An APP-driven complex outpatient antimicrobial therapy (COpAT) program for patients with bone and joint infections cut mean time to post-discharge follow-up from 20.1 to 9.7 days but did not significantly reduce 30-day readmissions or emergency department visits.
There is growing interest, driven by landmark clinical trials, in the practical implementation of the “oral is the new IV” mantra for patients with challenging-to-treat infections.1-3 As such, complex outpatient antimicrobial therapy (COpAT) programs are becoming more common. Not to be confused with outpatient parenteral antimicrobial therapy (OPAT), COpAT programs typically include patients who have transitioned to oral antimicrobial therapy but still require prolonged therapy and monitoring for potential adverse effects.4 Implementation of COpAT programs has demonstrated similar efficacy to OPAT programs but with fewer adverse events and improved patient satisfaction.5
A recent study published in Antimicrobial Stewardship & Healthcare Epidemiology sought to evaluate the impact of an advanced practice provider (APP)–driven COpAT program for patients with bone and joint infections who were discharged on at least 14 days of antimicrobial therapy.6 The authors hypothesized that their APP-driven COpAT program would allow for faster access to care post discharge, thereby improving outpatient monitoring and reducing complications and adverse events.6
The COpAT program in this study included a nurse, a medical assistant, an APP, and a physician medical director. A nurse practitioner (NP) was hired as the dedicated COpAT APP before program initiation. Postdischarge visits were primarily conducted via telehealth, with an emphasis on completing them within 14 days of hospital discharge. This was a new workflow created for the COpAT APP. Although pharmacists were not an explicit part of the COpAT team, there was collaboration with the transition-of-care pharmacy service before patient discharge. These pharmacists conducted a comprehensive medication review that included an assessment of laboratory values, comorbidities, drug-drug interactions, and medication access. This was a pre- vs postimplementation cohort study designed to evaluate the impact of the institution’s COpAT program.
There were 100 patients in the preintervention group and 135 in the postintervention group. Baseline characteristics were similar between the 2 groups, with the only difference being more patients having diabetic foot osteomyelitis in the postintervention group. See Table 1 for a condensed version of pertinent baseline characteristics.
Implementation of the COpAT program reduced the mean time to follow-up with either a physician or an APP from 20.1 days to 9.7 days (P < .001). Additionally, the percentage of patients seen by either a physician or an APP within 2 weeks of discharge increased from 42% to 83% (P < .001). Notably, the APP scheduled follow-ups for 90 patients, of which 76 were billed as transition-of-care management services under Medicare. Utilization of the transition-of-care pharmacy service at discharge increased from 8% to 42% (P < .001). There was no significant difference in all-cause 30-day readmission rate between the pre- and postintervention cohorts (15% [15/100] vs 11% [15/135]; P = .377) or in 30-day emergency department visits (10% [10/100] vs 15% [20/135]; P = .234).
The authors concluded that the implementation of their COpAT program and the transition-of-care pharmacy service improved time to outpatient follow-up and supported clinical decision-making before and after discharge. However, this did not result in a significant change in hospital readmissions or emergency department visits.
There are several limitations to this study. First, the study was limited to patients with bone and joint infections. However, it would be reasonable to conclude that a similar program for other infection types could yield comparable improvements. Second, all patients were insured and had stable housing at discharge, making it more challenging to extrapolate results to a more vulnerable patient population. Finally, not every institution may have the resources to implement an APP-driven program to help reduce the burden on infectious diseases physicians. Although this study institution was able to hire a dedicated NP to lead the COpAT program, other institutions may not have the same flexibility to create a new position.
This study adds to the growing body of literature supporting the benefits of COpAT programs for patients with oral antimicrobial options for treating complex infections. The reduced mean time to provider follow-up to 9.7 days is notable given previous study results indicating that the highest risk of adverse events for patients on OPAT occurs within the first 14 days after discharge.7-9 However, it is possible that one reason for the reduced mean time to provider follow-up identified in this study was the hiring of a dedicated COpAT APP, who also assisted with scheduling for most patients. Still, if patients can have their medication-related problems addressed sooner, hospital readmissions or emergency department visits may be avoided. It is possible that the present study did not find a difference in hospital readmissions or emergency department visits because of the high percentage of patients receiving exclusively oral antimicrobial therapy, leaving fewer patients at risk of central line–related complications associated with traditional OPAT.
As oral antimicrobial therapy for complex infections continues to expand, implementation of COpAT programs will be essential to ensure adequate monitoring, facilitate follow-up post discharge, and quickly manage adverse effects.
