Disparities in United States hospitalizations for serious infections in patients with and without opioid use disorder: A nationwide observational study


Autoři: June-Ho Kim aff001;  Danielle R. Fine aff002;  Lily Li aff002;  Simeon D. Kimmel aff006;  Long H. Ngo aff002;  Joji Suzuki aff002;  Christin N. Price aff002;  Matthew V. Ronan aff011;  Shoshana J. Herzig aff002
Působiště autorů: Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America aff001;  Harvard Medical School, Boston, Massachusetts, United States of America aff002;  Ariadne Labs, Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America aff003;  Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America aff004;  Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America aff005;  Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, Massachusetts, United States of America aff006;  Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts, United States of America aff007;  Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America aff008;  Department of Psychiatry, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America aff009;  Brigham and Women’s Physicians Organization, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America aff010;  Department of Medicine, West Roxbury VA Medical Center, Veterans Affairs Boston Healthcare System, Boston, Massachusetts, United States of America aff011
Vyšlo v časopise: Disparities in United States hospitalizations for serious infections in patients with and without opioid use disorder: A nationwide observational study. PLoS Med 17(8): e32767. doi:10.1371/journal.pmed.1003247
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003247

Souhrn

Background

Patients with opioid use disorder (OUD) who are hospitalized for serious infections requiring prolonged intravenous antibiotics may face barriers to discharge, which could prolong hospital length of stay (LOS) and increase financial burden. We investigated differences in LOS, discharge disposition, and charges between hospitalizations for serious infections in patients with and without OUD.

Methods and findings

We utilized the 2016 National Inpatient Sample—a nationally representative database of all discharges from US acute care hospitals. The population of interest was all hospitalizations for infective endocarditis, epidural abscess, septic arthritis, or osteomyelitis. The exposure was OUD, and the primary outcome was LOS until discharge, assessed by using a competing risks analysis to estimate adjusted hazard ratios (aHRs). Adjusted odds ratio (aOR) of discharge disposition and adjusted differences in hospital charges were also reported. Of 95,470 estimated hospitalizations for serious infections (infective endocarditis, epidural abscess, septic arthritis, and osteomyelitis), the mean age was 49 years and 35% were female. 46% had Medicare (government-based insurance coverage for people age 65+ years), and 70% were non-Hispanic white. After adjustment for potential confounders, OUD was associated with a lower probability of discharge at any given LOS (aHR 0.61; 95% CI 0.59–0.63; p < 0.001). OUD was also associated with lower odds of discharge to home (aOR 0.38; 95% CI 0.33–0.43; p < 0.001) and higher odds of discharge to a post-acute care facility (aOR 1.85; 95% CI 1.57–2.17; p < 0.001) or patient-directed discharge (also referred to as “discharge against medical advice”) (aOR 3.47; 95% CI 2.80–4.29; p < 0.001). There was no significant difference in average total hospital charges, though daily hospital charges were significantly lower for patients with OUD. Limitations include the potential for unmeasured confounders and the use of billing codes to identify cohorts.

Conclusions

Our findings suggest that among hospitalizations for some serious infections, those involving patients with OUD were associated with longer LOS, higher odds of discharge to post-acute care facilities or patient-directed discharge, and similar total hospital charges, despite lower daily charges. These findings highlight opportunities to improve care for patients with OUD hospitalized with serious infections, and to reduce the growing associated costs.

Klíčová slova:

Antibiotics – Health care facilities – Hospitalizations – Hospitals – Inpatients – Medical risk factors – Nosocomial infections – Opioids


Zdroje

1. Ronan MV, Herzig SJ. Hospitalizations related to opioid abuse/dependence and associated serious infections increased sharply, 2002–12. Health Aff (Millwood). 2016;35(5):832–7.

2. Schranz AJ, Fleischauer A, Chu VH, Wu L-T, Rosen DL. Trends in drug use-associated infective endocarditis and heart valve surgery, 2007 to 2017: a study of statewide discharge data. Ann Intern Med. 2019;170(1):31–40. doi: 10.7326/M18-2124 30508432

3. Hartman L, Barnes E, Bachmann L, Schafer K, Lovato J, Files DC. Opiate injection-associated infective endocarditis in the southeastern United States. Am J Med Sci. 2016;352(6):603–8. doi: 10.1016/j.amjms.2016.08.010 27916215

4. Gray ME, Rogawski McQuade ET, Scheld WM, Dillingham RA. Rising rates of injection drug use associated infective endocarditis in Virginia with missed opportunities for addiction treatment referral: a retrospective cohort study. BMC Infect Dis. 2018;18(1):532. doi: 10.1186/s12879-018-3408-y 30355291

