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Smismans A, Vantrappen A, Verbiest F, Indevuyst C, Van den Poel B, von Winckelmann S, Peeters A, Ombelet S, Lybeert P, Heremans A, Frans E, Ho E, Frans J. OPAT: proof of concept in a peripheral Belgian hospital after review of the literature. Acta Clin Belg 2018; 73:257-267. [PMID: 29385901 DOI: 10.1080/17843286.2018.1424503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Since its introduction in the 1970s in the United States, outpatient parenteral antibiotic/antimicrobial therapy (OPAT) has been adopted internationally for long-term intravenous (IV) treatment of stable infectious diseases. The aim is to provide a safe and successful completion of IV antimicrobial treatment at the ambulatory care center or at home without complications and costs associated with hospitalization. OPAT implementation has been accelerated by progress in vascular access devices, newly available antibiotics, the emphasis on cost-savings, as well as an improved patient comfort and a reduced incidence of health care associated infections with a similar outcome. OPAT utilization is supported by an extensive published experience and guidelines of the British Society of Antimicrobial Chemotherapy and the Infectious Diseases Society of America for adults as well as for children. Despite these recommendations and its widespread adoption, in Belgium OPAT is only fully reimbursed and established for cystic fibrosis patients. Possible explanations for this unpopularity include physician unfamiliarity and a lack of uniform funding arrangements with higher costs for the patient. This article aims to briefly review benefits, risks, indications, financial impact for supporting OPAT in a non-university hospital as standard of care. Our experience with OPAT at the ambulatory care center of our hospital and its subsequent recent introduction in the home setting is discussed.
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Affiliation(s)
- Annick Smismans
- Laboratory of Clinical Biology, Imelda Hospital, Bonheiden, Belgium
| | | | | | | | - Bea Van den Poel
- Laboratory of Clinical Biology, Imelda Hospital, Bonheiden, Belgium
| | | | | | - Sara Ombelet
- Internal Medicine, Imelda Hospital, Bonheiden, Belgium
| | - Peter Lybeert
- Internal Medicine, Imelda Hospital, Bonheiden, Belgium
| | | | - Eric Frans
- Internal Medicine, Imelda Hospital, Bonheiden, Belgium
| | - Erwin Ho
- Laboratory of Clinical Biology, Imelda Hospital, Bonheiden, Belgium
| | - Johan Frans
- Laboratory of Clinical Biology, Imelda Hospital, Bonheiden, Belgium
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Mitchell ED, Czoski Murray C, Meads D, Minton J, Wright J, Twiddy M. Clinical and cost-effectiveness, safety and acceptability of community intra venous antibiotic service models: CIVAS systematic review. BMJ Open 2017; 7:e013560. [PMID: 28428184 PMCID: PMC5775457 DOI: 10.1136/bmjopen-2016-013560] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Evaluate evidence of the efficacy, safety, acceptability and cost-effectiveness of outpatient parenteral antimicrobial therapy (OPAT) models. DESIGN A systematic review. DATA SOURCES MEDLINE, EMBASE, CINAHL, Cochrane Library, National Health Service (NHS) Economic Evaluation Database (EED), Research Papers in Economics (RePEc), Tufts Cost-Effectiveness Analysis (CEA) Registry, Health Business Elite, Health Information Management Consortium (HMIC), Web of Science Proceedings, International Pharmaceutical Abstracts, British Society for Antimicrobial Chemotherapy website. Searches were undertaken from 1993 to 2015. STUDY SELECTION All studies, except case reports, considering adult patients or practitioners involved in the delivery of OPAT were included. Studies combining outcomes for adults and children or non-intravenous (IV) and IV antibiotic groups were excluded, as were those focused on process of delivery or clinical effectiveness of 1 antibiotic over another. Titles/abstracts were screened by 1 reviewer (20% verified). 2 authors independently screened studies for inclusion. RESULTS 128 studies involving >60 000 OPAT episodes were included. 22 studies (17%) did not indicate the OPAT model used; only 29 involved a comparator (23%). There was little difference in duration of OPAT treatment compared with inpatient therapy, and overall OPAT appeared to produce superior cure/improvement rates. However, when models were considered individually, outpatient delivery appeared to be less effective, and self-administration and specialist nurse delivery more effective. Drug side effects, deaths and hospital readmissions were similar to those for inpatient treatment, but there were more line-related complications. Patient satisfaction was high, with advantages seen in being able to resume daily activities and having greater freedom and control. However, most professionals perceived challenges in providing OPAT. CONCLUSIONS There were no systematic differences related to the impact of OPAT on treatment duration or adverse events. However, evidence of its clinical benefit compared with traditional inpatient treatment is lacking, primarily due to the dearth of good quality comparative studies. There was high patient satisfaction with OPAT use but the few studies considering practitioner acceptability highlighted organisational and logistic barriers to its delivery.
