A population-based matched cohort study examining the mortality and costs of patients with community-onset Clostridium difficile infection identified using emergency department visits and hospital admissions.

Few studies have evaluated the mortality or quantified the economic burden of community-onset Clostridium difficile infection (CDI). We estimated the attributable mortality and costs of community-onset CDI. We conducted a population-based matched cohort study. We identified incident subjects with community-onset CDI using health administrative data (emergency department visits and hospital admissions) in Ontario, Canada between January 1, 2003 and December 31, 2010. We propensity-score matched each infected subject to one uninfected subject and followed subjects in the cohort until December 31, 2011. We evaluated all-cause mortality and costs (unadjusted and adjusted for survival) from the healthcare payer perspective (2014 Canadian dollars). During our study period, we identified 7,950 infected subjects. The mean age was 63.5 years (standard deviation = 22.0), 62.7% were female, and 45.0% were very high users of the healthcare system. The relative risk for 30-day, 180-day, and 1-year mortality were 7.32 (95% confidence interval [CI], 5.94-9.02), 3.55 (95%CI, 3.17-3.97), and 2.59 (95%CI, 2.37-2.83), respectively. Mean attributable cumulative 30-day, 180-day, and 1-year costs (unadjusted for survival) were $7,434 (95%CI, $7,122-$7,762), $12,517 (95%CI, $11,687-$13,366), and $13,217 (95%CI, $12,062-$14,388). Mean attributable cumulative 1-, 2-, and 3-year costs (adjusted for survival) were $10,700 (95%CI, $9,811-$11,645), $13,312 (95%CI, $12,024-$14,682), and $15,812 (95%CI, $14,159-$17,571). Infected subjects had considerably higher risk of all-cause mortality and costs compared with uninfected subjects. This study provides insight on an understudied patient group. Our study findings will facilitate assessment of interventions to prevent community-onset CDI.

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

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.

Population-based assessment of the outcomes in patients with postcolonoscopy colorectal cancers.

OBJECTIVE: The potential for cancers to not be detected on colonoscopy is increasingly recognised, but little is known about patient outcomes. The objective of this study was to assess the outcomes of patients diagnosed with postcolonoscopy colorectal cancers (PCCRCs). DESIGN: We conducted a population-based retrospective cohort study, including all patients diagnosed with colorectal cancer (CRC) in Ontario, Canada from 2003 to 2009. Patients were categorised into three groups: DETECTED (diagnosed within 6 months of first colonoscopy), PCCRC (diagnosed 6-36 months after first colonoscopy) or NOSCOPE (no colonoscopy within 36 months of diagnosis). Univariate and multivariable analyses were conducted to study overall survival, surgical treatment, emergency presentation and surgical complications. RESULTS: Overall, 45 104 patients were included, with 2804 being classified as having a PCCRC. Compared with the DETECTED group, PCCRC was associated with a significantly higher likelihood of stage IV disease (17.2% vs 12.9%), worse overall survival (5 year OS: 60.8% vs 68.3%, p<0.0001; adjusted HR: 1.25, 95% CI 1.17 to 1.32, p<0.0001), a higher likelihood of emergency presentation (OR: 2.86, 95% CI 2.56 to 3.13, p<0.001) and lower likelihood of surgical resection (OR: 0.61, 95% CI 0.55 to 0.67, p<0.001). However, patients with PCCRC had significantly better outcomes than those in the NOSCOPE group (stage IV: 37.1%, 5 year OS: 38.9%) CONCLUSIONS: Compared with CRC detected by colonoscopy, PCCRCs are associated with a higher risk of emergent presentation, a lower likelihood of surgical resection and most notably, significantly worse oncological outcomes. However, they have better outcomes than patients with no recent colonoscopy.

Use of colonic stents in emergent malignant left colonic obstruction: a Markov chain Monte Carlo decision analysis.

PURPOSE: This decision analysis examines the cost-effectiveness of colonic stenting as a bridge to surgery vs. surgery alone in the management of emergent, malignant left colonic obstruction. METHODS: We used a Markov chain Monte Carlo decision analysis model to determine the effect on health-related quality of life of two strategies: emergency surgery vs. emergency colonic stenting as a bridge to definitive surgery. All relevant health states were modeled during a patient's expected lifespan. Outcome measures were mortality, the proportion of patients requiring a colostomy, quality-adjusted life expectancy, and costs. Deterministic and probabilistic sensitivity analyses were performed. RESULTS: In our model, colonic stenting was more effective (9.2 quality-adjusted life months benefit) and less costly (CAD dollars 3,763; US dollars 3,135) than emergency surgery. Its benefits were secondary to reductions in acute mortality and in the likelihood of requiring a permanent colostomy. The results were only dependent on the rate of stenting complications (perforation, technical placement failure, and migration) and the patient's risk of surgical mortality, with the benefits being greatest among patients at high risk of operative mortality. CONCLUSIONS: Colonic stenting as a bridge to surgery is more effective and less costly than surgery in the treatment of emergent, malignant left colonic obstruction. The benefits are most pronounced in high-risk patients and are diminished by increases in stent placement failure rates and perforation rates. In low-risk patients, the benefits are more modest and may not outweigh the risks.

