- Email: [email protected]
Improving medication safety
Comment
Furthermore, applying clinical criteria for diagnosis of veno-occlusive disease implies some uncertainties as to the pathophysiology involved in the respective patients. Patients with and without elevated bilirubin meeting the criteria of veno-occlusive disease probably represent different disease stages. Notably, the investigators showed the efficacy of defibrotide irrespective of the disease criteria or stage applied. Furthermore, in recipients of allogeneic HSCT (70% of the study population), incidence and severity of acute, but not chronic, graft-versus-host disease were lower in the defibrotide group than in the control group. This finding is intriguing and further supports the prophylactic use of defibrotide in the allogeneic transplantation setting. Although the differences noted for grade 2–4 acute graftversus-host disease might be partly because of the higher proportion of matched-sibling donor transplants in the experimental group (29% for defibrotide vs 21% for controls), the protective effects of defibrotide against allogeneic immune attack merit further investigation. As discussed by the authors, experimental data suggest that the endothelial damage induced by cytotoxic drugs can be partly abrogated by defibrotide.13 This change might lead to a reduced activation of donor T cells in target organs of acute graft-versus-host disease. Most importantly, defibrotide prophylaxis was well tolerated and did not lead to an increased risk of bleeding. Restriction by the legislative authorities means that there are few randomised trials in children, and thus Corbacioglu and colleagues’ investigation11 is a pivotal European study—one that will hopefully change practice in paediatric patients and might also provide an impetus to investigate treatment options for adult patients.
*Uwe Platzbecker, Martin Bornhäuser Medizinische Klinik und Poliklinik I, Universitätsklinikum “Carl Gustav Carus” Dresden, 01307 Dresden, Germany [email protected] We declare that we have no conflicts of interest. 1
2
3 4
5
6
7
8
9
10
11
12
13
Shulman HM, Fisher LB, Schoch HG, Henne KW, McDonald GB. Venoocclusive disease of the liver after marrow transplantation— histological correlates of clinical signs and symptoms. Hepatology 1994; 19: 1171–81. Hogan WJ, Maris M, Storer B, et al. Hepatic injury after nonmyeloablative conditioning followed by allogeneic hematopoietic cell transplantation: a study of 193 patients. Blood 2004; 103: 78–84. McDonald GB. Hepatobiliary complications of hematopoietic cell transplantation, 40 years on. Hepatology 2010; 51: 1450–60. Attal M, Huguet F, Rubie H, et al. Prevention of hepatic venoocclusive disease after bone-marrow transplantation by continuous infusion of low-dose heparin—a prospective, randomized trial. Blood 1992; 79: 2834–40. Gluckman E, Jolivet I, Scrobohaci ML, et al. Use of prostaglandin-E1 for prevention of liver venoocclusive disease in leukemic patients treated by allogeneic bone-marrow transplantation. Br J Haematol 1990; 74: 277–81. Clift RA, Bianco JA, Appelbaum FR, et al. A randomized controlled trial of pentoxifylline for the prevention of regimen-related toxicities in patients undergoing allogeneic marrow transplantation. Blood 1993; 82: 2025–30. Ruutu T, Eriksson B, Remes K, et al. Ursodeoxycholic acid for the prevention of hepatic complications in allogeneic stem cell transplantation. Blood 2002; 100: 1977–83. Richardson P, Linden E, Revta C, Ho V. Use of defibrotide in the treatment and prevention of veno-occlusive disease. Expert Rev Hematol 2009; 2: 365–76. Chopra R, Eaton JD, Grassi A, et al. Defibrotide for the treatment of hepatic veno-occlusive disease: results of the European compassionate-use study. Br J Haematol 2000; 111: 1122–29. Richardson PG, Soiffer RJ, Antin JH, et al. Defibrotide for the treatment of severe hepatic veno-occlusive disease and multiorgan failure after stem cell transplantation: a multicenter, randomized, dose-finding trial. Biol Blood Marrow Transplant 2010; 16: 1005–17. Corbacioglu S, Cesaro S, Faraci M, et al. Defibrotide for prophylaxis of hepatic veno-occlusive disease in paediatric haematopoietic stem-cell transplantation: an open-label, phase 3, randomised controlled trial. Lancet 2012; published online Feb 23. DOI:10.1016/S0140-6736(11)61938-7. Richardson P, Tomblyn M, Kernan N, et al. Defibrotide (DF) in the treatment of severe hepatic veno-occlusive disease (VOD) with multiorgan failure (MOF) following stem cell transplantation (SCT): results of a phase 3 study utilizing a historical control. Blood 2009; 114: 272–73. Eissner G, Multhoff G, Gerbitz A, et al. Fludarabine induces apoptosis, activation, and allogenicity in human endothelial and epithelial cells: protective effect of defibrotide. Blood 2002; 100: 334–40.
