Tracking Substance Use Complications: A Collaborative Analysis of Public Health and Academic Medical Center Records on Drug Use-Associated Infective Endocarditis

Improving care for individuals with serious infections who inject drugs

Background

Hospitalizations for serious infections requiring long-term intravenous (IV) antimicrobials related to injection drug use have risen sharply over the last decade. At our rural tertiary care center, opportunities for treatment of underlying substance use disorders were often missed during these hospital admissions. Once medically stable, home IV antimicrobial therapy has not traditionally been offered to this patient population due to theoretical concerns about misuse of long-term IV catheters, leading to discharges with suboptimal treatment regimens, lengthy hospital stays, or care that is incongruent with patient goals and preferences.

Methods

A multidisciplinary group of clinicians and patients set out to redesign and improve care for this patient population through a health care innovation process, with a focus on increasing the proportion of patients who may be discharged on home IV therapy. Baseline assessment of current experience was established through retrospective chart review and extensive stakeholder analysis. The innovation process was based in design thinking and facilitated by a health care delivery improvement incubator.

Results

The components of the resulting intervention included early identification of hospitalized people who inject drugs with serious infections, a proactive psychiatry consultation service for addiction management for all patients, a multidisciplinary care conference to support decision making around treatment options for infection and substance use, and care coordination/navigation in the outpatient setting with a substance use peer recovery coach and infectious disease nurse for patients discharged on home IV antimicrobials. Patients discharged on home IV therapy followed routine outpatient parenteral antimicrobial therapy (OPAT) protocols and treatment protocols for addiction with their chosen provider.

Conclusion

An intervention developed through a design-thinking-based health care redesign process improved patient-centered care for people with serious infections who inject drugs.

Trends and characteristics of primary pyogenic spine infections among people who do and do not inject drugs: Northeast New York State, 2007 to 2018

Background:

Pyogenic spine infections (PSIs) are challenging to diagnose and treat. People who inject drugs (PWID) are at increased risk and contribute to rising PSI incidence.

Objective:

To analyze trends and characterize PSI in persons who do and do not inject drugs in northeast New York State (NYS), a predominantly rural region.

Methods:

A retrospective study of PSI patients at a regional tertiary care hospital from 2007 to 2018 was conducted. PSI incidence, population demographics, microbiology, surgical interventions, length of stay (LOS), and costs were compared between injection substance use disorder (ISUD) and non-ISUD cohorts.

Results:

Two hundred and seventy patients (59 ISUD and 211 non-ISUD) were included in this study. PSI incidence due to ISUD increased 1175% during the study time periods. The median age of the ISUD and non-ISUD cohorts was 39 and 65, respectively. Staphylococcus aureus was the most common causative organism, although a variety of bacterial and fungal pathogens were identified. Nearly half of the patients in each cohort required surgical intervention. Median acute care LOS was 12 days and comparable between cohorts. However, the ISUD cohort was frequently discharged against medical advice, or transferred back to acute care hospitals to complete antibiotic courses. Median inpatient hospital costs were approximately $25,000 and were comparable between cohorts. These costs do not reflect inpatient costs once the patient was transferred back to the referring hospital, nor costs for outpatient care. Medicaid and Medicare were the most common primary insurance payers for the ISUD and non-ISUD cohorts, respectively.

Conclusions:

Incidence of PSI has increased significantly coincident with the opioid epidemic and has had significant impact on a large, rural region of NYS. PSIs consume large amounts of healthcare resources. This study can inform hospitals and public health agencies regarding the need for substance abuse harm reduction strategies.