OPAT Protocols: Navigating Challenges

Segment description: Peter L. Salgo, MD; Yoav Golan, MD; and Bruce M. Jones, PharmD, BCPS, consider the barriers of developing simple protocols for outpatient parenteral antibiotic therapy in hospital systems and establishing a strong infrastructure to support them.

Peter L. Salgo, MD: If you don’t have a protocol and you want to institute the protocol, but hospitals are notoriously slow to respond, and bureaucratic, what are the barriers that you’ve seen to establishing these protocols and getting them on board and working?

Yoav Golan, MD: First, you want to have stakeholders be part of your protocol development committee, pharmacy and therapeutics committee, whatever it is.

Peter L. Salgo, MD: Who is a stakeholder?

Yoav Golan, MD: In this case, for example, you want to have an emergency department doctor, you want to have a wound center doctor, and maybe an infectious disease doctor. When they get involved in developing a protocol, they help shape the protocol in a way that works for them, and they become the owners of the protocol. They become the advocates for the protocol wherever they go, because one of the problems with protocols is that when some people are developing protocols for other people, in a way, that’s not convincing enough for the other people. They have to buy into it, and we’ve seen that with vaccination protocols, we’ve seen that with OPAT as well, and I think that’s the first important step.

Bruce M. Jones, PharmD, BCPS: Going back to infrastructure, as a big deal; the most common place I see this fail is, many times, on the case management side. If you’re dealing with an emergency department, they don’t have case managers that are there 24 hours a day, so being able to coordinate, whether it’s a prior authorization—which, if you’re giving this in the emergency department, it does not need—and being able to coordinate a lot of different factors and get these patients out. I think a lot of times, case management becomes an issue. If you have one cog in something that has a lot of moving parts, that right there stopped you.

Peter L. Salgo, MD: Now, one thing that you just said, which is interesting, is, you don’t need prior authorization.

Bruce M. Jones, PharmD, BCPS: Correct.

Peter L. Salgo, MD: Now, some of these drugs in the hospital, even vancomycin, you have to go to ID (infectious disease) and say, “Please let me use it” or “I can use it on an emergency basis for 24 hours, then you’re going to relook at this.” Here, of course, that doesn’t work because it’s good for 2 weeks. So, why don’t you need prior authorization in the ED?

Bruce M. Jones, PharmD, BCPS: Well, for insurance purposes, you don’t need prior authorization in the ED. Now, depending on your specific hospital, you still may require some kind of ID approval or something like that to use it.

Peter L. Salgo, MD: I see.

Bruce M. Jones, PharmD, BCPS: It goes back to kind of the gatekeeper function.

Peter L. Salgo, MD: You’re talking about reimbursement prior approval.

Bruce M. Jones, PharmD, BCPS: Correct.

Peter L. Salgo, MD: That also goes to the protocol, because you pointed out that if you’re going to give this drug, you better be darn sure the patient is not getting admitted anyway or that prior approval will be withdrawn, because you can do it a lot more cheaply if you’re in the hospital, with older drugs.

Yoav Golan, MD: Right.

Peter L. Salgo, MD: How are you certain that you’re going to be able to send these folks home? What’s your protocol?

Yoav Golan, MD: In our hospital, as I mentioned, we have a very simple algorithm for the emergency department. Physicians help to choose the right patient; someone who would be considered for admission for ID, who is stable, their comorbidities are not exacerbated, the infection is not concerning for necrotizing fasciitis, and they have some support at home. If the answers are “yes,” this is a candidate for dalbavancin. A call is given to the ID pharmacist, and the ID pharmacist will look at the patient qualifications to ensure that the patient is a good candidate from a reimbursement perspective. That does not mean, by the way, that we require reimbursement for the entire cost of the drug, because we do see the value in benefitting the patient by not admitting them, from the patient perspective and the hospital perspective. It doesn’t mean that we necessarily want to make money, or even get reimbursed for the entire amount, but we want to know that we are going to get reimbursed at least partially. When the ED doctor calls the wound center, they have an appointment ready for them, if needed. Our algorithm is a very, very simple algorithm, and it works because if it wasn’t simple, it wouldn’t be used, even if it made a lot of sense.

Bruce M. Jones, PharmD, BCPS: One of the questions that came up early on is, what do you do with these self-pay patients? You’re giving a high cost drug to a self-pay patient, and what I always said is, “You’re going to get burned one way or the other.” You admit this patient, you’re going to lose money no matter what you give them. A lot of times, especially in our infusion center, you may lose chair time from it, but one of the added benefits to this is, if you look at these drug companies, they will actually reimburse stock of the drug 1:1. You’re not out the cost of that drug, so that’s another plus, too, with those difficult to treat or even if you have issues with self-pay patients. I’ve always said, “Come one, come all.” We never look at it in terms of ability to pay when evaluating these.