InappropriateClostridium difficileTesting and Consequent Overtreatment and Inaccurate Publicly Reported Metrics

Abstract

BACKGROUND The nationally reported metric for Clostridium difficile infection (CDI) relies solely on laboratory testing, which can result in overreporting due to asymptomatic C. difficile colonization. OBJECTIVE To review the clinical scenarios of cases of healthcare facility-onset CDI (HO-CDI) and to determine the appropriateness of C. difficile testing on the basis of presence of symptomatic diarrhea in order to identify areas for improvement. DESIGN Retrospective cohort study. SETTING Northwestern Memorial Hospital, a large, tertiary academic hospital in Chicago, Illinois. PATIENTS The cohort included all patients with a positive C. difficile test result who were reported to the National Healthcare Safety Network as HO-CDI during a 1-year study period. METHODS We reviewed the clinical scenario of each HO-CDI case. On the basis of documentation and predefined criteria, appropriateness of C. difficile testing was determined; cases were deemed appropriate, inappropriate, or indeterminate. Statistical analysis was performed to compare demographic and clinical parameters among the categories of testing appropriateness. RESULTS Our facility reported 168 HO-CDI cases to NHSN during the study period. Of 168 cases, 33 (19.6%) were judged to be appropriate tests, 25 (14.8%) were considered inappropriate, and 110 (65.5%) were indeterminate. Elimination of inappropriate testing would have improved our facility's standardized infection ratio from 0.962 to 0.819. CONCLUSION Approximately 15% of HO-CDI cases were judged to be tested inappropriately. Testing only patients with clinically significant diarrhea would more accurately estimate CDI incidence, reduce unnecessary antibiotic use, and improve facilities' performance of reportable CDI metrics. Improved documentation could facilitate targeted interventions. Infect Control Hosp Epidemiol 2016;1395-1400.

Preventable Patient Harm: a Multidisciplinary, Bundled Approach to Reducing Clostridium difficile Infections While Using a Glutamate Dehydrogenase/Toxin Immunochromatographic Assay/Nucleic Acid Amplification Test Diagnostic Algorithm

“…Our laboratory standards discouraged testing of patients who received laxatives and/or stool softeners in the previous 48 h to reduce the risk of testing patients without clinically significant diarrhea, based on best practices documented in the literature (12,16). Our standards also discouraged testing patients who had been continuously symptomatic since their last positive test, as well as asymptomatic patients who had completed antibiotic therapy (avoiding a "test of cure") (9).…”

“…For large medical centers, this payment reduction may put millions of dollars in reimbursement at risk. As a result, there has been an increased emphasis on reducing CDI rates within health care institutions (6,12).…”

Prevention of Clostridium difficile Infection in Critically Ill Adults

“…Inappropriate testing for CDI leads to overreporting, unnecessary treatment, and increased costs associated with treatment of asymptomatic C. difficile colonization . It also results in poor‐quality metric performance for health care institutions and leads to diversion of limited infection control resources.…”

“…24 Inappropriate testing for CDI leads to overreporting, unnecessary treatment, and increased costs associated with treatment of asymptomatic C. difficile colonization. 25 It also results in poorquality metric performance for health care institutions and leads to diversion of limited infection control resources. To mitigate these consequences, accurate differentiation between C. difficile colonization and active CDI can be promoted through diagnostic stewardship.…”

Use of Computerized Clinical Decision Support for Diagnostic Stewardship in Clostridioides difficile testing: an Academic Hospital Quasi-Experimental Study

“…Overdiagnosis of Clostridioides difficile as a cause of healthcare-associated diarrhea is a prevalent problem in the USA due to increasing use of highly sensitive nucleic acid amplification tests, combined with a low threshold for testing of patients in the absence of significant diarrhea and in the presence of laxatives. [1][2][3] Others have reported on efforts at reducing unnecessary C. difficile testing through computerized clinical decision support (CCDS), with variable results. 4,5 We conducted a quasi-experimental study to evaluate the impact of CCDS on appropriateness of C. difficile testing.…”