Discharge Delays and Costs Associated With Outpatient Parenteral Antimicrobial Therapy for High-Priced Antibiotics

2019 ◽  
Vol 71 (7) ◽  
pp. e88-e93 ◽  
Author(s):  
Monica L Bianchini ◽  
Rachel M Kenney ◽  
Robyn Lentz ◽  
Marcus Zervos ◽  
Manu Malhotra ◽  
...  
Keyword(s):  
Antimicrobial Therapy ◽  
Private Insurance ◽  
Hospital Costs ◽  
Care Facility ◽  
Transitions Of Care ◽  
Beta Lactam ◽  
Outpatient Parenteral Antimicrobial Therapy ◽  
Subacute Care ◽  
Cost Effective Treatment ◽  
The Impact

Abstract Background Outpatient parenteral antimicrobial therapy (OPAT) is a widely used, safe, and cost-effective treatment. Most public and private insurance providers require prior authorization (PA) for OPAT, yet the impact of the inpatient PA process is not known. Our aim was to characterize discharge barriers and PA delays associated with high-priced OPAT antibiotics. Methods This was an institutional review board–approved study of adult patients discharged with daptomycin, ceftaroline, ertapenem, and novel beta-lactam-beta-lactamase inhibitor combinations from January 2017 to December 2017. Patients with an OPAT PA delay were compared with patients without a delay. The primary endpoint was total direct hospital costs from the start of treatment. Results Two-hundred patients were included: 141 (71%) no OPAT delay vs 59 (30%) OPAT delay. More patients with a PA delay were discharged to a subacute care facility compared with an outpatient setting: 37 (63%) vs 52 (37%), P = .001. Discharge delays and median total direct hospital costs were higher for patients with OPAT delays: 31 (53%) vs 21 (15%), P < .001 and $19 576 (interquartile range [IQR], 10 056–37 038) vs $7770 (IQR, 3031–13 974), P < .001. In multiple variable regression, discharge to a subacute care facility was associated with an increased odds of discharge delay, age >64 years was associated with a decreased odds of discharge delay. Conclusions OPAT with high-priced antibiotics requires significant care coordination. PA delays are common and contribute to discharge delays. OPAT transitions of care represent an opportunity to improve patient care and address access barriers.

scholarly journals 772. Access Denied: Impact of Insurance Denials for High-Cost Outpatient Parenteral Antimicrobial Therapy

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S343-S343
Author(s):  
Monica L Bianchini ◽  
Rachel Kenney ◽  
Robyn Lentz ◽  
Marcus Zervos ◽  
Manu Malhotra ◽  
...  
Keyword(s):  
Antimicrobial Therapy ◽  
Private Insurance ◽  
Hospital Costs ◽  
The United States ◽  
Delay Group ◽  
Transitions Of Care ◽  
Insurance Companies ◽  
Institutional Perspective ◽  
Outpatient Parenteral Antimicrobial Therapy ◽  
The Impact

Abstract Background Outpatient parenteral antimicrobial therapy (OPAT) allows patients to receive prolonged antimicrobial therapy while reducing the length of hospitalization and healthcare costs. In the United States, most public and private insurance companies require prior authorization (PA) for OPAT. The impact of OPAT PA delays is not known. This study aimed to characterize discharge barriers and authorization delays associated with high-cost OPAT antibiotics. Methods IRB-approved study of adult patients discharged with high-cost OPAT antibiotics from January to December 2017. Antibiotics were included based on the frequency of OPAT use and average sales price (ASP) greater than $100 per day, including: daptomycin, ceftaroline, ertapenem, and the novel β-lactam β-lactam inhibitor combinations. Patients with an OPAT authorization delay >24 hours were compared with patients without an OPAT authorization delay. Primary endpoint: total direct hospital costs, starting from the start of treatment with the OPAT antibiotic, from the institutional perspective using Healthcare Cost and Utilization Project and Center for Medicare and Medicaid Services 2019 ASP Drug Pricing data. Secondary outcomes: discharge delay and 30-day readmission or mortality. Results Two-hundred patients included: 151 (76%) no OPAT delay vs. 49 (25%) OPAT delay. The use of antibiotics was similar between groups, except ertapenem was more common in the no OPAT delay group: 60 (43%) vs. 15 (25%), P = 0.022. Patients with no OPAT delay were more commonly discharged with home infusion and less commonly to a facility: 75 (53%) vs. 19 (32%), P = 0.007, and 52 (37%) vs. 37 (63%), P = 0.001, respectively. Discharge delays were more common in patients with OPAT delays: 21 (15%) vs. 31 (53%), P < 0.001. The median total direct hospital costs were higher in patients with OPAT delays: $7,770 (3,031–13,974) vs. $19,576 vs. (10,056–37,038), P < 0.001. Table 1 compares the total direct hospital costs of patients with and without an authorization delay. Conclusion OPAT with high-cost antibiotics requires significant care coordination. Authorization delays for these antibiotics are common and may contribute to a delay in discharge. OPAT transitions of care represent an important opportunity for Infectious Diseases providers to improve care and address access barriers. Disclosures All authors: No reported disclosures.