Population-based assessment of the surgical management of locally advanced colorectal cancer.

BACKGROUND: Evidence-based guidelines recommend multivisceral resection for patients with locally advanced adherent colorectal cancer because it reduces local recurrence and improves survival. However, this procedure can increase morbidity compared with standard resection and may not be practiced uniformly. We performed a population-based study to examine surgical practice and outcomes among patients with locally advanced adherent colorectal cancer in the United States. METHODS: Patients who were 18 years or older and who had surgical resection for nonmetastatic, locally advanced adherent colorectal cancer from January 1, 1988, through December 31, 2002, were identified from the Surveillance, Epidemiology, and End Results (SEER) registry. Logistic regression was used to examine patient, tumor, and geographic factors associated with multivisceral resection. Cumulative early mortality (i.e., at 1 and 6 months after diagnosis) and 5-year survival were obtained from Kaplan-Meier estimates; adjusted risks of death were calculated using Cox proportional hazards models. All statistical tests were two-sided. RESULTS: We identified 8380 patients who underwent surgical resection for locally advanced adherent colorectal cancer, of whom 33.3% were managed with multivisceral resection. Among colon cancer patients, younger age at diagnosis, female sex, SEER region, node negativity, and left-sided tumors were independently associated with having had a multivisceral resection. Among rectal cancer patients, younger age at diagnosis and female sex were positively and statistically significantly associated with multivisceral resection, whereas receipt of neoadjuvant radiation was inversely and statistically significantly associated with multivisceral resection. Compared with standard resection, multivisceral resection was associated with improved overall survival for patients with colon (hazard ratio [HR] = 0.89, 95% confidence interval [CI] = 0.83 to 0.96) and rectal (HR = 0.81, 95% CI = 0.70 to 0.94) cancer, with no associated increase in early mortality. CONCLUSIONS: The majority of patients with locally advanced colorectal cancer did not receive a multivisceral resection. The geographic variation in the application of this procedure in patients with colon cancer suggests that local organizational structures and processes of care may play an important role in patient treatment and, therefore, prognosis.

Effect of socioeconomic status on out-of-hospital transport delays of patients with chest pain.

STUDY OBJECTIVES: The effect of socioeconomic status on out-of-hospital care has not been widely examined. We determine whether socioeconomic status was associated with out-of-hospital transport delays for patients with chest pain. METHODS: A retrospective study of patients with chest pain transported by means of ambulance in Toronto, Ontario, Canada, in 1999 was conducted. The primary outcome measure was the 90th percentile system response interval, with secondary outcomes being the 90th percentile on-scene interval, transport interval, and total out-of-hospital interval. Socioeconomic status was the primary independent variable. Covariates were age, sex, case severity, dispatch and return priority, time and day of transport, paramedic training, and percentage of high-rise apartments in the region. RESULTS: Four thousand three hundred fifty-six patients met the inclusion criteria. The 90th percentile system response interval and total out-of-hospital interval were 11 minutes and 49 minutes, respectively. In multivariate analyses, the highest socioeconomic status neighborhoods were significantly associated with decreased system response interval (34.0 seconds; 95% confidence interval [CI] 6.2 to 70.9 seconds) and transport interval (132.3 seconds; 95% CI 24.1 to 229.6 seconds). In addition, age (+45.3 seconds per 10 years; 95% CI 13.3 to 75.1 seconds), female sex (+205.0 seconds; 95% CI 78.1 to 287.7 seconds), and advanced care paramedic crews (+371.6 seconds; 95% CI 263.3 to 490.1 seconds) were associated with delays in total out-of-hospital interval. Lastly, calls originating from the highest socioeconomic status neighborhoods were dispatched the highest proportion of advanced care paramedic crews, despite similar dispatch priorities and case severities. CONCLUSION: High socioeconomic status neighborhoods were associated with shorter out-of-hospital transport intervals for patients with chest pain. In addition, out-of-hospital delays were associated with age, sex, and advanced care paramedic crew type, with calls from the highest socioeconomic status neighborhoods being most likely to receive advanced care paramedic crews.