eedlestick injuries pose a recognized occupational hazard to health care workers. The first case of occupationally acquired human immunodeficiency virus (HIV) infection was reported in 1984 and highlighted the risk of occupational exposure to HIV and hepatitis (Anonymous, 1984). During the past decade, the Occupational Safety and Health Administration (OSHA) of the U.S. Department of Labor has led government efforts to decrease the risk of exposure through needlestick injuries. In 1991, OSHA promulgated the first Bloodborne Pathogen Standard, requiring employers to maintain a written exposure control plan. This action was followed by the publication of a compliance directive urging employers to consider using new technologies to minimize or eliminate employee exposure to bloodborne pathogens through effective engineering and work practice controls (OSHA, 1992). Over time, the Standard and the compliance directive have been amended to account for the increased availability of improved technologies and interventions, such as vaccination and post-exposure prophylaxis (OSHA, 1998, 1999, 2001a, 2001b). The revised standard, which went into effect on April 18, 2001, redefined engineering controls to include sharps injury protection devices and needleless systems and required (OSHA, 2001a): • Annual review of exposure control plans to reflect the

Objective. To evaluate the cost-effectiveness of Project Dulce, a culturally specific diabetes case management and self-management training program, in four cohorts defined by insurance status. Data Sources/Study Setting. Clinical and cost data on 3,893 persons with diabetes participating in Project Dulce were used as inputs into a diabetes simulation model. Study Design. The Center for Outcomes Research Diabetes Model, a published, peer-reviewed and validated simulation model of diabetes, was used to evaluate life expectancy, quality-adjusted life expectancy (QALY), cumulative incidence of complications and direct medical costs over patient lifetimes (40-year time horizon) from a third-party payer perspective. Cohort characteristics, treatment effects, and case management costs were derived using a difference in difference design comparing data from the Project Dulce program to a cohort of historical controls. Long-term costs were derived from published U.S. sources. Costs and clinical benefits were discounted at 3.0 percent per annum. Sensitivity analyses were performed. Principal Findings. Incremental cost-effectiveness ratios of $10,141, $24,584, $44,941, and $69,587 per QALY gained were estimated for Project Dulce participants versus control in the uninsured, County Medical Services, Medi-Cal, and commercial insurance cohorts, respectively. Conclusions. The Project Dulce diabetes case management program was associated with cost-effective improvements in quality-adjusted life expectancy and decreased incidence of diabetes-related complications over patient lifetimes. Diabetes case management may be particularly cost effective for low-income populations.

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To project the long-term clinical and cost outcomes that accompany predefined improvements in glycaemic control in patients with type 2 diabetes. A peer-reviewed, validated, non-product-specific Markov model of type 2 diabetes was used to project the long-term clinical and cost outcomes associated with three HbA1c reduction scenarios (vs. no reduction): (i) decreasing mean HbA1c from 9.5% to 8.0%; (ii) from 8.0% to 7.0%; and (iii) from 7.0% to 6.5%. A typical baseline US type 2 diabetes cohort derived from National Health and Nutrition Examination Survey data was simulated over a lifetime horizon (35 years). Incidence of diabetes-related complications and costs (2005 USD) were accounted based on published data. Discount rates (3% per annum) were applied to clinical benefits and costs. Sensitivity analyses were performed. Stepwise reductions in HbA1c as an independent variable correlated with delayed time to diabetes-related complications and a reduced cumulative incidence of complications, including cardiovascular, renal and neurologic comorbidities. Related costs also decreased. Reductions in both poorly- (9.5-8.0%) and better-controlled (7.0-6.5%) patients produced incremental gains in undiscounted life expectancy (LE) [1.06 (0.31) and 0.32 (0.34) years [mean (SD)], respectively]. Similar improvement patterns were observed in quality-adjusted life expectancy (QALE). Benefits from sequential reduction scenarios, when aggregated, exhibited the most dramatic effect. Improved glycaemic control was associated with reductions in complication rates and costs, as well as increased LE and QALE among type 2 patients. These data illustrate the long-term importance of reaching normoglycaemia and support intensified HbA1c control as a cornerstone of effective long-term type 2 diabetes management.

This study is the first to show the relatively high risk both of NI and of NI that draws blood among nurses injecting insulin with a disposable syringe and confirms previous incidence estimates of NI among nurses. Additionally, this study reveals significant post-NI emotional distress, suggests significant under-reporting of NI to hospital officials, and demonstrates the need for a more effective needle safety device.