Medication risk factors associated with healthcare-associated Clostridium difficile infection: a multilevel model case-control study among 64 US academic medical centres.

OBJECTIVES: 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. METHODS: 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. RESULTS: 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)]; ß-lactam/ß-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)]. CONCLUSIONS: We found several medications that were associated with the risk of patients developing HA-CDI, including ß-lactam/ß-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.

CAM use among overweight and obese persons with radiographic knee osteoarthritis.

BACKGROUND: Obesity is associated with knee pain and is an independent predictor of incident knee osteoarthritis (OA); increased pain with movement often leads patients to adopt sedentary lifestyles to avoid pain. Detailed descriptions of pain management strategies by body mass index (BMI) level among OA patients are lacking. The objectives were to describe complementary and alternative medicine (CAM) and conventional medication use by BMI level and identify correlates of CAM use by BMI level. METHODS: Using Osteoarthritis Initiative baseline data, 2,675 patients with radiographic tibiofemoral OA in at least one knee were identified. Use of CAM therapies and conventional medications was determined by interviewers. Potential correlates included SF-12, CES-D, Western Ontario and McMaster Universities Osteoarthritis Index, and Knee injury and Osteoarthritis Outcome Score quality of life. Multinomial logistic regression models adjusting for sociodemographic and clinical factors provided estimates of the association between BMI levels and treatment use; binary logistic regression identified correlates of CAM use. RESULTS: BMI was inversely associated with CAM use (45% users had BMI ≥35 kg/m²; 54% had BMI <25 kg/m²), but positively associated with conventional medication use (54% users had BMI ≥35 kg/m²; 35.1% had BMI <25 kg/m²). Those with BMI ≥30 kg/m² were less likely to use CAM alone or in combination with conventional medications when compared to patients with BMI <25 kg/m². CONCLUSIONS: CAM use is common among people with knee OA but is inversely associated with BMI. Understanding ways to further symptom management in OA among overweight and obese patients is warranted.

Racial differences in symptom management approaches among persons with radiographic knee osteoarthritis.

BACKGROUND: The extent to which racial differences exist in use of treatments for osteoarthritis (OA) is debatable. The purpose of this study was to describe the differences between African Americans (AA) and Caucasian Americans (CA) in using treatment approaches to manage symptoms among individuals with radiographic-confirmed knee OA. METHODS: A cross-sectional study was conducted. Using data from the Osteoarthritis Initiative, we identified 508 AA and 2,075 CA with radiographic tibiofemoral OA in at least one knee. Trained interviewers asked questions relating to current OA treatments including seven CAM therapy categories-alternative medical systems, mind-body interventions, manipulation and body-based methods, energy therapies, and three types of biologically based therapies, as well as conventional medications. We categorized participants as: conventional medication only users, CAM only users, users of both and users of neither. Multinomial logistic regression models adjusting for sociodemographics and clinical/functional factors provided estimates of the association between race and treatment use. RESULTS: Overall, 16.5% of AA and 24.2% of CA exclusively used CAM to treat OA, 25.0% of AA and 23.8% of CA used CAM in conjunction with conventional medications, and 24.8% of AA and 14.6% of CA exclusively used conventional medications. After control for sociodemographic and clinical factors, AA were less likely than CA to use CAM therapies alone (adjusted odds ratio (OR) of using CAM alone relative to no CAM or conventional treatments: 0.68, 95% confidence interval (CI): 0.48-0.96) or with conventional medications (adjusted OR relative to no CAM or conventional treatments: 0.59, 95%CI: 0.42-0.83). However, no differences in use of conventional medications alone were observed after adjustment of covariates. CONCLUSION: CAM use is common among people with knee OA, but is less likely to be used by AA relative to CA. For effective CAM therapies, targeted outreach to underserved populations including education about benefits of various CAM treatments and providing accessible care may attenuate observed disparities in effective CAM use by race.

Fragmented ambulatory care and subsequent emergency department visits and hospital admissions among Medicaid beneficiaries.

