Management of suspected Lyme borreliosis: experience from an outpatient parenteral antibiotic therapy service

OBJECTIVES

Lyme borreliosis (LB) is the most common human tick-borne infection in Europe and the USA. In this study we set out to analyse the outcome of patients treated for Lyme disease via outpatient parenteral antibiotic therapy (OPAT) and the appropriateness of this treatment using current guidelines.

METHODS

This was a retrospective review of all patients with suspected LB managed via OPAT in Glasgow in 2000-11.

RESULTS

Of 72 patients treated for suspected LB, 35 patients (49%) were treated in accordance with guidelines and 36 (50%) were treated with no specific guidelines. A definite improvement was seen in 20 patients (28%). Adverse reactions were documented in 29 (40%) patients with neutropenia, and mild liver function derangement was most commonly observed.

CONCLUSION

These results show the complexity of translating well-substantiated regimens from clinical trials to actual clinical practice. OPAT was an effective way of administering parenteral therapy for Lyme disease but should not be undertaken lightly due to the rate of adverse events and low rates of success in certain patient groups seen in this study. In view of this, stricter criteria for inclusion to OPAT in line with published guidance should be applied to minimize patient harm and optimize success.

Pediatric home chemotherapy: infusing "quality of life"

A pediatric home chemotherapy program is described that has operated as part of the pediatric oncology services at the Children's Hospital at Montefiore since 2004. Currently the chemotherapy regimens include high-dose methotrexate; 5-day high-dose ifosfamide and etoposide; cyclophosphamide, doxorubicin, and vincristine; ifosfamide, carboplatin, and etoposide; and cisplatin and doxorubicin. The pediatric hematology/oncology program provides care to children with blood disorders and cancer of Bronx, NY, and surrounding areas. By providing patients receiving chemotherapy treatment with this special type of home infusion capability, the child and his or her family are able to spend more time at home and have less disruption in their family schedule.

[Dobutamine therapy at home under the guidance of a nurse practitioner, either as a bridge to cardiac transplantation or as destination therapy in severe heart failure]

OBJECTIVE

To evaluate the results of intravenous dobutamine therapy at home for ambulatory patients with severe heart failure.

DESIGN

Retrospective.

METHOD

Data were retrieved for the 40 patients that had been treated with intravenous dobutamine at home during the period from 1 January 1994 until mid-November 2006 at the Thorax Centre of Groningen University Medical Centre, The Netherlands. The patients were guided by a nurse practitioner.

RESULTS

The study group comprised 31 men and 9 women. The 22 patients on the waiting list for a heart transplant had an average age of 49 years. For the other 18 patients, on average 63 years old, it was destination therapy. The mean administered dosage ofdobutamine was 4 microg/kg/ min (range: 2-10). Pre-transplantation and destination therapy were given for an average of 3.5 and 1.5 months, respectively. A successful transplantation was performed in 14 (64%) of the 22 waiting-list candidates; 2 patients were still on the waiting list and 6 died while on the waiting list. Intravenous access complications and ICD shocks each occurred in 6 (15%) patients. The quality of life was reasonable to fair in the waiting-list patients and moderate to reasonable in those given destination therapy. The costs for medication and hire of the infusion pump were Euro 450 per month.

CONCLUSION

Dobutamine infusion therapy at home under the guidance of a nurse practitioner, either as a bridge to cardiac transplantation or as destination therapy in patients with severe heart failure, appeared safe, feasible and not expensive.

[Infusion of inotropic agents at home in patients with severe heart failure: an important role for the nurse practitioner]

Patients with severe heart failure commonly require intravenous inotropic agents to stabilise their haemodynamics and improve the clinical symptoms. Continuous intravenous inotropic agents in a home-based setting under the direction of specialised nurses has been introduced in patients waiting for cardiac transplantation and also as destination therapy. Since 1982, several case reports and case series have described the use of ambulatory intravenous dobutamine, but almost none of the available studies included a control group. Moreover, most trials were small and short in duration, and thus have not been able to provide reliable information about the effect of treatment on the risk of serious cardiac events. However, these data consistently demonstrate the feasibility of home infusion as well as an improved quality of life and reduced costs. Therefore, home infusion of dobutamine guided by a specialised nurse may be desirable in patients waiting for heart transplantation or as destination therapy in the last weeks of life.

[IgIV at home:experience of a center--economic aspects]

BACKGROUND

Intravenous Human immunoglobulin (IVIg) administration is a safe and efficacious treatment in IgG deficiency and auto-immune diseases. The most of the patients treated in hospital ask for home treatment.

MATERIAL AND METHODS

[corrected] Two cost studies were performed: on study comparing the cost of IVIg in hospital and at home in auto-immune diseases and another evaluating the cost of SCIg and IVIg in hospital and at home in immune deficiency.

