Cost-analysis of inpatient and outpatient parenteral antimicrobial therapy in orthopaedics: A systematic literature review

Parenteral Vancomycin in the Treatment of MRSA-Associated Diabetic Foot Infections: An Unnecessary Risk

Diabetic foot infections (DFIs) are a common and costly complication of diabetes. Soft tissue and bone infections in DFIs frequently lead to amputation and/or sepsis which can be costly for both the patient and the healthcare system. Staphylococcus aureus is the most commonly identified causative agent in DFIs, and people with diabetes may have an increased risk of infection with methicillin-resistant Staphylococcus aureus (MRSA). In addition to increased susceptibility to severe infection, MRSA in DFIs is associated with high rates of treatment failure, morbidity, and hospitalization costs meaning appropriate treatment is a high priority. While hospitalized patients are usually treated with intravenous (IV) vancomycin, this can be costly in terms of inpatient stays, staffing costs, and adverse events. For example, vancomycin-associated acute kidney injury not only delays hospital discharge and increases costs but is also a particular concern for patients with diabetes who already have an increased risk of kidney problems. Vancomycin-resistant strains of S. aureus have also been identified, which means that alternative treatment options may need to be explored. Treatment alternatives to IV vancomycin, including oral antibiotics, have been shown to provide similar efficacy, with reduced costs, outpatient or home-based administration, and with fewer serious adverse effects. Although infectious disease specialists often use IV vancomycin alone, or in combination, as a first-line therapeutic option, they are increasingly seeing the value of outpatient or at-home oral antibiotics as an alternative. This manuscript reviews the evidence for true costs of vancomycin therapy for MRSA-associated DFIs and examines the alternatives.

[Cost analysis of inpatient versus outpatient intravenous antibiotic treatment for periprosthetic joint infections : A simulation]

Hintergrund

Die parenterale Antibiotikagabe im Rahmen der Therapie von periprothetischen Infektionen erfordert in der Regel eine stationäre Behandlung und geht mit hohen Kosten einher.

Fragestellung

Es wurden tatsächliche stationäre Behandlungskosten („inpatient parenteral antibiotic therapy“ [IPAT]) mit simulierten Kosten einer ambulanten Behandlung („outpatient parenteral antibiotic therapy“ [OPAT]) von Patienten mit periprothetischen Gelenkinfektionen verglichen. Die Auswertung erfolgte aus Perspektive der Kostenträger (gesetzliche Krankenversicherung [GKV]) und Leistungserbringer (Krankenhäuser).

Material und Methoden

Die Analyse und Simulation erfolgten auf Grundlage einer ICD-10 (Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme, 10. Revision) für das Behandlungsjahr 2015 mit der Diagnose T84.

Ergebnisse

Die simulierte Reduktion von 159 Bettentagen bei den in die Studie eingeschlossenen 12 Patienten erbrachte aus Sicht der Kostenträger eine Reduktion der Gesamtkosten um >18.000 €. Aus Perspektive der Leistungserbringer verbesserte sich der Reinerlös um >22.000 €. Die Gesamtkosten der OPAT für den Kostenträger beliefen sich auf >57.000 €. Für den Leistungserbringer zeigte sich in der Differenz von Poliklinikerlös und -kosten der OPAT ein Verlust von >1500 €.

Diskussion

Die OPAT ist für Leistungserbringer insgesamt finanziell vorteilhaft. Weitere Vorteile durch Opportunitätskosten erscheinen interessant. Für den Kostenträger ist die OPAT insbesondere durch die ambulanten Medikamentenkosten mit einem finanziellen Mehraufwand verbunden. Der niedergelassene Sektor sollte durch die anzunehmende Mehrbelastung ebenso wie der anzunehmende Patientenkomfort bedacht werden.

Clinical benefits and costs of an outpatient parenteral antimicrobial therapy service

BACKGROUND

The enrolment of patients to an outpatient parenteral antimicrobial therapy (OPAT) service can be a means of mitigating financial burdens related to the provision of care and optimisation of hospital bed management.

OBJECTIVE

This study aimed to identify the clinical benefit of the Maltese OPAT service and to quantify the costs incurred to run it.

METHODS

The study period ran for 156 weeks during 1st October 2016 to 1st October 2019. Patient demographics, infection type, referring care team, antimicrobial agent/s used, type of vascular access device (VAD) available and service completion status (defined as provision of care without re-hospitalisation) were recorded. Time allocated for OPAT service delivery and expenses incurred were collected and an activity-based costing exercise was performed.

RESULTS

The patient population who benefited from the service was of 117, 15 of whom used the service twice, for a total of 132 episodes. Patients received 149 antimicrobial treatment courses, with ceftriaxone being the most common single agent used (n = 52, 34.9%). Teicoplanin with ertapenem was the most common regimen selected for combination therapy (n = 9, 52.9%). A total of 23 episodes (17.4%) resulted in a readmission, 6 (30%) of which were because of patient deterioration. The mean service running weekly cost was €455.47/$538.68 and a total of 3287 days of hospital stay were avoided. This effectively illustrates that the OPAT service optimised hospital bed availability without compromising care delivery.

CONCLUSION

The national OPAT service proved to be a safe and effective alternative for patient management to promote patient-centred care without hospitalisation.