Racial and ethnic disparities in health care-associated Clostridium difficile infections in the United States: State of the science

Leveraging multi-database linkages to assess racial and ethnic disparities among Carbapenem-resistant Enterobacterales cases in Tennessee, 2015-2019

BACKGROUND

Awareness of health disparities' impact on clinical outcomes is increasing. However, public health's ability to highlight these trends can be limited by data missingness, such as on race and ethnicity. To better understand race and ethnicity's impact, we compared all-cause 30-day mortality rates between non-Hispanic (NH) Black, NH White, and Hispanic/NH other racial and ethnic patients among cases of carbapenem-resistant Enterobacterales (CRE).

METHODS

We performed data linkage using CRE statewide surveillance, Hospital Discharge Data System, and vital records data to obtain demographics and clinical outcomes on CRE cases in TN. We evaluated the association between race and ethnicity with all-cause 30-day mortality among CRE cases.

RESULTS

Among 2,804 reported CRE cases from 2015 to 2019, 65% (n = 1,832) were missing race and ethnicity; data linkage methods reduced missingness to 10% (n = 285). 22%, 74%, and 3% of cases were among NH Black, NH White, and Hispanic/NH other patients, respectively. Thirty-day all-cause mortality among NH Black patients was 5.7 per 100,000 population, 1.9 and 5.7 times higher than NH White and Hispanic/NH other patients. We observed that the risk of dying within 30 days of CRE diagnosis was 35% higher for NH Black compared to NH White patients; unmeasured confounders may be present (adjusted risk ratio 1.35; 95% CI 1.00, 1.83).

CONCLUSION

Data linkage effectively reduced missingness of race and ethnicity. Among those with CRE, NH Blacks may have an increased risk of all-cause 30-day mortality. Data missingness creates barriers in identifying health disparities; data linkage is one approach to overcome this challenge.

Machine learning evaluation of inequities and disparities associated with nurse sensitive indicator safety events

PURPOSE

To use machine learning to examine health equity and clinical outcomes in patients who experienced a nurse sensitive indicator (NSI) event, defined as a fall, a hospital-acquired pressure injury (HAPI) or a hospital-acquired infection (HAI).

DESIGN

This was a retrospective observational study from a single academic hospital over six calendar years (2016-2021). Machine learning was used to examine patients with an NSI compared to those without.

METHODS

Inclusion criteria: all adult inpatient admissions (2016-2021). Three approaches were used to analyze the NSI group compared to the No-NSI group. In the univariate analysis, descriptive statistics, and absolute standardized differences (ASDs) were employed to compare the demographics and clinical variables of patients who experienced a NSI and those who did not experience any NSIs. For the multivariate analysis, a light grading boosting machine (LightGBM) model was utilized to comprehensively examine the relationships associated with the development of an NSI. Lastly, a simulation study was conducted to quantify the strength of associations obtained from the machine learning model.

RESULTS

From 163,507 admissions, 4643 (2.8%) were associated with at least one NSI. The mean, standard deviation (SD) age was 59.5 (18.2) years, males comprised 82,397 (50.4%). Non-Hispanic White 84,760 (51.8%), non-Hispanic Black 8703 (5.3%), non-Hispanic Asian 23,368 (14.3%), non-Hispanic Other 14,284 (8.7%), and Hispanic 30,271 (18.5%). Race and ethnicity alone were not associated with occurrence of an NSI. The NSI group had a statistically significant longer length of stay (LOS), longer intensive care unit (ICU) LOS, and was more likely to have an emergency admission compared to the group without an NSI. The simulation study results demonstrated that likelihood of NSI was higher in patients admitted under the major diagnostic categories (MDC) associated with circulatory, digestive, kidney/urinary tract, nervous, and infectious and parasitic disease diagnoses.

CONCLUSION

In this study, race/ethnicity was not associated with the risk of an NSI event. The risk of an NSI event was associated with emergency admission, longer LOS, longer ICU-LOS and certain MDCs (circulatory, digestive, kidney/urinary, nervous, infectious, and parasitic diagnoses).

