KOLAHUN

HIV Pre-exposure Prophylaxis and the Underground Economy

Recent large trials have shown some positive evidence that pre-exposure prophylaxis for HIV works.  The first was the iPrEx trial showing it worked in men who have sex with women.  Then we have the HTPN 052 trial showing it works in preventing transmission from one HIV+ partner to his/her HIV- partner in heterosexual couples.  

As these positive results have seeped into the mainstream press, inevitably, there's been a run on anti-retrovirals, as reported here by marketwatch:

The State of Florida Agency for Health Care Administration (AHCA) recently sent out an alert to Florida health care providers and pharmacies notifying them of stricter requirements for incoming pharmacy claims for HIV/AIDS medications. AHCA informed AHF that the change is in response to an increase in demand for Truvada for use as a prevention pill by HIV-negative individuals and the fraudulent prescriptions that are appearing as a result.

 And while the state of Florida is absolutely right to maintain legitimacy and control over prescription medicines, there's a larger story here.  What we see here is an excess of demand for HIV medications over the supply.  Good.  This reflects the fear that HIV- negative individuals have of being infected with the virus and the hope they are clinging to that pre-exposure prophylaxis works.  We want these individuals to take care for themselves and in doing so reduce the overall transmission of the disease.  We've been working on this for 30 years!

The stated fear of opponents of wide-spread pre-exposure prophylaxis is that it will lead to more promiscuous behavior - which should perhaps be called the bare-back theory.  And that used improperly, the virus will soon find resistance to the medications, making them less efficacious in other patients.  But there are still lots more positive benefits to pre-exposure prophylaxis medications than negative ones.  In vulnerable sex workers.  In stable discordant couples - both heterosexual and homosexual.  There are lots of people who would benefit.  

The CDC has started the discussion on the proper use of pre-exposure prophylaxis (see below).  Admittedly however, there are political and scientific motives for not forcibly pushing these yet.  But as we fill in the knowledge gaps, the right way to use this modality will be the same as birth control and condoms and other preventive measures - emphasis on the risk of improper use while encouragement on proper application.

 

Toothpaste out of the Tube - Hospitalists

Over the past ten years, the care of general internal medicine patients has specialized to 'hospitalists'.  These are doctors who are general doctors who 'specialize' in taking care of patients while in the hospital.  This has happened because:

1. clinic work has gotten so busy, practitioners don't have time to go see his/her patients in the hospital
2. hospital care of patients has gotten more complicated with dozens of new drugs and testing modalities
3. clinicians want the 'shift-work' benefits associated with hospitalist care

With that in mind, here's a study showing that there's not much financial benefit to the use of hospitalists:

Results:

In propensity score analysis, hospital length of stay was 0.64 day less among patients receiving hospitalist care. Hospital charges were $282 lower, whereas Medicare costs in the 30 days after discharge were $332 higher (P < 0.001 for both). Patients cared for by hospitalists were less likely to be discharged to home (odds ratio, 0.82 [95% CI, 0.78 to 0.86]) and were more likely to have emergency department visits (odds ratio, 1.18 [CI, 1.12 to 1.24]) and readmissions (odds ratio, 1.08 [CI, 1.02 to 1.14]) after discharge. They also had fewer visits with their primary care physician and more nursing facility visits after discharge.

Limitation:

Observational studies are subject to selection bias.

Conclusion:

Decreased length of stay and hospital costs associated with hospitalist care are offset by higher medical utilization and costs after discharge.

Primary Funding Source:

National Institute on Aging and National Cancer Institute.

 

This is sobering news for the use of hospitalists.  But, as with the toothpaste analogy, it's unlikely we're going to go back to a system where internists become generalists and decide to re-learn the care of complex hospital patients in addition to taking care of their clinic patients.  So this implies that we have to figure out why that secondary cost - the 30day ER re-visit - is high.  

Are patients let out of the hospital too early by hospitalists who don't know enough about the patients?  Do hospitalists understand post-hospital care sufficiently?  Is there appropriate return to the primary care physician?  Are there enough appointment slots in clinics for hospital follow-up patients? 

 

A House Divided

In 2010, California's Citizens Redistricting Commission began the long process of redrawing the state's Congressional, State Senate and Assembly legislative districts, closely watch by many politicians, political canidates, policy wonks, pundents, community based organizations, lobbyist, political action committees, lawyers, fundraisers, all those "connected" types - but largely unnoticed by residents of the low-income African American community being divided in half by a proposed voting district division line that, if approved on August 15, will divide San Francisco's second largest African American neighborhoods into two separate State Assembly districts, effectively diluting their political voice on each side of the line by making them minority voters in their own neighborhood.

According the the Commission's website, "How the district boundaries are configured can make the difference between empowering and maximizing the voters’ voices or minimizing and muting those voices."

You ain't kiddin!

Efforts are underway to encourage community resident and leaders to contact the Commission and convince them to move the boundary westward and maintain the integrity of the African American community in the Fillmore/Western Addition neighborhood that the proposed line would divide in half.

While districts shall not be drawn by the Commission to favor or discriminate against an incumbent, candidate, or political party, districts should be geographically compact, must be contiguous so that all parts of the district are connected to each other, must comply with the Voting Rights Act to ensure that minorities have an equal opportunity to elect representatives of their choice and, especially in this case, must respect the boundaries of neighborhoods and communities of interest and minimize their division, to the extent possible.

We'll see what happens come August 15.