Excess length of stay and mortality due to Clostridium difficile infection: a multi-state modelling approach

Kleef, Esther van; Green, N.; Goldenberg, Simon; Robotham, Julie V.; Cookson, Barry; Jit, Mark; Edmunds, W. John; Deeny, Sarah R

doi:10.1016/j.jhin.2014.08.008

Cited by 37 publications

(38 citation statements)

References 27 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Strain types are geographically variable 31 and have been linked to differences in disease severity, particularly among patients with the "epidemic" strain, BI/NAP1/027. 32 As demonstrated in our results and the study from van Kleef et al, 20 CDI severity impacts the magnitude of excess LOS; thus, hospitals that have a greater proportion of CDIs caused by epidemic strains may observe a greater impact of CDI on LOS.…”

Section: Discussionsupporting

confidence: 72%

“…In their cohort, patients with severe CDI had an excess LOS of 11.6 days (95% CI, 3.6-19.6), whereas patients with mild-tomoderate CDI only stayed an additional 5 days (95% CI, 1.1-9.5). 20 In contrast, Mitchell et al 19 observed that CDI did not significantly contribute to LOS among inpatients 2 years and older at a hospital in Australia (0.9 days, 95% CI, 1.8-3.6). 19 However, both of these studies were conducted at single institutions outside of the United States with relatively small numbers of CDI cases.…”

Section: Discussionmentioning

confidence: 91%

“…In agreement with previous work, the greatest impact of CDI was noted among patients who were admitted to the ICU at baseline 29 and those with severe CDI. 20 Some geographic variability in estimates was noted; the greatest impact of CDI on LOS was observed among facilities in the Northeast census region. The variability in our estimates was consistent with the variation in the estimates from similar studies.…”

Section: Discussionmentioning

confidence: 99%

“…12,19,20,26 To determine whether death might artificially reduce LOS, we constructed a second MSM in which death and discharge were treated as separate states. The overall estimates from the combined and separate endpoint models were nearly identical; therefore, all results presented are from the MSM using the combined figure 1.…”

Section: Discussionmentioning

confidence: 99%

“…The variability in our estimates was consistent with the variation in the estimates from similar studies. [19][20][21] To policy makers, accurate estimates of the economic burden attributable to CDI and other healthcare-associated infections (HAI) are critical to determining the potential cost-effectiveness of implementing interventions. Because hospital costs vary among facilities, direct estimates of excess costs may not accurately represent costs at other institutions, particularly in settings with substantially different payment models.…”

Section: Discussionmentioning

confidence: 99%

See 4 more Smart Citations

Excess Length of Stay Attributable to Clostridium difficile Infection (CDI) in the Acute Care Setting: A Multistate Model

Stevens

Khader

Nelson

et al. 2015

Infect. Control Hosp. Epidemiol.

View full text Add to dashboard Cite

Background. Evaluation of the economic impact of interventions designed to reduce the incidence of Clostridium difficile infection (CDI) depends on accurate estimates of healthcare resource use attributable to infection. Studies that do not account for the timing of infection overestimate attributable length of stay (LOS). The purpose of this study was to evaluate the excess LOS due to CDI using a multi-state model Methods. We conducted a retrospective cohort study of all patients hospitalized on a general medical, surgical, or intensive care unit within the US Department of Veterans Affairs (VA) health care system between January 1, 2005 and December 31, 2012. A diagnosis of CDI was based on a positive laboratory result by enzyme immunoassay or cytotoxin test. A multi-state approach, implemented through the etmpackage in R, was used to estimate the excess LOS attributable to CDI while accounting for the timing of infection. Confidence intervals were estimated using bootstrapping techniques. A composite outcome of discharge or death was used. Estimates from the multistate model were compared to traditional estimates, including crude comparisons, ordinary least squares (OLS), and a generalized linear model (GLM) with a log link and gamma distributionResults. During the study period, 4.2 million Veterans were followed up for nearly 22 million patient-days of observation. CDIs were observed in 43,661 (1%) of hospitalizations. The median LOS among patients with and without CDI was 10 (IQR: 17) and 3 (IQR: 4) days, respectively, for a crude difference of 7 days ( p < .0001). OLS regression returned an estimated excess LOS of 14.3 (95%CI: 14.0 -14.6) days. The estimated increase in LOS from the GLM model was 7.0 (95% CI: 6.9 -7.1) days. When accounting for the timing of infection in a multi-state model, the attributable LOS was estimated to be 2.28 (95% CI: 2.14 -2.41) daysConclusion. CDI significantly contributes to LOS in the acute care setting but the magnitude of its estimated impact is substantially smaller with methods that account for the time-varying nature of infection. Further efforts to control for time-varying confounding will refine these estimates. Estimates of CDI costs should be based on more accurate measures of attributable LOS to avoid overstating the benefit of interventions to reduce CDI

show abstract

Section: Discussionsupporting

confidence: 72%

Section: Discussionmentioning

confidence: 91%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 3 more Smart Citations

Excess Length of Stay Attributable to Clostridium difficile Infection (CDI) in the Acute Care Setting: A Multistate Model

Stevens

Khader

Nelson

et al. 2015

Infect. Control Hosp. Epidemiol.