CLINICAL RELEVANCE

Machine learning methodologies provide a new mechanism to investigate NSI events through the lens of health equity/disparity. Understanding which patients are at higher risk for adverse outcomes can help hospitals improve nursing care and prevent NSI injury and harm.

Carbapenem-Resistant enterobacterales in individuals with and without health care risk factors -Emerging infections program, United States, 2012-2015

BACKGROUND

Carbapenem-resistant Enterobacterales (CRE) are usually healthcare-associated but are also emerging in the community.

METHODS

Active, population-based surveillance was conducted to identify case-patients with cultures positive for Enterobacterales not susceptible to a carbapenem (excluding ertapenem) and resistant to all third-generation cephalosporins tested at 8 US sites from January 2012 to December 2015. Medical records were used to classify cases as health care-associated, or as community-associated (CA) if a patient had no known health care risk factors and a culture was collected <3 days after hospital admission. Enterobacterales isolates from selected cases were submitted to CDC for whole genome sequencing.

RESULTS

We identified 1499 CRE cases in 1194 case-patients; 149 cases (10%) in 139 case-patients were CA. The incidence of CRE cases per 100,000 population was 2.96 (95% CI: 2.81, 3.11) overall and 0.29 (95% CI: 0.25, 0.35) for CA-CRE. Most CA-CRE cases were in White persons (73%), females (84%) and identified from urine cultures (98%). Among the 12 sequenced CA-CRE isolates, 5 (42%) harbored a carbapenemase gene.

CONCLUSIONS

Ten percent of CRE cases were CA; some isolates from CA-CRE cases harbored carbapenemase genes. Continued CRE surveillance in the community is critical to monitor emergence outside of traditional health care settings.

Increasing Trends of Clostridium difficile Infection in Hospitalized Young Patients: A Study of the National Inpatient Sample From 2007 to 2017

Background

Clostridium difficile infection (CDI) is one of the rising public health threats in the United States. It has imposed significant morbidity and mortality in the elderly population. However, the burden of the disease in the young population is unclear. This study aimed to identify hospitalization trends and outcomes of CDI in the young population.

Methodology

We obtained data from the National (Nationwide) Inpatient Sample (NIS) for hospitalizations with CDI between 2007 and 2017. We used the International Classification of Diseases Ninth Edition-Clinical Modification (ICD-9-CM) and ICD-10-CM to identify CDI and other diagnoses of interest. The primary outcome of our study was to identify the temporal trends and demographic characteristics of patients aged less than 50 years old hospitalized with CDI. The secondary outcomes were in-hospital mortality, length of hospital stay (LOS), and discharge dispositions. We utilized the Cochran Armitage trend test and multivariable survey logistic regression models to analyze the trends and outcomes.

Results

From 2007 to 2017, CDI was present among 1,158,047 hospitalized patients. The majority (84.04%) of the patients were ≥50 years old versus 15.95% of patients <50 years old. From 2007 to 2017, there was a significant increase in CDI among <50-year-old hospitalized patients (12.6% from 2007 to 18.1% in 2017; p < 0.001). In trend analysis by ethnicities, among patients <50 years old, there was an increasing trend in Caucasians (63.9% versus 67.9%; p < 0.001) and Asian females (58.4% versus 62.6%; p < 0.001). We observed an increased trend of discharge to home (91.3% vs 95.8%; p < 0.001) in association with a decrease in discharge to facility (8.3% vs 4%; p < 0.001). The average LOS from 2007 to 2017 was 5 ± 0.03 days, which remained stable during the study period.

Conclusions

The proportion of young (<50 years old) hospitalized patients with CDI has been steadily increasing over the past decade. Our findings might represent new epidemiological trends related to non-traditional risk factors. Future CDI surveillance should extend to the young population to confirm our findings, and the study of emerging risk factors is required to better understand the increasing CDI hospitalization in the young population.

