Abstract:
As hospital admissions rise in correlation with the opioid crisis in the United States, drug use-associated (DUA) infections are clearly taking their toll on the economics of healthcare institutions. The opioid crisis has reshaped the treatment of DUA endocarditis, one of the many life-threatening DUA infections, in terms of both management and finances. Hospital administration leaders must adapt strategies to optimize the value of patient care given to those afflicted with both opioid-use disorders and their related infections and attempt to lower costs while improving quality of care. Only 14 percent of costs of DUA infections are covered by private insurance.
The authors review the opioid crisis impact on infectious diseases and the nationwide financial burden of DUA infections and provide a rationale behind an infectious disease-led program to improve quality of care and decrease costs.
During 2013–2016, 6.5 percent of adults age 20 and older reported using a prescription opioid analgesic in the previous 30 days.(1) According to the Centers for Disease Control and Prevention (CDC), more than 72,000 drug overdose deaths occurred in the United States during 2017, making drug overdose the leading cause of injury-related death. The CDC reports that the current rate is equivalent to 192 drug overdose deaths every day.(2)
However, overdose deaths are only a part of the landscape of opioid-use disorders. The morbidity and mortality tallies of opioid-use disorder (OUD) are extended by the dramatic rise in opioid-related infections, thereby causing serious financial consequences for healthcare institutions in the United States.
Following a discussion of the background of the emergence of OUD-related infections and their impact on hospital finances, we offer guidance for institutional leaders on ways to be better stewards of resources to curtail the costs of OUD-related infections.
The Opioid Crisis and Drug-Use Associated Infections
Persons who inject drugs (PWID) are a subset of those who have OUD. Noting that life-threatening infections are frequent complications for PWID, it comes as no surprise that associated with this epidemic is a rise in the prevalence of hepatitis C, HIV, and sexually transmitted diseases.(3) Beyond viral diseases, bacterial infections are also costly for healthcare systems.
Table 1 shows national estimates of hospitalizations related to opioid abuse/dependence and associated bacterial infections.(4)
The National (Nationwide) Inpatient Sample (NIS) is part of a family of databases and software tools developed for the Healthcare Cost and Utilization Project (HCUP). The NIS is a large, publicly available, all-payer inpatient healthcare database designed to produce U.S. regional and national estimates of inpatient utilization, access, charges, quality, and outcomes.(5) Unweighted, it contains data from more than 7 million hospital stays each year. Weighted, it estimates more than 35 million hospitalizations nationally.
Developed through a federal–state–industry partnership sponsored by the Agency for Healthcare Research and Quality (AHRQ), HCUP data inform decision making at the national, state, and community levels.(5)
Table 1 shows that within a decade (2002 to 2012), national estimates of hospitalization related to OUD infections increased significantly for endocarditis, osteomyelitis, septic arthritis, and epidural abscesses.(4) With the continued exponential growth of the opioid epidemic, the impact of OUD-related infections will continue to mount against the financial health of hospitals.(1)
More specifically, drug use-associated (DUA) endocarditis has redefined the scope, type, and finances of healthcare resources to treat this infection. As shown by a 10-year analysis of North Carolina hospitals, those hospitalized with DUA endocarditis have median hospital stays that are 10 days longer than those hospitalized without DUA heart infections. Further, according to the same analysis, DUA endocarditis hospitalizations register costs more than $50,000 higher than non-DUA heart disease hospitalizations. Of 22,825 endocarditis hospitalizations, 11 percent were DUA infective endocarditis.(6)
These findings are analogous to the dramatic escalation of DUA endocarditis reported by Day et al. at the Ohio State University Medical Center, where fewer than 17 percent of infective endocarditis cases in 2012 were drug-related as compared to a troubling 45 percent in 2017. The unreimbursed cost to providers and institutions for their management of DUA endocarditis and other DUA infections has suffered many-fold magnification in less than a decade.(7)
The Institutional Economics Of DUA Infections
The annual estimates of the opioid economic burden in the United States exceeded $500 billion in 2015.(8) More than $2.5 trillion was spent on the opioid crisis between 2015 and 2018.(9) The impact of this crisis is seen in clearly economic terms in a retrospective cohort study comparing NIS 2002 and 2012 discharge data.(4)
