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, 11 (2), e0146822
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Identification of Medicare Recipients at Highest Risk for Clostridium Difficile Infection in the US by Population Attributable Risk Analysis

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Identification of Medicare Recipients at Highest Risk for Clostridium Difficile Infection in the US by Population Attributable Risk Analysis

Erik R Dubberke et al. PLoS One.

Abstract

Background: Population attributable risk percent (PAR%) is an epidemiological tool that provides an estimate of the percent reduction in total disease burden if that disease could be entirely eliminated among a subpopulation. As such, PAR% is used to efficiently target prevention interventions. Due to significant limitations in current Clostridium difficile Infection (CDI) prevention practices and the development of new approaches to prevent CDI, such as vaccination, we determined the PAR% for CDI in various subpopulations in the Medicare 5% random sample.

Methods: This was a retrospective cohort study using the 2009 Medicare 5% random sample. Comorbidities, infections, and healthcare exposures during the 12 months prior to CDI were identified. CDI incidence and PAR% were calculated for each condition/exposure. Easy to identify subpopulations that could be targeted from prevention interventions were identified based on PAR%.

Findings: There were 1,465,927 Medicare beneficiaries with 9,401 CDI cases for an incidence of 677/100,000 persons. Subpopulations representing less than 15% of the entire population and with a PAR% ≥ 30% were identified. These included deficiency anemia (PAR% = 37.9%), congestive heart failure (PAR% = 30.2%), fluid and electrolyte disorders (PAR% = 29.6%), urinary tract infections (PAR% = 40.5%), pneumonia (PAR% = 35.2%), emergent hospitalization (PAR% = 48.5%) and invasive procedures (PAR% = 38.9%). Stratification by age and hospital exposures indicates hospital exposures are more strongly associated with CDI than age.

Significance: Small and identifiable subpopulations that account for relatively large proportions of CDI cases in the elderly were identified. These data can be used to target specific subpopulations for CDI prevention interventions.

Conflict of interest statement

Competing Interests: ERD reports grants and personal fees from Sanofi-Pasteur, during the conduct of the study; grants from Microdermis, personal fees and other from Merck, personal fees and other from Rebiotix, outside the submitted work. MAO reports grants from Sanofi Pasteur, during the conduct of the study; personal fees from Sanofi Pasteur, personal fees from Pfizer, outside the submitted work. DS reports other from Abbott Laboratories, other from Bristol-Myers Squibb, outside the submitted work. CPK reports personal fees from Astellas, personal fees from Novartis, personal fees from MedImmune, personal fees from Merck, grants and personal fees from Sanofi-Pasteur, grants from CSL-Behring, grants from Merck, personal fees from QuantiaMed, outside the submitted work. In addition, CPK has a patent Passive immunotherapy for CDI using IgA pending. DNG holds patents for the treatment and prevention of CDI licensed to ViroPharma/Shire, is a consultant for Merck, Shire, Rebiotix, Sanofi Pasteur and Actelion and holds research grants from CDC and United States Department of Veterans Affairs Research Service. YYX reports personal fees from Sanofi-Pasteur, during the conduct of the study; personal fees from Sanofi-Pasteur, outside the submitted work. CM reports other from Sanofi Pasteur, outside the submitted work. This does not alter the authors' adherence to PLOS ONE policies on sharing data and materials.

Figures

Fig 1
Fig 1
CDI incidence and CDI population attributable risk percent (PAR%) of comorbidities (A), infections within 3 months of CDI (B), and healthcare exposures within 3 months of CDI (C). No NH / No SNF = people without a nursing home or skilled nursing facility exposure within 3 months of CDI; Yes NH / No SNF = nursing home residents without a skilled nursing facility exposure within 3 months of CDI; No NH / Yes SNF = people without a nursing home exposure but with a skilled nursing facility exposure within 3 months of CDI; Yes NH / Yes SNF = nursing home residents.
Fig 2
Fig 2. Graph of populations size (X-axis) versus CDI incidence (Y-axis) of comorbidities, infections within three months of CDI, and healthcare exposures within three months of CDI.
The size of the circles represents the relative difference in population attributable risk percent (PAR%) for each exposure examined. (Comorbidities (blue bubbles): ANY COMORB = any comorbiditiy, ARTH = arthritis, BL ANEM = blood loss anemia, CA = solid tumor, CHF = congestive heart failure, COAG = coagulopathy, COPD = chronic lung disease, DEF ANEM = deficiency anemia, DEP = depression, DIAB = diabetes mellitus, FED = fluid and electrolyte disorder, HTN = hypertension, HYPOT4 = hypothyroid, LYMPH = lymphoma, MTCA = metastatic cancer, NEUR = other neurological disorder, OBES = obesity, PARAL = paralysis, PSY = psychoses, PULM CD = pulmonary circulatory disorder, PVD = peripheral vascular disease, RF = renal failure, VALVE = valvular disease, WT LOSS = weight loss; Infections (red bubbles): ABSC = abscess in organ/meningitis; ANY INF = any infection, B&J = bone/joint infection, GASTRO = gastroenteritis, GYN = female pelvic infection, INTRA ABD = intra-abdomional abscess/peritonitis, OM = otitis media, ORAL ABSC = oral abscess, PNA = pneumonia, SEPSIS = clinical sepsis, SEPT = septicemia/endovascular infection, SSI = surgical site infection, SSTI = skin/soft tissue infection, TONSIL = tonsillitis, URTI = upper respiratory tract infection, UTI = urinary tract infection, VIRAL = viral infection; Healthcare exposures (green bubbles): DIAL = outpatient dialysis, ED visit = emergency department visit without hospitalization, ELECT HOSP = non-emergent hospitalization, EMERG HOSP = emergent hospitalization, 2+ HOSP YEAR = at least two hospitalizations in the last year; INV = any invasive procedure, OUTPT INV, outpatient invasive procedure, SURG = surgery; Yes NH / No SNF = nursing home residents without a skilled nursing facility exposure within 3 months of CDI; No NH / Yes SNF = people without a nursing home exposure but with a skilled nursing facility exposure within 3 months of CDI Age (clear bubbles): 66–70 = 66 to 70 years old, 71–75 = 71 to 75 years old, 76–80 = 76 to 80 years old, 81–85 = 81 to 85 years old, 85+ = >85 years old)
Fig 3
Fig 3
CDI incidence and CDI population attributable risk percent (PAR%) of comorbidities (A), infections within 3 months of CDI (B), and healthcare exposures within 3 months of CDI (C) stratified by age. Comorbidities and infections were limited to those with a top three PAR%. No NH / No SNF = people without a nursing home or skilled nursing facility exposure within 3 months of CDI; Yes NH / No SNF = nursing home residents without a skilled nursing facility exposure within 3 months of CDI; No NH / Yes SNF = people without a nursing home exposure but with a skilled nursing facility exposure within 3 months of CDI; Yes NH / Yes SNF = nursing home residents.
Fig 4
Fig 4
CDI incidence and CDI population attributable risk percent (PAR%) of comorbidities (A), infections within 3 months of CDI (B), healthcare exposures within 3 months of CDI (C), and age stratified by hospital exposures (D) in the three months prior to CDI. Comorbidities and infections were limited to those with a top three PAR%. No NH / No SNF = people without a nursing home or skilled nursing facility exposure within 3 months of CDI; Yes NH / No SNF = nursing home residents without a skilled nursing facility exposure within 3 months of CDI; No NH / Yes SNF = people without a nursing home exposure but with a skilled nursing facility exposure within 3 months of CDI; Yes NH / Yes SNF = nursing home residents

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