scholarly journals 126. evaluation of Addition of Outpatient Parenteral Antimicrobial Therapy and Orthopedic ID Resources to Transitions-of-care Outcomes

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S192-S193
Author(s):  
Brett Young ◽  
Scott Bergman ◽  
Trevor C Van Schooneveld ◽  
Nicolas W Cortes-Penfield ◽  
Bryan Alexander
Keyword(s):  
Infectious Disease ◽  
Clinical Outcomes ◽  
Antimicrobial Therapy ◽  
Hospital Readmission ◽  
Academic Medical Center ◽  
Transitions Of Care ◽  
Day Hospital ◽  
Consult Service ◽  
Outpatient Parenteral Antimicrobial Therapy ◽  
The Impact

Abstract Background Our large academic medical center initiated both an Outpatient Parenteral Antimicrobial Therapy (OPAT) program supported by an infectious disease trained pharmacist, along with an Orthopedic Infectious Disease (OID) consult service to assist in caring for these specialized populations. We measured the impact of these services. Methods Patients discharged on parenteral antimicrobial therapy were divided into two groups. The pre-OPAT cohort included all patient receiving OPAT from 4/1/18 - 10/31/18; the post-OPAT cohort included all patients who received OPAT from 4/1/19 - 10/31/19 with OPAT consult (Fig 1). The OID consult service began in September 2018 prior to initiation of the OPAT program. The primary outcome was 30-day hospital readmission. Secondary outcomes included: length of stay (LOS), 90-day readmission, clinical outcomes, and identification of predictors of hospital readmission. Clinical outcomes included: time from final OR visit to discharge for OID patients and optimal treatment (cefazolin, oxacillin, or nafcillin) for MSSA. Results Introduction of these programs was associated with a reduction in all-cause 30-day readmission from 39.3% to 22.9%, and a reduction in 30-day readmission for patients on-treatment from 24.6% to 15.6% (p&lt; 0.01 for both). No difference was seen in hospital LOS (8 days in each cohort). In a subgroup analysis (Fig 2), OID patients in the post-OPAT cohort saw a median reduction of 2 days (7 days to 5 days, p=0.002) in time from final OR visit to discharge. Use of optimal treatments for MSSA increased in the post-OPAT cohort compared to pre-OPAT (65.2% to 80.9%; p=0.06). The 90-day hospital readmission rate were higher in the post-OPAT cohort among patients who lived in metro-area zip codes (p=0.03). Having an established primary care physician was associated with lower 90-day hospital readmission in both the pre-and post-OPAT cohorts (p=0.05 and 0.01, respectively). Conclusion Thirty-day readmission rates among patients discharged on OPAT significantly lowered following initiation of a combination of both a pharmacist-led OPAT program and OID consult service. OPAT and OID programs accrue additional efficiencies and clinical benefits to both patients and hospitals, which can be further evaluated and used to justify such service additions. Disclosures All Authors: No reported disclosures

Insurance type impacts the economic burden and survival of patients with newly diagnosed glioblastoma

