Effectiveness of telemedicine in outpatient parenteral antimicrobial therapy (Tele-OPAT): A systematic review

INTRODUCTION

Telemedicine is increasingly used to deliver healthcare in many clinical specialities. However, the adoption of telemedicine in the delivery of outpatient parenteral antimicrobial therapy (OPAT) has been relatively slow and limited. This study aims to collate current evidence for telemedicine in OPAT regarding clinical efficacy, safety, acceptability and cost-effectiveness.

METHODS

We systematically searched the Cochrane Library, CINAHL, EMCARE, EMBASE and MEDLINE databases through 24 July 2022, for relevant studies published in English. Research articles and conference abstracts were included if they involved any form of telephone or video consultation in delivering parenteral antibiotics in the home or outpatient setting. Study findings were synthesised into three main themes: patient outcomes and safety, patient and provider satisfaction and cost-effectiveness. The mixed methods appraisal tool was used to review the methodological quality of the studies. PROSPERO CRD42022342874.

RESULTS

The literature search yielded 311 articles, of which 12 (five full-length articles and seven conference abstracts) reporting over 1245 telemedicine interventions were reviewed. The reported outcomes were heterogeneous. Telemedicine was cost-effective and associated with high patient satisfaction and comparable complication rates compared to conventional OPAT. Considering six comparative studies, rehospitalisation risk was lower for telemedicine than conventional OPAT (risk ratio, 0.58; 95% confidence interval, 0.38-0.88; I2  =  31%).

DISCUSSION

The results of this review demonstrate that telemedicine has a role in delivering safe and cost-effective OPAT care, especially for patients residing in remote and geographically isolated locations. Nevertheless, high-quality studies and publication of existing data and experiences are needed to further validate this model of care delivery.

Recent innovations and new applications of outpatient parenteral antimicrobial therapy

INTRODUCTION

Outpatient parenteral antimicrobial therapy (OPAT) is safe and effective for selected patients managed within an organized clinical service. Service configurations however are evolving, patient populations are changing and new evidence is emerging which challenges traditional OPAT practice.

AREAS COVERED

This review will discuss evolving OPAT service delivery from the traditional model of infusion center toward nonspecialist, community and remotely delivered OPAT and the challenges this represents. We consider new patient populations including those with incurable infection or infections at the end of life and difficult to reach populations including people who inject drugs. The evidence base that underpins the multi-disciplinary approach to OPAT delivery will be examined and particularly the role of the antimicrobial pharmacist and specialist nurse. Evidence for new treatment options which challenge established OPAT practice including complex oral antibiotic regimens, long acting parenteral agents and drug stability in continuous infusion antibiotics will be considered. Finally we emphasize the central importance of antimicrobial stewardship and good clinical governance which should underpin OPAT practice.

EXPERT OPINION

Changing patient populations, service structures and team roles coupled with a growing infection management evidence base means that OPAT services and practice must evolve. Challenging traditional practice is essential to ensure best patient outcomes and cost-efficiency.

Teleoncology for children with cancer: A scoping review on applications and outcomes

BACKGROUND AND OBJECTIVES

Teleoncology can be used to reduce the limitations due to the lack of access to specialists, inadequate resources and training, and reducing unnecessary travels and arising of the costs. The purpose of this study was to review the literatures to identify and classify the areas of application and outcomes of using teleoncology in diagnosis, management, and treatment of children with cancer.

METHODS

This scoping review of the published literatures was conducted by searching the Web of Science, PubMed/Medline, Scopus, and Cochrane Library databases in October 2019. Studies investigated telemedicine in diagnosis, management, and treatment of cancer in children were also included. We identified and classified different applications and the reported outcomes of this technology.

RESULTS

In this study, 1834 articles were retrieved, and after removing the unrelated and duplicated articles, 20 articles were reviewed ultimately. We found that, teleoncology services were provided to the patients with cancer, their parents, and nurses in various clinical fields such as telepathology, telemental care (telepsychology), teleneurology, teledermatology, telehematology, and teleophthalmology. The findings also showed that, the outcomes of using telemedicine in children with cancer can be classified into six general categories (five primary and 14 secondary outcomes). Primary outcomes including diagnosis accuracy, reduced costs as well as mortality and secondary outcomes consist of improved relationship and training, better care management, satisfaction, and workload.

CONCLUSION

The use of telemedicine for children with cancer is growing, and there is a tendency for using this technology for families and clinical staff. Providing teleoncology services to children with cancer may improve diagnosis accuracy and reduce the cost and mortality rate. Also, better care management, appropriate relationships and training, increased satisfaction, and decreased workload may be achieved.

Updated good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) in adults and children in the UK

UK good practice recommendations for outpatient parenteral antimicrobial therapy (OPAT) were published in 2012 and 2015 for adult and paediatric patients, respectively. Here we update the initial good practice recommendations in a combined document based on a further review of the OPAT literature and an extensive consultation process. As with the previous good practice recommendations, these updated recommendations are intended to provide pragmatic guidance for new and established OPAT services across a range of settings and to act as a set of quality indicators for service evaluation and quality improvement.

Outpatient Parenteral Antimicrobial Therapy in Children

PURPOSE OF REVIEW

Over recent years, there has been a marked increase in the number of centres delivering paediatric outpatient parenteral antimicrobial therapy (pOPAT). Various factors have fuelled this drive, including the significant economic pressures faced by high-income countries to contain the cost of healthcare, resulting in a significant reduction of in-patient beds over the past 20 years. It is essential that pOPAT services have formal clinical governance structures in place to ensure the safe and effective management of children being ambulated on intravenous antibiotics. They also require oversight of antimicrobial decisions by a medically qualified infection specialist to ensure that the principles of antimicrobial stewardship are adhered to. This review aims to provide an evidence-based framework for delivering pOPAT services.

RECENT FINDINGS

There is increasing data supporting the implementation of admission avoidance strategies for children with cellulitis and pyelonephritis. In addition, recent data supports the management of a subset of children with febrile neutropenia within pOPAT services. Above all, there is a clear recognition that embedding antimicrobial stewardship within pOPAT services reduces duration of intravenous antibiotics (IVAbs) and improves patient management. pOPAT services are safe, cost-effective and associated with high levels of parent/patient satisfaction. Further research is required to develop risk prediction models for children being considered for pOPAT. Further data about the use of elastomeric devices in children and the acceptability of parental administration of IVAbs are also required.