Patients with life-threatening infections like endocarditis who need several weeks of intravenous (IV) antibiotics typically leave the hospital once stabilized and continue their treatment in outpatient settings. This is called outpatient parenteral antimicrobial treatment (OPAT); parenteral indicates intravenous route. For those with insurance, OPAT options include an infusion center, a skilled nursing facility, or at home with an infusion pump and home-health nursing assistance. All of these options require trained medical personnel to help with administering the IV antibiotic, leading to additional expenses that are unaffordable for patients without health insurance. The options, thus, for uninsured patients in the U.S. are limited.
At Parkland Hospital, an 862-bed safety-net hospital serving the indigent population of Dallas, Texas, our patients, despite being medically stable, historically remained in the hospital for up to 4–6 weeks to complete a course of intravenous antibiotics. This approach is both costly for the hospital and challenging for patients, who are unable to return to activities of daily living and remain exposed to risks of prolonged hospitalization, including hospital-acquired infections and falls.
In 2009, we launched an innovative program, called S-OPAT, born out of necessity, to address this problem. Self-administered outpatient parenteral antimicrobial treatment (S-OPAT) is an option where patients are taught to administer antibiotics themselves, at home, using a long-term indwelling IV catheter (PICC line) and low-cost accessories, such as an upside-down coat hanger hooked to a nail for hanging one’s IV bag. A case manager screens each patient to ensure he or she is an appropriate candidate for S-OPAT, assessing for requirements such as no history of IV drug use, having running water and a working refrigerator at home to store antibiotics, and ability to return for weekly clinic visits. A transitional care nurse instructs the patient (at bedside) on preparing and infusing the medication and on catheter care, and then tests for competency on three separate occasions to ensure a safe transition from hospital to home to complete therapy. Patients have weekly laboratory tests and PICC dressing changes and see a physician intermittently to make sure the infection resolves. They receive detailed instructions written at a fourth-grade literacy level in English and Spanish, as well as access to an online instructional video by scanning a QR code on the back of an IV bag with their cell phone.
We have successfully treated more than 2,000 patients with this self-care model since 2009. Our previously published data showed that patients in the S-OPAT program had a 47% reduction in 30-day readmission rates when compared to patients who were discharged from our hospital and received traditional health care–administered OPAT (H-OPAT) during the same time period. Furthermore, the S-OPAT program significantly improved resource use, with more than 27,000 inpatient bed days avoided in the first 4 years of operation (2010 to 2013). Parkland saved an estimated $10 million annually in direct costs, or $40 million total, and freed up beds for patients needing more intensive care. Our 2015 study did not address whether S-OPAT actually improves clinical outcomes such as cure rates for infections, but the risk of dying within 1 year of hospital discharge was not significantly different in the two groups.
Despite positive clinical outcomes at Parkland, the adoption of self-administered OPAT in other U.S. health care systems has been limited. To better understand barriers to its use, we surveyed patients and physicians to gather information on their values, preferences, opinions, and experiences with S-OPAT. Specifically, we sought to ask if patients prefer S-OPAT and if physicians would be willing to recommend it.
We developed and validated a questionnaire to interview (by phone) a random sample of patients who completed the S-OPAT program at Parkland. Questions assessed a patient’s ability to understand and master the various steps of self-administering IV antibiotics, successful completion of treatment, ability to return to work, and satisfaction around receiving treatment in the comfort of their home. A 5-point Likert scale (very poor, poor, fair, good, very good) was used to capture patients’ experiences. We reached 168/646 (26%) of patients contacted, and 149 agreed to participate. Of those surveyed, 45% were Hispanic and 72% were over age 45. The majority of participants were male (58%) and uninsured (59%); 30% spoke only Spanish.