5. Salehi Omran S, Chatterjee A, Chen ML, Lerario MP, Merkler AE, Kamel H. National trends in hospitalizations for stroke associated with infective endocarditis and opioid use between 1993 and 2015. Stroke. 2019;50(3):577–82. doi: 10.1161/STROKEAHA.118.024436 30699043

6. Wurcel AG, Anderson JE, Chui KKH, Skinner S, Knox TA, Snydman DR, et al. Increasing infectious endocarditis admissions among young people who inject drugs. Open Forum Infect Dis. 2016;3(3):ofw157. doi: 10.1093/ofid/ofw157 27800528

7. D’Couto HT, Robbins GK, Ard KL, Wakeman SE, Alves J, Nelson SB. Outcomes according to discharge location for persons who inject drugs receiving outpatient parenteral antimicrobial therapy. Open Forum Infect Dis. 2018;5(5):ofy056. doi: 10.1093/ofid/ofy056 29766017

8. Pericàs JM, Llopis J, González-Ramallo V, Goenaga MÁ, Muñoz P, García-Leoni ME, et al. Outpatient parenteral antibiotic treatment (OPAT) for infective endocarditis: a prospective cohort study from the GAMES cohort. Clin Infect Dis. 2019;69(10):1690–700. doi: 10.1093/cid/ciz030 30649282

9. Mansour O, Heslin J, Townsend JL. Impact of the implementation of a nurse-managed outpatient parenteral antibiotic therapy (OPAT) system in Baltimore: a case study demonstrating cost savings and reduction in re-admission rates. J Antimicrob Chemother. 2018;73(11):3181–8. doi: 10.1093/jac/dky294 30085088

10. Suzuki J, Johnson J, Montgomery M, Hayden M, Price C. Outpatient parenteral antimicrobial therapy among people who inject drugs: a review of the literature. Open Forum Infect Dis. 2018;5(9):ofy194. doi: 10.1093/ofid/ofy194 30211247

11. Vazirian M, Jerry JM, Shrestha NK, Gordon SM. Outcomes of outpatient parenteral antimicrobial therapy in patients with injection drug use. Psychosomatics. 2018;59(5):490–5. doi: 10.1016/j.psym.2018.02.005 29685397

12. Rapoport AB, Fischer LS, Santibanez S, Beekmann SE, Polgreen PM, Rowley CF. Infectious diseases physicians’ perspectives regarding injection drug use and related infections, United States, 2017. Open Forum Infect Dis. 2018;5(7):ofy132. doi: 10.1093/ofid/ofy132 30018999

13. Wakeman SE, Rich JD. Barriers to post-acute care for patients on opioid agonist therapy; an example of systematic stigmatization of addiction. J Gen Intern Med. 2017;32(1):17–9. doi: 10.1007/s11606-016-3799-7 27393486

14. Psaltikidis EM, Silva END, Moretti ML, Trabasso P, Stucchi RSB, Aoki FH, et al. Cost-utility analysis of outpatient parenteral antimicrobial therapy (OPAT) in the Brazilian national health system. Expert Rev Pharmacoecon Outcomes Res. 2018;19(3):341–52. doi: 10.1080/14737167.2019.1541404 30362845

15. Jewell C, Weaver M, Sgroi C, Anderson K, Sayeed Z. Residential addiction treatment for injection drug users requiring intravenous antibiotics: a cost-reduction strategy. J Addict Med. 2013;7(4):271–6. doi: 10.1097/ADM.0b013e318294b1eb 23648642

16. Dewan KC, Dewan KS, Idrees JJ, Navale SM, Rosinski BF, Svensson LG, et al. Trends and outcomes of cardiovascular surgery in patients with opioid use disorders. JAMA Surg. 2019;154(3):232–40. doi: 10.1001/jamasurg.2018.4608 30516807

17. Wurcel AG. Drug-associated infective endocarditis trends: what’s all the buzz about? Ann Intern Med. 2019;170(1):68–9. doi: 10.7326/M18-3026 30508422

18. Tank A, Hobbs J, Ramos E, Rubin DS. Opioid dependence and prolonged length of stay in lumbar fusion: a retrospective study utilizing the National Inpatient Sample 2003–2014. Spine (Phila Pa 1976). 2018;43(24):1739–45.

19. Rudasill SE, Sanaiha Y, Mardock AL, Khoury H, Xing H, Antonios JW, et al. Clinical outcomes of infective endocarditis in injection drug users. J Am Coll Cardiol. 2019;73(5):559–70. doi: 10.1016/j.jacc.2018.10.082 30732709

20. Freeman WJ, Weiss AJ, Heslin KC. Overview of U.S. hospital stays in 2016: variation by geographic region. Healthcare Cost and Utilization Project Statistical Brief #246. Rockville (MD): Agency for Healthcare Research and Quality; 2006.