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Affiliation(s)
- E D Mitchell
- Centre for Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - C Czoski Murray
- Centre for Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - D Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - J Minton
- Department of Infection and Travel Medicine, Leeds Teaching Hospitals NHS Trust, St James's Hospital, Leeds, UK
| | - J Wright
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - M Twiddy
- Centre for Health Services Research, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Minton J, Murray CC, Meads D, Hess S, Vargas-Palacios A, Mitchell E, Wright J, Hulme C, Raynor DK, Gregson A, Stanley P, McLintock K, Vincent R, Twiddy M. The Community IntraVenous Antibiotic Study (CIVAS): a mixed-methods evaluation of patient preferences for and cost-effectiveness of different service models for delivering outpatient parenteral antimicrobial therapy. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BackgroundOutpatient parenteral antimicrobial therapy (OPAT) is widely used in most developed countries, providing considerable opportunities for improved cost savings. However, it is implemented only partially in the UK, using a variety of service models.ObjectivesThe aims of this research were to (1) establish the extent of OPAT service models in England and identify their development; (2) evaluate patients’ preferences for different OPAT service delivery models; (3) assess the cost-effectiveness of different OPAT service delivery models; and (4) convene a consensus panel to consider our evidence and make recommendations.MethodsThis mixed-methods study included seven centres providing OPAT using four main service models: (1) hospital outpatient (HO) attendance; (2) specialist nurse (SN) visiting at home; (3) general nurse (GN) visiting at home; and (4) self-administration (SA) or carer administration. Health-care providers were surveyed and interviewed to explore the implementation of OPAT services in England. OPAT patients were interviewed to determine key service attributes to develop a discrete choice experiment (DCE). This was used to perform a quantitative analysis of their preferences and attitudes. Anonymised OPAT case data were used to model cost-effectiveness with both Markov and simulation modelling methods. An expert panel reviewed the evidence and made recommendations for future service provision and further research.ResultsThe systematic review revealed limited robust literature but suggested that HO is least effective and SN is most effective. Qualitative study participants felt that different models of care were suited to different types of patient and they also identified key service attributes. The DCE indicated that type of service was the most important factor, with SN being strongly preferred to HO and SA. Preferences were influenced by attitudes to health care. The results from both Markov and simulation models suggest that a SN model is the optimal service for short treatment courses (up to 7 days). Net monetary benefit (NMB) values for HO, GN and SN services were £2493, £2547 and £2655, respectively. For longer treatment, SA appears to be optimal, although SNs provide slightly higher benefits at increased cost. NMB values for HO, GN, SN and SA services were £8240, £9550, £10,388 and £10,644, respectively. The simulation model provided useful information for planning OPAT services. The expert panel requested more guidance for service providers and commissioners. Overall, they agreed that mixed service models were preferable.LimitationsRecruitment to the qualitative study was suboptimal in the very elderly and ethnic minorities, so the preferences of patients from these groups might not be represented. The study recruited from Yorkshire, so the findings may not be applicable nationally.ConclusionsThe quantitative preference analysis and economic modelling favoured a SN model, although there are differences between sociodemographic groups. SA provides cost savings for long-term treatment but is not appropriate for all.Future workFurther research is necessary to replicate our results in other regions and populations and to evaluate mixed service models. The simulation modelling and DCE methods used here may be applicable in other health-care settings.FundingThe National Institute for Health Research Health Service and Delivery Research programme.