Our results showed that 88% rated learning of self-administration of IV antibiotics as good or very good. Approximately 84% of respondents perceived the quality of self-care to be comparable to hospital care and were very satisfied with the program, reporting that they would use it again if needed. Such patient-reported outcomes are integral to advancing efforts to improve and expand new patient-centered care delivery models, and to helping patients decide on the best treatment options for themselves.
To understand physicians’ perceptions of S-OPAT, we developed a survey involving a case scenario of a Parkland patient who had successfully completed S-OPAT. It was presented to randomly selected physicians attending medical conferences around the country. Participants were asked if they would feel comfortable letting the patient self-administer antibiotics and to explain their reasoning. The case narration was: “36-year-old male with no significant medical history is admitted to the hospital with osteomyelitis and requires 6 weeks of intravenous antibiotics. He is Spanish speaking, has completed a fifth-grade education, and does not have health insurance. He denies history of illicit drug use and lives alone in a low-income housing unit. He wants to go home but cannot access services such as home-health nursing assistance [because of cost]. He is willing to learn to administer IV antibiotics himself. Do you feel comfortable teaching and training him in the hospital and then sending him home with a PICC line and antibiotics to self-administer IV therapy?”
Eighty-seven physicians completed the survey, for an overall response rate of 81%. Sixty-six (76%) physicians reported that they would not feel comfortable sending the patient home to self-administer antibiotics. The primary reasons given were that self-administration would be too complex; patients cannot be trusted to safely care for PICC lines; patients may not complete treatment; and medico-legal concerns. When asked if they would consider a patient with a higher level of literacy or better home environment, about one-quarter changed their answer to yes. Finally, 12% of physicians answered that they would consider the S-OPAT option if the patient could access home health nursing assistance. Sixty-five percent of physicians surveyed were not aware of the principles of patient empowerment and engagement, the concept of having patients be actively involved in their own care. Notably, the federal Centers for Medicare and Medicaid and Agency for Healthcare Research and Quality have identified patient engagement as a cornerstone to achieving better care, smarter spending, and healthier people.
Our results highlight some of the misconceptions physicians may have about patients’ abilities and interest in self-care. For example, many physicians consider low literacy a barrier to self-care. Also, many equate grade level completed in school with literacy, which research has shown to be unreliable. Our experience with S-OPAT shows that with population-specific health materials and instructions, even patients who would be considered “illiterate” successfully completed complex tasks involved with the process of self-administering IV antibiotics.
Some physicians also believe patients with lower socioeconomic status are suboptimal candidates for self-care. Yet, most of the 2,000-plus patients we treated through S-OPAT were uninsured and living at 200% of the poverty level. We believe that not giving these patients the choice to participate in self-care is a disservice to them. Medico-legal concerns related to self-care were also high among the surveyed physicians: What if the patient does not complete treatment or develops an infection from the indwelling catheter? Such questions are legitimate, but the evidence from our program should help allay these concerns.
Anecdotally, patients in this program feel affirmed and valued when they follow up in our clinic and are told, “Hey, you’re doing a great job,” or “Your PICC site looks beautiful.” We have also seen that the confidence and discipline required for self-care, together with the trust in their abilities by the health system, allow patients to make other positive decisions affecting their health.
Our findings about physicians’ hesitancy to offer S-OPAT to patients with low literacy and socioeconomic status begs another question. Why are we not recommending S-OPAT to well-educated patients with good living standards? Self-administered OPAT achieves the Triple Aim of improving the care experience, enhancing population health, and reducing per-capita costs of health care. In our opinion, the benefits of self-care for patients, the health care system, and society extend well beyond the 6 weeks of treatment.
In conclusion, we show that in trying to give optimal care to uninsured patients, physicians may hesitate to recommend S-OPAT based on preconceived notions of patients’ abilities, and that many physicians remain poorly informed about the value of patient engagement and empowerment. Understanding and optimizing human potential — our most natural resource — is essential to the success of high-value programs such as S-OPAT. The widespread adoption of self-care models will come not only from patients requesting them, but also from physicians initiating them.