Improving medication safety Published Online February 21, 2012 DOI:10.1016/S01406736(12)60078-6 See Articles page 1310
1278
Adverse drug events1 are a major problem for patient safety. A systematic review estimated that 18 adverse drug events per 100 outpatients, including almost seven preventable events, occur yearly.2 Preventable adverse drug events are caused by errors such as inappropriate prescription, medication discrepancies, non-adherence, and failure to monitor for side-effects or disease control. More than 20 years of research into medication safety has shown the efficacy of several interventions, including computer provider order entry, electronic
decision support, and some pharmacist interventions.3–5 However, progress in medication safety is insufficient, especially studies of the effect on hard patient outcomes, such as adverse drug events and health-care use. New interventions should be developed, and all interventions need to be rigorously tested so that we better understand how to successfully implement those already proven effective.6 In The Lancet, Anthony Avery and colleagues7 present the results of the PINCER study. In this pragmatic trial, www.thelancet.com Vol 379 April 7, 2012
Comment
www.thelancet.com Vol 379 April 7, 2012
activities or do not make tasks more efficient.10 Very few interventions can be adopted if those investing the time, money, and resources (eg, the general practice) do not benefit from their adoption (eg, from decreased downstream health-care costs). Can the PINCER intervention be adopted, and should it be? There are several caveats. Only a third of eligible practices participated in the study, with most practices declining because they were too busy. Whether the PINCER intervention would be successful if implemented in busy practices is unclear. When considering the costeffectiveness of the intervention, one must also consider the opportunity cost—what were the pharmacists no longer doing because they were spending time on PINCER? If additional pharmacy staff need to be hired to meet the needs of PINCER, the cost-effectiveness calculation would change. Furthermore, we know very little about whether some practices were more successful than others at implementing the intervention and, if so, why. Whether this intervention should be adopted outside the NHS depends on the degree to which incentives are aligned and the extent to which the electronic infrastructure is already in place (eg, electronic prescribing, and robust documentation of medical problems in an electronic medical record). In the USA, a fee-for-service system is dominant and without robust adoption of health information technology in primary care,6 immediate broad implementation is unlikely. However, with the wider adoption of meaningful use requirements for health information technology,11 and changes to the organisation of health care such as patient-centred medical homes12 and accountable care organisations,13 these prerequisites might be met soon. The PINCER trial is important because it shows how the elements necessary for a successful medicationsafety intervention can be combined on a large scale. Further research is needed to better understand how to successfully implement such interventions as broadly as possible, and the potential tradeoffs inherent in focusing efforts on certain measurable quality and safety goals, possibly at the expense of less measurable ones.