View full text Add to dashboard Cite

show abstract

Incidence and Outcomes Associated WithClostridium difficileInfections

et al. 2020

View full text Add to dashboard Cite

IMPORTANCE An understanding of the incidence and outcomes of Clostridium difficile infection (CDI) in the United States can inform investments in prevention and treatment interventions. OBJECTIVE To quantify the incidence of CDI and its associated hospital length of stay (LOS) in the United States using a systematic literature review and meta-analysis. DATA SOURCES MEDLINE via Ovid, Cochrane Library Databases via Wiley, Cumulative Index of Nursing and Allied Health Complete via EBSCO Information Services, Scopus, and Web of Science were searched for studies published in the United States between 2000 and 2019 that evaluated CDI and its associated LOS. STUDY SELECTION Incidence data were collected only from multicenter studies that had at least 5 sites. The LOS studies were included only if they assessed postinfection LOS or used methods accounting for time to infection using a multistate model or compared propensity score-matched patients with CDI with control patients without CDI. Long-term-care facility studies were excluded. Of the 119 full-text articles, 86 studies (72.3%) met the selection criteria. DATA EXTRACTION AND SYNTHESIS Two independent reviewers performed the data abstraction and quality assessment. Incidence data were pooled only when the denominators used the same units (eg, patient-days). These data were pooled by summing the number of hospital-onset CDI incident cases and the denominators across studies. Random-effects models were used to obtain pooled mean differences. Heterogeneity was assessed using the I 2 value. Data analysis was performed in February 2019. MAIN OUTCOMES AND MEASURES Incidence of CDI and CDI-associated hospital LOS in the United States. RESULTS When the 13 studies that evaluated incidence data in patient-days due to hospital-onset CDI were pooled, the CDI incidence rate was 8.3 cases per 10 000 patient-days. Among propensity score-matched studies (16 of 20 studies), the CDI-associated mean difference in LOS (in days) between patients with and without CDI varied from 3.0 days (95% CI, 1.44-4.63 days) to 21.6 days (95% CI, 19.29-23.90 days). CONCLUSIONS AND RELEVANCE Pooled estimates from currently available literature suggest that CDI is associated with a large burden on the health care system. However, these estimates should be interpreted with caution because higher-quality studies should be completed to guide future evaluations of CDI prevention and treatment interventions.

show abstract

Estimation of adjusted expected excess length‐of‐stay associated with ventilation‐acquired pneumonia in intensive care: A multistate approach accounting for time‐dependent mechanical ventilation

Bluhmki¹,

Allignol

Ruckly

et al. 2018

Biometrical J

View full text Add to dashboard Cite

The expected excess length-of-stay is an established concept to assess the health and economic impact of nosocomial, that is, hospital-acquired infections such as ventilation-acquired pneumonia in intensive care. Estimation must account for the timing of infection as in a multistate perspective, because common retrospective comparisons yield inflated estimates due to time-dependent bias. Since occurrence of ventilation-acquired pneumonia is closely linked to ventilation status, we suggest a multistate model incorporating time-dependent mechanical ventilation as additional states. The appeal is that the expected excess length-of-stay decomposes into extra days spent under ventilation and not under ventilation. This is not only highly relevant from a patient's perspective regarding quality of life, but also from an economic point of view, because ventilation is a major cost driver. The challenge is that estimation involves complex functionals of the matrix of transition probabilities, which in turn are based on the transition hazards. To address heterogeneity between patients, which is a common phenomenon in observational hospital epidemiology, we apply pseudovalue regression to adjust the ventilation-specific quantities for baseline confounding. The performance of our proposal is assessed by simulation and the methods are illustrated on data provided by 12 French intensive care units. Preliminary results indicate that the expected excess length-of-stay associated with ventilation-acquired pneumonia is mainly triggered by extra days spent under mechanical ventilation, and that the excess is most pronounced for intensive care patients with fewer comorbidities at baseline. We also find that such a decomposition is challenging for early times. Example code is provided.

show abstract

Excess length of stay and mortality due to Clostridium difficile infection: a multi-state modelling approach

Abstract: HA-CDI contributes to patients' expected LOS and risk of mortality. However, when quantifying the health and economic burden of hospital-onset of HA-CDI, the heterogeneity in the impact of HA-CDI should be accounted for.

Cited by 37 publications

References 27 publications

Excess Length of Stay Attributable to Clostridium difficile Infection (CDI) in the Acute Care Setting: A Multistate Model

Excess Length of Stay Attributable to Clostridium difficile Infection (CDI) in the Acute Care Setting: A Multistate Model

Incidence and Outcomes Associated WithClostridium difficileInfections

Estimation of adjusted expected excess length‐of‐stay associated with ventilation‐acquired pneumonia in intensive care: A multistate approach accounting for time‐dependent mechanical ventilation

Contact Info

Product

Resources

About