By Joe Martin
Spring 2018 Catalyst
On March 1, 2018, PHC4 released a new research brief on Clostridium difficile infections (known as C.diff or CDI) and their link to hospital admissions in Pennsylvania. Why should the business community care about this? Because such infections are preventable and cost a great deal of money to treat.
Hospital stays where CDI was the principal reason for the admission amounted to an estimated $41.6 million in hospital payments in FY 2017 — that's just one year, and just in hospital costs. Longer hospital stays and needed rehab keep people out for work for longer periods of time, leading to lost work time and productivity. CDI infections can cause severe suffering and can be life threatening. They are characterized by watery diarrhea, fever, loss of appetite and abdominal discomfort. Prolonged use of antibiotics, particularly in the elderly as well as those individuals with other illnesses (e.g., cancer) poses an elevated risk for individuals in contracting a CDI.
In 2017, there were 17,495 hospital admissions for patients with a CDI. Outcomes, such as death, complications and readmissions are often worse when patients hospitalized for common conditions also have a CDI. For example, patients admitted for sepsis (the body's serious inflammatory response to an infection) with a CDI had an in-hospital mortality rate of 12.6 percent, and a 30-day re-admission rate of 28.6 percent — which is significantly higher when compared with patients without a CDI (who had a 2017 mortality rate of 8.8 percent and a 30-day readmission rate of 19.3 percent).
Patients also tend to stay in the hospital longer and have higher costs when they are admitted with a CDI. Patients admitted with respiratory failure with a CDI had an average length of stay of 11 days, with an average payment of $22,543 versus those patients admitted with respiratory failure without a CDI who had an average length of stay of just four days and an average payment that was nearly half the amount, at $12,720.
The good news is that outcomes for CDI patients have improved in recent years. The in-hospital mortality rate for patients with a CDI dropped 42 percent since 2008. Other outcomes (readmissions and average length of stay) also improved. PHC4's research brief also includes CDI hospitalizations and outcomes by age category and payer.
Of the 17,495 CDI hospital admissions reported in 2017, 30 percent (5,330 patients) had CDI as their principal diagnosis; that is, CDI was the principal reason the patient was admitted. 50 percent (8,762 patients) were admitted to the hospital for another condition but also had a CDI at the time of admission. 20 percent (3,403 patients) were admitted to the hospital for another condition but developed a CDI after being admitted to the hospital. Patients who developed a CDI during their hospital stay had a higher mortality rate (8.5 percent); stayed in the hospital longer (an average of 13 days); and incurred a higher average payment ($25,709) when compared to patients who had a CDI when they were admitted.
Recent research suggests that care provided to sepsis patients, including the use of antibiotics, may lead to higher CDI rates. The CDI data used for this brief showed that about 10.4 percent of the CDI patients had a previous hospital stay with a sepsis diagnosis (within the previous 90 days). About 31.3 percent of patients with a secondary diagnosis of CDI had sepsis as a principal diagnosis — the most common principal diagnosis among these patients. Nearly 4.4 percent of patients with a CDI were readmitted to the hospital within 30 days specifically for sepsis — the most common reason for readmission.
The research brief also examined county level and population-based hospitalization rates. Rates include Pennsylvania residents of all ages and were calculated using PHC4 hospital admission data and U.S. Census Bureau population estimates. Higher rates for some counties might be dependent on larger numbers of residents with high-risk characteristics (e.g., factors related to age and gender).
In general, population-based data showed higher rates of CDI hospitalizations among older and female residents. Statewide, there were 13 CDI hospital admissions per 10,000 Pennsylvania residents in 2017. The rate was 46.3 per 10,000 for residents age 65 and older; 14.5 for females and 11.4 for males. For white (non-Hispanic) residents, the rate was 14.2 per 10,000. The rates for black (non-Hispanic) and Hispanic residents were 12.5 and 3.7, respectively.
How can CDI be avoided? Hand hygiene is regarded as the most important intervention to reduce healthcare-associated infections. A six-step method has been found to be the most effective at killing problematic bacteria; however, compliance with this technique has been found lacking. In a recent study, only 65 percent of providers completed the entire hand hygiene process, despite participants having instructions on the technique in front of them and having their technique observed. This warrants further investigation for this particular technique and how compliance rates can be improved.
Through the work of PHC4, Pennsylvania paved the way beginning in 2005 with the reporting of healthcare associated infections, and pushed the nation into making the prevention of these potentially deadly and often preventable conditions a priority. Much progress has been achieved in the past 10 years but clearly there is still more work to be done.
Joe Martin is executive director of the Pennsylvania Health Care Cost Containment Council.