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E D I T O R I A L C O M M E N TA R Y
The Economics of Clostridium difficile–Associated Disease
for Providers and Payers
Joseph A. Paladino, and Jerome J. Schentag
CPL Associates, Amherst, and School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY
(See the article by Dubberke et al. on pages 497–504)
Outbreaks of Clostridium difficile–associated disease (CDAD), especially the hypervirulent North American pulsed field
gel electrophoresis type 1 strain, have presented significant problems for patients,
hospitals, long-term care facilities, and clinicians [1–3]. The important study by
Dubberke et al. [4] in this issue of Clinical
Infectious Diseases calls attention to the financial burden facing hospitals and, indirectly, to payers. As noted by Dubberke
et al. [4], their findings are conservative,
as we will discuss further.
Hospital practitioners should be aware
that when a patient develops a nosocomial
infection, particularly with a pathogen resistant to standard therapy, payer reimbursement likely fails to cover the increased cost of care that results [5]. We
noted in a study more than a decade ago
that the cost of CDAD could be among
the most influential components of the
cost of patients hospitalized with a serious
infection and receiving potent antibiotic
therapy [6].
The study at Barnes-Jewish Hospital [4]
Received 7 November 2007; accepted 8 November 2007;
electronically published 15 January 2008.
Reprints or correspondence: Dr. Joseph A. Paladino, CPL
Associates LLC, 3980 Sheridan Dr., Ste. 501, Buffalo, NY
14226 ([email protected]).
Clinical Infectious Diseases 2008; 46:505–6
2008 by the Infectious Diseases Society of America. All
rights reserved.
1058-4838/2008/4604-0003$15.00
DOI: 10.1086/526531
has several unique aspects. As an evaluation of nearly all patients admitted within
calendar year 2003 (excluding surgical and
short-term patients), it provides a large
sample, so that prevalence as well as cost
impact can be estimated. In addition to
analyzing the index hospitalization for
each patient as well as for the cohort, the
study also includes a 6-month follow-up.
This is of increasing importance, because
the recurrence rate for CDAD is problematic [7].
With use of fairly sophisticated statistical techniques in 2 complementary analyses, the attributable cost of CDAD found
by Dubberke et al. [4] would be $2,500–
$3,500 in current (2007) costs for the index hospitalization. This figure is quite
conservative, given the fact that patients
who had a surgical procedure at any time
during the hospitalization were excluded.
Moreover, the patients were treated in
2003, which is near the beginning of the
emergence of the North American pulsed
field gel electrophoresis type 1 strain [3].
The strain, known to be associated with
more colectomies, increased morbidity
and mortality [1, 2, 8], is now more prevalent, with a likely increased economic
burden. In addition, the unmatched patients (and therefore excluded from the
study) in their case-control analysis [4]
tended to be the more costly patients. Because no controls were found for some
patients, we can only speculate, as noted
properly by Dubberke et al. [4], that had
those patients been matched, the attributable cost of CDAD would be even
higher.
Dubberke et al. [4] have contributed
much in the way of useful information.
It is commendable that patients were observed for 180 days. However, the economic interpretation is unclear. Under
typical
diagnostic-related-group-based
payer systems, a rehospitalization (after a
specific minimum number of days) would
engender a full diagnostic-related-group
reimbursement. It is here that their study
would benefit from traditional health economic methodology [9]. Specifically, establishing the study’s perspective [10] was
not stated. The index hospitalization
would be most appropriately analyzed under a hospital-provider perspective. Indeed, because direct medical costs were
considered, the study effectively did take
this perspective. The same perspective
would be valid for the rehospitalization,
because the hospital would receive reimbursement for a new event.
However, more information could have
been developed had the authors conducted the follow-up period from a payer
or managed care perspective. This would
have required consideration of outpatient
health care resources used during that
time (as noted by the authors [4]). And
for reasons noted above, the cost of the
additional hospitalization is more perti-
EDITORIAL COMMENTARY • CID 2008:46 (15 February) • 505
nent to the payer. The follow-up costs as
reported [4] do not adequately reflect any
real economic model to either a payer or
provider for outpatient care or for rehospitalizations.
It is clear from this study of a large
number of patients [4] that CDAD has
significant economic consequences. It us
our hope that other researchers will continue to analyze this disease and generate
additional data.
2.
3.
4.
Acknowledgments
Potential conflicts of interest.
no conflicts.
J.A.P. and J.J.S.:
5.
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