Clostridioides difficile Infection Treatment and Outcome Disparities in a National Sample of United States Hospitals

Clostridioides difficile infection (CDI) disproportionately affects certain populations, but few studies have investigated health outcome disparities among patients with CDI. This study aimed to characterize CDI treatment and health outcomes among patients by age group, sex, race, and ethnicity. This was a nationally representative, retrospective cohort study of patients with laboratory-confirmed CDI within the Premier Healthcare Database from January 2018 to March 2021. CDI therapies received and health outcomes were compared between patients by age group, sex, race, and Hispanic ethnicity using bivariable and multivariable statistical analyses. A total of 45,331 CDI encounters were included for analysis: 38,764 index encounters and 6567 recurrent encounters. CDI treatment patterns, especially oral vancomycin use, varied predominantly by age group. Older adult (65+ years), male, Black, and Hispanic patients incurred the highest treatment-related costs and were at greatest risk for severe CDI. Male sex was an independent predictor of in-hospital mortality (aOR 1.17, 95% CI 1.05−1.31). Male sex (aOR 1.25, 95% CI 1.18−1.32) and Black race (aOR 1.29, 95% CI 1.19−1.41) were independent predictors of hospital length of stay >7 days in index encounters. In this nationally representative study, CDI treatment and outcome disparities were noted by age group, sex, and race.

Disparities in the incidence of community-acquired Clostridioides difficile infection: An area-based assessment of the role of social determinants in Bernalillo County, New Mexico

BACKGROUND

Community-associated Clostridioides difficile infections (CA-CDIs) share many risk factors with health care-associated cases, although the role of socioeconomic factors is poorly understood. This study estimates the influence of several census tract-level measures of socioeconomic status on CA-CDI incidence rates.

METHODS

CA-CDI case data from the New Mexico Emerging Infections Program were analyzed using quasi-Poisson regression modeling. Geocoded cases were assigned census tract-level socioeconomic measures to explore racial, ethnic and socioeconomic disparities in CA-CDI incidence.

RESULTS

Regression modeling identified census tract-level socioeconomic measures as well as individual and medical measures that together accounted for 57% of the variance in CA-CDI rates. At the census tract level, socioeconomic factors associated with an increase in CA-CDI incidence included a high percentage of individuals lacking health insurance and a low percentage of individuals with low educational attainment. A subanalysis that included racial and ethnic designation revealed that ethnicity had no significant effect, but compared to white race, other races were significantly more likely to acquire CA-CDI.

CONCLUSIONS

Although this work reveals the role of certain socioeconomic and race and ethnicity risk factors in the incidence of CA-CDI, it also underscores the complex relationships that exist between socioeconomic status and access to health care.

Factors Associated with the Use of Fecal Microbiota Transplant in Patients with Recurrent Clostridium difficile Infections

OBJECTIVE To identify the factors associated with first Clostridium difficile infection (CDI) that predict fecal microbiota transplantation (FMT) for recurrent CDI DESIGN We carried out a retrospective single-center cohort study to compare the clinical characteristics of 200 patients who underwent FMT for recurrent CDI to 75 patients who did not. SETTING A single academic hospital in the United States PATIENTS Adult patients RESULTS The time from first to second CDI correlated to subsequent FMT use. Concomitant inflammatory bowel disease (IBD; P=.002), use of immunosuppressive therapy (P=.04), and use of metronidazole within 2 months before the first CDI (P=.02) correlated positively to subsequent FMT in univariate analysis. The use of oral vancomycin for first CDI was more common in those who required FMT than those who did not in univariate (P=.02) and multivariate (P=.03) analyses. In contrast, intravenous vancomycin use within 2 months before the first CDI reduced the risk for FMT in univariate P=.000003) and multivariate (P=.0001) analyses. Black patients with recurrent CDI were less likely to receive FMT than white patients (P=.00005). Patients who received FMT were also less likely to have comorbidities. CONCLUSIONS This study provides important insights into the factors predictive for FMT in patients with recurrent CDI and highlights the potential racial and medical characteristics that affect the access of the patients to FMT. Infect Control Hosp Epidemiol 2018;39:302-306.