Outpatient Parenteral Antimicrobial Therapy Outcomes Metrics Assessment Survey

TL;DR

This study surveyed healthcare professionals about metrics used in outpatient antibiotic therapy and found that while some metrics are seen as important, they are rarely tracked due to resource limitations.

Contribution

The study identifies key outcome metrics for outpatient parenteral antimicrobial therapy and barriers to their collection, offering guidance for program development.

Findings

Several outcome metrics were perceived as highly important but were not being collected by most programs.

Common barriers to data collection included lack of funding, technology, and staffing.

The findings can help guide the establishment or restructuring of OPAT programs.

Abstract

We surveyed outpatient parenteral antimicrobial therapy team members to assess the importance of specific program metrics while eliciting collection barriers, which can guide establishing or restructuring programs. Several metrics were felt to be highly important but were not being collected by programs. Identified barriers included a lack of funding, technology support, and staffing.

We present the analysis of a cross-sectional, electronic survey of OPAT team members to assess program outcome metrics currently being used, the perceived importance of selected metrics, and barriers to collection. While a number of metrics were considered highly important, only a few programs were able to collect the data needed to track these metrics. Our data can provide guidance and support for establishing or restructuring OPAT programs to determine which outcome metrics to collect and track at a program level.

Figures

Distribution of OPAT outcome metric scores: 1 (least important) through 10 (most important). Abbreviations: OPAT, outpatient parenteral antimicrobial therapy; PICC, peripherally inserted central catheter.

Tables

Table 1.. Survey Participant and OPAT Program Characteristics and Outcome Metrics Barriers (N = 87)

	No. (%)
Survey participant and OPAT program characteristics
Gender: women	53 (60.9)
Race and ethnicity
White	69 (79.3)
Asian	13 (15)
Combined groupa	4 (4.6)
Country: United States	81 (92.9)
Institution setting
Academic medical center	63 (72.4)
Community teaching medical center	13 (14.9)
Community nonteaching medical center	5 (5.7)
Private practice	3 (3.4)
Otherb	7 (8.0)
Participant's role in OPAT
Director/codirector	31 (35.6)
Member of the OPAT team: responsible for day-to-day program operation, involved with improvement processes	25 (28.7)
Provider who cares for patients with OPAT: involved with process improvement but not in the day-to-day logistics of OPAT program	18 (20.7)
Provider who cares for patients with OPAT: no involvement with program or process changes	9 (10.3)
Former OPAT member	2 (2.3)
Not involved in OPAT	2 (2.3)
Duration of participant's current role in OPAT, y
<1	4 (4.6)
1–4	33 (37.9)
5–9	29 (33.3)
>10	19 (21.8)
Roles included in participant's OPAT model
Physician	70 (80.5)
Advanced practice provider	25 (28.7)
Pharmacist	33 (37.9)
Nurse (BSN/RN)	37 (42.5)
Medical assistant	11 (12.6)
Social worker/case manager	5 (5.7)
Administration/nonclinical personnel	10 (11.6)
Participants with an FTE-supported role	39 (44.8)
Percentage of FTE support in those with an FTE-supported role
<10	5 (5.7)
10–25	10 (11.5)
25–50	12 (13.8)
50–75	6 (6.9)
>75	6 (6.9)
Percentage of weekly hours spent on OPAT
<10	25 (28.7)
10–25	30 (34.5)
25–50	16 (18.4)
50–75	5 (5.7)
>75	11 (12.6)
OPAT program includes patients with substance use disorders	62 (71.3)
Addiction medicine consult service available	47 (54.0)
Multidisciplinary discharge planning meeting	18 (20.7)
Antimicrobial stewardship program in OPAT	49 (56.3)
Required OPAT data reporting to hospital leadership
Yes	13 (14.9)
Yes, but not regularly	14 (16.1)
Barriers to OPAT outcome metric data collection
Staffing shortages	27 (31.0)
Lack of administrative support	28 (32.2)
Lack of funding	25 (28.7)
Lack of a data system to track patients or technology support to build a system	35 (40.2)
Lack of skilled nursing facility support	5 (5.7)
Lack of addiction medicine team	6 (6.9)
Other	6 (6.9)

Full text

Outpatient parenteral antimicrobial therapy (OPAT) is integral to the care of patients receiving intravenous antimicrobials outside the hospital [1, 2]. OPAT has been shown to improve patient satisfaction and reduce length of hospital stay, hospital-acquired infections, and overall health care cost [2–5]. While many institutions have instituted formal OPAT programs, there are limited data on metrics or outcomes assessment related to OPAT programs. These data are critical for assessing the impact of quality improvement efforts and programmatic changes on the functionality and quality of OPAT programs.

