University of Lynchburg DMSc Doctoral Project Assignment Repository

University of Lynchburg DMSc Doctoral Project Assignment Repository




Dr Elyse Watkins


Importance Clostridium difficile infection (CDI) is associated with high morbidity and mortality. The US Centers for Medicaid and Medicare Services (CMS) has established quality metrics associated with federal reimbursement for treatment of CDI. Due to the nature of their disease and its surgical treatment, bladder cancer (BC) patients are at increased risk of CDI, but little to no information is known about CDI in bladder cancer patients who undergo radical cystectomy (RC) at our cancer institute which is within an academic hospital system. The purpose of this investigation is to describe CDI rates in these patients.

Methods Rates of CDI for BC patients were estimated by year using an established database of patients who were managed with RC from 2015 through 2018. Patients whose RC occurred outside of the system were excluded from analyses. Patient demographic and clinical characteristics were described and stratified by year of RC. The rates of CDI were compared across the hospital’s American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) semiannual reports and the infection control rates of CDI for the main hospital campus which includes this cancer center.

Results The analytic surgical sample included 200 individuals, of whom 10 (5%) had laboratory confirmed CDI after RC: 2015 (0), 2016 (2), 2017 (7), and 2018 (1). There was discordance in NSQIP-defined data. There was an increased incidence of CDI in this surgical population in 2017 which exceeded the year-end incidence rate for the hospital. Demographics of this surgical population were primarily male (73.5%) Caucasian (87%) smokers (75.5%) with a median age of 70 years.

Conclusions and Relevance Based on the incidence of CDI in this surgical population for the past four years, CDI rates are similar across various definitions and metrics. Revision of current protocols pertinent to muscle-invasive bladder cancer management by radical cystectomy are notimperative. However, the reporting measurements for the hospital overall, NSQIP, and the surgical patient sample are singularly different, yielding outcomes that are not statistically comparative. In order to manage CDI in this surgical population, the reporting departments should consider an interdepartmental, collaborative tool to provide meaningful and predictive data. Exploration is recommended around the application of Enhanced Recovery After Surgery (ERAS) protocols which were implemented in 2016, especially as compared to RC surgical data starting in 2011, to demonstrate the impact of CDI on system resource utilization.


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