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Background The key epidemiological drivers of Clostridioides difficile transmission are not well understood. We estimated epidemiological parameters to characterize variation in C. difficile transmission, while accounting for the imperfect nature of surveillance tests. Methods We conducted a retrospective analysis of C. difficile surveillance tests for patients admitted to a bone marrow transplant (BMT) unit or a solid tumor unit (STU) in a 565-bed tertiary hospital. We constructed a transmission model for estimating key parameters, including admission prevalence, transmission rate, and duration of colonization to understand the potential variation in C. difficile dynamics between these 2 units. Results A combined 2425 patients had 5491 admissions into 1 of the 2 units. A total of 3559 surveillance tests were collected from 1394 patients, with 11% of the surveillance tests being positive for C. difficile. We estimate that the transmission rate in the BMT unit was nearly 3-fold higher at 0.29 acquisitions per percentage colonized per 1000 days, compared to our estimate in the STU (0.10). Our model suggests that 20% of individuals admitted into either the STU or BMT unit were colonized with C. difficile at the time of admission. In contrast, the percentage of surveillance tests that were positive within 1 day of admission to either unit for C. difficile was 13.4%, with 15.4% in the STU and 11.6% in the BMT unit. Conclusions Although prevalence was similar between the units, there were important differences in the rates of transmission and clearance. Influential factors may include antimicrobial exposure or other patient-care factors. [ABSTRACT FROM AUTHOR]

Objective. To examine the effect of changes in parent-child coresidence on caregiving decisions of non-resident siblings over a 5-year period while controlling for characteristics of the elderly parent and adult children in the family network. Method. We use difference-in-difference models applied to Health and Retirement Study-Assets and Health Dynamics of the Elderly data to test the hypothesis that the formation of a joint household between a parent and one of her children raises the bargaining power of non-resident siblings, who then reduce their care to the parent. Similarly, the dissolution of a parent-child household is expected to increase the bargaining power of the child who no longer coresides with the parent relative to her siblings. Results. We find that children whose parent and sibling begin coresiding during the study period are less likely to provide care and provide fewer hours of care than children whose parents never coresided with a child. Adult children whose parent cease coresiding with a sibling, on the other hand, have a higher likelihood of providing care and provide significantly more hours of care relative to children whose parents either coresided with a sibling in both time periods or never coresided with a child. Discussion. Meeting the needs of the growing elderly population while maintaining them in the community is a particular focus of long-term care policy. To the extent that shared living is an important component of such care, the observed sensitivity of nonresident children's caregiving efforts has implications for the well-being of both disabled parents and their coresiding adult children. [ABSTRACT FROM AUTHOR]

Background: Aromatase inhibitors (AIs) substantially reduce breast cancer mortality in clinical trials, but high rates of nonadherence to these long-term oral therapies have reduced their impact outside of trials. We examined the association of generic AI availability with AI adherence among a large national breast cancer cohort. Methods: Using a quasi-experimental prepost design, we examined the effect of generic AI introductions (7/2010 and 4/2011) on adherence among a national cohort of women with incident breast cancer in 2006 and 2007 who were enrolled in the Medicare D pharmaceutical coverage program. Medicare D claims were used to calculate AI adherence, defined as a medication possession ratio of 80% or more of eligible days, over 36 months. Multivariable logistic regression models estimated with generalized estimating equations were applied to longitudinal adherence data to control for possible confounders, including receipt of a Medicare D low-income subsidy, and to account for repeated measures. All statistical tests were two-sided. Results: Sixteen thousand four hundred sixty-two Medicare D enrollees were eligible. Adherence declined throughout the study. However, among women without a subsidy, the median quarterly out-of-pocket cost of anastrozole fell from $183 in the fourth quarter of 2009 to $15 in 2011, and declines in adherence were attenuated with generic AI introductions. Regression-adjusted adherence probabilities were estimated to be 5.4% higher after generic anastrozole was introduced in 2010 and 11% higher after generic letrozole/exemestane was introduced in 2011. Subsidy recipients had higher adherence rates throughout the study. Conclusions: The introduction of generic medications attenuated the decline in adherence to AIs over three years of treatment among breast cancer survivors not receiving low-income subsidies for Medicare D coverage. [ABSTRACT FROM AUTHOR]

Objective To adapt and automate the medication regimen complexity index (MRCI) within the structure of a commercial medication database in the post-acute home care setting. Materials and Methods In phase 1, medication data from 89 645 electronic health records were abstracted to line up with the components of the MRCI: dosage form, dosing frequency, and additional administrative directions. A committee reviewed output to assign index weights and determine necessary adaptations. In phase 2 we examined the face validity of the modified MRCI through analysis of automatic tabulations and descriptive statistics. Results The mean number of medications per patient record was 7.6 (SD 3.8); mean MRCI score was 16.1 (SD 9.0). The number of medications and MRCI were highly associated, but there was a wide range of MRCI scores for each number of medications. Most patients (55%) were taking only oral medications in tablet/capsule form, although 16% had regimens with three or more medications with different routes/forms. The biggest contributor to the MRCI score was dosing frequency (mean 11.9). Over 36% of patients needed to remember two or more special instructions (eg, take on alternate days, dissolve). Discussion Medication complexity can be tabulated through an automated process with some adaptation for local organizational systems. The MRCI provides a more nuanced way of measuring and assessing complexity than a simple medication count. Conclusions An automated MRCI may help to identify patients who are at higher risk of adverse events, and could potentially be used in research and clinical decision support to improve medication management and patient outcomes. [ABSTRACT FROM AUTHOR]

