BACKGROUND: Cancer is a major cause of mortality and a major contributor to health care costs in the United States. An increasing number of cancer patients are treated with oral cancer therapy. Older patients are more likely to have cancer and to be at risk for adherence problems with oral cancer drugs. As a result of substantial cost sharing required for oral cancer drugs and the possibility of early entry into the Medicare Part D coverage gap, high out-of-pocket (OOP) drug costs could put elderly beneficiaries at great risk for delaying or discontinuing their cancer therapies. OBJECTIVES: To (a) determine the OOP costs of oral cancer treatment and the numbers of patients that delay or discontinue oral cancer therapy and (b) examine the relationship between OOP costs and medication discontinuation or delay among older Medicare beneficiaries. METHODS: A cross-sectional study was conducted using a 5% sample of Medicare beneficiaries who filled a prescription for imatinib, erlotinib, anastrozole, letrozole,...

Few long-term multicenter investigations have evaluated the relationships between aggregate antimicrobial drug use in hospitals and bacterial resistance. We measured fluoroquinolone use from 1999 through 2003 in a network of US hospitals. The percentages of fluoroquinolone-resistant Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) were obtained from yearly antibiograms at each hospital. Univariate linear regression showed significant associations between a hospital's volume of fluoroquinolone use and percent resistance in most individual study years (1999–2001 for P. aeruginosa, 1999–2002 for S. aureus). When the method of generalized estimating equations was used, a population-averaged longitudinal model incorporating total fluoroquinolone use and the previous year's resistance (to account for autocorrelation) did not show a significant effect of fluoroquinolone use on percent resistance for most drug-organism combinations, except for the relationship between levofloxacin use and percent MRSA. The ecologic relationship between fluoroquinolone use and resistance is complex and requires further study.

Objective.: The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for Clostridium difficile infection (CDI) is used for surveillance of CDI. However, the ICD-9-CM code alone cannot separate nosocomial cases from cases acquired outside the institution. The purpose of this study was to determine whether combining the ICD-9-CM code with medication treatment data for CDI in hospitalized patients could enable us to distinguish between patients with nosocomial CDI and patients who were admitted with CDI. The primary objective was to compare the sensitivity, specificity, and predictive value of using the combination of ICD-9-CM code for CDI and CDI treatment records to identify cases of nosocomial CDI with the sensitivity, specificity, and predictive value of using the ICD-9-CM code alone.Design.: Validation sample cross-sectional study.Setting.: Academic health center.Methods.: Administrative claims data from July 1, 2004, to June 30, 2005, were queried to identify adults discharged with an ICD-9-CM code for CDI and to find documentation of CDI therapy with oral vancomycin or metronidazole. Laboratory and medical records were queried to identify symptomatic CDI toxin-positive adult patients with nosocomial CDI and were compared with records of patients whose cases were predicted to be nosocomial by means of ICD-9-CM code and CDI therapy data.Results.: Of 23,920 adult patients discharged from the hospital, 62 had nosocomial CDI according to symptoms and toxin assay. The sensitivity of the ICD-9-CM code alone for identifying nosocomial CDI was 96.8%, the specificity was 99.6%, the positive predictive value was 40.8%, and the negative predictive value was 100%. When CDI drug therapy was included with the ICD-9-CM code, the sensitivity ranged from 58.1% to 85.5%, specificity was virtually unchanged, and the range in positive predictive value was 37.9%–80.0%.Conclusion.: Combining the ICD-9-CM code for CDI with drug therapy information increased the positive predictive value for nosocomial CDI but decreased the sensitivity.

The main objective of this study was to determine patient- and hospital-level medication risk factors associated with Clostridium difficile infection (CDI) occurrence among patients clustered within hospitals using a multilevel model. Patients with healthcare-associated (HA)-CDI were identified from among 64 academic medical centres in 2009. A frequency match was conducted; for each case, up to two controls were selected, matched on similar pre-infection length of stay and clinical service line. Patient- and hospital-level medication use, including antibacterial and gastric acid-suppressant agents, was assessed using a two-level logistic regression model. A total of 5967 CDI cases and 8167 controls were included in the analysis. The odds of acquiring HA-CDI increased with the following medications [OR (95% CI)]: anti-methicillin-resistant Staphylococcus aureus agents [1.38 (1.22–1.56)]; third- or fourth-generation cephalosporins [1.75 (1.62–1.89)]; carbapenems [1.60 (1.44–1.79)]; β-lactam/β-lactamase inhibitor combinations [1.49 (1.36–1.64)]; vancomycin [1.73 (1.57–1.89)]; and proton pump inhibitors [1.43 (1.30–1.57)]. The odds of acquiring HA-CDI decreased with the following medications: clindamycin [0.74 (0.63–0.87)]; and macrolides [0.88 (0.77–0.99)]. Controlling for patient-level covariates, no hospital-level medication covariates that we analysed had statistically significant effects on HA-CDI. The odds of acquiring HA-CDI increased with the hospital proportion of patients aged ≥65 years [1.01 (1.00–1.02)]. We found several medications that were associated with the risk of patients developing HA-CDI, including β-lactam/β-lactamase inhibitor combinations, third- or fourth-generation cephalosporins, carbapenems, vancomycin, proton pump inhibitors and anti-methicillin-resistant S. aureus agents. There were no medication effects significant at the hospital level.