Science Photo Library
72 general practices were randomly assigned to receive simple computer-generated feedback for patients at risk for medication errors, or to also receive electronic feedback for specific potential prescribing or monitoring errors, and pharmacist interventions to help correct identified errors and improve local safety systems. At 6 months’ followup, patients in the intervention group were significantly less likely to have been prescribed a non-selective nonsteroidal anti-inflammatory drug if they had a history of peptic ulcer without gastroprotection (OR 0·58, 95% CI 0·38–0·89); a β blocker if they had asthma (0·73, 0·58–0·91); or an angiotensin-converting enzyme inhibitor or loop diuretic without suitable monitoring (0·51, 0·34–0·78). The intervention also improved composite prescribing and monitoring outcomes. The study is important for several reasons. First, it was large, including more than 70 practices and almost 70 000 patients at risk. Second, it shows the benefits of combining health information technology with a dedicated patient-safety intervention. Third, even the simple cost-effectiveness analysis in the report shows the potential for cost savings (ie, if health-care use as a result of adverse drug events is reduced) or at least cost utility (when considering the effect of adverse drug events avoided on quality-adjusted life-years). To improve medication safety, three components are necessary: incentives that encourage investments in patient safety; process redesign to achieve specific medication-safety goals; and effective means by which to support these efforts.8 In Avery and colleagues’ study, all three are in place to some extent. In the UK National Health Service (NHS), financial incentives exist for investment in patient safety, especially when harm can result in avoidable health-care use. The process redesign in this case was simple but effective (having study pharmacists act as the effector group). The PINCER intervention was able to identify specific targets for action. Other patient safety interventions have failed when one or more of these components have been missing. Health information technology might be ineffective without a coordinated local effort to improve quality and safety, or at the very least identification of someone to take action.9 Health information technology should do more than just fit into workflow. Instead, it should promote a restricted number of best practices. Conversely, pharmacist interventions might be ineffective if they are not focused on specific high-yield
Jeffrey L Schnipper, *Jeffrey M Rothschild Division of General Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA 02120–1613, USA [email protected]
1279
Comment
JLS receives funding from Sanofi-Aventis for an investigator-initiated study of discharge interventions in patients with diabetes, and is a consultant to QuantiaMD, for which he has written online educational material for providers and patients about medication safety. JMR declares that he has no conflicts of interest.
7
1
8
2
3 4
5 6
Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324: 377–84. Thomsen LA, Winterstein AG, Sondergaard B, Haugbolle LS, Melander A. Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care. Ann Pharmacother 2007; 41: 1411–26. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med 2003; 348: 2526–34. Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med 2006; 166: 955–64. Institute of Medicine. Health IT and patient safety: building safer systems for better care. Washington, DC: National Academy of Sciences, 2011. Simon SR, Soran CS, Kaushal R, et al. Physicians’ use of key functions in electronic health records from 2005 to 2007: a statewide survey. J Am Med Inform Assoc 2009; 16: 465–70.
9
10
11 12 13
Avery AJ, Rodgers S, Cantrill JA, et al. A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. Lancet 2012; published online Feb 21. DOI:10.1016/S01406736(11)61817-5. Schnipper JL. Medication safety: are we there yet? Comment on “Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients”. Arch Intern Med 2011; 171: 1019–20. Schnipper JL, Linder JA, Palchuk MB, et al. Effects of documentation-based decision support on chronic disease management. Am J Manag Care 2010; 16 (suppl): SP72–81. Holland R, Lenaghan E, Harvey I, et al. Does home based medication review keep older people out of hospital? The HOMER randomised controlled trial. BMJ 2005; 330: 293. Blumenthal D. Launching HITECH. N Engl J Med 2010; 362: 382–85. Bates DW, Bitton A. The future of health information technology in the patient-centered medical home. Health Aff (Millwood) 2010; 29: 614–21. Berwick DM. Making good on ACOs’ promise—the final rule for the Medicare shared savings program. N Engl J Med 2011; 365: 1753–56.
