Clinical burden of recurrent Clostridioides difficile infection in the medicare population: A real-world claims analysis

Abstract

Objective: To describe 12-month outcomes for beneficiaries in the 100% Medicare Fee-for-Service (FFS) population with primary and recurrent Clostridioides difficile infection (CDI).

Design: A retrospective, descriptive, cohort study of CDI claims from the 100% Medicare FFS population, with a first CDI diagnosis between January 1, 2010, and December 31, 2016.

Setting: Any US-based provider that submitted inpatient or outpatient CDI diagnosis claims to Medicare FFS.

Patients: The study included patients aged ≥65 years with continuous enrollment in Medicare Parts A, B, and D during 12 months before and 12 months after the index period.

Methods: The number of CDI and recurrent (rCDI) episodes, healthcare resource utilization, treatments, complications, and procedures were calculated for pre-index and follow-up periods. The data were stratified by number of rCDI episodes (ie, no rCDI, 1 rCDI, 2 rCDI, and ≥3 rCDI).

Results: Of 268,762 patients with an index CDI, 34.7% had at least 1 recurrence. Of those who had 1 recurrence, 59.1% had a second recurrence and of those who had 2 recurrences, 58.4% had ≥3 recurrences. Incident psychiatric conditions occurred in 11.3%-18.2% of each rCDI cohort; 6.0% of patients with rCDI underwent subtotal colectomy, and 1.1% of patients underwent diverting loop ileostomy. After each CDI episode, ∼1 in 5 patients had a documented sepsis event. Over the 12-month follow-up, 30% of patients experienced sepsis, and sepsis occurred in 27.0% of the cohort with no rCDI, compared to 35.5% of patients in the rCDI cohorts.

Conclusions: Elderly patients with CDI and rCDI experienced a significant clinical burden and complications.

Fig. 1.

Study design. (a) Definition of index CDI episode, including CDI claims (red), the 14-day CDI claim-free period after last CDI claim, and 8-week period to identify rCDI. (b) Definition of rCDI episodes. The rCDI episode (orange) indicates a hypothetical point at which the first rCDI episode occurs during the 8-week window after the index CDI claim-free period. Following this first rCDI episode, a new 14-day claim-free period occurs plus a new window for a subsequent rCDI episode. Multiple rCDI could occur after an index CDI event in this manner, until 12 months following the index CDI date.

Fig. 2.

Timing of the first bowel surgery. All-cause subtotal colectomy was performed on 6.0% of all patients with CDI and was most commonly performed after the index CDI episode. All-cause diverting loop ileostomy was performed on 1.1% of all patients with CDI and was most commonly performed after the fourth or subsequent rCDI episode.

Fig. 3.

Proportion of patients experiencing sepsis, by recurrence cohort. During the 12-month follow-up, 80,502 patients (30.0%) with CDI or rCDI experienced sepsis. All instances of sepsis were counted and, therefore, 1 patient could have had multiple sepsis events during follow-up. Sepsis events after the fourth or later CDI recurrence were not reported.