RESULTS

The Home treatment by the IVIg is possible with a care society and safe. Any serious adverse events is occurred, because of a good selection of the patients. The total cost of IVIg seems to be cheaper at home than the hospital treatment with IVIg and home treatment with SCIg.

CONCLUSION

The home IVIg substitution is possible. This alternative can be proposed at the patient with a stable clinical status, according to his hope and the wish of his family. This alternative is interesting for the life quality and the cost.

Home Inotropic Therapy in Children

BACKGROUND

Inotropic therapy is a well-established practice for children with advanced congestive heart failure (CHF). Traditionally, children have been maintained on inotropic therapy in the hospital under close, monitored supervision. Changes to UNOS listing criteria now allow patients awaiting heart transplantation to be discharged to home yet maintain 1B status. In adults, home inotropic therapy has been shown to be a safe and cost-effective bridge to transplantation. To date, there are limited data on the use of home inotropic therapy in children.

METHODS

We reviewed the safety and efficacy of continuous ambulatory home inotropic therapy in children. Data were obtained from a single institution from January 2000 to January 2007.

RESULTS

There were 14 pediatric patients with end-stage CHF, who received home intravenous inotropic therapy. The indications for home inotropic therapy included palliative care (n = 8) and awaiting heart transplantation (n = 6). Patients ranged in age from 6 to 18 years (median 14.5 years). The majority of subjects (n = 11) received milrinone at a dose of 0.5 to 1.0 mug/kg/min, 2 received dobutamine at 5 mug/kg/min, and 1 received both agents. Duration of therapy ranged from 14 to 476 days (median 68 days). There were 26 hospital re-admissions and 4 suspected catheter infections. No unexpected deaths or pump failures occurred.

CONCLUSIONS

Based on this initial review, continuous home inotropic therapy in children with CHF is safe with few complications. Home inotropic therapy may result in substantial cost-savings and improve family dynamics by avoiding prolonged hospitalization.

[Efficiency of the home intravenous antibiotics treatment in cystic fibrosis]

BACKGROUND AND OBJECTIVE

The objective of our study was to determine the costs saving with the implementing of a home intravenous antibiotic treatment (HIVAT) program for patients with cystic fibrosis and to compare it with the conventional system (inpatient).

PATIENTS AND METHOD

Consecutive patients in an adults cystic fibrosis unit were selected who received some days of HIVAT, between January 2002 and December 2004. For the analysis of costs saving of the HIVAT, we used the difference between the total costs of the avoided stay days and the costs generated by the domiciliary therapy (drugs, expendable equipment) and by the ambulatory medicine unit in case the patients were not hospitalized. All patients received a therapy with an intravenous antibiotic for a minimum of 14 days. All these data were provided by the accounting service of the hospital with the aid management Clinical Financier Program (GECLIF).

RESULTS

22 patients with cystic fibrosis needed 85 intravenous antibiotics treatments during the 3 years of the study, of which: 43 cycles were completely domiciliary, 14 inpatient and 28 were combined (hospital and home). The 71 cycles of HIVAT originated 909 days at home, with an average (standard deviation) of 12.80 (4.18) days and 43 treatments in ambulatory medicine unit. The home antibiotic treatments that originated greater cost (3,964.34 Euro) was meropenem (1 g/6 h) i.v. with linezolid (600 mg/12 h) via oral combination during 14 days, and in second place the association of ceftazidime, tobramycine and linezolid, whose cost in cycle of 14 days was of 2464.84 Euro. The average saving cost in the 3 years of study was of 2,647.29 Euro by each cycle of HIVAT and global 197,689.78 Euro.

CONCLUSIONS

HIVAT obtained important sanitary costs saving and this was greater every year, not due to the increase of days at home, but due to the rising cost per day of hospital stays every new year.

Outpatient parenteral antibiotic therapy in Singapore

Outpatient parenteral antibiotic therapy (OPAT) remains in its infancy in Singapore, with the first patients enrolled 4 years ago. Singapore's three largest hospitals, with over 3000 inpatient beds, now have designated and approved OPAT services. This study reviews the demographic, clinical and cost data of all patients enrolled in 2005 to facilitate benchmarking between services in Singapore and abroad and also to identify common needs for further development. In 2005, 225 OPAT enrollments in 208 different patients resulted in 4050 days of OPAT care. Orthopaedic diagnoses constituted 40% of admissions. Vancomycin was the most frequently used antibiotic (34%). The re-admission rate was 8.9%, but complications of OPAT care were only occasionally implicated. An estimated $207,200 was saved by patients despite there being significant financial disincentives to subsidised patients. OPAT is a safe, cost-efficient system that is becoming increasingly accepted in Singapore by patients, clinicians and management. Our three services have evolved independently into very similar practices. There is potential for further innovation, including outreach and carer-delivered dosing. However, major financial disincentives require review.