METHODS

We conducted a cross-sectional electronic survey of OPAT team members to assess program outcome metrics currently being used and the perceived importance of selected metrics (Supplementary Appendix 1). We collected respondent demographics, role in OPAT, and factors related to OPAT program structure. Participants rated OPAT metrics by perceived importance from 1 to 10, with 1 defining least important and 10 defining most important. Outcome metrics proposed in the survey were collected from a literature review, in addition to metrics planned for collection in our OPAT program [1–10].

We administered the anonymous survey via Qualtrics (https://www.qualtrics.com). We posted the survey link on the Infectious Diseases Society of America IDea Exchange and emailed it to a group of OPAT team members via an online OPAT chat group, both of which include members in the United States and internationally with a variety of clinical roles (providers, nurses, pharmacists). The survey link was open for data collection from 16 May to 16 August 2024, with 2 reminders posted.

We performed all analyses in SAS statistical software 9.4 (SAS Institute; https://www.sas.com). We used descriptive statistics to examine the perceived importance of OPAT metrics, as well as participant, institutional, and program characteristics, reporting proportions for categorical variables and median values (IQR, SD) for continuous variables.

RESULTS

The OPAT survey was started by 112 participants; 87 (77.6%) scored at least 1 outcome metric and were included in analyses (Table 1). Among these 87 participants, 81 (92.9%) reported practicing in the United States. Most commonly, participants practiced in academic medical centers (n = 63, 72.4%) and were currently practicing in a formal OPAT capacity (n = 56, 64.4%).

Of the 39 participants with full-time equivalent (FTE) support for OPAT, 24 (61.5%) reported weekly time spent equivalent to their FTE, and 10 (25.6%) and 5 (12.8%) indicated working more and less than their FTE, respectively. Of note, half of participants had an active current OPAT role (n = 45, 51.7%) without FTE support.

The inclusion of patients with substance use disorder in OPAT programs was reported by 62 (71.3%) participants; incorporation of antimicrobial stewardship (ASP) was noted by 49 (56.3%). Most participants (n = 49, 56.3%) were not required to report OPAT program data to hospital leadership.

A median score of 8 to 10 was seen in 12 of the 16 outcome metrics (Supplementary Table 1, Figure 1). The highest-scoring metrics included the proportion of patients with adverse reactions due to antimicrobials (10; SD, 1.39), the proportion of patients readmitted to the hospital during their OPAT course related to infection or antimicrobial adverse effects (10; SD, 1.45), and clinical outcomes (10; SD, 1.68). The lowest-scoring metrics included the proportion of patients completing their antibiotic course as inpatients (5; SD, 2.79) and length of hospital stay prior to OPAT (6; SD, 2.60).

Distribution of OPAT outcome metric scores: 1 (least important) through 10 (most important). Abbreviations: OPAT, outpatient parenteral antimicrobial therapy; PICC, peripherally inserted central catheter.

Sixteen (18.4%) respondents listed additional outcomes that they were collecting: patient follow-up, proportion of patients enrolled in OPAT, dose adjustments, medication errors, rate of discharge plan verification, central line removal confirmation, and reasons for extension therapy.

The most commonly reported barriers to collecting metrics were lack of a data system to track patients or technology support to build a system (n = 35, 40.2%), followed by a lack of administrative support (n = 28, 33.2%), staffing shortages (n = 27, 31.0%), and lack of funding (n = 25, 28.7%).

DISCUSSION

Although key components of OPAT programs have been proposed, significant variability exists among programs and within published literature, limiting comparison of metrics across programs and studies, especially internationally [6–8]. Our data provide metric selection guidance for establishing or restructuring OPAT programs and elicit barriers to successfully using those metrics in practice.

