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China's National Reimbursement Drug List (NRDL) covers medicines that are included in national health insurance schemes. NRDL updates take into account evidence and recommendations of experts from the fields of medicine, health economics, pharmacy and health policy. A negotiation mechanism between the government and manufacturers was introduced in 2017 to include a more detailed evaluation and negotiation for high cost drugs. However, the values that are considered in NRDL decision making are not well-understood. This study aims to investigate the influence of available evidence and other factors on coverage decisions.
Outcomes of the 2017 and 2018 NRDL negotiations were analyzed. Logistic regression was used to investigate factors associated with listing decisions. Ordinary least squares and Tobit regression were used to investigate factors associated with negotiated price discounts. Independent variables were published cost-effectiveness analysis (CEA), incremental cost-effectiveness ratio (ICER), disease area, burden of disease (disability-adjusted life years), company ownership (domestic or foreign) and regulatory approval year.
Twenty-eight out of sixty-two negotiated drugs had one or more published CEA studies in the English or Chinese language, although neither the presence of a study nor the central ICER estimates were predictive of price discount or listing. A longer time since regulatory approval was a significant predictor of listing (p < 0.05). Disease area (oncology) and ownership (foreign) were significant predictors of a higher price discount (p < 0.01).
The NRDL plays a key role in providing access to healthcare for the 95 percent of China's population that is covered by public insurance. We found several factors that were associated with reimbursement decisions. Many of the medicines in the NRDL negotiation have CEA evidence, although the role of CEA in reimbursement decision making in China remains inconclusive.
Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in China. However, early identification of patients with COPD in the community is challenging. This study used a real-world survey of the Chinese urban adult population to estimate the prevalence of COPD diagnosis or COPD-risk, examine the health outcomes and healthcare resource use of these groups, and investigate the sociodemographic factors associated with these statuses.
Respondents to the 2017 National Health and Wellness Survey in China (n = 19,994) were classified into: COPD (diagnosed), COPD-risk (undiagnosed), and control (undiagnosed, not at-risk) using their self-reported diagnosis and Lung Function Questionnaire (LFQ) score. These groups were compared by healthcare resource use and health outcomes (EuroQol [EQ-5D] and Work Productivity and Activity Impairment questionnaires). Factors associated with being in these groups were investigated using pairwise comparisons (t-tests and chi-square tests) and multivariable logistic regression.
In total, 3,320 respondents (16.6%) had a suspected risk of COPD but did not report receiving a diagnosis. This was projected to 105.3 million people (16.9% of urban adults). Relative to the controls, COPD-risk and COPD-diagnosed respondents had higher healthcare resource use, lower productivity, and lower health-related quality of life (HRQoL) (p < 0.05). Age, smoking, alcohol consumption, weight, exercise, comorbidities, gender, education, employment, and air pollution were associated with increased odds of COPD-risk relative to the controls (p < 0.05).
A substantial group of individuals, undiagnosed, but with a risk of COPD, have impaired HRQoL, lower productivity, and elevated healthcare resource use. A range of sociodemographic factors are predictive of COPD risk, which may support targeted screening. Case-detection tools such as the LFQ may offer a convenient approach for identifying individuals for further definitive testing and appropriate treatment in China.
At its late Pleistocene maximum, the Laurentide Ice Sheet was the largest ice mass on Earth and a key player in the modulation of global climate and sea level. At the same time, this temperate ice sheet was itself sensitive to climate, and high-magnitude fluctuations in ice extent, reconstructed from relict glacial deposits, reflect past changes in atmospheric temperature. Here, we present a cosmogenic 10Be surface-exposure chronology for the Berlin moraines in the White Mountains of northern New Hampshire, USA, which supports the model that deglaciation of New England was interrupted by a pronounced advance of ice during the Bølling-Allerød. Together with recalculated 10Be ages from the southern New England coast, the expanded White Mountains moraine chronology also brackets the timing of ice sheet retreat in this sector of the Laurentide. In conjunction with existing chronological data, the moraine ages presented here suggest that deglaciation was widespread during Heinrich Stadial 1 event (~18–14.7 ka) despite apparently cold marine conditions in the adjacent North Atlantic. As part of the White Mountains moraine system, the Berlin chronology also places a new terrestrial constraint on the former glacial configuration during the marine incursion of the St. Lawrence River valley north of the White Mountains.
We evaluated the impact of an electronic health record based 72-hour antimicrobial time-out (ATO) on antimicrobial utilization. We observed that 6 hours after the ATO, 21% of empiric antimicrobials were discontinued or de-escalated. There was a significant reduction in the duration of antimicrobial therapy but no impact on overall antimicrobial usage metrics.
