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Measuring the Cost of Overtesting and Overdiagnosis of Clostridioides difficile Infection
Background: C. difficile is the leading healthcare-associated pathogen. The C. difficile real-time polymerase chain reaction (PCR) stool test, used by >70% of hospitals, is highly sensitive but cannot differentiate colonization from infection. Inappropriate C. difficile testing may result in over...
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| Published in: | Infection control and hospital epidemiology 2020-10, Vol.41 (S1), p.s315-s316 |
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| Main Authors: | , , |
| Format: | Article |
| Language: | English |
| Subjects: | |
| Online Access: | Get full text |
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| Summary: | Background:
C. difficile
is the leading healthcare-associated pathogen. The
C. difficile
real-time polymerase chain reaction (PCR) stool test, used by >70% of hospitals, is highly sensitive but cannot differentiate colonization from infection. Inappropriate
C. difficile
testing may result in overdiagnosis and unnecessary treatment. Healthcare costs attributed to
C. difficile
are substantial, but the economic burden associated with
C. difficile
false positives in colonized patients is poorly understood.
C. difficile
PCR cycle threshold (CT) is as an inverse proxy for organism burden; high CT (≥30.9) has a high (>98%) negative predictive value compared to the reference gold standard, thus is a marker of colonization. Conversely, a low CT (≤28.0) suggests high organism burden and high specificity for true infection.
Methods:
A propensity score matching model for cost per hospitalization was developed to determine the costs of a hospital stay associated with
C. difficile
and to isolate the financial impacts of both true
C. difficile
infection and false positives. Relevant predictors of
C. difficile
positivity used in the model were age, Charlson comorbidity index, white blood cell count, and creatinine. We used CT data to identify and compare 3 inpatient groups: (1) true CDI, (2)
C. difficile
colonization, and (3)
C. difficile
negative.
Results:
A diagnosis of
C. difficile
adds significantly (>$3,000) to unadjusted hospital cost compared to a negative result. Propensity-adjusted analyses demonstrated that
C. difficile
colonization was associated with significantly increased (median, $5,000) hospital cost whereas any positive or true diagnoses of
C. difficile
were not associated with increased cost. Colonized patients also had significantly higher lengths of stay (1 day) and cost per length of stay ($218 per day).
Conclusions:
This is the first
C. difficile
cost analysis to utilize PCR CT data to differentiate colonization. Surprisingly, patients with a high CT had disproportionately higher hospital costs compared to matched
C. difficile–
negative patients, which was not seen among patients with a low CT or with any positive result. We hypothesize that this unexpected finding may be due to misdiagnosis and mistreatment of diarrhea not caused by
C. difficile
or unadjusted factors associated with high cost and non–
C. difficile
diarrhea. In addition, the discrepantly high cost attributed to
C. difficile
diagnosis cited in the literature ($3,000–11,000 per hospita |
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| ISSN: | 0899-823X 1559-6834 |
| DOI: | 10.1017/ice.2020.908 |