Investigating Racial Disparities in Treatment of Clostridium difficile Infections

Abstract

Introduction: Locally and at other centers, whites appear to be referred more frequently for fecal microbiota transplant (FMT). Recent studies have implicated white race as a potential risk factor for C. difficile infection (CDI), though racial differences in CDI rates may be related to disparities in health care access. It is important to identify barriers that may limit access to FMT in minority patients. Methods: This cross-sectional study implemented patient and provider surveys that were distributed at 4 clinic sites in Rhode Island. The patient survey was available in English, Spanish, and Portuguese and was designed to target a 6th grade reading level. The surveys assessed knowledge and attitudes around CDI and FMT and were distributed over a two-month time frame (Jan-Mar 2017). Patient and provider concerns about FMT were analyzed using generalized linear modeling and Tukey's method for multiple comparisons. Results: 48 provider and 90 patient surveys were collected with baseline demographics in Table 1. In our preliminary analysis, patient surveys were analyzed for differences in concerns regarding FMT between those who had heard of FMT (22) and those who had not (65). There were no significant differences in concerns between the two groups. Among the 12 listed concerns, 4 were ranked significantly higher (95% CI): contracting illness, safety, insurance coverage, and cost (Figure 1). High ranking provider concerns included patient acceptance, cost, and insurance coverage (95% CI, Figure 2). Of note, 60% stated they could not pay $385 to undergo FMT. 57% of Hispanic patients were unsure or unwilling to undergo FMT similar to non-Hispanic, 60.6%. When comparing race, Caucasian vs non-Caucasian, there was also no difference in unwillingness to undergo FMT (60% vs 61.9%). Among providers, practice type (private vs hospital clinic) did not impact willingness to refer for FMT. However, of 48 provider responses, less than half (46%) chose FMT as a treatment option after the third CDI recurrence.Figure: Patient concerns about FMT. Patient population divided into those who have heard of FMT (red) and those who have not (blue).Figure: Provider concerns about FMT.Table: Table. Characteristics of patient populationConclusion: FMT has emerged as a definitive treatment option for recurrent CDI and should be offered to all patients when clinically indicated. We show here that providers and patients share similar concerns with regards to FMT—namely cost and insurance coverage. Our goal of investigating racial disparities in treatment for CDI was limited by sample size, sample population, literacy, and survey return. Further studies are necessary to promote equitable access to this effective, emerging therapy.