Self-Administered Outpatient Antimicrobial Infusion by Uninsured Patients Discharged from a Safety-Net Hospital: A Propensity-Score-Balanced Retrospective Cohort Study

Abstract

BackgroundOutpatient parenteral antimicrobial therapy (OPAT) is accepted as safe and effective for medically stable patients to complete intravenous (IV) antibiotics in an outpatient setting. Since, however, uninsured patients in the United States generally cannot afford OPAT, safety-net hospitals are often burdened with long hospitalizations purely to infuse antibiotics, occupying beds that could be used for patients requiring more intensive services. OPAT is generally delivered in one of four settings: infusion centers, nursing homes, at home with skilled nursing assistance, or at home with self-administered therapy. The first three—termed healthcare-administered OPAT (H-OPAT)—are most commonly used in the United States by patients with insurance funding. The fourth—self-administered OPAT (S-OPAT)—is relatively uncommon, with the few published studies having been conducted in the United Kingdom. With multidisciplinary planning, we established an S-OPAT clinic in 2009 to shift care of selected uninsured patients safely to self-administration of their IV antibiotics at home. We undertook this study to determine whether the low-income mostly non-English-speaking patients in our S-OPAT program could administer their own IV antimicrobials at home with outcomes as good as, or better than, those receiving H-OPAT.Methods and FindingsParkland Hospital is a safety-net hospital serving Dallas County, Texas. From 1 January 2009 to 14 October 2013, all uninsured patients meeting criteria were enrolled in S-OPAT, while insured patients were discharged to H-OPAT settings. The S-OPAT patients were trained through multilingual instruction to self-administer IV antimicrobials by gravity, tested for competency before discharge, and thereafter followed at designated intervals in the S-OPAT outpatient clinic for IV access care, laboratory monitoring, and physician follow-up. The primary outcome was 30-d all-cause readmission, and the secondary outcome was 1-y all-cause mortality. The study was adequately powered for readmission but not for mortality. Clinical, sociodemographic, and outcome data were collected from the Parkland Hospital electronic medical records and the US census, constituting a historical prospective cohort study. We used multivariable logistic regression to develop a propensity score predicting S-OPAT versus H-OPAT group membership from covariates. We then estimated the effect of S-OPAT versus H-OPAT on the two outcomes using multivariable proportional hazards regression, controlling for selection bias and confounding with the propensity score and covariates.Of the 1,168 patients discharged to receive OPAT, 944 (81%) were managed in the S-OPAT program and 224 (19%) by H-OPAT services. In multivariable proportional hazards regression models controlling for confounding and selection bias, the 30-d readmission rate was 47% lower in the S-OPAT group (adjusted hazard ratio [aHR], 0.53; 95% CI 0.35–0.81; p = 0.003), and the 1-y mortality rate did not differ significantly between the groups (aHR, 0.86; 95% CI 0.37–2.00;...

Outcomes of Outpatient Parenteral Antimicrobial Therapy With Ceftriaxone for Methicillin-Susceptible Staphylococcus aureus Bloodstream Infections—A Single-Center Observational Study

“…Furthermore, once-daily regimens facilitate patients receiving therapy at an infusion center, which is the only outpatient option for Medicare patients without a significant out-of-pocket cost [ 22 ]. The results of this study would be encouraging especially for Medicare patients and for those centers that offer self-directed OPAT, where cost and ease of dosing are important considerations [ 25 , 26 ].…”

A retrospective analysis of adverse events among patients receiving daptomycin versus vancomycin during outpatient parenteral antimicrobial therapy

“…The primary analysis was performed using logistic regression, adjusting for 6 variables chosen a priori based on prior studies: age, CCI, location of OPAT treatment, receipt of combination therapy with either β-lactam or fluoroquinolone, baseline renal function, and availability of weekly safety labs 1 5 , 14 , 23 – 25 , 28 To measure the association between antimicrobial choice and hospital readmission and emergency room visits, 3 variables were chosen a priori for inclusion in a logistic regression model: age, CCI, and location of OPAT treatment 5 14 , 28 A sensitivity analysis including patients who died during the OPAT treatment course was completed to ensure that our results were robust to inclusion and exclusion criteria.…”

Financial Analysis of Dalbavancin for Acute Bacterial Skin and Skin Structure Infections for Self-Pay Patients

“…Interestingly, there were a high amount of infectious diseases (ID) consults in this population, with a higher percentage in the SOC group (37% vs 48%). This could be attributed to the underlying difficult transitions of care decisions with a self-pay patient population [ 26 ]. All of the patients discharged to receive dalbavancin in this study were empirically started on vancomycin at admission.…”