Paying to prevent HIV infection in young women? Published Online February 15, 2012 DOI:10.1016/S01406736(12)60036-1
Alfredo Caliz/Panos
See Articles page 1320
1280
Between a quarter and a third of young women in sub-Saharan Africa are infected with HIV by the time they reach their early 20s. Structural factors such as poor education, poverty, and gender and power inequalities are important determinants of young women’s vulnerability to HIV infection.1,2 However, until now, no rigorously assessed intervention targeting this group has significantly reduced HIV infection and no intervention that targets structural factors has directly affected HIV infection.3,4 In The Lancet, Sarah Baird and colleagues5 report the results of a randomised controlled trial done with adolescent girls in rural Malawi, examining the effects of a cash transfer programme on risk of HIV
infection. The investigators report that schoolgirls who received monthly cash payments of varying amounts were significantly less likely than girls who did not receive payments to be infected with HIV (1·2% vs 3·0%; OR 0·36, 95% CI 0·14–0·91) and HSV-2 (0·7% vs 3·0%; OR 0·24, 0·09–0·65), to have an older male partner (0·5% vs 2·5%; OR 0·20, 0·07–0·59), and to have sexual intercourse once per week (3·0% vs 6·5%; OR 0·46, 0·26– 0·82) at follow-up (18 months for biological outcomes and 12 months for behavioural outcomes). There is a well-established protective effect of schooling on HIV risk6–8 and cash transfer programmes are able to increase school attendance.9,10 Additionally, published work suggests that improvement of young women’s socioeconomic status can reduce risk of HIV infection, giving greater financial autonomy and less dependence on male partners.11,12 Baird and colleagues’ study5 was designed to test both risk reduction pathways. In one group, a conditional cash transfer (CCT) was paid to the girl and her caregiver contingent on school attendance. In another group, the girl and her caregiver were given an unconditional cash transfer (UCT). The comparator was a group of girls who received no cash. When both intervention groups were pooled together, the cash transfer groups were associated with fewer HIV and HSV-2 infections than the no cash transfer group, which seemed to be caused by girls who received the intervention having younger male partners and www.thelancet.com Vol 379 April 7, 2012
Furthermore, applying clinical criteria for diagnosis of veno-occlusive disease implies some uncertainties as to the pathophysiology involved in the respective patients. Patients with and without elevated bilirubin meeting the criteria of veno-occlusive disease probably represent different disease stages. Notably, the investigators showed the efficacy of defibrotide irrespective of the disease criteria or stage applied. Furthermore, in recipients of allogeneic HSCT (70% of the study population), incidence and severity of acute, but not chronic, graft-versus-host disease were lower in the defibrotide group than in the control group. This finding is intriguing and further supports the prophylactic use of defibrotide in the allogeneic transplantation setting. Although the differences noted for grade 2–4 acute graftversus-host disease might be partly because of the higher proportion of matched-sibling donor transplants in the experimental group (29% for defibrotide vs 21% for controls), the protective effects of defibrotide against allogeneic immune attack merit further investigation. As discussed by the authors, experimental data suggest that the endothelial damage induced by cytotoxic drugs can be partly abrogated by defibrotide.13 This change might lead to a reduced activation of donor T cells in target organs of acute graft-versus-host disease. Most importantly, defibrotide prophylaxis was well tolerated and did not lead to an increased risk of bleeding. Restriction by the legislative authorities means that there are few randomised trials in children, and thus Corbacioglu and colleagues’ investigation11 is a pivotal European study—one that will hopefully change practice in paediatric patients and might also provide an impetus to investigate treatment options for adult patients.
