C Difficile Linked to Longer, More Intensive Hospital Stays for Geriatrics

Paul Feuerstadt, MD

New research suggests a high burden of death and hospital costs is associated with recurrent clostridium difficile infections for older adults.

A team, led by Paul Feuerstadt, MD, Yale University School of Medicine, identified the mortality, cost, and health care resource utilization for Medicare beneficiaries at least 65 years old who suffered a primary CDI episode only or any recurrent CDI.

In the retrospective, observational, claim analysis study, the investigators examined patients who had an inpatient or outpatient CDI diagnosis claim to Medicare and continuous enrollment in Medicare parts, A, B, and D during the 12-month pre- and post-index periods.

Medicare Claims

To find this data, the team used 100% Medicare Fee-for-Service claims data between 2009-2017. They identified 345,893 primary CDI cases and 151,596 recurrent CDI episodes.

They also summarized demographic and clinical characteristics, mortality, health care resource utilization, and costs per patient per month for 12 months before and up to 12 months after episodes start.

The investigators also used regression models to estimate hospitalization risk, hospital length of stay, and cost to adjust for comorbidities.

Risk of Death

Overall, the recurrent CDI cohort were nearly 10 times likelier to suffer from a CDI-associated death (25.4%) than the primary CDI cohort (2.7%).

The investigators also found various trends based on demographics.

Decedents were more likely to be older, have higher Charlson Comorbidity Index scores, and were more likely to be Black compared to survivors.

Comorbidities

Finally, the investigators adjusted for comorbidities.

Here, they found decedents during follow-up had higher hospitalization rates (pCDI: OR, 1.83; P <.001; rCDI: OR, 2.58; P <.001). Decedents with recurrent CDI had more intensive care unit use (OR, 2.34; P <.001) compared with survivors.

Overall decedents had a longer length of stay (pCDI: +3.1 days; P <.01; rCDI: +2.6 days), and higher total cost (pCDI: +303%; P <.001; rCDI: +297%; P <.001).

“CDI is an important contributing diagnosis to all-cause mortality, particularly for recurrences,” the authors wrote. “Prior to death, older Medicare beneficiaries who experienced CDI received longer, more intensive, and more costly care compared with survivors.”

C Difficile Trends

The study could be used to drive future medical decisions.

“Clinicians should be particularly attentive to prevention, identification, and appropriate treatment of CDI in older adults,” the authors wrote. “Better treatments to reduce primary C difficile infection and recurrences in this vulnerable population can lower both mortality and economic burden.”

C difficile infection rates have been highly scrutinized in recent years.

In 2017 there was approximately 462,000 cases in the US and despite some positive trends over the past decade, cases have plateaued in recent years.

In addition, 35% of patients diagnosed with a first CDI episode will go on to develop recurrence and 65% of patients who experience at least 1 recurrence will suffer a subsequent recurrence.

Costs associated with the disease also remain high, with direct medical costs related to recurrent CDI in the US coming in at an estimated $2.8 billion per year. There is also higher per-patient costs linked to CDI-related surgery or hospitalization during the year after recurrence and a higher risk of death compared to patients who do not experience a recurrence.

The study, “Mortality, Health Care Use, and Costs of Clostridioides difficile Infections in Older Adults,” was published online in the Journal of the American Medical Directors Association.