1984. Implementation of an integrated infectious disease and substance use disorder team for the treatment of severe injection-related infections

Background

Hospitalizations for severe injection drug use-related infections (SIRIs) are characterized by high costs, frequent patient-directed discharge, and high readmission rates. Beyond the health system impacts, these admissions can be traumatizing to people who inject drugs (PWID), who often receive inadequate treatment for their substance use disorders (SUD). The Jackson SIRI team was developed as an integrated infectious disease/SUD treatment team for patients hospitalized at a public safety-net hospital in Miami, Florida in 2020. In order to facilitate implementation of this team, we conducted a qualitative study of patients and providers to identify barriers and facilitators to the team’s success.

Methods

Participants were patients with history of SIRIs (n=7) at the Jackson Memorial Hospital (JMH) and healthcare providers (HCPs) (n=8) at JMH. Semi-structured qualitative interviews were performed with a guide created using the Consolidated Framework for Implementation Science (CFIR). Interviews were transcribed and double coded by study team members using determinants adapted from the CFIR.

Results

Key barriers to SIRI team success included: 1) complexity of SIRI and SUD care requiring multidisciplinary teams and resources; 2) lack of resources for PWID experiencing homelessness, financial insecurity, and uninsured status; 3) stigma and lack of knowledge around addiction and medications for SUD; and 4) suspected understaffing and underfunding for the team. Facilitators of team success included: 1) holistic, integrated care being more efficient and effective than fragmented care; 2) the team’s advocacy for PWID as a means of institutional culture change; 3) provision of close post-hospital follow-up for an often-abandoned population; 4) non-judgmental, harm reduction-oriented approach; and 5) addressing diverse needs such as housing, insurance, and psychological wellbeing.

Conclusion

Integration of infectious disease and substance use disorder treatment is a promising approach to managing patients with SIRIs; however, success depends on institutional buy-in, holistic care beyond the medical domain, and an ethos rooted in harm reduction.

Disclosures

Susanne Doblecki-Lewis, MD, MSPH, Gilead Sciences: Grant/Research Support.

1643. Infectious Sequelae of Injection Drug Use at a County Safety-Net Hospital Decline Following Establishment of a Syringe Service Program

Background

Infectious sequelae of injection drug use (ISIDU) and overdose are frequent but preventable among people who inject drugs (PWID). Syringe service programs (SSP) are an evidence-based harm reduction strategy to reduce incidence of ISIDU among PWID. Additionally, SSPs are noted to produce significant cost-savings for healthcare systems. Under current state legislation, Miami houses the only SSP in Florida, the IDEA SSP. This study builds on previous work characterizing morbidity and cost of ISIDU. This study sought to evaluate differences in admission rates and associated ISIDU costs at Jackson Memorial Hospital (JMH) in Miami before and after implementation of the IDEA SSP.

Methods

Retrospective data collected from a chart review of patients hospitalized for ISIDU and overdose was used to evaluate morbidity and cost of ISIDU at JMH from December 1, 2015 to December 1, 2017, stratified by December 1, 2016—the opening of the IDEA SSP—as an index date. An algorithm utilizing ICD-10 codes for drug use and sequelae was used to identify PWID population. Specific infections investigated were: endocarditis, osteomyelitis, bacteremia- and/or -sepsis (BOS), and skin-and-soft-tissue-infections (SSTIs). Pearson’s chi-square test for independence used to report P-values for associations between infections and total charges using a 2-tailed t-test.

Results

726 admissions were identified during the study period, 328 PWID in the pre-index cohort vs. 398 in the post-index cohort. The median age of total sample was 45.24. 95.12% of the pre-index cohort were uninsured or had publicly-funded insurance vs. 96.48% post-index. Most ISIDU did not change significantly between pre-post cohorts, although bacteremia and sepsis declined significantly among opioid injectors (P = 0.026). Overdoses decreased significantly among PWID generally (57% decline pre-post; P = 0.0006), as well as for patients who inject opioids specifically (70% decline pre-post; P = 0.0034). Median cost declined by 20.5% among PWID, and 29.1% among opioid injectors in particular.

