Hospital studies self-care program, with positive results

When leaders at Parkland Health & Hospital System in Dallas launched a novel program for administering long-term antibiotics to Parkland Memorial Hospital patients, they were seeking to address two problems that vex many provider organizations: disparities in the delivery of health care services and the inappropriate use of health care resources.

Kavita Bhavan, M.D., medical director of the Infectious Diseases Outpatient Parenteral Antimicrobial Therapy Clinic at Parkland, says the clinic treats many patients who need intravenous antimicrobial therapy for several weeks to recover from serious infections stemming from illness or injury.

Providers can administer long-term intravenous antimicrobial therapy to insured patients at a number of locations: an infusion center, a physician’s office, a skilled nursing facility or, most frequently, at home with support from home health services. Uninsured patients, however, have no access to home health nurses or other options, so they traditionally have been treated as inpatients at Parkland.

“It wasn’t unheard of to be here 42 days getting IV antibiotics,” says Bhavan, who also serves as associate professor of internal medicine at the University of Texas Southwestern Medical Center. That meant inpatient beds were being tied up by patients who could be treated at home.

At the same time, the patients receiving long-term antibiotics did not want to be in the hospital unnecessarily, part of what Bhavan recognized as a disparity in the quality of care provided to uninsured patients versus their insured peers.

In response, Bhavan and her colleagues developed a program to train patients to self-administer IV antibiotics at home, which frees up nearly 6,000 bed days and saves Parkland more than $7.5 million in unreimbursed care in a single year.

Now in its eighth year, Parkland’s self-administered OPAT, program, or S-OPAT, has shown that low-income patients can provide self-care that is equal to or, in some cases, better than that provided by medical professionals.

Measuring the results

Parkland conducted a study from January 2009 through October 2013 to compare the outcomes of uninsured patients enrolled in the S-OPAT program with those of insured patients who received health care-administered therapy, or H-OPAT, in which their drugs were delivered at an infusion center, in a nursing home or at home with skilled nursing assistance.

Of the 1,168 patients discharged from Parkland to receive antimicrobial treatments as outpatients, 944 participated in the S-OPAT program and 224 received H-OPAT services.

• The 30-day, all-cause readmission rate was 17 percent for S-OPAT patients and 24 percent for H-OPAT patients.
• The one-year, all-cause mortality rate for the S-OPAT group was 5.4 percent, which was not significantly different from that of the H-OPAT group.
• The S-OPAT patients avoided a median of 26 days of inpatient care. This means that, over the 46-month program, Parkland avoided 27,666 inpatient days that would have been needed to care for these patients had they been treated in the hospital.

More recent results show the program’s return on investment. In Parkland’s fiscal year 2015, the direct costs associated with the S-OPAT program were $957,933, or $3,574 per patient. During that year, the program freed up 5,893 inpatient bed days, translating into direct cost avoidance of $7.6 million, according to the research brief “Teaching Uninsured Patients to Self-Administer IV Antibiotics at Home,” published in NEJM Catalyst.

More research

Bhavan plans to publish at least two more articles examining data from the pilot study. One will report on the high levels of satisfaction expressed by patients in the S-OPAT program; the other will examine the collateral benefits of activating a patient in this type of self-care.

“If you engage a patient to take ownership in one process effectively, and they feel good about it because they are doing a great job, what does that mean for their other health conditions?” she says. “We have shown that these patients who have successfully completed the program don’t come back into the hospital.”

Most of her patients have one or more chronic comorbidities, such as high blood pressure or diabetes. Because the program collects data on patients over time, Bhavan can examine whether their health metrics — blood sugar levels, blood pressure, smoking status and others — change during their course of antibiotic therapy.

Those findings may help health system leaders think about the return on investment of self-care initiatives in terms of their population health management goals.

“If you’re going to come up with interventions, how do you get the maximum return on those investments in ways where you are not just solving one problem but perhaps getting collateral benefits in other areas as well?” Bhavan says.

Lola Butcher is a contributing writer to Trustee.