2020 ◽  
Vol 133 (1) ◽  
pp. 89-99
Author(s):  
Ankush Chandra ◽  
Jacob S. Young ◽  
Cecilia Dalle Ore ◽  
Fara Dayani ◽  
Darryl Lau ◽  
...  
Keyword(s):  
Economic Burden ◽  
Private Insurance ◽  
Hospital Costs ◽  
Primary Care Providers ◽  
Tumor Diameter ◽  
Inpatient Hospital ◽  
Lengths Of Stay ◽  
Insured Patients ◽  
The Impact ◽  
Privately Insured

OBJECTIVEGlioblastoma (GBM) carries a high economic burden for patients and caregivers, much of which is associated with initial surgery. The authors investigated the impact of insurance status on the inpatient hospital costs of surgery for patients with GBM.METHODSThe authors conducted a retrospective review of patients with GBM (2010–2015) undergoing their first resection at the University of California, San Francisco, and corresponding inpatient hospital costs.RESULTSOf 227 patients with GBM (median age 62 years, 37.9% females), 31 (13.7%) had Medicaid, 94 (41.4%) had Medicare, and 102 (44.9%) had private insurance. Medicaid patients had 30% higher overall hospital costs for surgery compared to non-Medicaid patients ($50,285 vs $38,779, p = 0.01). Medicaid patients had higher intensive care unit (ICU; p < 0.01), operating room (p < 0.03), imaging (p < 0.001), room and board (p < 0001), and pharmacy (p < 0.02) costs versus non-Medicaid patients. Medicaid patients had significantly longer overall and ICU lengths of stay (6.9 and 2.6 days) versus Medicare (4.0 and 1.5 days) and privately insured patients (3.9 and 1.8 days, p < 0.01). Medicaid patients had similar comorbidity rates to Medicare patients (67.8% vs 68.1%), and both groups had higher comorbidity rates than privately insured patients (37.3%, p < 0.0001). Only 67.7% of Medicaid patients had primary care providers (PCPs) versus 91.5% of Medicare and 86.3% of privately insured patients (p = 0.009) at the time of presentation. Tumor diameter at diagnosis was largest for Medicaid (4.7 cm) versus Medicare (4.1 cm) and privately insured patients (4.2 cm, p = 0.03). Preoperative (70 vs 90, p = 0.02) and postoperative (80 vs 90, p = 0.03) Karnofsky Performance Scale (KPS) scores were lowest for Medicaid versus non-Medicaid patients, while in subgroup analysis, postoperative KPS score was lowest for Medicaid patients (80, vs 90 for Medicare and 90 for private insurance; p = 0.03). Medicaid patients had significantly shorter median overall survival (10.7 months vs 12.8 months for Medicare and 15.8 months for private insurance; p = 0.02). Quality-adjusted life year (QALY) scores were 0.66 and 1.05 for Medicaid and non-Medicaid patients, respectively (p = 0.036). The incremental cost per QALY was $29,963 lower for the non-Medicaid cohort.CONCLUSIONSPatients with GBMs and Medicaid have higher surgical costs, longer lengths of stay, poorer survival, and lower QALY scores. This study indicates that these patients lack PCPs, have more comorbidities, and present later in the disease course with larger tumors; these factors may drive the poorer postoperative function and greater consumption of hospital resources that were identified. Given limited resources and rising healthcare costs, factors such as access to PCPs, equitable adjuvant therapy, and early screening/diagnosis of disease need to be improved in order to improve prognosis and reduce hospital costs for patients with GBM.

Antimicrobial Stewardship by Transitions of Care Pharmacists at Hospital Discharge

2020 ◽  
pp. 001857872095117
Author(s):  
Noah Leja ◽  
Curtis D. Collins ◽  
Janice Duker
Keyword(s):  
High Risk ◽  
Hospital Discharge ◽  
Antimicrobial Therapy ◽  
Treatment Duration ◽  
Descriptive Study ◽  
Pharmacological Therapy ◽  
Transitions Of Care ◽  
Antimicrobial Use ◽  
The Impact ◽  
Hospital Discharge Date