In the area of electromagnetic metrology, binary coded excitation signals become more and more important and various binary coded sequences are available. The measurement approach is to assess the impulse response function of a device under test by correlating the response signal with the excitation signal. In order to achieve a high measurement reproducibility as well as a high dynamic range, the generated binary coded signals have to provide low-noise. In this contribution, a low-noise signal generator realized with a field programmable gate array is presented. The performance investigation of different kinds of binary coded excitation signals and different correlation concepts have been practically investigated. With a chip rate of 5 Gchip/s, the generator can be utilized for ultra-wideband applications. In order to allow for a low-noise and long-term stable signal generation, a new clock generator concept is presented and results of phase noise measurements are shown. Furthermore, an algorithm to fast and precisely shifting the time lag between two binary coded signals for correlating excitation and response signals with a hardware correlator is presented. Finally, the realized demonstrator system is tested using two commonly used types of binary coded sequences.
Contaminated hands of healthcare workers (HCWs) are an important source of transmission of healthcare-associated infections. Alcohol-based hand sanitizers, while effective, do not provide sustained antimicrobial activity. The objective of this study was to compare the immediate and persistent activity of 2 hand hygiene products (ethanol [61% w/v] plus chlorhexidine gluconate [CHG; 1.0% solution] and ethanol only [70% v/v]) when used in an intensive care unit (ICU).
Prospective, randomized, double-blinded, crossover study
Three ICUs at a large teaching hospital
In total, 51 HCWs involved in direct patient care were enrolled in and completed the study.
All HCWs were randomized 1:1 to either product. Hand prints were obtained immediately after the product was applied and again after spending 4–7 minutes in the ICU common areas prior to entering a patient room or leaving the area. The numbers of aerobic colony-forming units (CFU) were compared for the 2 groups after log transformation. Each participant tested the alternative product after a 3-day washout period.
On bare hands, use of ethanol plus CHG was associated with significantly lower recovery of aerobic CFU, both immediately after use (0.27 ± 0.05 and 0.88 ± 0.08 log10 CFU; P = .035) and after spending time in ICU common areas (1.81 ± 0.07 and 2.17 ± 0.05 log10 CFU; P<.0001). Both the antiseptics were well tolerated by HCWs.
In comparison to the ethanol-only product, the ethanol plus CHG sanitizer was associated with significantly lower aerobic bacterial counts on hands of HCWs, both immediately after use and after spending time in ICU common areas.
Catheter-associated urinary tract infections (CAUTIs) are among the most common hospital-acquired infections (HAIs). Reducing CAUTI rates has become a major focus of attention due to increasing public health concerns and reimbursement implications.
To implement and describe a multifaceted intervention to decrease CAUTIs in our ICUs with an emphasis on indications for obtaining a urine culture.
A project team composed of all critical care disciplines was assembled to address an institutional goal of decreasing CAUTIs. Interventions implemented between year 1 and year 2 included protocols recommended by the Centers for Disease Control and Prevention for placement, maintenance, and removal of catheters. Leaders from all critical care disciplines agreed to align routine culturing practice with American College of Critical Care Medicine (ACCCM) and Infectious Disease Society of America (IDSA) guidelines for evaluating a fever in a critically ill patient. Surveillance data for CAUTI and hospital-acquired bloodstream infection (HABSI) were recorded prospectively according to National Healthcare Safety Network (NHSN) protocols. Device utilization ratios (DURs), rates of CAUTI, HABSI, and urine cultures were calculated and compared.
The CAUTI rate decreased from 3.0 per 1,000 catheter days in 2013 to 1.9 in 2014. The DUR was 0.7 in 2013 and 0.68 in 2014. The HABSI rates per 1,000 patient days decreased from 2.8 in 2013 to 2.4 in 2014.
Effectively reducing ICU CAUTI rates requires a multifaceted and collaborative approach; stewardship of culturing was a key and safe component of our successful reduction efforts.
Bipolar disorder is a highly heritable polygenic disorder. Recent
enrichment analyses suggest that there may be true risk variants for
bipolar disorder in the expression quantitative trait loci (eQTL) in the
We sought to assess the impact of eQTL variants on bipolar disorder risk
by combining data from both bipolar disorder genome-wide association
studies (GWAS) and brain eQTL.
To detect single nucleotide polymorphisms (SNPs) that influence
expression levels of genes associated with bipolar disorder, we jointly
analysed data from a bipolar disorder GWAS (7481 cases and 9250 controls)
and a genome-wide brain (cortical) eQTL (193 healthy controls) using a
Bayesian statistical method, with independent follow-up replications. The
identified risk SNP was then further tested for association with
hippocampal volume (n = 5775) and cognitive performance
(n = 342) among healthy individuals.
