Six years ago, our large safety-net hospital, Dallas-based Parkland Memorial, started teaching uninsured patients with diagnosed infections who require an extended course of intravenous antibiotics to self-administer the treatment at home. More than 1,000 patients later, this population has shorter hospital stays and lower readmission rates.
Self-administered outpatient parenteral antimicrobial therapy can be delivered safely and effectively in a population of uninsured, largely low-literacy patients.
Perceived educational obstacles can be overcome with effective training of patients and materials that are well designed and tailored to the population
The program empowers patients to complete therapy safely in the comfort of their own homes, surrounded by family and with limited interruption in their lives.
Provider initiative, multidisciplinary team involvement, and supportive health system leaders are essential to the success of the program.
Nurse-assisted outpatient parenteral antimicrobial therapy (OPAT) is safe and effective for medically stable patients. However, uninsured patients generally cannot afford this service, and safety-net hospitals often don’t offer it because the costs are not reimbursed. Patients who stay in the hospital only to receive prolonged IV antibiotic therapy increase their potential exposure to hospital-acquired complications, delay their return to work and other activities, and occupy beds that patients who require more intensive services could use. Common diagnoses in this population include osteomyelitis, septic arthritis, infective endocarditis, pyelonephritis, and intra-abdominal infections.
Most patients at Parkland Memorial Hospital come from lower-income (<200% of US poverty level), lower-literacy households; 48% are uninsured. Clinicians traditionally perceive this population as having limited capabilities for self-care, but a physician-led multidisciplinary team convinced Parkland’s management to pursue a trial of self-administered OPAT with these patients. An analyst was assigned to work with clinicians and, using administrative files, assess whether excess hospital days, redundant tests, and other unnecessary costs could be reduced.
Self-administered OPAT has been described in published research from the United Kingdom, but not yet in the United States. We were not driven by the UK research, but by a motivation to prevent complications associated with prolonged hospitalization, to limit resource utilization, and to empower our patients.
We aimed to reduce health care disparities for uninsured patients hospitalized for long-term antibiotic therapy, usually 4 to 6 weeks but sometimes longer, by enabling them to complete therapy at home. We sought to improve their outcomes, lower their hospital-based risks, increase their sense of self-efficacy, and reduce costs.
Inpatients requiring long-term IV antibiotics were accepted into the OPAT program according to written eligibility criteria that were assessed at an infectious diseases/OPAT consultation (see figure). Patients who were homeless, IV drug users, or medically unstable were ineligible.
Before discharge, eligible patients received standardized training in self-administration of IV antibiotics (no infusion pumps were provided). Educational materials, developed at a fourth-grade literacy level, included illustrations of the apparatus, supplies, hand hygiene practices, and techniques for aseptically connecting the antibiotic solution to the IV catheter. Instruction was delivered at the hospital bedside using a pamphlet available in English and Spanish. A smaller group of patients who spoke less common languages were trained with the assistance of the hospital’s multilingual telephone-translation services. Written and video instructions are posted on our website.
According to a standardized teach-back protocol, patients were repeatedly required to show mastery of all steps in self-administration of IV antibiotics by gravity. Patients were then discharged home and followed throughout their treatment course, with weekly clinic visits for PICC-line (peripherally inserted central catheter) maintenance, laboratory monitoring, and evaluation by an infectious disease physician or nurse practitioner.
Patients have shown intrinsic motivation to take responsibility for their own care, knowing that they have access to health care professionals, including a 24-hour nurse call center and regularly scheduled visits to the OPAT clinic.
The team comprised infectious disease physicians, transitional care nurses, case managers or social workers, clinical pharmacists, and health literacy experts. Team members had support from key members of hospital leadership, including the CEO and chief medical officer.
In the first three years of the program, having uninsured patients self-administer IV antibiotics rather than staying in the hospital for that treatment saved 27,666 hospital bed-days (an average of 26 bed-days per patient). In FY2015, the direct program cost was $957,933 or $3,574 per patient; the program resulted in 5,893 fewer bed-days, which translates to an average direct cost avoidance of $7,561,130. Compared with patients discharged from our hospital with traditional nurse-administered OPAT services for similar infections, patients in our program had 30-day hospital readmission rates that were 47% lower than those with similar diagnoses who were not in the program.
We have shown that delivery system changes that improve quality and lower costs can occur when front-line clinicians have substantive input into organizational operations. These fundamental questions guided our decision making:
- How can our processes be more patient-centered?
- What effects will change have on costs and reimbursement?
- Is it the right thing to do ethically?
The result: Our self-administered OPAT program allowed patients to receive extended care at home and enabled us to allocate public resources more efficiently.
A multidisciplinary, collaborative approach involving infectious disease specialists, clinical pharmacy specialists, physician assistants, case managers, and OPAT transitional care nurses — complemented by use of the electronic medical record — was critical in implementing this transition of care model. We were only able to gain the engagement and time commitment of this team with the support of an executive sponsor, who had the ability to assign resources, and the advocacy of the system’s medical director. In short, we found that systems can improve when administrators create a climate in which good ideas from clinicians are considered and supported.
Now that we have a successful program, we are thinking about these next steps:
- Expand services to increase access to care, meet the growing demand for traditional infusions by gravity, and introduce the use of pumps for other antimicrobial infusions when necessary.
- Track patient outcomes, including outcomes that patients themselves consider important, such as returning to work and resuming care for dependents at home.
We thank L. Steven Brown, MPH, for extensive work in analyzing the clinical outcomes data for Parkland’s OPAT program. We also thank Dr. Christopher Madden and Dr. Carlos Girod for their leadership and instrumental roles in developing and growing the program.