Objectives: This study assessed the impact transitions of care (TOC) pharmacists have on optimizing antimicrobial use for patients at high risk for mortality at hospital discharge. In addition, this study aimed to summarize and categorize the types of interventions made. Methods: This was a retrospective descriptive study that included adult patients 18 years of age or older who were at high risk for readmission and mortality. Participants were selected if they had a hospital discharge date between January 2017 and June 2018, but were excluded if they were discharged to a facility where medications were managed by healthcare employees or if they were hospice eligible. TOC pharmacists identified eligible participants and reviewed their discharge medication lists to optimize pharmacological therapy, contacting the discharging prescriber if therapy changes were identified. The therapy recommendations made by TOC pharmacists were documented in an internal database for further analysis. Results: A total of 1100 patients were analyzed by TOC pharmacists during the studied timeframe and a total of 2066 interventions were made. With respect to study objectives, 298 (14.4%) of the interventions made by TOC pharmacists involved antimicrobial recommendations, affecting 255 (23.2%) patients. Recommendations involving dosing (89, 29.9%), treatment duration (74, 24.8%), and drug interactions (41, 13.8%) were the most frequent types of interventions made. Sixty-six (25.9%) patients received multiple interventions and 240 (80.5%) recommendations were accepted by the provider. Conclusion: An opportunity exists to optimize antimicrobial therapy surrounding the time of hospital discharge.

Characterization of Drug-Related Problems Occurring in Patients Receiving Outpatient Antimicrobial Therapy

2017 ◽  
Vol 30 (6) ◽  
pp. 600-605 ◽  
Author(s):  
Cory M. Hale ◽  
Jeffrey M. Steele ◽  
Robert W. Seabury ◽  
Christopher D. Miller
Keyword(s):  
Antimicrobial Therapy ◽  
Hospital Readmission ◽  
Care Management ◽  
Hospital Readmissions ◽  
Antimicrobial Treatment ◽  
Transitions Of Care ◽  
Drug Related Problems ◽  
Patient Harm ◽  
Outpatient Parenteral Antimicrobial Therapy

Background: Despite the numerous benefits of outpatient parenteral antimicrobial therapy (OPAT), appreciable risks of drug-related problems (DRPs) exist. No studies to date comprehensively assess DRPs in this population. Objectives: Objectives of this study were to (1) characterize the frequency and types of DRPs experienced by patients discharged on OPAT and (2) determine the fraction of adverse drug reactions (ADRs) resulting in hospital readmission or emergency department (ED) presentation and changes in therapy. Methods: This was a retrospective chart analysis evaluating consecutive adult patients discharged on OPAT between May 2015 and October 2015. Patients were assessed for the presence of DRPs until the cessation of antimicrobial treatment, including oral step-down therapy. The outcome of each ADR was recorded, including those resulting in hospital readmissions, presentation to the ED, or changes in antimicrobials. Results: Among 144 patients discharged on OPAT, 199 DRPs occurred in 91 (63.2%) patients. Harm and potential impaired efficacy occurred in 76.9% and 23.1%, respectively. The ADRs comprised 59% of DRPs, occurring in 44.4% of patients. The second most common DRP type was drug interactions (DIs), accounting for 22.6% of DRPs. Rifampin, fluoroquinolones, and daptomycin had the highest frequencies of preventable DRPs in the form of DIs, whereas cephalosporins had the fewest DRPs. Approximately 26% of ADRs caused changes in therapy and 9% resulted in hospital readmission or ED utilization. Conclusion: DRPs with the potential to cause patient harm or impair treatment efficacy often occur with OPAT, most commonly ADRs and DIs. Enhanced monitoring and transitions of care management may reduce the incidence of these DRPs.

scholarly journals Maximising the opportunity of a self‑administration outpatient parenteral antimicrobial therapy pathway

2021 ◽  
Vol 15 (1) ◽  
pp. 15-23
Keyword(s):  
Clinical Outcomes ◽  
Antimicrobial Therapy ◽  
Patient Questionnaire ◽  
University Hospitals ◽  
Self Administration ◽  
Patient Response ◽  
Outpatient Parenteral Antimicrobial Therapy ◽  
Nurse Empowerment ◽  
The University ◽  
The Impact

