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In This Issue of Archives of Internal Medicine |

In This Issue of Archives of Internal Medicine FREE

Arch Intern Med. 2002;162(2):127. doi:10.1001/archinte.162.2.127.
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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.

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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.

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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 Graphic Jump LocationTable 5 Break-even Costs and Average Age at First Event

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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.

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Table Graphic Jump LocationTable 5 Break-even Costs and Average Age at First Event



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