Cost Drivers Associated with Clostridium difficile-Associated Diarrhea in a Hospital Setting

Hospitalization Costs

Based on claims data, the mean (±SD) and median (Q1–Q3) plan costs for the duration of a CDAD-associated hospitalization (2011 USD) for these 500 patients were found to be $35,621 (± $100,502) and $13,153 ($8,209–$26,893), respectively.

Discussion

While multiple studies have documented the considerable economic burden associated with CDAD [5–10], this study was the first to our knowledge to evaluate the specific hospital resources that are used during an extended hospital stay for CDAD. This real-world analysis, in conjunction with the Quimbo et al claims analysis, demonstrated the significant burden associated with CDAD in terms of both fixed costs (eg, hospital stay) as well as the variable components that drive these expenditures (eg, consultations, ICU stay).

The mean ($35,621) and median ($13,153) total costs associated with the CDAD segment of the hospitalization, as measured via the claims, were quite high despite a greater prevalence of mild CDAD rather than severe infection, and required only a general hospital room stay. Both of the above CDAD hospital cost measures were well above the mean US general hospitalization cost of $11,666 and the median cost of $7334 measured from Healthcare Cost and Utilization Project data [15]. However, the mean cost of hospitalization reported in the current study falls within the range of previously reported costs for CDAD-associated hospitalizations [5,8,10]. While the mean cost may have been disproportionately inflated by a few extreme cases, the median CDAD-associated hospitalization cost was nearly twice the median cost of an average general hospital stay in the US [15]. Our finding that these elevated costs were observed among patients with mild CDAD and its relative magnitude compared with the average hospitalization costs (approximately 3-fold higher) were also consistent with the literature. For instance, Pakyz and colleagues reported that relative to patients without CDAD, hospital costs were tripled for patients with low-severity CDAD and 10% higher for those with more severe CDAD, presumably because CDAD resulted in costly complications that prolonged what would have otherwise been a short, simple hospital stay [10].

Type of hospital room could also be an important driver of cost. While most patients stayed in general hospital rooms, more than half were isolated for at least a day, and 12% of patients required nearly 2 weeks of intensive care. Taken together, 26% of patients in the current study were required to stay in a special care unit or a non–general hospital room for 5.5 to 12.2 days. This is consistent with the 28% of patients with CDAD that required stay on a special care unit previously reported by O’Brien et al [5].Additionally, previous research from Canadian health care data has shown that a single ICU stay costs an average of $7000 more per patient per day than a general hospital room (1992 Canadian dollars) or $9589 (2013 USD calculated using historical exchange rate data and adjusted for inflation) [16].However, despite this additional cost and resource burden, it appears that overall only 53.4% of all patients received care within an isolated setting as guidelines recommended.

Repeated specialist visits, procedures and multiple testing (concomitant diagnostic EIA and nondiagnostic tests) potentially added to the health care resource utilization and costs, along with the extra resources associated with specialized hospital care. We found that roughly one-third of patients consulted a specialist, although we did not distinguish between ‘formal’ and ‘informal’ consultations. Numerous studies published over the past 2 decades have demonstrated increased costs and resource utilization associated with specialist consultations [17–21]. Although the focused knowledge and experience of specialists may reduce morbidity and mortality [18,21], specialists are more likely than generalists to order more diagnostic tests, perform more procedures, and keep patients hospitalized longer and in ICUs, all of which contribute to higher costs without necessarily leading to improved health outcomes [21].

Limitations

One major limitation of this study was the inability to assess the individual costs of the resources used for each individual patient either through the medical charts or via claims. Additionally, the burden of CDAD was found to continue beyond the hospital stay, with documented evidence of persisting infection in 84% of patients at the point of discharge. Since the medical records obtained were limited to a single hospitalization and a single place of service, the data capture of an entire CDAD episode remains potentially incomplete for a number of patients who had recurrences or who had visited multiple sites of care in addition to the hospital (ie, emergency department or outpatient facility). The transition to outpatient care is often multifaceted and challenging for patients, especially those who are elderly and have multiple underlying conditions [18]. Access to care become more difficult, and patients become wholly responsible for taking their medication as prescribed and following other post-discharge treatment stratagems. Furthermore, no differentiation was made between patients having a primary versus secondary CDAD diagnosis.