Bundle in the Bronx: Impact of a Transition-of-Care Outpatient Parenteral Antibiotic Therapy Bundle on All-Cause 30-Day Hospital Readmissions

Abstract

Background: A streamlined transition from inpatient to outpatient care can decrease 30-day readmissions. Outpatient parenteral antibiotic therapy (OPAT) programs have not reduced readmissions; an OPAT bundle has been suggested to improve outcomes. We implemented a transition-of-care (TOC) OPAT bundle and assessed the effects on all-cause, 30-day hospital readmission.

Methods: Retrospectively, patients receiving postdischarge intravenous antibiotics were evaluated before and after implementation of a TOC-OPAT program in Bronx, New York, between July, 2015 and February, 2016. Pearson's χ² test was used to compare 30-day readmissions between groups, and logistic regression was used to adjust for covariates. Time from discharge to readmission was analyzed to assess readmission risk, using log-rank test to compare survival curves and Cox proportional hazards model to adjust for covariates. Secondary outcomes, 30-day emergency department (ED) visits, and mortality were analyzed similarly.

Results: Compared with previous standard care (n = 184), the TOC-OPAT group (n = 146) had significantly lower 30-day readmissions before (13.0% vs 26.1%, P < .01) and after adjustment for covariates (odds ratio [OR] = 0.51; 95% confidence interval [CI], 0.27-0.94; P = .03). In time-dependent analyses, TOC-OPAT patients were at significantly lower risk for readmission (log-rank test, P < .01; hazard ratio = 0.56; 95% CI, 0.32-0.97; P = .04). Propensity-matched sensitivity analysis showed lower readmissions in the TOC-OPAT group (13.6% vs 24.6%, P = .04), which was attenuated after adjustment (OR = 0.51; 95% CI, 0.25-1.05; P = .07). Mortality and ED visits were similar in both groups.

Conclusions: Our TOC-OPAT patients had reduced 30-day readmissions compared with the previous standard of care. An effective TOC-OPAT bundle can successfully improve patient outcomes in an economically disadvantaged area.

Keywords: bundle; outpatient parenteral antibiotic therapy; readmission; transitional care model..

Figure 1.

Patient selection and exclusions for control and Transition-of-Care Outpatient Parenteral Antibiotic Therapy (TOC-OPAT) groups. For the control group, 431 patients age 18 and older who were discharged from the hospital to their home or a skilled nursing facility from January 1, 2015 to June 30, 2015 and received intravenous (IV) antibiotics after discharge were identified retrospectively using Clinical Looking Glass software (Emerging Health Information Technology, Yonkers, NY). Of those, patients were excluded if they did not receive an Infectious Diseases (ID) consult before hospital discharge to assess the appropriateness of outpatient IV antibiotics (n = 246) or were transferred to an outside hospital or to the inpatient rehabilitation (rehab) unit (n = 1). The remaining 184 patients were included in the control group analysis. For the TOC-OPAT group, 179 patients (all age 18 or older) were referred to the program by inpatient ID providers and subsequently discharged from the hospital to their home or a skilled nursing facility between July 1, 2015 and February 29, 2016. Of those, patients were excluded (1) if they did not receive any antibiotics (n = 5) or exclusively oral antibiotics (n = 26) after discharge or (2) if they were transferred to an outside hospital or the inpatient rehabilitation unit (n = 2). The remaining 146 patients were included in the TOC-OPAT group analysis.