21. Fine JP, Gray RJ. A Proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc. 1999;94(446):496–509.

22. Gray RJ. A class of $K$-sample tests for comparing the cumulative incidence of a competing risk. Ann Stat. 1988;16(3):1141–54.

23. Pakzad H, Thevendran G, Penner MJ, Qian H, Younger A. Factors associated with longer length of hospital stay after primary elective ankle surgery for end-stage ankle arthritis. J Bone Joint Surg Am. 2014;96(1):32–9. doi: 10.2106/JBJS.K.00834 24382722

24. Wang Y, Stavem K, Dahl FA, Humerfelt S, Haugen T. Factors associated with a prolonged length of stay after acute exacerbation of chronic obstructive pulmonary disease (AECOPD). Int J Chron Obstruct Pulmon Dis. 2014;9:99–105. doi: 10.2147/COPD.S51467 24477272

25. Bowles KH, Holmes JH, Ratcliffe SJ, Liberatore M, Nydick R, Naylor MD. Factors identified by experts to support decision making for post acute referral. Nurs Res. 2009;58(2):115–22. doi: 10.1097/NNR.0b013e318199b52a 19289932

26. Ho J, Archuleta S, Sulaiman Z, Fisher D. Safe and successful treatment of intravenous drug users with a peripherally inserted central catheter in an outpatient parenteral antibiotic treatment service. J Antimicrob Chemother. 2010;65(12):2641–4. doi: 10.1093/jac/dkq355 20864497

27. Allison GM, Muldoon EG, Kent DM, Paulus JK, Ruthazer R, Ren A, et al. Prediction model for 30-day hospital readmissions among patients discharged receiving outpatient parenteral antibiotic therapy. Clin Infect Dis. 2014;58(6):812–9. doi: 10.1093/cid/cit920 24357220

28. Beieler A, Magaret A, Zhou Y, Schleyer A, Wald A, Dhanireddy S. Outpatient parenteral antimicrobial therapy in vulnerable populations—people who inject drugs and the homeless. J Hosp Med. 2019;14(2):105–9. doi: 10.12788/jhm.3138 30785418

29. Buehrle DJ, Shields RK, Shah N, Shoff C, Sheridan K. Risk factors associated with outpatient parenteral antibiotic therapy program failure among intravenous drug users. Open Forum Infect Dis. 2017;4(3):ofx102. doi: 10.1093/ofid/ofx102 28680904

30. Tattevin P, Revest M. Outpatient parenteral antibiotic treatment (OPAT) for infective endocarditis: insights from the real life. Clin Infect Dis. 2019;69(10):1701–2. doi: 10.1093/cid/ciz027 30649207

31. Iversen K, Ihlemann N, Gill SU, Madsen T, Elming H, Jensen KT, et al. Partial oral versus intravenous antibiotic treatment of endocarditis. N Engl J Med. 2019;380(5):415–24. doi: 10.1056/NEJMoa1808312 30152252

32. Boucher HW. Partial oral therapy for osteomyelitis and endocarditis—is it time? N Engl J Med. 2019;380(5):487–9. doi: 10.1056/NEJMe1817264 30699312

33. Li H-K, Rombach I, Zambellas R, Walker AS, McNally MA, Atkins BL, et al. Oral versus intravenous antibiotics for bone and joint infection. N Engl J Med. 2019;380(5):425–36. doi: 10.1056/NEJMoa1710926 30699315

34. Englander H, Wilson T, Collins D, Phoutrides E, Weimer M, Korthuis PT, et al. Lessons learned from the implementation of a medically enhanced residential treatment (MERT) model integrating intravenous antibiotics and residential addiction treatment. Subst Abus. 2018;39(2):225–32. doi: 10.1080/08897077.2018.1452326 29595367

35. Marks LR, Munigala S, Warren DK, Liang SY, Schwarz ES, Durkin MJ. Addiction medicine consultations reduce readmission rates for patients with serious infections from opioid use disorder. Clin Infect Dis. 2018;68(11):1935–7.

36. Department of Health and Human Services. Nondiscrimination and opioid use disorder. Washington (DC): Department of Health and Human Services; 2018 [cited 2019 Mar 29]. Available from: https://www.hhs.gov/sites/default/files/fact-sheet-nondiscrimination-and-opioid-use.pdf.

37. US Department of Justice. U.S. Attorney’s Office settles disability discrimination allegations at skilled nursing facility. Washington (DC): US Department of Justice; 2018 [cited 2019 Mar 29]. Available from: https://www.justice.gov/usao-ma/pr/us-attorney-s-office-settles-disability-discrimination-allegations-skilled-nursing.

38. Legal Action Center. DOJ settlement with skilled nursing facility: excluding people on addiction medication violates the ADA. New York: Legal Action Center; 2018 [cited 2020 Jul 15]. Available from: https://www.lac.org/news/doj-settlement-with-skilled-nursing-facility-excluding-people-on-addiction-medication-violates-the-ada.