*Uwe Platzbecker, Martin Bornhäuser Medizinische Klinik und Poliklinik I, Universitätsklinikum “Carl Gustav Carus” Dresden, 01307 Dresden, Germany [email protected] We declare that we have no conflicts of interest. 1
2
3 4
5
6
7
8
9
10
11
12
13
Shulman HM, Fisher LB, Schoch HG, Henne KW, McDonald GB. Venoocclusive disease of the liver after marrow transplantation— histological correlates of clinical signs and symptoms. Hepatology 1994; 19: 1171–81. Hogan WJ, Maris M, Storer B, et al. Hepatic injury after nonmyeloablative conditioning followed by allogeneic hematopoietic cell transplantation: a study of 193 patients. Blood 2004; 103: 78–84. McDonald GB. Hepatobiliary complications of hematopoietic cell transplantation, 40 years on. Hepatology 2010; 51: 1450–60. Attal M, Huguet F, Rubie H, et al. Prevention of hepatic venoocclusive disease after bone-marrow transplantation by continuous infusion of low-dose heparin—a prospective, randomized trial. Blood 1992; 79: 2834–40. Gluckman E, Jolivet I, Scrobohaci ML, et al. Use of prostaglandin-E1 for prevention of liver venoocclusive disease in leukemic patients treated by allogeneic bone-marrow transplantation. Br J Haematol 1990; 74: 277–81. Clift RA, Bianco JA, Appelbaum FR, et al. A randomized controlled trial of pentoxifylline for the prevention of regimen-related toxicities in patients undergoing allogeneic marrow transplantation. Blood 1993; 82: 2025–30. Ruutu T, Eriksson B, Remes K, et al. Ursodeoxycholic acid for the prevention of hepatic complications in allogeneic stem cell transplantation. Blood 2002; 100: 1977–83. Richardson P, Linden E, Revta C, Ho V. Use of defibrotide in the treatment and prevention of veno-occlusive disease. Expert Rev Hematol 2009; 2: 365–76. Chopra R, Eaton JD, Grassi A, et al. Defibrotide for the treatment of hepatic veno-occlusive disease: results of the European compassionate-use study. Br J Haematol 2000; 111: 1122–29. Richardson PG, Soiffer RJ, Antin JH, et al. Defibrotide for the treatment of severe hepatic veno-occlusive disease and multiorgan failure after stem cell transplantation: a multicenter, randomized, dose-finding trial. Biol Blood Marrow Transplant 2010; 16: 1005–17. Corbacioglu S, Cesaro S, Faraci M, et al. Defibrotide for prophylaxis of hepatic veno-occlusive disease in paediatric haematopoietic stem-cell transplantation: an open-label, phase 3, randomised controlled trial. Lancet 2012; published online Feb 23. DOI:10.1016/S0140-6736(11)61938-7. Richardson P, Tomblyn M, Kernan N, et al. Defibrotide (DF) in the treatment of severe hepatic veno-occlusive disease (VOD) with multiorgan failure (MOF) following stem cell transplantation (SCT): results of a phase 3 study utilizing a historical control. Blood 2009; 114: 272–73. Eissner G, Multhoff G, Gerbitz A, et al. Fludarabine induces apoptosis, activation, and allogenicity in human endothelial and epithelial cells: protective effect of defibrotide. Blood 2002; 100: 334–40.
Improving medication safety Published Online February 21, 2012 DOI:10.1016/S01406736(12)60078-6 See Articles page 1310
1278
Adverse drug events1 are a major problem for patient safety. A systematic review estimated that 18 adverse drug events per 100 outpatients, including almost seven preventable events, occur yearly.2 Preventable adverse drug events are caused by errors such as inappropriate prescription, medication discrepancies, non-adherence, and failure to monitor for side-effects or disease control. More than 20 years of research into medication safety has shown the efficacy of several interventions, including computer provider order entry, electronic
decision support, and some pharmacist interventions.3–5 However, progress in medication safety is insufficient, especially studies of the effect on hard patient outcomes, such as adverse drug events and health-care use. New interventions should be developed, and all interventions need to be rigorously tested so that we better understand how to successfully implement those already proven effective.6 In The Lancet, Anthony Avery and colleagues7 present the results of the PINCER study. In this pragmatic trial, www.thelancet.com Vol 379 April 7, 2012
Comment
www.thelancet.com Vol 379 April 7, 2012