[Outpatient parenteral antimicrobial therapy (OPAT) in bone and joint infections]

The medical treatment of many bone and joint infections (including chronic osteomyelitis, prosthetic joint infection, and septic arthritis) requires prolonged intravenous antimicrobial therapy. For some patients, this treatment could be administered outside the hospital in a program that offers outpatient parenteral antimicrobial therapy (OPAT). In France, we have no registry of patients receiving OPAT. Initiation of this program requires specific criteria based on a patient evaluation and selection, and an interdisciplinary team of professionals committed to high-quality patient care. Various vascular access devices and infusion pump therapy are used to administer OPAT. The most common parenteral agents for OPAT are beta-lactams and glycopeptids (specifically vancomycin). Antimicrobial courses are stopped prematurely in 3 to 10% of the cases because of an adverse reaction or vascular access complications. Several published studies demonstrate the effectiveness of OPAT and higher patient satisfaction than hospital care. In addition, OPAT is clearly more cost-effective than intravenous therapy provided in the hospital setting. Some diagnoses, such as cellulites, community-acquired pneumonia, and endocarditis may be managed with OPAT.

Willingness to pay to assess patient preferences for therapy in a Canadian setting

Background

Adult outpatient parenteral antibiotic therapy (OPAT) programs have been reported in the literature for over 20 years, however there are no published reports quantifying preference for treatment location of patients referred to an OPAT program. The purpose of this study was to elicit treatment location preferences and willingness to pay (WTP) from patients referred to an OPAT program.

Methods

A multidisciplinary, single centre, prospective study at a 1000-bed Canadian adult tertiary care teaching hospital. This study involved a WTP questionnaire that was administered over a 9-month study period. Eligible and consenting patients referred to the OPAT program were asked to state their preference for treatment location and WTP for a hypothetical treatment scenario involving intravenous antibiotic therapy. Multiple linear regression analysis was performed to determine predictors of WTP.

Results

Of 131 eligible patients, 91 completed the WTP questionnaire. The majority of participants were males, married, in their sixth decade of life and had a secondary school education or greater. The majority of participants were retired or they were employed with annual household incomes less than $60,000. Osteomyelitis was the most common type of infection for which parenteral therapy was required. Of those 87 patients who indicated a preference, 77 (89%) patients preferred treatment at home, 10 (11%) patients preferred treatment in hospital. Seventy-one (82%) of these patients provided interpretable WTP responses. Of these 71 patients, 64 preferred treatment at home with a median WTP of $490 CDN (mean $949, range $20 to $6250) and 7 preferred treatment in the hospital with a median WTP of $500 CDN (mean $1123, range $10 to $3000). Tests for differences in means and medians revealed no differences between WTP values between the treatment locations. The total WTP for the seven patients who preferred hospital treatment was $7,859 versus $60,712 for the 64 patients who preferred home treatment. Income and treatment location preference were independent predictors of WTP.

Conclusion

This study reveals that treatment at home is preferred by adult inpatients receiving intravenous antibiotic therapy that are referred to our OPAT program. Income and treatment location appear to be independently associated with their willingness to pay.

Home continuous positive inotropic infusion as a bridge to cardiac transplantation in patients with end-stage heart failure

BACKGROUND

The clinical use of positive inotropic therapy at home in patients awaiting cardiac transplantation has not been reported since United Network for Organ Sharing (UNOS) regulations were changed to allow home infusions in Status 1B patients.

METHODS

We observed 21 consecutive patients with UNOS 1B status during positive inotropic therapy at home. We used hemodynamic monitoring at the initiation of therapy to optimize dosing. We selected for home therapy patients with stable clinical status and improved functional capacity during inotropic treatment. Implantable cardioverter defibrillators were placed in all but 1 patient before discharge.

RESULTS

Initial positive inotropic therapy included dobutamine in 12 patients (mean dose, 4.5 mcg/kg/min; range, 2.5-7.5 mcg/kg/min), milrinone in 8 patients (mean dose, 0.44 mcg/kg/min; range, 0.375-0.55 mcg/kg/min), and dopamine at a dose of 3 mcg/kg/min in 1 patient. Patients had improved functional capacity (New York Heart Association Class 3.7 +/- 0.1 to 2.4 +/- 0.2, p < 0.01), improved renal function (serum creatinine, 1.5 +/- 0.1 to 1.3 +/- 0.1, p < 0.01), improved resting hemodynamics, and decreased number of hospitalizations during positive inotropic infusion therapy when compared with pre-treatment baseline. Implantable cardioverter defibrillator discharges were infrequent (0.19 per 100 patient days of follow-up). Actuarial survival to transplantation at 6 and 12 months was 84%.

