Enhancing Outcomes in Outpatient Parenteral Antimicrobial Therapy
Nabin K. Shrestha, MD, MPH, evaluates the Cleveland Clinic's Outpatient Parenteral Antimicrobial Therapy (OPAT) program, revealing its effectiveness in managing infections while highlighting challenges in monitoring and the impact of infectious disease pharmacists on patient outcomes.
The OPAT program at Cleveland Clinic has been established for over 40 years, offering benefits like shorter hospital stays, cost savings, and improved patient satisfaction, although it also faces challenges like limited control and monitoring in an outpatient setting. A multidisciplinary team structure is crucial for delivering patient-centered care and minimizing errors. This study aims to outline the operations and practices of the Cleveland Clinic OPAT program.
In the study of 197 patients undergoing OPAT, the average age was 63 years, with 62.6% being male. Key comorbidities included diabetes (38.6%), chronic kidney disease (36.5%), and heart failure (28.9%). The most common infections were in the bone and joint (29.4%) and endovascular systems (22.3%). Staphylococcus aureus was the most frequently identified organism (25.4%).
Nabin K. Shrestha, MD, MPH, infectious disease physician at Cleveland Clinic discusses the challenges of OPAT, “So often, people are discharged either to a home or a skilled nursing facility on the IV antibiotic treatment. Now, one of the challenges, a major challenge, is that when people leave the hospital, they are no longer under our control, and so we have to rely on other people to do the tests that we ask them to do. One of the major challenges that's faced by many OPAT programs is that you want certain lab tests done for monitoring, and it's just hard to get those results.”
Most patients (62.4%) were discharged home with home health care, indicating that OPAT can effectively support recovery in a home setting. Overall, these results suggest that OPAT is a viable option for managing infections in patients with significant comorbidities.
Further analysis revealed important insights regarding patient outcomes. “What we found also is that if you looked at the readmission rates or ED visits, and we compared them for people who had the monitoring done, if you looked at the people who had more than 80% of the monitoring done as targeted, the outcomes were no different. We did not find any significant difference in the ED visits or the readmission rates, whether they had more than 80% of their tests completed as planned or they were not.”
The study employed a retrospective observational design, focusing on patients over 18 years of age undergoing OPAT between January 1, 2022, and December 31, 2022. A random sample of 200 OPAT courses was generated from the Cleveland Clinic OPAT registry; however, three patients were excluded for not meeting the inclusion criteria. Exclusion criteria also encompassed OPAT courses initiated in the outpatient setting. For statistical analysis, descriptive statistics were utilized for all primary and secondary outcomes, a linear regression model was applied for the clinical lab abnormalities (CSLA), and hazard plots were created for emergency department visits and readmissions.
Completing and monitoring laboratory tests during OPAT courses is crucial for detecting CLSA. In discussing the future of the OPAT program, Shrestha explains, “This was a study which is meant to be a part one of two studies. Last year, we hired a couple of infectious disease pharmacists to help with the OPAT program, and the idea was that they would help with this monitoring and take actions as soon as possible. First, they would make sure that we obtain the results as needed, and the others, whenever results came in, they would be acted on it efficiently. And the question is whether having those pharmacists made a difference in our outcomes. And this was part when this was done, before we had the pharmacists, and we will have to look at what happens in the year after we had pharmacists to see if it made a difference.” There are also clinical and operational opportunities to improve the OPAT workflow, enhancing both safety and efficiency within the program.