The primary payer distribution did not change between 2002 and 2012 for those admissions with OUD with and without associated infections, but the cost burden of the provision of care exponentially escalated for each hospital and provider. Medicaid and self-pay were the most common primary payers. Compared to hospitalizations of patients diagnosed with OUD overall, PWID with infectious diseases were more likely to be uninsured in both 2002 and 2012.(4) The total inpatient charges for hospitalizations related to OUD more than tripled between 2002 ($4.57 billion) and 2012 ($14.85 billion; p < 0.001), and the increase remains significant after accounting for inflation ($11.64 billion in 2012 represented in 2002 dollars; p < 0.001).(4)
In 2012, the estimated total charge per hospitalization with an OUD diagnosis was $28,543, but for OUD with associated infections the total charge was significantly higher at $107,207. The increased rate in each cohort of infection directly correlated with concurrent OUD diagnosis.(4) Admissions related to OUD with associated infections were more likely to die during the hospitalization, less likely to be sent home, and more likely to be discharged to another medical facility compared to admissions with opioid use overall in both 2002 and 2012 (p < 0.001).(4)
This study demonstrates the increasing magnitude of downstream complications associated with this epidemic, which has a tremendous impact on a healthcare system’s financial well-being. It is important to remember that the total charges reported in this study reflect only inpatient charges and do not include the cost of discharge care. Concerns over the ability to complete the treatment course independently, the use of indwelling intravenous catheters, and high readmission rates often require the completion of therapy in a monitored setting. A larger proportion of individuals with severe infections require further care in skilled nursing facilities compared to those with OUD overall.
The total cost to the healthcare system is much higher than for the stay covering hospitalization charges noted. Only 14 percent of the discharge orders with DUA infections are covered by private insurance. This means that the transfer of care to other facilities would likely be declined, resulting in a higher number of extended inpatient stays and higher unreimbursed costs for those hospitalized.(4) Strategic plans in handling DUA infections at an institutional level need innovative leadership from and collaboration among infectious disease physicians, addiction medicine providers, and C-suite operatives.
Outpatient Parenteral Antimicrobial Therapy
Outpatient parenteral antimicrobial therapy (OPAT) is used to administer non-oral antibiotics without the necessity of hospitalization. This modality of therapy is particularly helpful in patients who are not severely ill but still require a prolonged treatment course that cannot be given orally.
The Emerging Infection Network among infectious disease (ID) physicians conducted a national provider survey to evaluate ID perspectives and common practices in PWID care. Of 1,276 ID providers, 53 percent (N = 672) were involved in the study.(10) Seventy-eight percent of ID physicians treat PWID; 88 percent of these physicians saw more than one infected PWID per month, and 43 percent saw more than six such patients per month. Regardless if OUD was inactive or remote, the majority of ID physicians (65 percent to 70 percent) rarely, if ever, discharged the patient on OPAT, i.e., via a catheter line, with a DUA infection.(10)
Care practices such as these translate into financial losses for the healthcare institution. Possibly because of the lack of precise Infectious Disease Society of America (IDSA) practice guidelines for OPAT use in PWID with DUA diseases combined with the provider’s fear of line abuse by the addict, many afflicted with OUD and infections receive all of their parenteral antimicrobial care in the hospital, which may last from two to six weeks.(11)
Educating providers to diagnose, intervene, and treat OUD in the setting of associated infectious diseases must be an institutional priority and should therefore receive additional internal sponsorship. Many societies and continuing professional educational meetings are initiating such programs, but the quickest means of managing provider knowledge is to offer such modules locally to tailor to specific educational opportunities for growth. The reasoning for institutional education initiatives addressing OUD is that the cause of the infection is the OUD. Until the disease source is controlled, the variables of non-compliance, relapse of infections, new infections, and re-hospitalization will keep repeating themselves.
