Original Research

Cost Drivers Associated with Clostridium difficile-Associated Diarrhea in a Hospital Setting

Journal of Clinical Outcomes Management. 2015 March;22(3)

References

1. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. Available at: www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-2013-508.pdf. Accessed March 6, 2013.

2. Louie TJ, Miller MA, Mullane KM, et al. Fidaxomicin versus vancomycin for Clostridium difficile infection. N Engl J Med 2011;364:422–31.

3. Lowy I, Molrine DC, Leav BA, et al. Treatment with monoclonal antibodies against Clostridium difficile toxins. N Engl J Med 2010;362:197–205.

4. Bouza E, Dryden M, Mohammed R, et al. Results of a phase III trial comparing tolevamer, vancomycin and metronidazole in patients with Clostridium difficile-associated diarrhoea [ECCMID abstract O464]. Clin Microbiol Infect 2008;14(Suppl s7):S103–4.

5. O’Brien JA, Betsy JL, Caro J, Davidson DM. The emerging infectious challenge of Clostridium difficile-associated disease in Massachusetts hospitals: clinical and economic consequences. Infect Control Hosp Epidemiol 2007;28:1219–27.

6. Dubberke ER, Wertheimer AI. Review of current literature on the economic burden of Clostridium difficile infection. Infect Control Hosp Epidemiol 2009;30:57–66.

7. Ghantoji SS, Sail K, Lairson DR, et al. Economic healthcare costs of Clostridium difficile infection: a systematic review. J Hosp Infect 2010;74:309–18.

8. Kyne L, Hamel MB, Polavaram R, Kelly CP. Health care costs and mortality associated with nosocomial diarrhea due to Clostridium difficile. Clin Infec Dis 2002;34:346–53.

9. Forster AJ, Taljaard M, Oake N, et al. The effect of hospital-acquired infection with Clostridium difficile on length of stay in hospital. CMAJ 2012;184:37–42.

10. Pakyz A, Carroll NV, Harpe SE, et al. Economic impact of Clostridium difficile infection in a multihospital cohort of academic health centers. Pharmacotherapy 2011;31:546–51.

11. Quimbo RA, Palli SR, Singer J, et al. Burden of Clostridium difficile-associated diarrhea among hospitalized patients at high risk of recurrent infection. J Clin Outcomes Manag 2013;20:544–54.

12. Golan Y, Mullane KM, Miller MA, et al. Low recurrence rate among patients with C. difficile infection treated with fidaxomicin. Poster presented at: 49th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy; 12–15 Sep 2009; San Francisco, CA.

13. Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 1997;32:920–4.

14. Cornely OA, Crook DW, Esposito R, et al. Fidaxomicin versus vancomycin for infection with Clostridium difficile in Europe, Canada, and the USA: a double-blind, non-inferiority, randomised controlled trial. Lancet Infect Dis 2012;12:281–9.

15. Palli SR, Strauss M, Quimbo RA, et al. Cost drivers associated with Clostridium-difficile infection in a hospital setting. Poster presented at American Society of Health System Pharmacists Midyear Clinical Meeting; December 2012; Las Vegas, NV.

16. Noseworthy TW, Konopad E, Shustack A, et al. Cost accounting of adult intensive care: methods and human and capital inputs. Crit Care Med 1996;24:1168–72.

17. Classen DC, Burke JP, Wenzel RP. Infectious diseases consultation: impact on outcomes for hospitalized patients and results of a preliminary study. Clin Infect Dis 1997;24:468–70.

18. Petrak RM, Sexton DJ, Butera ML, et al. The value of an infectious diseases specialist. Clin Infect Dis 2003;36:1013–7.

19. Sellier E, Pavese P, Gennai S, et al. Factors and outcomes associated with physicians’ adherence to recommendations of infectious disease consultations for patients. J Antimicrob Chemother 2010;65:156–62.

20. Jollis JG, DeLong ER, Peterson ED, et al. Outcome of acute myocardial infarction according to the specialty of the admitting physician. N Engl J Med 1996;335:1880–7.

21. Harrold LR, Field TS, Gurwitz JH. Knowledge, patterns of care, and outcomes of care for generalists and specialists. J Gen Intern Med 1999;14:499–511.

Study Definitions

Diarrhea was defined as 3 or more unformed (includes bloody, watery, thin, loose, soft, and/or unformed stool) bowel movements per day.CDAD severity was classified as mild (4–5 unformed bowel movements per day or WBC ≤ 2000/mm ³); moderate (6–9 unformed bowel movements per day or WBC between 12,001/mm ³ and 15,000/mm ³); or severe (≥10 unformed bowel movements per day or WBC ≥15,001/mm ³) [12,13]. Diarrhea was considered to be resolved when the patient had no more than 3 unformed stools for 2 consecutive days and lasting until treatment was completed, with no additional therapy required for CDAD as of the second day after the end of the course of therapy [2,14].CDAD episode was defined as the duration from the date of the CDAD diagnosis or confirmation (whichever occurred first), to the date of diarrhea resolution (where documented) or discharge date.

Cost Measures

The total hospital health plan paid costs for the entire inpatient episode (includes treatment costs, diagnostics, services provided, etc.) were estimated using medical claims present in the database and pertaining to the hospitalization from where medical records were abstracted. Then the proportionate amount for the duration of the CDAD episode (from CDAD diagnosis to the diarrhea resolution date or the discharge date in cases where the resolution date could not be ascertained) was calculated to estimate the average CDAD associated in-hospital costs.

Analysis

Means (± standard deviation [SD]), medians (interquartile range Q1 to Q3), and relative frequencies were calculated for continuous and categorical data, respectively. This analysis was descriptive in nature; hence, no statistical tests to determine significance were conducted.

Results

We had a 55.3% success rate in obtaining the medical records from the contacted hospitals with refusal to participate/consent by the hospital in question being the most frequent reason for failure in 3 out of 4 cases. An additional attrition of 39.3% was observed among the medical records received, with absence of a MAR form (23.9%) and confirmatory CDAD diagnosis or note (9.1%) being the most frequent criteria for discarding an available record prior to abstraction (Figure).

Patient Characteristics

Consistent with the characteristics of the overall CDAD population within the original database, the randomly selected patients whose records were abstracted were predominantly women and elderly with a mean age of 66 (± 17.6) years ( Table 1 ). Patients had a mean BMI of 26.7 (± 7.6), with 44% classified as being either overweight or obese. Most of the cohort had either CDAD or diarrhea as a primary diagnosis at admission. Among those with no admission diagnosis of CDAD or diarrhea, the mean time to CDAD acquisition was about approximately 1 week after admission.

CDAD Characteristics and Complications

Using a derived definition of severity, most CDAD cases were classified either as

mild or severe ( Table 2 ). For those with available diarrhea information, as expected the majority of patients reported thin/loose/soft or watery stools during the course of their CDAD episode. Patients had on average 5.5 (± 13.3) stools per day during the CDAD episode. In addition to diarrhea, stomach pain, vomiting, and dehydration were commonly reported. A relatively low proportion of patients had serious complications including mucosal inflammation and colectomy. One of every 5 patients was a recurrent CDAD case with documented prior CDAD.

CDAD-Related Resource Utilization