Objectives. To examine whether stability of living arrangements and changes in household composition—both types and frequency—influence nursing home placement or timing to entry among older people. Methods. Data from the first 5 waves of the Assets and Health Dynamics of the Elderly (1993–2002) on 8,093 persons aged 70 years or older at baseline are used in probit and hazard models to predict nursing home entry and time to entry. Results. Stable living arrangements carry different risks of institutionalization. Those living continuously alone or with others were at highest risk; at lowest risk were those living continuously with a spouse or the same child (lowest overall). Changes in household composition were protective against nursing home entry and slowed time to entry; types of change were not influential when number of changes was taken into account. Discussion. Results suggest that stability of living arrangements in and of itself is not protective against institutionalization. Having options that allow one to change living arrangements over time in response to changing needs for assistance is of importance if the goal is to avoid institutional care or extend community residence prior to entry. [ABSTRACT FROM PUBLISHER]

Subject recruitment for epidemiologic studies is associated with major challenges due to privacy laws now common in many countries. Privacy policies regarding recruitment methods vary tremendously across institutions, partly because of a paucity of information about what methods are acceptable to potential subjects. The authors report the utility of an opt-out method without prior physician notification for recruiting community-dwelling US women aged 65 years or older with incident breast cancer in 2003. Participants (n = 3,083) and possibly eligible nonparticipants (n = 2,664) were compared using characteristics derived from billing claims. Participation for persons with traceable contact information was 70% initially (2005–2006) and remained over 90% for 3 follow-up surveys (2006–2008). Older subjects and those living in New York State were less likely to participate, but participation did not differ on the basis of socioeconomic status, race/ethnicity, underlying health, or type of cancer treatment. Few privacy concerns were raised by potential subjects, and no complaints were lodged. Using opt-out methods without prior physician notification, a population-based cohort of older breast cancer subjects was successfully recruited. This strategy may be applicable to population-based studies of other diseases and is relevant to privacy boards making decisions about recruitment strategies acceptable to the public. [ABSTRACT FROM PUBLISHER]

Objectives. The objective of this study was to investigate the effect of parental marital status, marital history, and family type on intergenerational living arrangements and adult children's time and cash transfers to their unpartnered disabled elderly parents. Methods. We used data from the Asset and Health Dynamics Among the Oldest Old survey to estimate the joint probabilities that an adult child provides time and/or cash transfers to a parent and to analyze a five-level categorical variable capturing parent-child living arrangements. Results. The estimates suggest significant detrimental effects of parental divorce and step relationship on time transfers and on the probability of coresidence with the index child. Family type, as captured by the composition of the index child's sibling network according to kin relationship to the parent, also affected transfers and living arrangement choices of adult children. Discussion. The findings that transfers from adult children to their unpartnered disabled elderly parents depend on parental marital status and kin relationship suggest that changing family patterns are altering the traditional role of the family as a support network. These findings raise concerns about the care likely to be available to future cohorts of elderly persons who will have experienced substantially higher rates of divorce, remarriage, and step parenthood than the cohort considered in this study. [ABSTRACT FROM AUTHOR]

In this article, we use a two-stage bargaining model to analyze the living arrangement of a disabled elderly parent and the assistance provided to the parent by her adult children. The first stage determines the living arrangement: the parent can live in a nursing home, live alone in the community, or live with any child who has invited coresidence. The second stage determines the assistance provided by each child in the family. Working by backward induction, we first calculate the level of assistance that each child would provide to the parent in each possible living arrangement. Using these calculations, we then analyze the living arrangement that would emerge from the first stage game. A key assumption of our model is that family members cannot or will not make binding agreements at the first stage regarding transfers at the second stage. Because coresidence is likely to reduce the bargaining power of the coresident child relative to her siblings, coresidence may fail to emerge as the equilibrium living arrangement even when it is Pareto efficient. That is, the outcome of the two-stage game need not be Pareto efficient. [ABSTRACT FROM AUTHOR]

The authors present their response to two commentaries published in the "American Journal of Epidemiology." They highlight the role of their article "Heightened attention to medical privacy: challenges for unbiased sample recruitment and a possible solution" in driving a discussion on the challenge of sample recruitment and the advancement of research. They cite one commentary for describing the risk to U.S. progress in research. They rebut another commentary by stressing the absence of link between response and nonresponse biases.