OBJECTIVES: Results of previous studies of Medicare beneficiaries have shown that more fragmented ambulatory care is associated with more emergency department (ED) visits and hospital admissions. Whether this observation is generalizable to Medicaid beneficiaries is unknown. STUDY DESIGN: We conducted a 3-year retrospective cohort study in the 7-county Hudson Valley region of New York. We included 19,330 adult Medicaid beneficiaries who were continuously enrolled, were attributed to a primary care provider, and had 4 or more ambulatory visits in the baseline year. METHODS: We measured fragmentation using a modified Bice-Boxerman Index. Cox proportional hazards models were used to determine associations between fragmentation score and ED visits or, separately, hospital admissions, adjusting for age, gender, and chronic conditions. RESULTS: The average beneficiary had 15 ambulatory visits in the baseline year, spread across 5 providers, with the most frequently seen provider accounting for 48% of the visits. One-fourth of the sample had more than 20 ambulatory visits and more than 7 providers, with the most frequently seen provider accounting for fewer than 33% of visits. For every 0.1-point increase in fragmentation score, the adjusted hazard of an ED visit over 2 years of follow-up increased by 1.7% (95% CI, 0.5%-2.9%). Having more fragmented care was not associated with a change in the hazard of a hospital admission. CONCLUSIONS: Among Medicaid beneficiaries, having more fragmented care was associated with a modest increase in the hazard of an ED visit, independent of chronic conditions. Fragmented ambulatory care may be modifiable and may represent a novel target for improvement.

Extent of Health Care Fragmentation in Different Payer Populations: Evidence from the Hudson Valley of New York.

Health care fragmentation occurs when patients see multiple ambulatory providers, but no single provider accounts for a substantial proportion of visits. Most previous studies have measured fragmentation in Medicare, which may not be generalizable. The study objective was to compare the extent of fragmented ambulatory care across commercially insured, Medicare, and Medicaid populations. The authors conducted a cross-sectional study of adults (N = 256,047) in the Hudson Valley region of New York, who were continuously insured (through 5 commercial payers, Medicare, or Medicaid), were attributed to a primary care physician, and had ≥4 ambulatory visits in the study year. Fragmentation was calculated using a reversed Bice-Boxerman Index, which captures both dispersion of care across providers and the relative share of visits by each provider. Chi-square tests, t tests, and correlation were used to compare patient characteristics and patterns of care across payers. Patients with Medicare had more chronic conditions (45% had ≥5 chronic conditions) than patients with commercial insurance (20%) or Medicaid (23%) (P < 0.01). However, mean fragmentation scores were comparable across all 3 payer populations: 0.73 (commercial insurance), 0.74 (Medicare), 0.72 (Medicaid). The correlation between number of chronic conditions and fragmentation was weak across payers, ranging from r = 0.004 to r = 0.12. If the extent of fragmentation does not vary with payer type or with the number of chronic conditions, it suggests that the causes of fragmentation may be more numerous and more complex than medical need alone.

Fragmented ambulatory care and subsequent healthcare utilization among Medicare beneficiaries.

OBJECTIVES: We sought to determine the associations between fragmented ambulatory care and subsequent emergency department (ED) visits and hospital admissions, while considering possible interactions between fragmentation and number of chronic conditions. STUDY DESIGN: We conducted a cohort study over 3 years among 117,977 fee-for-service Medicare beneficiaries who were attributed to primary care physicians in a 7-county region of New York and had 4 or more ambulatory visits in the baseline year. METHODS: We calculated fragmentation scores using a modified Bice-Boxerman Index and, because scores were skewed, divided them into quintiles. We used Cox regression models to determine associations between fragmentation and ED visits and, separately, hospital admissions, stratifying by number of chronic conditions and adjusting for age, gender, number of ambulatory visits, and case mix. RESULTS: Among those with 1 to 2 or 3 to 4 chronic conditions, having the most (vs the least) fragmented care significantly increased the hazard of an ED visit and, separately, increased the hazard of an admission (adjusted P <.05 for each comparison). Among those with 5 or more chronic conditions, having the most fragmented care significantly increased the hazard of an ED visit but decreased the hazard of an admission (adjusted P <.05 for each comparison). Among those with 0 chronic conditions, having fragmented care was not associated with either outcome. CONCLUSIONS: The relationship between fragmented ambulatory care and subsequent utilization varies with the number of chronic conditions. Beneficiaries with a moderate burden of chronic conditions (1-2 or 3-4) appear to be at highest risk of excess ED visits and admissions due to fragmented care.