Background: The University Hospitals of Leicester NHS Trust outpatient parenteral antimicrobial therapy (OPAT) service has expanded rapidly with more nurse-led direction. Aims: A retrospective study between 1 July 2014 and 31 December 2019 was undertaken to assess the impact of OPAT expansion on beds released for further utilisation, clinical outcomes, adverse vascular access device (VAD) outcome, and self- and family-administered parenteral antimicrobial therapy. Method: Data were extracted from the OPAT Patient Management System and from a patient questionnaire survey. Findings: 1084 completed patient episodes were recorded in 958 patients, rising from 39 episodes in 2014 to 265 in 2019. The number of beds released for further utilisation correspondingly rose from 828 in 2014 to 8462 in 2019. The proportion of patients/family members trained to self-administer rose from 25% to 75%, with clinical cure/improvement of infection remaining high at between 84.6% and 92.8% of patients annually. Serious adverse VAD events remained low throughout. The patient response was generally positive. Conclusion: Nurse empowerment within OPAT can lead to significant improvements and patient benefits, while maintaining clinical outcomes.

scholarly journals 138. Implementation of an Antimicrobial Stewardship Order Set in the Emergency Department at a Quaternary Care Facility

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S182-S182
Author(s):  
Salma M . Al Shaqfa ◽  
Rania M El Lababidi ◽  
Wasim S El Nekidy ◽  
Mohamed Hisham ◽  
Rama Nasef ◽  
...  
Keyword(s):  
Emergency Department ◽  
Antimicrobial Stewardship ◽  
Antimicrobial Therapy ◽  
Care Facility ◽  
Primary Study ◽  
Inpatient Setting ◽  
Evidence Based ◽  
Number Of Patients ◽  
The Impact ◽  
Order Set

Abstract Background Implementation of antimicrobial stewardship (AS) interventions in the emergency department (ED) has been associated with improved patient outcomes. One potentially promising AS strategy is the implementation of an ED-specific, evidence-based antimicrobial order set. In this study, we aimed to examine the impact of implementing an ED-specific order set (EDOS) on the appropriateness of empiric antimicrobial therapy. Methods We conducted a pre-post quasi experimental study on 160 adult patients presenting to the ED with suspected or confirmed common infections at our quaternary healthcare facility. The EDOS was implemented in December 2020, providing evidence-based recommendations for the management of common infectious diseases. Data was collected between September 2019 and March 2020 for the pre-EDOS implementation group and between January 2021 and April 2021 for the post-EDOS implementation group. Pregnant women and patients with suspected or confirmed COVID-19 infection were excluded. Data were analyzed using two-sample T-test and mixed effects logistic regression. The primary study outcome was the appropriateness of antimicrobials selected, and the secondary outcomes were clinical and microbiologic cure, length of hospital stay, Clostridioides difficile infection, and the number of changes in antimicrobial therapy on transition to inpatient setting. Results A total of 100 ED patients pre-EDOS implementation and 60 patients post-EDOS implementation were compared. At baseline, patients in the post-EDOS group were older (59.83±20.30 years vs. 50.17±19.97 years, P=0.0037). A higher number of patients in the post-EDOS group had a history of multiple comorbidities (76.67% vs. 54%, P=0.0039). There was a higher rate of appropriate antimicrobial use in the post-EDOS group as compared to the pre-EDOS group (88.3% vs. 50%, P&lt; 0.001). Longer hospital stays were observed in the post-EDOS group (P=0.0005). Clinical cure was similar between the two groups (96.6% vs. 94%, P=0.4568). Conclusion In our study, we observed higher rates of appropriate antimicrobial selection after implementation of an EDOS. Use of an EDOS may represent a valuable AS intervention to guide appropriate antimicrobial prescribing in the ED, and larger studies are needed to confirm those findings. Disclosures All Authors: No reported disclosures

Impact of a Multidisciplinary Team Review of Potential Outpatient Parenteral Antimicrobial Therapy Prior to Discharge from an Academic Medical Center

2011 ◽  
Vol 45 (11) ◽  
pp. 1329-1337 ◽  
Author(s):  
Brett H Heintz ◽  
Jenana Halilovic ◽  
Cinda L Christensen
Keyword(s):  
Central Venous Catheter ◽  
Hospital Discharge ◽  
Antimicrobial Therapy ◽  
Multidisciplinary Team ◽  
Cost Savings ◽  
Venous Catheter ◽  
Central Venous ◽  
Central Venous Catheter Placement ◽  
Outpatient Parenteral Antimicrobial Therapy ◽  
The Impact