Conclusion

ISIDU continues to represent significant morbidity for PWID in Miami-Dade County and substantial cost to the health system. Severe infections, including bacteremia and sepsis, declined significantly among opioid injectors, the PWID subset most strongly associated with local SSP services. This change following the establishment of a local SSP suggests direct effects on the frequency of hospital admissions for ISIDU. Despite local increases in drug use, overall PWID frequency and ISIDU charges did not change significantly. OD and admission frequency amongst opioid users and cost-per-patient declined between groups, suggesting a potential decrease in ISIDU and attendant costs. While median charges per admission declined, they were statistically insignificant and may represent stagnation in ISIDU-associated costs following SSP establishment. Diminishment in opioid user admissions and OD suggest additional possible positive epidemiological effects of the SSP. Weaknesses included difficulty of associating outcomes, limited post-index time period, and potential misclassification when establishing a standardized algorithm for PWID identification.

Disclosures

All authors: No reported disclosures.

The Hepatitis C Virus Care Continuum: Linkage to Hepatitis C Virus Care and Treatment Among Patients at an Urban Health Network, Philadelphia, PA

Improving care and treatment for persons infected with hepatitis C virus (HCV) can reduce HCV-related morbidity and mortality. Our primary objective was to examine the HCV care continuum among patients receiving care at five federally qualified health centers (FQHCs) in Philadelphia, PA, where a testing and linkage to care program had been established. Among the five FQHCs, one served a homeless population, two served public housing residents, one served a majority Hispanic population, and the last, a "test and treat" site, also provided HCV treatment to patients. We analyzed data from electronic health records of patients tested for HCV antibody from 2012 to 2016 and calculated the percentage of patients across nine steps of the HCV care continuum ranging from diagnosis to cure. We further explored factors associated with successful patient navigation through two steps of the continuum using multivariable logistic regression. Of 885 chronically infected patients, 92.2% received their RNA-positive result, 82.7% were referred to an HCV provider, 69.4% were medically evaluated by the provider, 55.3% underwent liver disease staging, 15.0% initiated treatment, 12.0% completed treatment, 8.7% were assessed for sustained virologic response (SVR), and 8.0% achieved SVR. Regression results revealed that test and treat site patients were significantly more likely to be medically evaluated (adjusted odds ratio [aOR], 2.76; 95% confidence interval [CI], 1.82-4.17) and to undergo liver disease staging (aOR, 1.92; 95% CI, 1.02-2.86) than patients at the other FQHCs combined. Conclusion: In this US urban setting, over two thirds of HCV-infected patients were linked to care; although treatment uptake was low overall, it was highest at the test and treat site; scaling up treatment services in HCV testing settings will be vital to improve the HCV care continuum.

Sonographic evaluation and conservative management of newborns with myelomeningocele and hydronephrosis

Hydronephrosis has been reported in 7 to 60 per cent of all newborns with myelomeningocele. However, most of these reports have been based upon x-ray findings obtained after closure of the myelomeningocele. To determine whether the radiographic abnormalities might be secondary to the neurosurgical procedure in a manner analogous to spinal shock, a prospective study of 34 newborns with myelomeningoceles was done during a 5-year period. Renal and bladder sonography was done on day 1 of life before surgical intervention and for varying periods thereafter. A total of 31 infants (91 per cent) had normal renal sonograms preoperatively but 6 of these had bilateral hydronephrosis and distended bladders postoperatively. Three patients had urinary retention before postoperative sonography could be obtained. For these 9 patients intermittent catheterization was required for 4 to 14 days until bladder tone recovered. Urinary retention in the infant with myelomeningocele may be a transient consequence of the myelomeningocele repair and should be treated conservatively for at least 2 weeks before surgical intervention is considered seriously.