Increasing Ketamine Use for Refractory Status Epilepticus in US Pediatric Hospitals.

Ketamine is an emerging therapy for pediatric refractory status epilepticus. The circumstances of its use, however, are understudied. The authors described pediatric refractory status epilepticus treated with ketamine from 2010 to 2014 at 45 centers using the Pediatric Hospital Inpatient System database. For comparison, they described children treated with pentobarbital. The authors estimated that 48 children received ketamine and pentobarbital for refractory status epilepticus, and 630 pentobarbital without ketamine. Those receiving only pentobarbital were median age 3 [interquartile range 0-10], and spent 30 [18-52] days in-hospital, including 17 [9-28] intensive care unit (ICU) days; 17% died. Median cost was $148 000 [81 000-241 000]. The pentobarbital-ketamine group was older (7 [2-11]) with longer hospital stays (51 [30-93]) and more ICU days (29 [20-56]); 29% died. Median cost was $298 000 [176 000-607 000]. For 71%, ketamine was given ≥1 day after pentobarbital. Ketamine cases per half-year increased from 2 to 9 ( P < .05). Ketamine is increasingly used for severe pediatric refractory status epilepticus, typically after pentobarbital. Research on its effectiveness is indicated.

Association between Smoking and Health Outcomes in Postmenopausal Women Living with Multiple Sclerosis.

Background. In multiple sclerosis (MS), symptom management and improved health-related quality of life (HrQOL) may be modified by smoking. Objective. To evaluate the extent to which smoking is associated with worsened health outcomes and HrQOL for postmenopausal women with MS. Methods. We identified 251 Women's Health Initiative Observational Study participants with a self-reported MS diagnosis. Using a linear model, we estimated changes from baseline to 3 years for activities of daily living, total metabolic equivalent tasks (MET) hours per week, mental and physical component scales (MCS, PCS) of the SF-36, and menopausal symptoms adjusting for years since menopause and other confounders. Results. Nine percent were current and 50% past smokers. Age at smoking initiation was associated with significant changes in MCS during menopause. PCS scores were unchanged. While women who had ever smoked experienced an increase in physical activity during menopause, the physical activity levels of women who never smoked declined. Residual confounding may explain this finding. Smoking was not associated with change in menopausal symptoms during the 3-year follow-up. Conclusion. Smoking was not associated with health outcomes among post-menopausal women with MS.

A systematic review of pharmacological pain management in multiple sclerosis.

BACKGROUND: Both chronic and acute pain have been cited as the most common symptoms amongst patients with multiple sclerosis (MS), with recent prevalence estimates as high as 83 %. The evidence for spasticity and trigeminal neuralgia pharmacological treatments in MS has been systematically reviewed, but no equivalent reviews have been published concerning MS pain unrelated to these two conditions. OBJECTIVE: Our objective was to systematically review pain management strategies for the reduction of non-spastic and non-trigeminal neuralgic pain in MS patients. DATA SOURCES: Experimental studies published after 1965 were chosen for review by searching electronic databases (e.g. PubMed, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index Expanded, Conference Proceedings Citation Index-Science, and clinicaltrials.gov) and bibliographies/citations of previously published reviews. STUDY SELECTION: Studies were included if all participants were adults clinically diagnosed with MS, study sample was not restricted to participants with spasticity or trigeminal neuralgia, and participant-reported pain was a primary or secondary outcome measured with a validated tool. STUDY APPRAISAL AND SYNTHESIS METHODS: Records were screened and methodological qualities of included studies were assessed independently by two reviewers under the supervision of another reviewer using the principles recommended in the Cochrane Handbook for Systematic Review of Interventions and the levels of evidence espoused by the American Academy of Neurology. RESULTS: Fifteen studies met the inclusion and exclusion criteria for review; interventions included antidepressants, anticonvulsants, dextromethorphan/quinidine, cannabinoids, and opioids/opioid antagonists. The pooled effect size for anticonvulsants (4 studies, 78 participants) was -1.88 (95 % CI: -3.13 to -0.64). The pooled effect size for cannabinoids (3 studies, 565 participants) was 0.08 (95 % CI: -0.74 to 0.89). Overall, only four trials reported Class 1 evidence. For these trials, dizziness was the most commonly reported adverse event, followed by nausea and somnolence. LIMITATIONS: The relatively small number of trials in MS patients with chronic pain precludes specific recommendations for treatment strategies. The review did not reveal any studies of drug combinations. CONCLUSIONS: More trials with rigorous design and reporting are needed to determine effective treatments for specific pain types presenting in people living with MS.