A literature review on OPAT among PWID by Suzuki et al., found PWID were often excluded from being offered OPAT.(12) However, data from existing studies showed OPAT to be safe and effective for PWID with rates of OPAT completion (72 percent to 100 percent), mortality (0 percent in seven studies and 1.9 percent to 10 percent in three reviews), and catheter-related complications comparable to rates among non-SUD patients.
Rates of misuse of the venous catheter in OUD patients were rarely reported, but rates of hospital readmissions were higher compared to non-OUD patients (0.6 percent to 41 percent).(12) Based on these data, OPAT among PWID given outside the hospital setting has the potential to significantly increase cost savings to healthcare systems. But, well-designed clinical research in this field is limited; therefore, the Infectious Disease Society of America (IDSA) guidelines for OPAT among OUD patients with infections is lacking.
The current OPAT guidelines have no recommendation for OPAT use among PWID with infections; this is a clear reflection of the absence of robust data.(11) Studies regarding outcomes of PWID on OPAT in their homes, institution sponsored residencies, or rehabilitation facilities are needed, although some exist for institutions such as sponsoring homeless shelters.(13) Additional data on institutional opportunities to render optimized patient care more efficiently are needed.
Need for Opioid-Use Disorder Screening
The key to managing and improving outcomes of OUD is not providing OPAT, building shelters, or initiating rehabilitation initiatives per se, but rather promoting the collective need for all providers to screen for OUD. Next, we must address and manage the disorder, regardless of community settings.
The number of patients admitted to hospitals with DUA infections may be underreported due to lack of routine OUD screening by providers. Several evidence-based, quick-screening evaluations can be integrated into a standard infectious disease or hospitalist’s consultation. Seval et al. provide a guide for ID physicians to screen and treat OUD in the setting of associated infectious diseases. These skills are becoming more and more essential to all clinicians’ toolkits.(14) Addiction is often missed as a potential diagnosis for the underlying cause of the infection, and when unaddressed, it leads to treatment failures and readmissions due to relapses or new infections.(14,15)
When OUD is suspected or diagnosed, a hospital provider has two options, as illustrated in Figure 1: treat only the infection or evaluate OUD as the source of the infection.(16) In addition to an ID consultation, addiction medicine consultations should be utilized for patients with serious OUD-related infections. Marks et al. showed better outcomes and lower readmission rates with addiction medicine consultation.(17) If addiction medicine consultation isn’t available, the primary care provider hospitalist or ID physician must be able to manage OUD patients. OPAT plus medication-assisted therapy (MAT) at home has been found to shorten hospital lengths of stay by as much as 23.5 days.(18,19)
Figure 1. Protocol for PWID requiring IV antibiotics
Similarly, implementation of a standardized protocol for hospitalized PWID who require OPAT reduced length of stay without increasing 30-day readmissions.(16) These initiatives are reimbursed as outlined by the Substance Abuse and Mental Health Service Administration. Screening, brief intervention, and referral to treatment (SBIRT) services should be introduced as normal coding practice for ID and hospitalists dealing with OUD.(20) Strategies such as screening for OUD in hospitalized individuals, initiating MAT, and streamlining coordination of care between hospital and the community are essential to systematically tackling the goliath that is the opioid epidemic.
The C-Suite Opportunities
Leaders in C-suites are aware of the operational losses associated with the opioid crisis and related infections. Closing the gap requires better appropriations of non-reimbursed expenses to prevent and offset the financial burden to its institution.