CONCLUSIONS

Continuous positive inotropic therapy at home was safe and was associated with decreased health care costs in selected patients awaiting cardiac transplantation.

Comparative costs of home positive inotropic infusion versus in-hospital care in patients awaiting cardiac transplantation

BACKGROUND

Outpatient positive inotropic support combined with implantation of an automatic implantable cardioverter defibrillator (AICD) may be used as a successful bridge to cardiac transplantation in patients with end-stage heart failure. A detailed comparative cost analysis of this outpatient strategy versus in-hospital care has not been previously reported.

METHODS AND RESULTS

Twenty-one United Network for Organ Sharing 1B patients awaiting cardiac transplantation received continuous outpatient inotropic therapy for a total of 3070 patient-days. Daily costs for outpatient and in-hospital treatment were calculated. Nonparametric decision analysis was used to determine the strategy with greatest cost savings (immediate hospital discharge after AICD implantation versus in-hospital care). A threshold analysis was performed to test the robustness of the decision analysis model. The outpatient strategy realized an average savings of $71,300 to $120,500 per patient. Decision analysis showed that no fixed period of in-hospital monitoring was more cost-saving than immediate hospital discharge after AICD implantation. Threshold analysis revealed that AICD costs would need to exceed $82,000 (currently $62,000) or that the difference between the outpatient and the in-hospital costs would need to be < or = $475 per day for any other intermediate strategy to be considered cost-saving.

CONCLUSION

Outpatient inotropic therapy combined with AICD implantation in selected patients awaiting cardiac transplantation is an effective cost-minimizing strategy.

Subcutaneous immunoglobulin replacement in primary immunodeficiencies

The use of small portable pumps for subcutaneous infusion of IgG in patients with primary immunodeficiencies was introduced more than 20 years ago. In the US, i.v.i.g. became more popular, but in other countries, many patients use the subcutaneous route. Pharmacokinetics of IgG differ when smaller doses are given more frequently, as is commonly done with subcutaneous regimens, as compared to the large boluses given every 21-28 days in most i.v. regimens. Differences include lower peaks and higher troughs, which may be preferable for some patients. Advantages of the subcutaneous route include increased patient autonomy, decreased systemic adverse effects, and the lack of a requirement for vascular access. Disadvantages include limitation in the volume that can be administered at any one time, necessitating frequent dosing; and the requirement for reliability if a patient is to self or home infuse. Obstacles may be encountered because no preparation of IgG is currently licensed for subcutaneous use in the US. Subcutaneous IgG replacement may be preferable to i.v. infusions or i.m. injections for carefully selected patients.

Achieving change in the NHS: a study to explore the feasibility of a home-based cancer chemotherapy service

A major focus of current health policy in the United Kingdom is the development of services that meet the public's expectations. To achieve this there is a need to evaluate current provision to ensure that the best use is made of finite resources. The study reported here adopted an interview approach to examine an existing outpatient chemotherapy service, and to consider the feasibility of introducing a home based model. Following a review of literature on this topic data were obtained from in-depth interviews with patients and professionals regarding the present service. These were then combined with an analysis of service contracts and financial estimates. The poor quality of much of the cost-related information limited the conclusions which could be drawn, and emphasised the need for access to more accessible and robust financial information upon which to base change. The study also illustrated the benefits of feasibility studies; especially when cost-effectiveness and patient satisfaction are the driving forces behind proposed changes to clinical services.

Continuous subcutaneous terbutaline administration prolongs pregnancy after recurrent preterm labor

OBJECTIVE

This study was undertaken to study the effectiveness of continuous subcutaneous terbutaline (SQT) in the home after recurrent preterm labor (RPTL).

STUDY DESIGN

Women with RPTL at less than 32 weeks' gestation were treated with continuous SQT administered in the home compared with matched control patients.

RESULTS

Fifteen SQT patients were compared with 45 women (3:1) treated with no tocolytic therapy after hospitalization. Gestational age at delivery more than 37 weeks (53% vs 4%), percentage delivered at less than 32 weeks (0% vs 47%), overall and pregnancy prolongation (49.8 +/- 19.2 days vs 24.5 +/- 12.8 days) were all significantly better in the study group (P <.001). The total number of maternal hospital days (9.8 +/- 2.1 vs 15.9 +/- 7.4, P <.0001), duration of NICU stay (1.9 +/- 4.9 vs 19.8 +/- 29.3 days, P <.001), and total cost for newborn care (6,995 +/- 14,822 US dollars vs 62,033 +/- 89,978 US dollars, P <.002) favored the study patients. For every dollar spent on SQT, there was a savings of 4.67 US dollars in newborn hospital costs for control patients.