activities or do not make tasks more efficient.10 Very few interventions can be adopted if those investing the time, money, and resources (eg, the general practice) do not benefit from their adoption (eg, from decreased downstream health-care costs). Can the PINCER intervention be adopted, and should it be? There are several caveats. Only a third of eligible practices participated in the study, with most practices declining because they were too busy. Whether the PINCER intervention would be successful if implemented in busy practices is unclear. When considering the costeffectiveness of the intervention, one must also consider the opportunity cost—what were the pharmacists no longer doing because they were spending time on PINCER? If additional pharmacy staff need to be hired to meet the needs of PINCER, the cost-effectiveness calculation would change. Furthermore, we know very little about whether some practices were more successful than others at implementing the intervention and, if so, why. Whether this intervention should be adopted outside the NHS depends on the degree to which incentives are aligned and the extent to which the electronic infrastructure is already in place (eg, electronic prescribing, and robust documentation of medical problems in an electronic medical record). In the USA, a fee-for-service system is dominant and without robust adoption of health information technology in primary care,6 immediate broad implementation is unlikely. However, with the wider adoption of meaningful use requirements for health information technology,11 and changes to the organisation of health care such as patient-centred medical homes12 and accountable care organisations,13 these prerequisites might be met soon. The PINCER trial is important because it shows how the elements necessary for a successful medicationsafety intervention can be combined on a large scale. Further research is needed to better understand how to successfully implement such interventions as broadly as possible, and the potential tradeoffs inherent in focusing efforts on certain measurable quality and safety goals, possibly at the expense of less measurable ones.
Science Photo Library
72 general practices were randomly assigned to receive simple computer-generated feedback for patients at risk for medication errors, or to also receive electronic feedback for specific potential prescribing or monitoring errors, and pharmacist interventions to help correct identified errors and improve local safety systems. At 6 months’ followup, patients in the intervention group were significantly less likely to have been prescribed a non-selective nonsteroidal anti-inflammatory drug if they had a history of peptic ulcer without gastroprotection (OR 0·58, 95% CI 0·38–0·89); a β blocker if they had asthma (0·73, 0·58–0·91); or an angiotensin-converting enzyme inhibitor or loop diuretic without suitable monitoring (0·51, 0·34–0·78). The intervention also improved composite prescribing and monitoring outcomes. The study is important for several reasons. First, it was large, including more than 70 practices and almost 70 000 patients at risk. Second, it shows the benefits of combining health information technology with a dedicated patient-safety intervention. Third, even the simple cost-effectiveness analysis in the report shows the potential for cost savings (ie, if health-care use as a result of adverse drug events is reduced) or at least cost utility (when considering the effect of adverse drug events avoided on quality-adjusted life-years). To improve medication safety, three components are necessary: incentives that encourage investments in patient safety; process redesign to achieve specific medication-safety goals; and effective means by which to support these efforts.8 In Avery and colleagues’ study, all three are in place to some extent. In the UK National Health Service (NHS), financial incentives exist for investment in patient safety, especially when harm can result in avoidable health-care use. The process redesign in this case was simple but effective (having study pharmacists act as the effector group). The PINCER intervention was able to identify specific targets for action. Other patient safety interventions have failed when one or more of these components have been missing. Health information technology might be ineffective without a coordinated local effort to improve quality and safety, or at the very least identification of someone to take action.9 Health information technology should do more than just fit into workflow. Instead, it should promote a restricted number of best practices. Conversely, pharmacist interventions might be ineffective if they are not focused on specific high-yield
Jeffrey L Schnipper, *Jeffrey M Rothschild Division of General Medicine and Primary Care, Brigham and Women’s Hospital, Boston, MA 02120–1613, USA [email protected]
1279
Comment
JLS receives funding from Sanofi-Aventis for an investigator-initiated study of discharge interventions in patients with diabetes, and is a consultant to QuantiaMD, for which he has written online educational material for providers and patients about medication safety. JMR declares that he has no conflicts of interest.
