. It should be used to clarify expectations--of the volunteer and of the volunteer administrator. Once volunteers are on board, the key to managing and retaining volunteers is to recognize what motivates the individual volunteer--whether it is the desire to acquire job-related skills, to socialize, or simply to learn new things--and to provide the volunteer with these opportunities. Continuing education, training, and feedback are essential ingredients of any volunteer program. Another key to retaining volunteers is appropriate recognition. Although volunteers may appreciate the traditional pin or letter of thanks, volunteer administrators should explore other means of recognition that are tied in to the individual volunteer's motives for volunteering in the first place. Involving volunteers in the development and refinement of the volunteer program and considering their suggestions for improvements are important ways of keeping them involved and signaling recognition of their expertise and value.(ABSTRACT TRUNCATED AT 400 WORDS)

Heterosexual and perinatal transmission of human immunodeficiency virus in a low prevalence community.

Six previously unidentified cases of human immunodeficiency virus (HIV) infection were found during an investigation and follow-up of three clusters of heterosexually and perinatally transmitted HIV infections. The investigations were to identify those infected, to interrupt the transmission of HIV, to attempt to reduce the likelihood of the development of the acquired immunodeficiency syndrome among those found to be seropositive, and to show the usefulness of traditional disease control strategies during this epidemic. Our findings indicate the value of contact tracing for HIV infections and the need to provide and evaluate educational activities regarding the transmission of HIV in low prevalence populations.

Economic examination of cefoperazone therapy.

Medical records of 1137 patients from 35 hospitals were reviewed to examine the total cost of care for patients receiving cefoperazone as initial therapy compared to a control group receiving alternative agents. The direct costs of care measurable through a retrospective review of patient records were examined, including the cost of antibiotic acquisition, drug administration, laboratory testing, and room and board. Results of a regression analysis show that cefoperazone as initial therapy is associated with lower costs for all factors studied except acquisition cost. Antibiotic acquisition averaged $24 per patient more for the cefoperazone group (p less than 0.01). However, for cefoperazone patients drug administration was $63 less (p less than 0.0001), laboratory testing costs averaged $9 less (p = 0.22), and costs associated with room and board charges were $80 less (p = 0.40). Total costs averaged $3073 per cefoperazone patient and $3228 per control patient (p = 0.20). These data suggest that the previously accepted definitions of antimicrobial costs (i.e., cost per gram, cost per dose, cost per day) may no longer be adequate in this era of cost containment. In order to make sound clinical decisions with lowest total costs, practitioners should identify how and where costs are incurred.

Drug therapy assessments by pharmacists.

Drug therapy assessments made for ambulatory patients by pharmacists and those made by the patients' primary physicians were compared. Using refill assessment guidelines, pharmacists evaluated the drug therapy regimens of patients attending a general medicine clinic before they were seen by their physicians. At the end of each clinic day, the pharmacists compared their assessments with the physician evaluations. Of the 155 drug regimens reviewed, the study pharmacists would have continued 104 (67.1%) without alteration, changed 48 (31.0%), and referred three patients (1.9%) with new problems for physician evaluation. The differences between pharmacist assessment and physician agreement were not significant (p greater than 0.2), but there was a significant difference between pharmacist assessment and physician actions (p less than 0.005), because the physicians actually changed only 52% of the drugs they agreed could be changed. The study suggests that the pharmacist is able to detect drug therapy problems and to recommend appropriate actions for resolving them.