Sulfonylureas and risk of falls and fractures: a systematic review.

BACKGROUND: Sulfonylureas have been linked to increased risk of hypoglycemia. Hypoglycemia may lead to falls, and falls may lead to fracture. However, studies quantifying the association between sulfonylureas and fractures are sparse and yield inconsistent results. OBJECTIVE: The purpose of this article was to review the literature regarding sulfonylurea use and falls or fall-related fractures among older adults with type 2 diabetes mellitus and to delineate areas for future research. DATA SOURCES: We searched MEDLINE (1966-March 2012) and CINAHL (1937-March 2012) for studies of patients with type 2 diabetes mellitus living in the community or nursing homes. STUDY SELECTION: The search algorithms combined three domains: (1) diabetic patients, (2) sulfonylurea medications, and (3) fractures or falls. We included only publications in English that pertained to human subjects. We found 9 randomized trials and 12 non-experimental studies that met the inclusion criteria. STUDY APPRAISAL AND SYNTHESIS METHODS: The guidelines provided by the Cochrane handbook or Agency for Healthcare Research and Quality (AHRQ) Methods Guide are too general to distinguish the quality of included non-experimental studies, so we developed several specific domains based on those general guidelines. These domains included study design, study population, follow-up time, comparison group, exposure definition, outcome definition, induction period, confounding adjustment, and attrition or missing data. The data were not amenable to a meta-analysis. RESULTS: No clinical trials included fracture as a primary endpoint. Most clinical trials excluded older adults. Most studies were not designed to evaluate the risk of sulfonylureas on fractures or falls. Studies did not show an increased risk of falls/fractures with sulfonylurea. LIMITATIONS: The data available from existing studies suffer from methodological limitations including insufficient events, lack of primary endpoints, exclusion of older adults, and lack of clarity or inappropriate comparison groups. CONCLUSION: Future studies are needed to appropriately estimate the effect of sulfonylureas on falls or fall-related fractures in older adults who are at increased risk for hypoglycemia, the hypothesized mechanism for fractures related to sulfonylurea therapy.

Gender-specific correlates of complementary and alternative medicine use for knee osteoarthritis.

BACKGROUND: Knee osteoarthritis (OA) increases healthcare use and cost. Women have higher pain and lower quality of life measures compared to men even after accounting for differences in age, body mass index (BMI), and radiographic OA severity. Our objective was to describe gender-specific correlates of complementary and alternative medicine (CAM) use among persons with radiographically confirmed knee OA. METHODS: Using data from the Osteoarthritis Initiative, 2,679 women and men with radiographic tibiofemoral OA in at least one knee were identified. Treatment approaches were classified as current CAM therapy (alternative medical systems, mind-body interventions, manipulation and body-based methods, energy therapies, and three types of biologically based therapies) or conventional medication use (over-the-counter or prescription). Gender-specific multivariable logistic regression models identified sociodemographic and clinical/functional correlates of CAM use. RESULTS: CAM use, either alone (23.9% women, 21.9% men) or with conventional medications (27.3% women, 19.0% men), was common. Glucosamine use (27.2% women, 28.2% men) and chondroitin sulfate use (24.8% women; 25.7% men) did not differ by gender. Compared to men, women were more likely to report use of mind-body interventions (14.1% vs. 5.7%), topical agents (16.1% vs. 9.5%), and concurrent CAM strategies (18.0% vs. 9.9%). Higher quality of life measures and physical function indices in women were inversely associated with any therapy, and higher pain scores were positively associated with conventional medication use. History of hip replacement was a strong correlate of conventional medication use in women but not in men. CONCLUSIONS: Women were more likely than men to use CAM alone or concomitantly with conventional medications.