CONCLUSION

In this small study, the use of SQT significantly prolongs pregnancy, decreases serious neonatal complications, and reduces the duration of hospitalization for both mother and infant, as well as neonatal costs.

Geriatric assessment and management protocols: issues for home infusion therapy providers

The accurate assessment of patients' health, functional abilities, and sociobehavioral status is essential for providing quality, cost-effective infusion services to home-based elders. Baseline and ongoing assessment identifies serious current, emerging, and potential problems, and facilitates interventions to prevent significant comorbidities and premature mortality. Three types of assessment (screening, intermediate or evaluation, and comprehensive) have been used successfully with geriatric populations across a variety of settings to improve patient outcomes. Further, Medicare now requires the completion of an OASIS assessment for the reimbursement of home health services to all seniors. Geriatric assessment has been found to improve care quality and cost effectiveness, but protocol development and evaluation can be challenging. Home infusion therapy providers, encouraged to implement and evaluate evidence-based assessment and management protocols, question the usefulness of these protocols, especially for short-term geriatric patients. Research, education, and policy strategies can be used to overcome the many barriers to developing quality, cost-effective assessment and management protocols for elderly home infusion therapy recipients.

Why is high-tech healthcare at home purchasing underdeveloped and what could be done to improve it?

Executive Letter (95)5 initiated a change of health policy preventing general practitioners (GPs) from prescribing packages of "high-tech healthcare at home" (HTHC). From 1 April 1995, district health authorities were required to establish contracts to purchase such care. Several reasons were behind this policy change including the belief that contracting would improve service quality by encouraging competition between potential suppliers, securing better value for money, and establishing service specifications and monitoring mechanisms. Our survey of 98 health authorities, however, highlighted that contracting for home total parenteral nutrition, intravenous antibiotics for patients with cystic fibrosis, intravenous chemotherapy and continuous ambulatory peritoneal dialysis is largely undeveloped. The majority of districts contracted with historic providers and authorities freely admitted that they did not know whether they were obtaining value for money or a service of adequate quality. Only three districts had developed a strategy for purchasing HTHC as required by the Executive Letter, and only 17 had plans to re-examine their approach. Contracting for HTHC presents practical problems, including the complexity of the process and the significant time demands for efficient and effective contracting. Phase two of this research sought to produce a "guide to good practice" for health authorities wishing to re-examine and improve their purchasing. We conducted case study analyses in districts that had made effective progress and those that had encountered difficulties, drawing upon lessons learned. We reported our findings to the NHS Executive and supplemented this with a "toolbox" that included sample documents covering areas such as tendering, monitoring mechanisms, service specifications and different purchasing approaches.

Economic evaluation of antineoplasic chemotherapy administered at home or in hospitals

OBJECTIVES

Comparative economic evaluations of chemotherapy administered in hospital day-care units or in the home are relatively scarce. Furthermore, most existing evaluations do not include methodologic studies. This study seeks to compare the costs of anticancer chemotherapy with hospital at-home care versus a hospital day-care unit in the Rhône-Alpes region of France.

METHODS

This study is based on a randomized controlled crossover trial that included 42 patients, to whom chemotherapy courses were alternatively given in both settings. All cost categories were taken into account according to microcosting methods. A detailed assessment was performed on coordination and health care in both structures (marginal costs and average costs), from the viewpoint of society.

RESULTS

The marginal cost for one chemotherapy administration was significantly higher with hospital at-home care than in the hospital day-care unit ($232.5 vs. $157, p < .0001). Conversely, the average cost was significantly lower with home care than at the hospital ($252.6 vs. $277.3, p = .0002).

CONCLUSIONS

The results show that the interest of developing home care in anticancer chemotherapy is questionable regarding costs. In the French healthcare system, where there is a surplus of hospital beds, marginal costs seem to be more relevant indicators in most cases than average costs.

The changing face of Canadian home parenteral therapy

This article describes the Calgary Health Region Home Parenteral Therapy Program (HPTP), which has successfully shifted infusion therapies such as anti-infectives, analgesics, hydration, vasodilators, glucocorticoids, and iron-chelating agents from the hospital to patients' homes. Particular attention is given to the parenteral administration of anti-infectives, which currently accounts for more than 95% of program adult therapy days.

Positive inotropic drug infusions for patients with heart failure: current controversies and best practice

Patients who experience severe symptoms of heart failure and repeated hospitalizations for exacerbations may benefit from positive inotropic drug infusion therapy such as dobutamine or milrinone. This article provides an overview of inotropic drug delivery in the home including current controversies and best practices to ensure safe home care policies and practice.

