title: Trend, Risk Factors, and Costs of Clostridium difficile Infections in Vascular Surgery.
abstract: BACKGROUND
  Starting in December 2013, the Hospital Inpatient Quality Reporting Program included Clostridium difficile infection (CDI) rates as a new publically reported quality measure. Our goal was to review the trend, hospital variability in CDI rates, and associated risk factors and costs in vascular surgery.
  
  
  METHODS
  The rates of CDI after major vascular procedures including aortic abdominal aneurysm (AAA) repair, carotid endarterectomy or stenting, lower extremity revascularization (LER), and LE amputation were identified using Nationwide Inpatient Sample database for 2000-2011. Risk factors associated with CDI were analyzed with hierarchical multivariate logistic regression. Extra costs, length of stay (LOS), and mortality were assessed for propensity-matched hospitalizations with and without CDI.
  
  
  RESULTS
  During the study period, the rates of CDI after vascular procedures had increased by 74% from 0.6 in 2000 to 1.05% in 2011, whereas the case fatality rate was stable at 9-11%. In 2011, the highest rates were after ruptured aortic abdominal aneurysm (rAAA) repair (3.3%), followed by lower extremity amputations (2.3%) and elective open AAA (1.3%). The rates of CDI increased after all vascular procedures during the 12 years. The highest increase was after endovascular LER (151.8%) and open rAAA repair (135.7%). In 2011, patients who had experienced CDI had median LOS of 15 days (interquartile range, 9-25 days) compared with 8.3 days for matched patients without CDI, in-hospital mortality 9.1% (compared with 5.0%), and $13,471 extra cost per hospitalization. The estimated cost associated with CDI in vascular surgery in the United States was ∼$98 million in 2011. Hospital rates of CDI varied from 0 to 50% with 3.5% of hospitals having infection rates ≥5%. Factors associated with CDI included multiple chronic conditions, female gender, surgery type, emergent and weekend hospitalizations, hospital transfers, and urban locations.
  
  
  CONCLUSIONS
  Despite potential reduction of infection rates as evidenced by the experience of hospitals with effective interventions, CDI is increasing among vascular surgery patients. It is associated with prolonged LOS, increased mortality, and higher costs.
authors.affiliation: Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY. Electronic address: natalia.egorova@mountsinai.org.
authors.forename: Natalia N
authors.initials: NN
authors.lastname: Egorova
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY; Division of Vascular and Endovascular Surgery, Boston University School of Medicine, Boston, MA.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Siracuse
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY.
authors.forename: James F
authors.initials: JF
authors.lastname: McKinsey
authors.affiliation: Division of Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY.
authors.forename: Roman
authors.initials: R
authors.lastname: Nowygrod
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016009:Chi-Square Distribution; D016360:Clostridioides difficile / Q000302:isolation & purification*; D003015:Clostridium Infections / Q000191:economics / Q000453:epidemiology* / Q000382:microbiology / Q000401:mortality; D016208:Databases, Factual; D005260:Female; D017721:Hospital Costs / Q000639:trends*; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007902:Length of Stay / Q000191:economics / Q000639:trends; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D057216:Propensity Score; D012307:Risk Factors; D013530:Surgical Wound Infection / Q000191:economics / Q000453:epidemiology* / Q000382:microbiology / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014652:Vascular Diseases / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000191:economics / Q000401:mortality / Q000639:trends*