Similar to successful infection prevention and antimicrobial stewardship programs, an OUD taskforce comprised of both ID and addiction medicine providers could significantly streamline care processes. Addiction must be accepted as a treatable condition; education is the key to not only abolishing the stigma, but also equipping physicians with the tools necessary to diagnose and treat OUD.(21)
Education programs should train physicians to accurately diagnose and subsequently manage OUD. The use of MAT, which consists of prescribing buprenorphine, methadone, and naloxone to OUD inpatients, has been proven to decrease mortality rates.(22,23) Unfortunately, the U.S. Surgeon General reports that only one out of 10 Americans with OUD receives treatment, with most receiving non-evidence-based care.(24) Many hospitals and institutions simply do not have access to addiction medicine providers.
In efforts to increase the number of physicians who can prescribe MAT and integrate addiction treatment into primary care settings, Congress passed the Drug Addiction Treatment Act of 2000. Physicians who complete an approved course in appropriately prescribing buprenorphine receive a waiver to facilitate MAT outside of opioid treatment programs.(25,26) Those with DUA infections who receive an addiction medicine consultation, compared with those who don’t, have a significantly higher completion rate of antibiotic therapy and less likelihood of being discharged against medical advice.(26)
The implementation of a standardized protocol requiring ID and addiction medicine consultations for hospitalized PWID who need OPAT reduces the length of stay without increasing 30-day readmissions.(26) Referral to addiction treatment is also associated with decreased mortality in PWID with infective endocarditis.(26) Successful completion of treatment reduces the chances of readmission. Addiction medicine consultations or requiring MAT-trained providers (ID or primary care) clearly lead to better outcomes and improved financial stewardship of the institution.
The savings from reduced length of stay and decreased readmissions would support institutional funding of education and funded positions for ID/addiction medicine physicians analogous to antimicrobial stewardship programs and infection prevention. Some of these institutional savings should be dedicated to establishing addiction medicine programs and providing MAT waiver education for all providers, but especially in family medicine, internal medicine, and infectious disease specialties.
Critical action items that each hospital system leader in the C-suite should prioritize include: (1) address addiction or OUD diagnoses (see Table 2 ); (2) utilize both ID and addiction medicine consultations (or MAT by other providers) to create best practices for DUA infections (see Table 3); (3) determine pipelines to community support programs for those with OUD; and (4) provide champions to establish a continuum of care for PWID who need OPAT (see Table 4).
Since ID providers are adept at handling public health initiatives and should be seeing all those with DUA infections, there is a call for a new subspecialty within the field of ID.(15) An ID specialist would be the champion in creating a cohesive DUA infection initiation in partnership with addiction medicine providers. Additionally, ID consultation with DUA infected patients may provide oral alternatives, determining the duration and route of antimicrobial therapy in addition to offering MAT.
Morrisette et al. showed that long-acting lipoglycopeptides, “lineless antibiotics” used at the University of Colorado, might reduce hospital length of stay. There was an estimated median savings of $40,455 (IQR, $20,900–$62,700) in PWID vs. $19,555 (IQR, $15,375–$23,735 in non-PWID) (p = 0.065) with Staphylococcal infections.(28) Use of long-acting lipoglycopeptides may be equally effective as standard-of-care for those with serious Staphylococcal infections.
Such treatment options may offer a safety advantage and secure earlier discharge with significant cost savings for an institution. Supporting additional institutionally funded time for ID providers likely would improve the quality of care for PWID with infections (outcomes) and control indirect costs not reimbursed to the institution (reduced length of stay and decreased readmissions or relapses of infections).
In summary, the opioid crisis has resulted in rising DUA infections. Due to lack of OUD screening, the degree of the impact of these infections is likely underestimated. The data clearly show that the current approaches to address the opioid crisis are detrimental to the financial well-being of healthcare institutions. A team of C-suite physicians and ID champions with addiction medicine providers needs to analyze institutional opportunities (research, patient services and education) and make local recommendations to improve patient outcomes, decrease LOS and lessen readmission rates.
The result of improved OUD care among those with infections combined with operational expense management would be to ultimately optimize the value of clinical care offered by one’s institution.
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