Use of insurance claims data to assess outpatient antimicrobial therapy for gram-positive infections

With the increasing frequency of antibiotic-resistant gram-positive infections in the United States, many patients are being treated outside the hospital setting. The majority of studies on the cost of outpatient antimicrobial therapy involve retrospective medical record review or prospective data collection. These methods tend to be expensive and time consuming, and often fail to produce a sufficiently large sample size. Analysis of insurance claims data offers a convenient approach for studying the costs associated with outpatient therapy for gram-positive infections. To demonstrate this approach, a study of the cost of intravenous vancomycin home care therapy was conducted using claims data from a large insurance company.

Cost perspectives for outpatient intravenous antimicrobial therapy

Intravenous antimicrobial therapy often continues after a patient is discharged from the hospital or it begins in the outpatient setting. Reimbursement for this therapy varies by payer. The United States Outpatient Parenteral Antibiotic Therapy (OPAT) Outcomes Registry is a valuable resource for quantifying cost by payer, as well as for describing practice patterns and adverse events related to intravenous antimicrobial therapy. To describe the reimbursement structure and cost of intravenous vancomycin home care therapy for four different types of payers, a survey of home infusion companies was done. Also surveyed were infusion programs participating in the OPAT Outcomes Registry, representing four different types of payers, to determine the cost of outpatient intravenous therapy. A retrospective cohort study of these infusion programs was conducted to describe practice patterns and to identify adverse events that resulted from intravenous vancomycin. We found that the cost of outpatient therapy was substantial, although nonuniform, across payer types. Alternative outpatient therapies associated with lower risks for adverse events and lower costs should be considered.

Maintaining infusion therapy services in the long-term care setting

The volume of infusion therapy services provided in the long-term care setting has declined. One major influence has been the changes in reimbursement experienced in this sector of the industry. This article is intended to stimulate the long-term care clinician to reexamine the service offered and to be creative in his or her approach to building infusion services. The article also explores parallels to the home infusion industry, which has evolved through similar changes, with the intent of learning from its experiences.

Clinical and cost-effectiveness of continuous subcutaneous terbutaline versus oral tocolytics for treatment of recurrent preterm labor in twin gestations

OBJECTIVE

To compare the clinical and cost-effectiveness of treating recurrent preterm labor with continuous subcutaneous terbutaline versus oral tocolytics in twin gestations.

STUDY DESIGN

In a retrospective, matched-cohort design, twin pregnancies treated as outpatients with continuous subcutaneous terbutaline were identified from a perinatal database, then matched 1:1 by gestational age at recurrent preterm labor to those receiving oral tocolytics. There were 353 patients per treatment group. A cost model was used to compare antepartum hospital, nursery, and outpatient charges.

RESULTS

Infants of the subcutaneous terbutaline group had greater gestational age at delivery, higher birth weights, and less frequent neonatal intensive care unit admission. Charges for antepartum hospitalization and nursery were significantly less in the subcutaneous terbutaline group, while charges for outpatient services were less for the oral group. Mean total estimated charges were US$17,109 less for those receiving subcutaneous terbutaline.

CONCLUSION

Improved clinical outcomes and decreased nursery utilization suggest cost-effectiveness of outpatient continuous subcutaneous terbutaline versus oral tocolytics for the treatment of recurrent preterm labor.

Home intravenous antibiotic therapy programme, 1999

OBJECTIVES

To evaluate the cost-effectiveness and safety of the Home Intravenous Antibiotic Therapy (HIAT) program in the district of Haifa and Western Galilee in Northern Israel.

METHODS

We checked all the medical records of all the patients who had been treated at home with intravenous antibiotics during 1999. We reviewed the mean clinical diagnosis, aetiological agent, type of antibiotic given, complications and cost evaluation.

RESULTS

During 1999, 250 patients received 284 courses of HIAT. The total duration of treatments was 3404 days; 61% of the patients were referred from clinical departments from one of the medical centres in our area. Soft-tissue infections and osteomyelitis were the most common clinical diagnoses at 40%. Pseudomonas aeruginosa was the most frequent pathogen presented and Ceftazidine the most common antimicrobial agent prescribed. The HIAT program saved $815 000 during 1999. Only minor complications were present.

CONCLUSIONS

HIAT is effective, safe, comfortable for the patients, and has an important economical impact.

Convalescent phase outpatient parenteral antiinfective therapy for children with complicated appendicitis

BACKGROUND

Children with a perforated or gangrenous appendix become clinically stable after medical and/or surgical therapy but often remain in the hospital solely to complete parenteral antibiotic therapy. This prospective study investigates the outcomes when children who meet specified criteria are discharged to complete parenteral antibiotic therapy at home.