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Affiliation(s)
- Jane Minton
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - David Meads
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Stephane Hess
- Institute of Transport Studies, University of Leeds, Leeds, UK
| | | | | | - Judy Wright
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Claire Hulme
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | | | - Philip Stanley
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Kate McLintock
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Maureen Twiddy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Gregson D, Evans G, Patrick D, Bowie W. Lyme disease: How reliable are serologic results? CMAJ 2015; 187:1193-1194. [PMID: 26323708 DOI: 10.1503/cmaj.150874] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Dan Gregson
- Division of Infectious Diseases (Bowie), University of British Columbia, Vancouver, BC; Association of Medical Microbiology and Infectious Disease Canada (Evans), Department of Medicine, Queen's University, Kingston, Ont.; School of Population and Public Health (Patrick), University of British Columbia, Vancouver, BC; Association of Medical Microbiology and Infectious Disease Canada (Gregson), Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alta.
| | - G Evans
- Division of Infectious Diseases (Bowie), University of British Columbia, Vancouver, BC; Association of Medical Microbiology and Infectious Disease Canada (Evans), Department of Medicine, Queen's University, Kingston, Ont.; School of Population and Public Health (Patrick), University of British Columbia, Vancouver, BC; Association of Medical Microbiology and Infectious Disease Canada (Gregson), Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alta
| | - David Patrick
- Division of Infectious Diseases (Bowie), University of British Columbia, Vancouver, BC; Association of Medical Microbiology and Infectious Disease Canada (Evans), Department of Medicine, Queen's University, Kingston, Ont.; School of Population and Public Health (Patrick), University of British Columbia, Vancouver, BC; Association of Medical Microbiology and Infectious Disease Canada (Gregson), Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alta
| | - William Bowie
- Division of Infectious Diseases (Bowie), University of British Columbia, Vancouver, BC; Association of Medical Microbiology and Infectious Disease Canada (Evans), Department of Medicine, Queen's University, Kingston, Ont.; School of Population and Public Health (Patrick), University of British Columbia, Vancouver, BC; Association of Medical Microbiology and Infectious Disease Canada (Gregson), Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alta
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Affiliation(s)
- Sandra Pearson
- Independent consultant psychiatrist; medical director and trustee, Lyme Disease Action
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Lyme borreliosis in southern United Kingdom and a case for a new syndrome, chronic arthropod-borne neuropathy. Epidemiol Infect 2014; 143:561-72. [PMID: 24814098 DOI: 10.1017/s0950268814001071] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
This series of serologically confirmed Lyme disease is the largest reported in the UK and represents 508 patients who presented to one hospital in the South of England between 1992 and 2012. The mean rate of borreliosis throughout this period was 9·8/100,000 population, much higher than the reported national rate of 1·7/100,000. The actual rate increased each year until 2009 when it levelled off. Patients clinically presented with rash (71%), neurological symptoms (16%, of whom half had VII cranial nerve palsies), arthropathy (8%), pyrexia (5%), cardiac abnormalities (1%) or other manifestations (<1%). Twenty percent of patients had additional non-specific symptoms of fatigue, myalgia, and cognitive changes. Serological diagnosis was with a two-tiered system of ELISA and immunoblot. There was a marked seasonal presentation in the summer months and in the first and sixth decades of life. A third of patients gave a clear history of a tick bite. The median interval between tick bite and clinical symptoms was 15 days [interquartile range (IQR) 9-28 days], with a further interval of 14 days to clinical diagnosis/treatment (IQR 2-31 days). Most cases were acquired locally and only 5% abroad. Patients responded to standard antibiotic therapy and recurrence or persistence was extremely rare. A second group of patients, not included in the clinical case series, were those who believed they had Lyme disease based on a probable tick bite but were seronegative by currently available validated tests and presented with subjective symptoms. This condition is often labelled chronic Lyme disease. These patients have a different disease from Lyme disease and therefore an alternative name, chronic arthropod-borne neuropathy (CAN), and case definition for this condition is proposed. We suggest that this chronic condition needs to be distinguished from Lyme disease, as calling the chronic illness 'Lyme disease' causes confusion to patients and physicians. We recommend research initiatives to investigate the aetiology, diagnosis and therapy of CAN.
