![[ Visit SHEA online ]](images/banner.gif)
Background: U.S. health care reform legislation specifically encourages analyses of subpopulations, recognizing the emergence of targeted therapies. Several provisions of the legislation emphasize “value” by linking Medicare payments to quality of care; for example, hospitals will be penalized for certain readmissions that were reasonably preventable.
Objective: To describe demographic and clinical characteristics of hospital inpatient Clostridium difficile infection (CDI) patients, particularly subpopulations at high risk of CDI recurrence and negative outcomes.
Methods: Data sources were 2008 Nationwide Inpatient Sample (NIS), 2009 Medicare Provider Analysis and Review (MedPAR) file, Florida fiscal year 2006-2007 Medicaid claims (FL), and 2007-2008 Medicare 5% Standard Analytical Files (SAF). Inpatient stays with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code of 008.45 were identified as CDI claims. Demographics are from NIS. A patient with an initial and subsequent CDI hospitalization was identified as having a recurrence. Recurrence was calculated within 3 months and 1 year for the SAF data; and within 30 days, 3 months, and 1 year for the FL data.
Results: The mean (median) age of CDI patients was 68.4 (73) years. Less than half (42%) were male. Medicare was the largest payer (68%), followed by private insurance (19%), and Medicaid (8%). In aggregate, 83% of CDI cases were among the following subpopulations: aged 65-79 33%, advanced elderly (aged 80+) 34%, bone marrow transplant 0.4%, human immunodeficiency virus 1%, organ transplant 2%, inflammatory bowel disease 5%, cancer 16%, or renal impairment 36%. Among Medicaid CDI patients aged <65, 12%, 17%, and 21% were re-hospitalized with a diagnosis of CDI within 30 days, 3 months, and 1 year, respectively. Among Medicare CDI patients aged 65+, 14% and 24% were re-hospitalized with a diagnosis of CDI within 3 months and 1 year, respectively, across the subpopulations. Almost a third (31%) of the Medicare CDI hospital stays (initial or re-hospitalizations) included services in the intensive care unit (ICU) with a mean (SD) length of stay in the ICU of 8.2 (9.8) days. Medicaid CDI patients aged <65 with a recurrence within 3 months had an annual all-cause mortality rate of 27% compared to 20% for patients without a recurrence; whereas, Medicare CDI patients aged 65+ with a recurrence within 3 months had an annual all-cause mortality rate of 52% compared to 49% for patients without a recurrence, compared to 59% versus 57% for aged 80+.
Conclusions: This study emphasizes the unmet need for more targeted therapies in subpopulations at high risk of CDI recurrence, particularly in light of the “value” considerations that are increasingly at the forefront of payer initiatives.