METHODS

Children age 1 to 17 years with appendicitis complicated by generalized peritonitis or intraabdominal abscess were eligible to participate. Subjects whose fever was decreasing, who were able to tolerate oral liquids and for whom further parenteral antibiotic therapy was deemed necessary were discharged from the hospital to receive outpatient parenteral antiinfective therapy (OPAT) with meropenem. Therapy was administered by a family member and supervised by home care nurses. Study personnel visited the home daily to collect data on adverse events, compliance and resource utilization. Pa tients served as their own controls in models of reduced hospitalization and net cost savings.

RESULTS

Discharged on average on the fourth postoperative day, 87 children received 4.5 +/- 2.1 days of OPAT. Six (7%) children were subsequently readmitted for complications including bowel obstruction (4 children), intraabdominal abscess (1 child) and pleural effusion (1 child). Another child developed a viral syndrome during OPAT. All other patients recovered uneventfully. Six (7%) children discontinued meropenem prematurely because of rash (4 patients) or diarrhea (2 patients). According to models in which each day of OPAT replaced a day of inpatient care, discharge to OPAT reduced hospitalization by 42 +/- 15% and saved a median of $2908 (10th to 90th percentile range, $1,077 to $4,707) per patient.

CONCLUSION

Convalescent phase OPAT is a cost-effective alternative to continued hospitalization for children with complicated appendicitis who are clinically stable yet require further parenteral antibiotic therapy.

Pharmaceutical intervention in the care of cystic fibrosis patients

In a prospective, randomised, cross-over study including cystic fibrosis patients with indications for HIVAT (home intravenous antibiotic treatment) the prospect of pharmaceutical intervention was investigated. A comparison between the use of disposable infusion devices with antibiotics from the pharmacy and when the patients prepared the drugs themselves was performed. During a first treatment course the patients received either infusion devices during 5 days or reconstituted the drugs themselves during 5 days, or vice versa. During a second treatment course the order was the reversed. Eight patients were included, out of which six completed the original design as a cross-over study, yielding a total of 550 doses of antibiotics. The patients preferred infusion devices from the pharmacy prepared according to GMP (Good Manufacturing Practice) as opposed to reconstituting the antibiotics themselves. Points of view presented included no anxiety over the correct dosage of drugs and less disruption of family and social life. In a practical sense, portable devices are more expensive than the preparation of the drugs by the patients themselves. However, when comparing with in-hospital treatment the direct costs for a hospital stay exceed that of the devices. Another part of the study evaluated the quality of life using a modified form of SEIQoL-DW (Schedule for the Evaluation of Individual Quality of Life - Direct Weighting). Twenty patients took part in the study and the overall quality of life scores increased significantly when patients received infusion devices compared to reconstituting the drugs themselves.

Cost analysis of an adult outpatient parenteral antibiotic therapy (OPAT) programme. A Canadian teaching hospital and Ministry of Health perspective

BACKGROUND

Outpatient parenteral antibiotic therapy (OPAT) programmes have become prevalent over the past 2 decades. From the US perspective, these programmes have been shown to reduce healthcare costs. No comprehensive analysis has been published from the Canadian perspective.

OBJECTIVE

To describe a Canadian OPAT programme for the 3-year period since its inception and to conduct a treatment cost analysis.

DESIGN AND METHODS

Demographics and resource utilisation data (health professional labour, laboratory and diagnostic tests, antimicrobials, delivery, home nursing care, catheters and catheter placement) were prospectively collected for enrollees in the OPAT programme over the evaluation period. Avoided hospital resource utilisation was estimated via retrospective chart review by the investigators. Costs were retrospectively assigned to each resource and total cost avoidance by the OPAT programme was determined from each perspective.

PERSPECTIVE

A teaching hospital and a provincial Ministry of Health (MOH).

MAIN OUTCOME MEASURES AND RESULTS

140 treatment courses were initiated for 117 adult patients (mean age 54 years) who were enrolled into the programme. Mean pre-OPAT length of hospital stay was 12 days, and mean OPAT duration was 22.5 days. Bone/joint (39%), skin and soft tissue (16%), cardiac (13%) and respiratory tract (12%) infections were the most common infections managed. The most commonly used antimicrobials were vancomycin (29%), cloxacillin +/- gentamicin (22%) and ceftriaxone +/- gentamicin (11%) 85% of enrollees successfully completed their planned antimicrobial treatment regimens. Premature discontinuation of antimicrobial therapy for various reasons occurred in the remaining 15% of courses. The mean cost per treatment course of OPAT was 1910 Canadian dollars ($Can) from the hospital perspective and $Can6326 from the MOH perspective. Assuming that patients would have otherwise completed their antimicrobial therapy in hospital, the mean cost per treatment course was estimated to be $Can14,271. The overall cost avoidance of the OPAT programme was $Can1,730,520 (hospital perspective) and $Can1,009,450 (MOH perspective) over the 3-year assessment period. Sensitivity analyses revealed the results to be robust to plausible changes.

