Smoother Care Transitions Cut Readmissions for OPAT Patients

Readmission reduction has the potential for broad impact, especially in disadvantaged populations.

Interventions to improve transitions of care (TOC) for patients receiving intravenous antibiotics can reduce readmission rates by about 13% for this high-risk population, a new study suggests.

Theresa Madaline, MD (left), from The University Hospital for Albert Einstein College of Medicine, Bronx, New York, and colleagues published the results of their study in Open Forum Infectious Diseases.

“Readmission reduction using a TOC bundle approach for high-risk patients with infectious diseases has the potential for broad impact, considering that infection-related readmissions account for approximately one-third of all readmissions, and other similarly socioeconomically disadvantaged patient populations have demonstrated a high risk for rehospitalization,” the authors write.

Outpatient parenteral antimicrobial therapy (OPAT) allows some patients with serious infections who need intravenous antibiotics to be treated outside a hospital setting. This helps to reduce length of hospitalization and treatment costs.

However, according to the authors, patients living in crowded homes who do not have commercial insurance have higher all-cause and infection-related 30-day readmission rates. Clinicians are thus challenged to improve infection-related outcomes in disadvantaged patients in poorer neighborhoods.

In an interview with Contagion, an MD Magazine sister publication, Madaline said that she and co-author Priya Nori (right) noticed that when patients in the hospital were discharged with outpatient intravenous antibiotics, the patients would return to the hospital a few weeks later with a complication of treatment or a worsening infection.

“The patients clearly needed a support system outside the hospital during a complicated treatment course, and the current systems in place were not working well,” she stressed. “We got together and talked about how we might best support this patient population and our TOC-OPAT program was born.”

Montefiore Health System initiated the TOC-OPAT program in July 2015. The program incorporated a care bundle involving components that aimed to improve patient outcomes by enhancing communication between OPAT physicians and patients’ caregivers at homecare agencies or nursing facilities. These components included a multidisciplinary OPAT team, education of patients and families, coordinated care transition, and outpatient care coordination.

Dr. Madaline and colleagues conducted a retrospective study to examine the effect of this program on hospital readmissions, emergency department (ED) use, and mortality in the Bronx — New York City’s poorest borough.

Researchers analyzed data from the TOC-OPAT program registry and Montefiore’s electronic medical record system to identify patients who received an inpatient infectious diseases (ID) consultation and intravenous antibiotics after hospital discharge.

They compared patients who were in the TOC-OPAT program and were discharged between July 2015 and February 2016, with patients who received care before the program was initiated and were discharged from January 2015 to June 2015.

The researchers found that patients in the TOC-OPAT group were significantly less likely than those in the control group to be readmitted to hospital within 30 days of discharge (13.0% vs 26.1%, P < .01). More TOC-OPAT patients also attended an ID follow-up visit within 30 days of discharge (67% vs 18%; P < .01).

Madaline believes that this model is applicable to almost any patient population.

“An important takeaway is that, even with limited resources and high risk patients, both high-quality and cost-effective care is possible,” she emphasized.

“Creative solutions to problems observed in the course of regular clinical care can be more impactful than an abundance of resources,” she added. “We hope that others can use a similar approach to many kinds of clinical problems, even in high risk populations.”

Madaline also stressed the importance of regular team meetings with a focus on continuous process improvement.

“Focusing on improving the important processes will ultimately improve the final outcomes,” she said. “The first thing you try might not always be the answer, but continuing to improve the process will eventually yield the results you desire.”

She and her colleagues are also keen to examine best practices for the treatment of osteomyelitis, and to develop an algorithm for treatment duration.

“Determining the best time to stop treatment can be difficult and we aim to minimize the negative effects of antibiotics and risks of prolonged intravenous therapy while maintaining high cure rates and return to health for our patients,” she said. “We are also hoping to look at outcomes in our patients with orthopedic infections as a sub-population, as these infections are particularly difficult to treat.”