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Outpatient parenteral antimicrobial therapy. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2014; 24:9-11. [PMID: 24421785 DOI: 10.1155/2013/205910] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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MacKenzie M, Rae N, Nathwani D. Outcomes from global adult outpatient parenteral antimicrobial therapy programmes: A review of the last decade. Int J Antimicrob Agents 2014; 43:7-16. [DOI: 10.1016/j.ijantimicag.2013.09.006] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 09/21/2013] [Indexed: 12/16/2022]
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Affiliation(s)
- DA Barr
- Brownlee Centre for Infectious diseases, Gartnavel General Hospital, Glasgow, UK
| | - RA Seaton
- Brownlee Centre for Infectious diseases, Gartnavel General Hospital, Glasgow, UK
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Seaton RA, Barr DA. Outpatient parenteral antibiotic therapy: principles and practice. Eur J Intern Med 2013; 24:617-23. [PMID: 23602223 DOI: 10.1016/j.ejim.2013.03.014] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 03/21/2013] [Accepted: 03/21/2013] [Indexed: 11/27/2022]
Abstract
Outpatient parenteral antimicrobial therapy (OPAT) refers to the administration of a parenteral antimicrobial in a non inpatient or ambulatory setting with the explicit aim of facilitating admission avoidance or early discharge. Whilst OPAT has predominantly been the domain of the infection specialist, the internal medicine specialist has a key role in service development and delivery as a component of broader ambulatory care initiatives such as "hospital at home". Main drivers for OPAT are patient welfare, reduction of risk of health care associated infection and cost-effective use of hospital resources. The safe practice of OPAT is dependent on a team approach with careful patient selection and antimicrobial management with programmed and adaptable clinical monitoring and assessment of outcome. Gram-positive infections, including cellulitis, bone and joint infection, bacteraemia and endocarditis are key infections potentially amenable to OPAT whilst resistant Gram-negative infections are of increasing importance. Ceftriaxone, teicoplanin, daptomycin and ertapenem lend themselves well to OPAT due to daily (or less frequent) bolus administration, although any antimicrobial may be administered if the patient is trained to administer and/or an appropriate infusion device is employed. Clinical experience from NHS Greater Glasgow and Clyde is presented to illustrate the key principles of OPAT as practised in the UK. Increasingly complex patients with multiple medical needs, the relative scarcity of inpatient resources and the broader challenge of ambulatory care and "hospital at home" will ensure the internal medicine specialist will have a key role in the future development of OPAT.
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Affiliation(s)
- R A Seaton
- Brownlee Centre for Infectious Diseases, Gartnavel General Hospital, 1053 Great Western Road, Glasgow, G12 0YN, United Kingdom.
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White B, Seaton RA, Evans TJ. Letter of response to Stricker et al. QJM 2013; 106:202-3. [PMID: 23220703 DOI: 10.1093/qjmed/hcs228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Stricker RB, Delong AK, Johnson L. Outpatient parenteral antibiotic therapy for Lyme borreliosis: a 'real world' view. QJM 2013; 106:201-3. [PMID: 23220702 DOI: 10.1093/qjmed/hcs227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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