39. Mass.gov. Circular letter: DHCQ 16-11-662—Admission of residents on medication assisted treatment for opioid use disorder. Mass.gov; 2016 [cited 2019 Mar 29]. Available from: https://www.mass.gov/circular-letter/circular-letter-dhcq-16-11-662-admission-of-residents-on-medication-assisted.

40. Glasgow JM, Vaughn-Sarrazin M, Kaboli PJ. Leaving against medical advice (AMA): risk of 30-day mortality and hospital readmission. J Gen Intern Med. 2010;25(9):926–9. doi: 10.1007/s11606-010-1371-4 20425146

41. Chan ACH, Palepu A, Guh DP, Sun H, Schechter MT, O’Shaughnessy MV, et al. HIV-positive injection drug users who leave the hospital against medical advice: the mitigating role of methadone and social support. J Acquir Immune Defic Syndr. 2004;35(1):56–9. doi: 10.1097/00126334-200401010-00008 14707793

42. Ti L, Milloy MJ, Buxton J, McNeil R, Dobrer S, Hayashi K, et al. Factors associated with leaving hospital against medical advice among people who use illicit drugs in Vancouver, Canada. PLoS ONE. 2015;10(10):e0141594. doi: 10.1371/journal.pone.0141594 26509447

43. Rosenthal ES, Karchmer AW, Theisen-Toupal J, Castillo RA, Rowley CF. Suboptimal addiction interventions for patients hospitalized with injection drug use-associated infective endocarditis. Am J Med. 2016;129(5):481–5. doi: 10.1016/j.amjmed.2015.09.024 26597670

44. Larochelle MR, Bernson D, Land T, Stopka TJ, Wang N, Xuan Z, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study. Ann Intern Med. 2018;169(3):137–45. doi: 10.7326/M17-3107 29913516

45. Suzuki J. Medication-assisted treatment for hospitalized patients with intravenous-drug-use related infective endocarditis. Am J Addict. 2016;25(3):191–4. doi: 10.1111/ajad.12349 26991660

46. Trowbridge P, Weinstein ZM, Kerensky T, Roy P, Regan D, Samet JH, et al. Addiction consultation services—linking hospitalized patients to outpatient addiction treatment. J Subst Abuse Treat. 2017;79:1–5. doi: 10.1016/j.jsat.2017.05.007 28673521

47. Wakeman SE, Metlay JP, Chang Y, Herman GE, Rigotti NA. Inpatient addiction consultation for hospitalized patients increases post-discharge abstinence and reduces addiction severity. J Gen Intern Med. 2017;32(8):909–16. doi: 10.1007/s11606-017-4077-z 28526932

48. Englander H, Mahoney S, Brandt K, Brown J, Dorfman C, Nydahl A, et al. Tools to support hospital-based addiction care: core components, values, and activities of the improving addiction care team. J Addict Med. 2019;13(2):85–9. doi: 10.1097/ADM.0000000000000487 30608265

49. Peterson C, Xu L, Mikosz CA, Florence C, Mack KA. US hospital discharges documenting patient opioid use disorder without opioid overdose or treatment services, 2011–2015. J Subst Abuse Treat. 2018;92:35–9. doi: 10.1016/j.jsat.2018.06.008 30032942

50. Miller AC, Polgreen PM. Many opportunities to record, diagnose, or treat injection drug-related infections are missed: a population-based cohort study of inpatient and emergency department settings. Clin Infect Dis. 2018;68(7):1166–75.

51. Baggett TP, Hwang SW, O’Connell JJ, Porneala BC, Stringfellow EJ, Orav EJ, et al. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med. 2013;173(3):189–95. doi: 10.1001/jamainternmed.2013.1604 23318302

52. Tsai J, Kasprow WJ, Rosenheck RA. Latent homeless risk profiles of a national sample of homeless veterans and their relation to program referral and admission patterns. Am J Public Health. 2013;103(Suppl 2):S239–47.

53. Bachhuber MA, Roberts CB, Metraux S, Montgomery AE. Screening for homelessness among individuals initiating medication-assisted treatment for opioid use disorder in the Veterans Health Administration. J Opioid Manag. 2015;11(6):459–62. doi: 10.5055/jom.2015.0298 26728642


Článek vyšel v časopise

PLOS Medicine


2020 Číslo 8

Nejčtenější v tomto čísle

Tomuto tématu se dále věnují…


Přihlášení
Zapomenuté heslo

Nemáte účet?  Registrujte se

Zapomenuté heslo

Zadejte e-mailovou adresu se kterou jste vytvářel(a) účet, budou Vám na ni zaslány informace k nastavení nového hesla.

Přihlášení

Nemáte účet?  Registrujte se