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

Stevens, Vanessa; Khader, Karim; Nelson, Richard E.; Jones, Makoto; Rubin, Michael; Brown, Kevin A.; Evans, Martin E.; Greene, Tom; Slade, Eric P.; Samore, Matthew H.

doi:10.1017/ice.2015.132

Cited by 22 publications

(38 citation statements)

References 34 publications

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“…The greatest impact on LOS occurred among patients with severe CDI. The excess LOS for mild-to-moderate CDI was 0.75 days (95% CI: 0.59 - 0.89), and for severe CDI, it was 4.11 days (95% CI: 3.90 - 4.32) [23]. Intensive care unit (ICU) patients with CDI in particular have a greater adverse outcome.…”

Section: Discussionmentioning

confidence: 99%

Lack of Association Between the Clinical Outcome of Clostridium difficile Infection and Current Steroids Use

et al. 2017

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BackgroundThe purpose of this study was to compare the outcome of Clostridium difficile infection (CDI) in patients on systemic steroids for various indications to patients not on steroids in term of disease severity, and associated morbidity and mortality.MethodsWe retrospectively reviewed records of all patients with CDI at our hospital from January 2011 to December 2016. Patients were evaluated for baseline characteristics, comorbidities, medications, disease severity, disease-related length of stay (LOS) from the diagnosis of CDI to discharge, need for surgical intervention, and disease-related mortality. Based on systemic steroids use, patients who were using steroids for different indications constituted the study population, and those with no steroids use were clustered as a control group.ResultsOf the 258 patients included, males were 127 (49%). Severe and severe-complicated CDI developed in 21/63 (33.3%) and 1/63 (1.6%) of patients on steroids (average daily dose of 20 mg), and in 73/195 (37.4%) and 5/195 (2.6%) of patients with no steroids use (P = 0.56 and P = 0.66, respectively). Surgical intervention was not required in the steroids group and 5/195 (2.7%) of patients not on steroids underwent bowel surgeries (P = 0.38). Mean LOS (days) was 11.6 ± 1.5 in the steroids group and 10.4 ± 0.7 in the no-steroids group (P = 0.4). CDI-related mortality occurred in 9/63(14.3%) of patients on steroids, and in 15/195 (7.7%) of patients not on steroids (P = 0.12; odds ratio (OR): 2; 95% confidence interval (CI): 0.8 - 4.8).ConclusionThere was no significant difference in the severity of CDI, need for surgical interventions, disease-related LOS and mortality in systemic steroids users compared to patients not on steroids.

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Section: Discussionmentioning

confidence: 99%

Lack of Association Between the Clinical Outcome of Clostridium difficile Infection and Current Steroids Use

et al. 2017

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“…7,24 We therefore performed two follow-up analyses to account for this. First, we stratified the LOS comparison by the time of CDI diagnosis for case definition (iv) into 0–3 day, 3–8 day, and ≥8 day case cohorts, training new propensity models for re-matching, with similar performance (Figure S5).…”

Section: Resultsmentioning

confidence: 99%

“…7,24,36 Unlike visit diagnosis codes, toxin assay results provide a presumptive time-to-infection that we incorporated into two different statistical methods addressing time-dependent bias. When using a case definition of either toxin assay being positive, the measured difference in LOS in the multistate model corresponded closely with the difference seen in the “early HA” stratum of a time-stratified propensity-matched analysis (3.3 vs. 3.1 days).…”

Section: Discussionmentioning

confidence: 99%

“…3 Estimates of the per-patient cost of CDI have varied from $2,871 to $122,318 due to differences in methodology, patient inclusion criteria, and regional costs. 4–6 Given the high hospital-to-hospital variability of these costs, 7,8 infection control officers, hospital administrators, and clinicians would benefit from estimates tailored to their particular population and healthcare practices. Concretely defining the potential economic savings of CDI prevention would empower stakeholders to prudently choose among the many available validated interventions.…”

Section: Introductionmentioning

confidence: 99%

“…Most previous studies of CDI cost do not account for the possibility that longer LOS increases the risk of CDI, i.e., reverse causation, and therefore likely overestimate the cost of CDI. 7,24 To adjust for this, we stratify our analysis by the time of CDI diagnosis to find the change in LOS conditional on minimal prior exposure to the hospital environment. Finally, we compare these results to a multistate model of competing time-dependent risks between discharge and the onset of CDI.…”

Section: Introductionmentioning

confidence: 99%

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Estimating Local Costs Associated WithClostridium difficileInfection Using Machine Learning and Electronic Medical Records

Pak

Chacko

O’Donnell

et al. 2017

Infect. Control Hosp. Epidemiol.

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Background Reported per-patient costs of Clostridium difficile infection (CDI) vary by two orders of magnitude among different hospitals, implying that infection control officers need precise, local analyses to guide rational decision-making between interventions. Objective We sought to comprehensively estimate changes in length of stay (LOS) attributable to CDI at one urban tertiary-care facility using only data automatically extractable from the electronic medical record (EMR). Methods We performed a retrospective cohort study of 171,938 visits spanning a 7-year period. 23,968 variables were extracted from EMR data recorded within 24 hours of admission to train elastic net regularized logistic regression models for propensity score matching. To address time-dependent bias (reverse causation), we separately stratified comparisons by time-of-infection and fit multistate models. Results The estimated difference in median LOS for propensity-matched cohorts varied from 3.1 days (95% CI, 2.2–3.9) to 10.1 days (95% CI, 7.3–12.2) depending on the case definition; however, dependency of the estimate on time-to-infection was observed. Stratification by time to first positive toxin assay, excluding probable community-acquired infections, showed a minimum excess LOS of 3.1 days (95% CI, 1.7–4.4). Under the same case definition, the multistate model averaged an excess LOS of 3.3 days (95% CI, 2.6–4.0). Conclusions Two independent time-to-infection adjusted methods converged on similar excess LOS estimates. Changes in LOS can be extrapolated to a marginal dollar costs by multiplying by average costs of an inpatient-day. Infection control officers can leverage automatically extractable EMR data to estimate costs of CDI at their own institution.

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Incidence and Outcomes Associated WithClostridium difficileInfections

et al. 2020

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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.

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

Cited by 22 publications

References 34 publications

Lack of Association Between the Clinical Outcome of Clostridium difficile Infection and Current Steroids Use

Lack of Association Between the Clinical Outcome of Clostridium difficile Infection and Current Steroids Use

Estimating Local Costs Associated WithClostridium difficileInfection Using Machine Learning and Electronic Medical Records

Incidence and Outcomes Associated WithClostridium difficileInfections

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