Safety-net hospitals, C. diff colonization

Summaries from ACP Hospitalist Weekly.

Disadvantaged neighborhoods and safety-net hospitals had higher readmission rates

Patients who lived or were hospitalized in disadvantaged neighborhoods in Maryland had significantly higher risk of readmission within 30 days, a recent study found.

The retrospective observational study included all Maryland residents discharged from a hospital in the state in 2015. Researchers used an area deprivation index to assess the disadvantage of the neighborhoods where the patients lived and a safety-net index to assess the hospitals at which they were treated. Results were published by Annals of Internal Medicine on July 2 and appeared in the July 16 issue.

Image by Getty Images
Image by Getty Images

Overall, 13.4% of discharged patients were readmitted within 30 days. Patients living in neighborhoods at the 90th percentile of disadvantage had a readmission rate of 14.1% (95% CI, 13.6% to 14.5%) compared with 12.5% (95% CI, 11.8% to 13.2%) for similar patients living in neighborhoods at the 10th percentile. Patients discharged from hospitals at the 90th percentile of safety-net status had a readmission rate of 14.8% (95% CI, 13.4% to 16.1%) compared with 11.6% (95% CI, 10.5% to 12.7%) for similar patients discharged from hospitals at the 10th percentile of safety-net status.

The results have a number of practical implications, according to the study authors. “First, the effect of the neighborhoods in which patients live and in which the hospital serves merits the clinician's awareness because it is associated with readmission, an important clinical outcome,” they said. It's also important to consider the effects of neighborhoods themselves, rather than taking them as a marker of individual socioeconomic status, they explained.

Other important findings of the study include that hospitals' safety-net status was associated with readmissions despite Maryland's unique hospital rate-setting system, under which safety-net hospitals have higher profit margins. The generalizability of the results is limited by the state's rate-setting, so the findings should be tested in other states, the authors said. “This study clarifies the problem more than the solution, which may be paying more for care of patients from disadvantaged neighborhoods, decreasing penalties, investing in improving neighborhoods, or using a wait-and-see strategy,” the authors said.

An accompanying editorial also highlighted potential solutions to these disparities in outcomes. “Social and public health interventions, such as antiobesity and tobacco control campaigns, increasing access to health care services, and providing greater access to healthy foods and opportunities for physical activity, have worked previously and have the potential to further improve individual and population health,” the editorial said. It added that additional benefits could be achieved with improvements in “education, poverty reduction, social and welfare services, affordable housing, job creation, labor market opportunities, and transportation.”

Study identifies potential predictors of hospital-onset C. difficile infection among colonized patients

Longer length of stay, exposure to multiple classes of antibiotics, use of opioids, and cirrhosis may help predict progression to Clostridioides difficile infection during hospitalization in colonized patients, a retrospective study found.

Researchers assessed a cohort of colonized patients identified through a systematic C. difficile screening program at an academic tertiary hospital in Canada. Overall, 513 of 960 patients who screened positive on admission between November 2013 and January 2017 were included in the study. Exclusion criteria included history of C. difficile infection, presence of diarrhea or other severe gastrointestinal symptoms on admission, short hospital stay, and palliative care admission. Results of the industry-supported study were published online on July 9 by Clinical Infectious Diseases.

A total of 39 (7.6%) patients developed hospital-onset C. difficile infection, with a 30-day attributable mortality of 15%. The factors independently associated with an increased risk of hospital-onset C. difficile infection were longer length of stay (adjusted odds ratio [OR] per day, 1.03; P=0.006), exposure to multiple classes of antibiotics (adjusted OR per class, 1.45; P=0.02), use of opioids (adjusted OR, 2.78; P=0.007), and cirrhosis (adjusted OR, 5.49; P=0.008). The antimicrobials that correlated with the greatest risk of hospital-onset C. difficile infection were beta-lactams with beta-lactamase inhibitors (OR, 3.65; P<0.001), first-generation cephalosporins (OR, 2.38; P=0.03), and carbapenems (OR, 2.44; P=0.03).

On the other hand, use of laxatives was associated with a lower risk of C. difficile infection (adjusted OR, 0.36; P=0.01). This finding contrasts with those of other studies that had suggested use of laxatives was associated with increased occurrence of C. difficile infection in the general population. “We hypothesize that laxatives could increase the risk of colonization by decreasing resistance to colonization, but not of progression to [C. difficile infection] once colonization has occurred,” the study authors said.

Patient age and proton-pump inhibitor use were not significant predictors of hospital-onset C. difficile infection. Also, primary prophylaxis against C. difficile with oral vancomycin or oral or IV metronidazole was not a significant predictor, although the study had limited power to detect a difference in the incidence of C. difficile infection among these patients.

Limitations of the study include a lack of information on patients' immune status and the use of single-step screening by polymerase chain reaction, rather than the currently recommended two-step detection method, the authors noted. They added that due to the single-center design, results may not be generalizable to other health care settings.