EP708 - Temporal Trends in C. Difficile–Associated Mortality and Place of Death From 2003–2023

Purpose/Background: Clostridium difficile infection (CDI) remains a leading cause of infectious disease-related mortality in the United States. While its incidence and in-hospital outcomes are well-documented, the longitudinal trends in CDI-attributable mortality and the settings where patients ultimately die are poorly characterized. Understanding these patterns has growing relevance in the era of value-based care, where end-of-life outcomes and healthcare costs are increasingly tied to the quality and efficiency of care delivery.

Methods/Interventions: Using CDC WONDER mortality data (2003-2023), we evaluated trends in crude CDI-related mortality rates and place of death (inpatient medical facility, outpatient medical facility or emergency room, home, nursing home, hospice facility, other). Joinpoint regression was used to assess temporal trends and identify statistically significant changes.

Results/Outcomes: Between 2003 and 2023, CDI-associated mortality declined after 2015 (Annual Percent Change [APC] −12.8%, 95% CI −18.5 to −9.9) but plateaued in recent years (Figure 1A). Most deaths occurred in inpatient medical facilities, followed by nursing homes and hospice facilities (Figure 1B). Inpatient deaths declined until 2013, followed by an increase after 2020 (APC 1.6%, 95% CI 0.6 to 3.1). Nursing home deaths declined after 2015 (APC −10.0%, 95% CI −12.5 to −8.0). Hospice deaths increased between 2008-2015 (APC 13.3%, 95% CI 4.2 to18.9), then stabilized. Home deaths, consistently < 5% before 2019, showed an increase following the COVID-19 pandemic.

Conclusion/Discussion: Our analysis reveals that while the broad distribution of CDI mortality by setting has remained consistent, significant underlying shifts have occurred. The rise in deaths attributed to hospitals after 2013 reflects enhanced detection following the start of mandatory LabID reporting that year. Post-2019, the decline in nursing home deaths and a rise in home deaths point to influence of the COVID-19 pandemic. As inpatient deaths are substantially more costly, these findings also highlight opportunities for improving care alignment and resource utilization under value-based care models. Ultimately, these trends illustrate how surveillance systems and evolving healthcare pressures shape the distribution of mortality across care settings.

Figure 1A: Crude mortality rates (per 100,000) from Clostridium Difficile infections in the US, 2003-2023 Figure 1B: Patterns of place of death from Clostridium Difficile infections in the US, 2003-2023