Shah A, Petrak R, Fliegelman R, et al. Infectious diseases specialty intervention is associated with better outcomes among privately insured individuals receiving outpatient parenteral antimicrobial therapy. Clin Infect Dis.
2019 Apr 1. doi: 10.1093/cid/ciy674.
Since its advent in the 1970s, outpatient parenteral antimicrobial therapy (OPAT) has enabled patients to avoid the costs and risks of lengthy hospital stays and re-engage sooner in their activities of daily living. Initially shown to be safe and effective in patients with cystic fibrosis
and bolstered by its inherent benefits, the use of OPAT has spread to numerous patient populations and settings ranging from pediatrics to the elderly and private practice to tertiary medical centers.
Although often planned and managed by infectious diseases specialists, OPAT is also prescribed by non-ID providers. One single-center study
showed that OPAT led by ID specialists (ID-led OPAT) verses without ID consultation (other OPAT) had better follow-up, including lab monitoring, and fewer errors in prescribing, but did not show a difference in 60-day hospitalization or emergency department (ED) admission rates.
To further evaluate the impact of ID specialty consultation on hospitalization rates and fiscal outcomes in patients receiving OPAT, a team of investigators from throughout the United States conducted a retrospective analysis using a national database of insurance claims. Their findings were published recently in Clinical Infectious Diseases
The study utilized administrative claims from IBM®
Research Databases for events occurring between January 2012 and December 2014 and index events (ED visits or inpatient stays related to an primary or secondary infectious diagnosis) between January 2013 and November 2014.
Patients included had the same health insurance plan for 6 months prior to and for 30 days after the index event, surgical or medical admission, were aged 65 or under, and had an OPAT procedure code with evidence of OPAT within 14 days for discharge. Claims were excluded if there was an acute hospitalization 30 days prior to index event or for the same cause as the index event within 6 months, discharged to or readmitted within 7 days to an acute care hospital, or death during index event.
Those with an ID outpatient provider claim with 14 days from first OPAT claim were considered ID-led OPAT while those without evidence of ID specialist involvement were other OPAT. The 2 cohorts were propensity matched for patient- and hospital-related variables. The outcomes studied were ED admission, hospital admission, and total spending within 30 days of index event. Regression models were used for each outcome.
Of the 10,818 index events followed by OPAT, 4317 (39.9%) were ID-led and the remainder were other OPAT. The majority (92%) of index events were related to hospital admissions with slight majority surgical (58%) and 20% including an ICU stay. Soft-tissue and osteomyelitis were the most common infections (40%) followed by septic arthritis and cardiovascular infections (20-26%). Nearly half the patients were aged 55-64 and 38% were female. Most were located in South and North America (65%), although rural locations were a minority (11.1%).
ID-led OPAT had lower rates of 30-day admissions to the hospital (6.2% vs 9.4% for other OPAT, p < 0.001, OR 0.661, 95% CI 0.557-0.791) and lower rates of 30-day ED admissions (1.3% vs 2.6%, p < 0.001, OR 0.449 95% CI 0.311-0.645). Those with a diagnosis of osteomyelitis and septic arthritis were more likely to have an ED admission and those with an ICU stay more likely to have a hospital admission. ID-led OPAT also resulted in $1487.56 less in total health care payments (95% CI -$2688.56-$266.58) in the first 30 days after the index event.
The investigators concluded, “Among privately insured individuals under the age of 65, ID consultations during OPAT are associated with large and significant reductions in the rate of ED admissions and hospital admissions in the 30 days after index events.”
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