Integrative analysis revealed a significant association between a brain
eQTL rs6088662 on chromosome 20q11.22 and bipolar disorder (log Bayes
factor = 5.48; bipolar disorder P =
5.85×10–5). Follow-up studies across multiple independent
samples confirmed the association of the risk SNP (rs6088662) with gene
expression and bipolar disorder susceptibility (P =
3.54×10–8). Further exploratory analysis revealed that
rs6088662 is also associated with hippocampal volume and cognitive
performance in healthy individuals.
Our findings suggest that 20q11.22 is likely a risk region for bipolar
disorder; they also highlight the informative value of integrating
functional annotation of genetic variants for gene expression in
advancing our understanding of the biological basis underlying complex
disorders, such as bipolar disorder.
Radiological terror presents a real threat, but little is known about how low-income, urban African Americans may respond to such threats. The aim of this study was to understand the unique challenges of this group and to explore their knowledge of what a “dirty bomb” is, their intended behaviors should one occur, and their barriers to complying with “shelter in place” recommendations.
Thirty-seven 18-65-year-olds who were users of community centers in disadvantaged areas participated in 3 focus groups in Philadelphia. Results were analyzed by using the Krueger method of analyzing narrative text.
The responses highlighted little knowledge or concern about a dirty bomb. Lack of trust in local authorities was expressed, with participants indicating that they did not feel their needs were addressed. While shelter in place was understood, most said they would still check on family or talk with others to get the “whole truth” because the most trusted information sources were neighbors and community leaders.
Our results indicate that a risk communication intervention for urban minorities may support desirable behaviors in the event of a dirty bomb, but successful communication will require establishing a local leader as a spokesperson to convince people of the importance of sheltering in place.(Disaster Med Public Health Preparedness. 2015;0:1-10)
Stable isotope ratios of carbon, nitrogen, and sulfur in human bone collagen are used routinely to aid in the reconstruction of ancient diets. Isotopic analysis of human remains from sites in the Iron Gates section of the Lower Danube Valley has led to conflicting interpretations of Mesolithic diets in this key region of southeast Europe. One view (Bonsall et al. 1997, 2004) is that diets were based mainly on riverine resources throughout the Mesolithic. A competing hypothesis (Nehlich et al. 2010) argues that Mesolithic diets were more varied with at least one Early Mesolithic site showing an emphasis on terrestrial resources, and riverine resources only becoming dominant in the Later Mesolithic. The present article revisits this issue, discussing the stable isotope data in relation to archaeozoological and radiocarbon evidence.
Archaeological investigations in the Iron Gates reach of the Lower Danube Valley between 1964 and 1984 revealed an important concentration of Stone Age sites, which together provide the most detailed record of Mesolithic and Early Neolithic settlement from any area of southeastern Europe. Over 425 human burials were excavated from 15 sites. Of these, less than one-fifth have been directly dated. This article presents 37 new AMS dates on human bone from five sites in the Iron Gates, together with the corresponding δ13C and δ15N values. They include the first dates on human bone from two sites, Icoana and Velesnica. The results are important for the chronology of Stone Age mortuary practices in the Iron Gates and the timing of the Mesolithic–Neolithic transition in the region.
To review and describe device utilization and central line-associated bloodstream (CLABSI) events among patients in a non-intensive care unit (ICU) setting and to examine the morbidity and mortality associated with these events.
One-year descriptive review.
A single tertiary center with a 1,200-bed hospital and 209 adult ICU beds.
Hospitalized patients identified as having a CLABSI event attributed to a non-ICU setting.
The cohort was identified from a prospective infection prevention database. Charts and administrative data sets were reviewed to further characterize the patients. Device utilization ratios (DURs) and CLABSI rates were calculated using National Health and Safety Network (NHSN) CLABSI definitions. Need for ICU stay and crude mortality rates were recorded.
A total of 136 patients with 156 CLABSIs were identified, of whom 78 (57%) were being treated for a hematological malignancy (HM). The overall DUR was 0.27. A tunneled line was in place for 118 (76%) of the CLABSI events, and a peripherally inserted central catheter was in place for 32 (21%) of the CLABSI events. The non-ICU CLABSI rate was significantly higher than the concurrent ICU rate (2.1 CLABSIs per 1,000 catheter-days vs 1.5 CLABSIs per 1,000 catheter-days; P = .02). Hospital mortality was 23% in the affected group and was significantly higher in patients with HM.
CLABSI rates over a 1-year period were higher in patients outside the ICU at our hospital and were associated with significant mortality.