7
1
8
2
3 4
5 6
Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324: 377–84. Thomsen LA, Winterstein AG, Sondergaard B, Haugbolle LS, Melander A. Systematic review of the incidence and characteristics of preventable adverse drug events in ambulatory care. Ann Pharmacother 2007; 41: 1411–26. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med 2003; 348: 2526–34. Kaboli PJ, Hoth AB, McClimon BJ, Schnipper JL. Clinical pharmacists and inpatient medical care: a systematic review. Arch Intern Med 2006; 166: 955–64. Institute of Medicine. Health IT and patient safety: building safer systems for better care. Washington, DC: National Academy of Sciences, 2011. Simon SR, Soran CS, Kaushal R, et al. Physicians’ use of key functions in electronic health records from 2005 to 2007: a statewide survey. J Am Med Inform Assoc 2009; 16: 465–70.
9
10
11 12 13
Avery AJ, Rodgers S, Cantrill JA, et al. A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. Lancet 2012; published online Feb 21. DOI:10.1016/S01406736(11)61817-5. Schnipper JL. Medication safety: are we there yet? Comment on “Potentially inappropriate medications defined by STOPP criteria and the risk of adverse drug events in older hospitalized patients”. Arch Intern Med 2011; 171: 1019–20. Schnipper JL, Linder JA, Palchuk MB, et al. Effects of documentation-based decision support on chronic disease management. Am J Manag Care 2010; 16 (suppl): SP72–81. Holland R, Lenaghan E, Harvey I, et al. Does home based medication review keep older people out of hospital? The HOMER randomised controlled trial. BMJ 2005; 330: 293. Blumenthal D. Launching HITECH. N Engl J Med 2010; 362: 382–85. Bates DW, Bitton A. The future of health information technology in the patient-centered medical home. Health Aff (Millwood) 2010; 29: 614–21. Berwick DM. Making good on ACOs’ promise—the final rule for the Medicare shared savings program. N Engl J Med 2011; 365: 1753–56.
Paying to prevent HIV infection in young women? Published Online February 15, 2012 DOI:10.1016/S01406736(12)60036-1
Alfredo Caliz/Panos
See Articles page 1320
1280
Between a quarter and a third of young women in sub-Saharan Africa are infected with HIV by the time they reach their early 20s. Structural factors such as poor education, poverty, and gender and power inequalities are important determinants of young women’s vulnerability to HIV infection.1,2 However, until now, no rigorously assessed intervention targeting this group has significantly reduced HIV infection and no intervention that targets structural factors has directly affected HIV infection.3,4 In The Lancet, Sarah Baird and colleagues5 report the results of a randomised controlled trial done with adolescent girls in rural Malawi, examining the effects of a cash transfer programme on risk of HIV
infection. The investigators report that schoolgirls who received monthly cash payments of varying amounts were significantly less likely than girls who did not receive payments to be infected with HIV (1·2% vs 3·0%; OR 0·36, 95% CI 0·14–0·91) and HSV-2 (0·7% vs 3·0%; OR 0·24, 0·09–0·65), to have an older male partner (0·5% vs 2·5%; OR 0·20, 0·07–0·59), and to have sexual intercourse once per week (3·0% vs 6·5%; OR 0·46, 0·26– 0·82) at follow-up (18 months for biological outcomes and 12 months for behavioural outcomes). There is a well-established protective effect of schooling on HIV risk6–8 and cash transfer programmes are able to increase school attendance.9,10 Additionally, published work suggests that improvement of young women’s socioeconomic status can reduce risk of HIV infection, giving greater financial autonomy and less dependence on male partners.11,12 Baird and colleagues’ study5 was designed to test both risk reduction pathways. In one group, a conditional cash transfer (CCT) was paid to the girl and her caregiver contingent on school attendance. In another group, the girl and her caregiver were given an unconditional cash transfer (UCT). The comparator was a group of girls who received no cash. When both intervention groups were pooled together, the cash transfer groups were associated with fewer HIV and HSV-2 infections than the no cash transfer group, which seemed to be caused by girls who received the intervention having younger male partners and www.thelancet.com Vol 379 April 7, 2012