Chagas disease (CD), caused by Trypanosoma cruzi , affects ∼288,000 individuals in the US. Among those infected, 30-40% develop chronic Chagas cardiomyopathy, a form of nonischemic cardiomyopathy (NICM) characterized by heart failure (HF), heart block, and malignant arrhythmias. Although long considered nonendemic in the US, mounting evidence of autochthonous CD, most notably in Texas, has prompted reevaluation of this designation. Serologic testing is recommended for individuals with epidemiologic risk factors. , However, little is known about real-world diagnostic practices nationally, particularly among patients with established HF or NICM.
To address this gap, we conducted a serial cross-sectional analysis of CD testing and diagnosis among US adults aged ≥20 years hospitalized between 2012 and 2024 using data from the Texas Inpatient Public Data Use File (TIPUDF), Epic Cosmos, and the TriNetX US Collaborative Network. The TIPUDF is an administrative dataset maintained by the Texas Department of State Health Services capturing encounter-level information on 93% to 97% of all hospital discharges in the state. Epic Cosmos and TriNetX are electronic health record (EHR)-derived datasets that aggregate clinical data from participating health care organizations; while neither captures all US hospitalizations, both are broadly representative of the US healthcare seeking population. From Epic Cosmos, we defined 3 analytic cohorts: the entire US, notifiable US states, and Texas alone. Notifiable states included those that require mandatory reporting of CD: Arizona, Arkansas, Louisiana, Mississippi, Tennessee, Texas, Utah, Washington, and California (San Diego County and Los Angeles County). Together with the TIPUDF and the national TriNetX cohort, a total of 5 analytic cohorts were examined.
Primary outcomes included CD testing, defined as any serologic assay for T cruzi captured in Epic Cosmos and TriNetX (TIPUDF does not include laboratory data), and CD diagnosis, defined using ICD-9/ICD-10 codes. Annual prevalences of CD testing and diagnosis were assessed overall and within nonmutually exclusive cardiac subgroups (HF, HF with reduced ejection fraction [HFrEF], and NICM) using R version 4.5.1. The UT Southwestern Institutional Review Board determined this analysis of deidentified datasets did not meet the definition of human subjects research (Y2-24-004).
We identified 32.2 million hospitalizations from the TIPUDF; 9.8 million patients in Texas, 22.4 million in notifiable states, and 136.8 million nationally from Epic Cosmos; and 30.1 million patients nationally from TriNetX ( Table 1 ).
Table 1
Cohort characteristics
| Texas | Notifiable US States | Entire US | |||
|---|---|---|---|---|---|
| Texas hospital discharges | Epic cosmos | Epic cosmos | Epic cosmos | TriNetX | |
| N | 32,190,817 | 9,807,102 | 22,435,437 | 136,831,548 | 30,091,253 |
| Demographics | |||||
| Age in years, % | |||||
| 20-44 | 32.1 | 37.5 | 35.4 | 34.4 | 38.4 |
| 45-64 | 28.2 | 32.8 | 31.9 | 31.4 | 30.5 |
| 65-74 | 17.9 | 15.3 | 15.9 | 16.3 | 15.5 |
| 75-84 | 14.2 | 9.9 | 10.8 | 11.2 | 11.3 |
| ≥85 | 7.5 | 5.0 | 6.0 | 6.7 | 4.4 |
| Female, % | 54.3 | 56.2 | 55.9 | 54.9 | 54.1 |
| Hispanic, % | 26.6 | 23.0 | 15.2 | 10.7 | 11.0 |
| Race, % | |||||
| Native American | 0.3 | 0.8 | 1.1 | 1.1 | 0.6 |
| Asian or Pacific Islander | 2.0 | 5.1 | 4.9 | 4.6 | 4.7 |
| Black | 13.9 | 17.7 | 17.9 | 15.4 | 19.9 |
| White | 67.3 | 69.9 | 69.7 | 70.4 | 62.8 |
| Other | 16.6 | 11.0 | 13.4 | 11.8 | 12.0 |
| Smoking history, % | – | 29.5 | 32.1 | 34.2 | – |
| Comorbidities | |||||
| Diabetes, % | 29.0 | 17.4 | 16.7 | 16.0 | 15.4 |
| Coronary artery disease % | 20.9 | 13.0 | 13.3 | 13.8 | 12.0 |
| Heart block/arrhythmia, % | 17.1 | 15.0 | 15.3 | 17.3 | 16.4 |
| Heart failure, % | 16.6 | 7.2 | 7.4 | 7.4 | 7.1 |
| Heart failure with reduced ejection fraction, % | 6.4 | 3.4 | 3.5 | 3.6 | 3.5 |
| Nonischemic cardiomyopathy, % | 2.5 | 2.1 | 2.2 | 2.6 | 2.5 |
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