Background:: Outpatient parenteral antimicrobial therapy (OPAT) is frequently prescribed at hospital discharge, often without infectious diseases (ID) clinician oversight. We developed a multidisciplinary team, including an ID pharmacist, to review OPAT care plans at hospital discharge to improve safety, clinical efficacy, practicality, and appropriateness of the proposed antimicrobial regimen. Objective: To evaluate the impact of the OPAT team on regimen safety, efficacy, and complexity; calculate the economic benefits of the service by avoiding hospital discharge delay, central venous catheter placement, or need for OPAT; and evaluate the discharge environment among OPAT referrals. Methods: In an observational design, we analyzed the impact of an OPAT team from July 2009 through June 2010 at a large academic tertiary care hospital. All patients with plans for continued parenteral therapy after discharge referred to the OPAT team were included in the analysis. Patients were excluded if OPAT was cancelled prior to processing of the referral. Results: During the 1-year study period. 569 of 644 consecutive referrals to the OPAT team met inclusion criteria, resulting in 494 OPAT courses. Interventions by an ID pharmacist were made for safety (56%), regimen complexity (41%), and efficacy (29%). Lack of formal ID physician consultation resulted in more interventions for safety (64% vs 48%, p < 0.001) and efficacy (36% vs 21%, p < 0.001). Discharge delays were avoided for 35 referrals, resulting in 228 hospital days avoided and approximately $366,000 in hospital bed cost savings. Use of OPAT was avoided in 75 referrals (13.2%), preventing central venous catheter placement in 48 patients (8.4%), resulting in an additional $58,080 in cost savings. Conclusions: The OPAT team optimized safety, efficacy, and convenience of OPAT while providing substantial cost savings. Further studies are needed to confirm the program's cost-effectiveness.

Dedicated paediatric Outpatient Parenteral Antimicrobial Therapy medical support: a pre–post observational study

2017 ◽  
Vol 103 (2) ◽  
pp. 165-169 ◽  
Author(s):  
Ariel O Mace ◽  
Charlie McLeod ◽  
Daniel K Yeoh ◽  
Julie Vine ◽  
Yu-Ping Chen ◽  
...  
Keyword(s):  
Antimicrobial Therapy ◽  
Best Practice ◽  
Medical Team ◽  
Medical Support ◽  
Outpatient Parenteral Antimicrobial Therapy ◽  
Best Practice Guidelines ◽  
Paediatric Outpatient ◽  
Observational Cohort ◽  
The Many ◽  
The Impact

ObjectiveDespite the many benefits of paediatric Outpatient Parenteral Antimicrobial Therapy (OPAT) programmes, there are risks associated with delivering inpatient-level care outside of hospital. There is a paucity of evidence defining how best to mitigate these risks. We examined the impact of introducing a dedicated medical team to OPAT, to define the role of increased medical oversight in improving patient outcomes in this cohort.DesignA prospective 24-month pre–post observational cohort study.SettingThe Hospital in the Home (HiTH) programme at Princess Margaret Hospital (PMH) for Children, Western Australia.PatientsAll OPAT admissions to HiTH, excluding haematology/oncology patients.InterventionsPMH introduced a dedicated OPAT medical support team in July 2015 to improve adherence to best-practice guidelines for patient monitoring and review.Main outcome measuresDuration of OPAT, adherence to monitoring guidelines, drug-related and line-related adverse events and readmission to hospital.ResultsThere were a total of 502 OPAT episodes over 24 months, with 407 episodes included in analyses. Following the introduction of the OPAT medical team, adherence to monitoring guidelines improved (OR 4.90, 95% CI 2.48 to 9.66); significantly fewer patients required readmission to hospital (OR 0.45, 95% CI 0.24 to 0.86) and there was a significant reduction in the proportion of patients receiving prolonged (≥7 days) OPAT (OR 0.67, 95% CI 0.45 to 0.99).ConclusionThe introduction of a formal medical team to HiTH demonstrated a positive clinical impact on OPAT patients’ outcomes. These findings support the ongoing utility of medical governance in a nurse-led HiTH service.

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