From the 2021 HVPAA National Conference
Bilal Ashraf (UTSW), Emily Hoff, Steven Brown, Jillian Smartt, Sheryl Mathew, David Johnson, Kapila Marambage, Kavita Bhavan
Background
People who use drugs (PWUD) often require extended parenteral antibiotics for a variety of reasons. PWUD are excluded from outpatient parenteral antimicrobial therapy (OPAT) due to concerns of catheter misuse, nonadherence, and both patient and staff safety. Standard of care often requires treatment at skilled nursing facilities (SNF), which can impair personal responsibilities. To evaluate clinical outcomes of OPAT among PWUD, we conducted a retrospective study of a cohort of PWUD discharged from Parkland Health and Hospital System (PHHS) to SNF for OPAT therapy.
Methods
We identified PWUD discharged from PHHS to SNF for extended antibiotic therapy between 01/01/2017 and 04/30/2018 (N=129). Demographics, drug use history, discharge diagnosis, antibiotic therapy, discharge disposition from SNF (against medical advice (AMA), early non-AMA discharges vs completed antibiotic courses), 30-day emergency department (ED) utilization, and 30-day readmission were extracted from the electronic medical record. ED-utilization and 30-day readmission rates were analyzed for each disposition group. We also estimated cost, based on data from the Department of Health and Human Services.
Results
While the majority of patients completed treatment (64%), a significant minority left AMA (20%) or early non-AMA (16%). Patients who left early-AMA or non-AMA had increased rates of composite 30-day hospital readmission or ED-utilization (54% vs 35% vs 23%, p=0.01) and increased rates of 30-day hospital readmissions (31% vs 25% vs 8%, p=0.01) compared to those who completed treatment. However, there was no significant difference in ED-utilization between those who completed treatment and those who did not (23% vs 10% vs 15%, p=0.43). Women were more likely to complete their treatment course compared to men (12.0% vs 41.3%; p<0.01). Estimated cost per patient was $5,338.
Conclusions
Over a third of PWUD with complex infections requiring parenteral antibiotics who are discharged to SNF do not complete treatment. These patients experience increased healthcare utilization compared those who complete therapy, perhaps stemming from increased rates of complications. There remains significant room for quality improvement in the setting of post-acute care for PWUD requiring extended courses of parental antibiotics. OPAT in select patients may be a safer, more cost-effective, patient-centered alternative.