Survey responses indicate that metrics such as readmission rates, adverse reactions to antimicrobials, and clinical outcomes of treatment were felt to be highly important outcome metrics for OPAT programs. However, only a fraction of respondents reported that these data were being actively collected (37.9%, 27.6%, and 19.5% of responses, respectively), with respondents reporting multiple barriers to collection.

Many studies reporting clinical outcomes in OPAT have been published [9, 10]; however, per our survey, consistent collection of these metrics is limited. Clinical outcomes are of interest to an OPAT program to implement interventions around antimicrobial selection, dosing, and management of adverse effects. Yet, there are many other factors influencing these outcomes that must be considered and are outside the influence of an OPAT program, including comorbidities, adequate source control, retained hardware, antimicrobial resistance, and, especially in the United States, access to medication and adequate insurance coverage. More than half of survey respondents reported a formal ASP component. ASP efforts in OPAT may include antimicrobial selection, duration of therapy, and appropriate intravenous-to-oral switches. In the United States, antimicrobial selection is heavily influenced by insurance coverage and treatment setting and so requires different approaches than inpatient administration. However, tracking these data within an OPAT program may still shed light on opportunities for improvement [11–13].

Readmission rates were the most common metric collected by survey participants and are a common outcome reported in current OPAT literature [14–16]. The ability to capture readmission data has allowed us to identify risk factors for readmission specific to our OPAT population [14, 15]. While readmissions may be directly related to clinical outcomes and antibiotic-related adverse effects, the ability of an OPAT program to show cost savings is often tied to metrics such as readmission rate and reduced length of hospital stay [16]. Furthermore, demonstrating reduction in readmissions, adverse effects, and vascular line complications has additional benefit toward justifying a program's cost to hospital leadership. Readmissions during an OPAT course are multifaceted, however, and improvement in rates with various OPAT interventions has been shown to plateau, as there are indications for readmission outside the control of an OPAT team [3, 17, 18].

Measuring patient satisfaction in OPAT was felt to be important, although <2% of respondents reported collecting these data. Studies of patient satisfaction have been published [19–21], specifically related to preferences for antibiotics or infusion methods [22, 23], and ongoing evaluation may highlight real-time issues experienced and allow better coordination and quality improvement measures.

The most common barrier to collecting data was the lack of a system to track patients or technology support to build a tracking system. These are similar to barriers seen in OPAT programs in general [24]. It could be argued that dedicating more resources to efficient tracking and data collection systems could improve the overall efficiency of programs and thus warrants further investigation. The next most common was a lack of administrative and staffing support. There is a significant discrepancy in the FTE dedicated to OPAT and the actual time spent on OPAT tasks as reported by respondents. Similar discrepancies have been noted between time spent on OPAT and billable time [25], further illustrating the need for dedicated resources to follow metrics and implement changes to improve patient care. Based on our survey responses, programs have significant variability in terms of team makeup, addiction medicine consult, discharge planning, and ASP component, highlighting the need for standardized metric reporting to evaluate the impact of these components. An OPAT data registry in the United Kingdom has shown that standardizing metrics allows for compilation of data, allowing conclusions to be drawn about the efficacy and safety of OPAT programs [26]. Similar models in the United States and internationally would greatly enhance our ability to compile and use OPAT data and compare intervention impacts across programs to ultimately improve patient care.

Our study has limitations. The majority of respondents were practicing in academic centers within the United States, limiting generalizability to other settings. Additionally, OPAT team members not participating in the OPAT group chat or regularly reading the Infectious Diseases Society of America IDea Exchange would not be included, limiting program representation. To protect participant confidentiality, we did not collect facility data nor limit the number of respondents from each program, which limits our ability to determine program representation.

CONCLUSION

While OPAT members reported a number of metrics highly important, few programs are able to collect the data needed to track these metrics. Efforts are needed to standardize program metrics and electronic health records for improved access to crucial OPAT data. These data can provide guidance for establishing or restructuring OPAT programs on metric selection.

Supplementary Material

ofaf283_Supplementary_Data