CONCLUSIONS

This analysis supports the premise that an adult OPAT programme can substantially reduce healthcare costs in the Canadian healthcare setting.

Reducing home nursing visit costs using a remote access infusion pump system

The use of a remote access infusion pump system in patients receiving intravenous therapy in the home provided a method to monitor patients and to reduce the number of unscheduled and after-hours nursing visits. Option Care of Rockwall, Texas, a locally owned IV company that is part of a national network, was able to avoid 13 nursing visits during a 4-month period with patients receiving pain management or continuous heparin therapy with the use of an infusion pump system that allowed remote access by telephone. An appreciable cost savings was documented with the use of this device.

Care and management issues regarding central venous access devices in the home and long-term care setting

Experience and comfort with central venous access devices (CVADs) has increased dramatically during the past 2 decades. However, coordination of care remains a challenge as patients with long-term catheters move between levels of care with multiple healthcare providers. Standardizing CVAD maintenance and the teaching of patients and caregivers across the care continuum can be beneficial for patients and professionals. Effective communication among all care providers enhances teamwork and improves efficiency. The consistent collection and evaluation of data regarding CVAD complications and outcomes is important for assessing quality and determining best practices.

Out-patient and home-parenteral antibiotic therapy (OHPAT): evaluation of the impact of one year's experience in Tayside

OBJECTIVE

An out-patient and home parenteral antibiotic therapy programme for the treatment of suitable infections was developed over a four year period. This paper describes the impact of one year's experience of its implementation on various measures of outcome.

DESIGN

Each patient treatment has a full integrated care pathway (ICP) and patient satisfaction questionnaire completed. The ICP documents the clinical progress of the patient and incorporates various measures of quality of care on the 101 number of patients treated from April 1998 to March 1999 are presented here.

SETTING

Dundee Teaching Hospitals NHS Trust (now Tayside University Hospitals NHS Trust).

SUBJECTS

Patients with a range of infections requiring intravenous antibiotics.

MAIN MEASURES

Number of patients treated with various infections, clinical and microbiological outcome, drug and vascular access complication rates, impact on drug costs and in-patient bed days, and measurement of patient satisfaction/quality of life.

RESULTS

Patients were treated over a 12 month period. 51.5 per cent had skin & soft tissue infections and 22.8 per cent bone & joint sepsis. 57 per cent of patients received out-patient and 34 per cent self or carer administered home therapy. Ninety-four per cent of patients were cured or improved following treatment. Only 7.5 per cent of patients required an unscheduled admission to hospital. Twelve per cent of patients had some type of vascular device related adverse event (partly due to a faulty batch of lines) and six per cent of patients had a drug related reaction. The additional daily cost of drugs was minimal (< 12 Pounds/day) and more than 1,461 bed days have been saved across the Directorates. The patient satisfaction level was high.

Home care. An emerging solution to the healthcare crisis

As the nation's policy makers and healthcare professionals have wrestled with changing the fundamental way that medical care is delivered in this country, they have considered many options. Home care is one option that should be considered seriously. It is one of the fastest growing segments of the U.S. healthcare system because it's cost-effective, improves patients' quality of life, and can efficiently treat patients with a broad range of medical conditions.

Patient selection in outpatient parenteral antimicrobial therapy

Outcome data as well as reported anecdotal experience over the past 20 years indicate that any infection can be safely treated with parenteral antimicrobials outside the hospital setting. However, outpatient parenteral antimicrobial therapy (OPAT) is a reasonable option only when the final decision for patient selection is based on the judgment of a knowledgeable, experienced physician, and when an experienced qualified provider is available. Criteria to be considered include clinical status, patient acceptance, ability to comply with the plan of treatment, home environment, support systems, and reimbursement. Physician direction and participation in appropriate patient selection will become increasingly important as the growth of managed care increases the importance of cost-savings.

Outpatient parenteral antimicrobial therapy for osteomyelitis

OPAT for osteomyelitis is effective, safe, and well-established. There are particular considerations with osteomyelitis, however, that relate to patient selection and the plans of therapy. Orthopedic infections may impose physical considerations that need to be considered. Concomitant medical problems, such as diabetes, must be considered and may be good reasons for hospital care aside from the infection. Further investigations of treatment of osteomyelitis are clearly needed, with OPAT patients being good subjects to study.