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      The Economic Burden of Hospital-Acquired Clostridium difficile Infection: A Population-Based Matched Cohort Study

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          Abstract

          BACKGROUND

          High-quality cost estimates for hospital-acquired Clostridium difficile infection (CDI) are vital evidence for healthcare policy and decision-making.

          OBJECTIVE

          To evaluate the costs attributable to hospital-acquired CDI from the healthcare payer perspective.

          METHODS

          We conducted a population-based propensity-score matched cohort study of incident hospitalized subjects diagnosed with CDI (those with the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Canada code A04.7) from January 1, 2003, through December 31, 2010, in Ontario, Canada. Infected subjects were matched to uninfected subjects (those without the code A04.7) on age, sex, comorbidities, geography, and other variables, and followed up through December 31, 2011. We stratified results by elective and nonelective admissions. The main study outcomes were up-to-3-year costs, which were evaluated in 2014 Canadian dollars.

          RESULTS

          We identified 28,308 infected subjects (mean annual incidence, 27.9 per 100,000 population, 3.3 per 1,000 admissions), with a mean age of 71.5 years (range, 0–107 years), 54.0% female, and 8.0% elective admissions. For elective admission subjects, cumulative mean attributable 1-, 2-, and 3-year costs adjusted for survival (undiscounted) were $32,151 (95% CI, $28,192–$36,005), $34,843 ($29,298–$40,027), and $37,171 ($30,364–$43,415), respectively. For nonelective admission subjects, the corresponding costs were $21,909 ($21,221–$22,609), $26,074 ($25,180–$27,014), and $29,944 ($28,873–$31,086), respectively.

          CONCLUSIONS

          Hospital-acquired CDI is associated with substantial healthcare costs. To the best of our knowledge, this study is the first CDI costing study to present longitudinal costs. New strategies may be warranted to mitigate this costly infectious disease.

          Infect Control Hosp Epidemiol 2016;37:1068–1078

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          Most cited references30

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          Cost of care for elderly cancer patients in the United States.

          Timely estimates of the costs of care for cancer patients are an important element in the formulation of national cancer programs and policies. We estimated net costs of care for elderly cancer patients in the United States for the 18 most prevalent cancers and for all other tumor sites combined. We used Surveillance, Epidemiology, and End Results-Medicare files to identify 718,907 cancer patients and 1,623,651 noncancer control subjects. Within each tumor site, noncancer control subjects were matched to patients by sex, age group, geographic location, and phase of care (ie, initial, continuing, and last year of life). Costs of care were estimated for each phase by use of Medicare claims data from January 1, 1999, through December 31, 2003. Per-patient net costs of care were applied to the 5-year survival of cancer patients by phase of care to estimate 5-year costs of care and extrapolated to the elderly US Medicare population diagnosed with cancer in 2004. Across tumor sites, mean net costs of care were highest in the initial and last year of life phases of care and lowest in the continuing phase. Mean 5-year net costs varied widely, from less than $20,000 for patients with breast cancer or melanoma of the skin to more than $40,000 for patients with brain or other nervous system, esophageal, gastric, or ovarian cancers or lymphoma. For elderly cancer patients diagnosed in 2004, aggregate 5-year net costs of care to Medicare were estimated to be approximately $21.1 billion. Costs to Medicare were highest for lung, colorectal, and prostate cancers, reflecting underlying incidence, stage distribution at diagnosis, survival, and phase-specific costs for these tumor sites. The costs of cancer care to Medicare are substantial and vary by tumor site, phase of care, stage at diagnosis, and survival.
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            Mortality attributable to nosocomial Clostridium difficile-associated disease during an epidemic caused by a hypervirulent strain in Quebec.

            Since 2002 an epidemic of Clostridium difficile-associated disease (CDAD) caused by a hypervirulent toxinotype III ribotype 027 strain has spread to many hospitals in Quebec. The strain has also been found in the United States, the United Kingdom and the Netherlands. The effects of this epidemic on mortality and duration of hospital stay remain unknown. We measured these effects among patients admitted to a hospital in Quebec during 2003 and 2004. We compared mortality and total length of hospital stay among inpatients in whom nosocomial CDAD developed and among control subjects without CDAD matched for sex, age, Charlson Comorbidity Index score and length of hospital stay up to the diagnosis of CDAD in the corresponding case. Thirty days after diagnosis 23.0% (37/161) of the patients with CDAD had died, compared with 7.0% (46/656) of the matched control subjects (p < 0.001). Twelve months after diagnosis, mortality was 37.3% (60/161) among patients with CDAD and 20.6% (135/656) among the control subjects (p < 0.001), for a cumulative attributable mortality of 16.7% (95% confidence interval 8.6%-25.2%). Each case of nosocomial CDAD led, on average, to 10.7 additional days in hospital. This study documented a high attributable mortality among elderly patients with CDAD mostly caused by a hypervirulent strain, which represents a dramatic change in the severity of this infection.
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              A Tutorial and Case Study in Propensity Score Analysis: An Application to Estimating the Effect of In-Hospital Smoking Cessation Counseling on Mortality

              Propensity score methods allow investigators to estimate causal treatment effects using observational or nonrandomized data. In this article we provide a practical illustration of the appropriate steps in conducting propensity score analyses. For illustrative purposes, we use a sample of current smokers who were discharged alive after being hospitalized with a diagnosis of acute myocardial infarction. The exposure of interest was receipt of smoking cessation counseling prior to hospital discharge and the outcome was mortality with 3 years of hospital discharge. We illustrate the following concepts: first, how to specify the propensity score model; second, how to match treated and untreated participants on the propensity score; third, how to compare the similarity of baseline characteristics between treated and untreated participants after stratifying on the propensity score, in a sample matched on the propensity score, or in a sample weighted by the inverse probability of treatment; fourth, how to estimate the effect of treatment on outcomes when using propensity score matching, stratification on the propensity score, inverse probability of treatment weighting using the propensity score, or covariate adjustment using the propensity score. Finally, we compare the results of the propensity score analyses with those obtained using conventional regression adjustment.
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                Author and article information

                Journal
                Infection Control & Hospital Epidemiology
                Infect. Control Hosp. Epidemiol.
                Cambridge University Press (CUP)
                0899-823X
                1559-6834
                September 2016
                June 20 2016
                September 2016
                : 37
                : 9
                : 1068-1078
                Article
                10.1017/ice.2016.122
                27322606
                b1889c8d-ef30-440f-a8bf-ac8c01dad485
                © 2016

                https://www.cambridge.org/core/terms

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