Trained patients can self-administer IV antibiotics at home—but doctors don’t trust them

Having patients self-administer IV antibiotics has been associated with improved outcomes and lower healthcare costs, but many physicians don’t trust the patients to safely care for themselves at home, according to an article in NEJM Catalyst.

The authors, all from University of Texas Southwestern Medical Center in Dallas, noted patients with life-threatening infections like endocarditis usually need several weeks of IV antibiotics. This therapy is usually provided in an outpatient setting once they are discharged from the hospital, requiring trained medical personnel.

However, uninsured patients’ options are more limited. Because of this, Parkland Hospital, an 862-bed safety-net hospital in Dallas, typically kept medically stable patients in the hospital for four to six weeks to complete their course of IV 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,” the authors pointed out.

In 2009, the hospital began the self-administered outpatient parenteral antimicrobial treatment (S-OPAT) program where patients were taught to take the antibiotics themselves using a long-term indwelling IV catheter (PICC line) and low-cost accessories.

All patients were screened to ensure they were an appropriate candidate for S-OPAT and were asked to return for weekly clinical visits. Before they transitioned to home care, they were tested on three separate occasions for competency. In addition, they received instructions written at a fourth-grade reading level in both English and Spanish, as well as access to an online instructional video.

More than 2,000 patients have been successfully treated with this model, the authors reported, and results published in PLOS Medicine in December 2015 were promising.

“Patients in the S-OPAT program had a 47 percent 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,” Deepak Agrawal, MD, MBA, MPH; Anisha Ganguly; and Kavita P. Bhavan, MD, MHS, wrote in NEJM Catalyst.

“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.”

Agrawal and colleagues noted their 2015 study didn’t evaluate clinical outcomes such as cure rates for infections, but no significant mortality difference was detected one year after hospital discharge.

The new data related to this program highlights the differences in patient experience and physician expectations. The researchers surveyed 149 participants who completed the program—45 percent Hispanic, 59 percent uninsured and 72 percent over the age of 45—and found high satisfaction with S-OPAT. About 84 percent said the quality of care was comparable to hospital care and they would use the program again if needed.

Physicians were also surveyed about whether they would be comfortable teaching self-administration of IV therapy to a 36-year-old, Spanish-speaking male with a fifth-grade education, no health insurance, no history of illegal drug use and a diagnosis of osteomyelitis. The case narration also specified the individual lived alone in a low-income housing unit.

More than three-quarters (76 percent) of the 87 physicians who completed the survey said they would not feel comfortable sending the patient home to self-administer antibiotics. They feared self-administration would be too complex, but one-quarter of physicians changed their answer when the patient was assigned a higher level of literacy or a better home environment, according to Agrawal and colleagues.

“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,” Agrawal et al. wrote.

The authors pointed out low levels of literacy and socioeconomic status didn’t prevent the individuals in their study from learning the home care model.

“Self-administered OPAT achieves the Triple Aim of improving the care experience, enhancing population health, and reducing per-capita costs of health care,” they concluded. “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.”

Read the full NEJM Catalyst report here.