Inequitable access to an outpatient parenteral antimicrobial therapy service: linked cross-sectional study

Colin Sumpter,Clark D Russell,Claire Mackintosh

doi:10.1186/s12939-020-01261-w

Abstract

Study aimTo assess whether Outpatient Parenteral Antimicrobial Therapy (OPAT) is provided equitably across gender and social groups in a tertiary care setting.BackgroundOPAT is a widely used and growing approach in high income countries to early discharge or admission avoidance for patients requiring intravenous antimicrobials. There is however a risk that equitable access to healthcare could be eroded unintentionally by expansion of outpatient or ambulatory approaches such as this. Anecdotal evidence in our service, and from published studies, have identified a gender and social group equity gap in outpatient services.MethodsService data on inpatient cellulitis episodes over a seven-year period were matched to OPAT referral data to create a retrospective cross-sectional linked dataset. All individuals admitted from 2012 to 2017 inclusive for a primary diagnosis of cellulitis were included: 6295 admissions of 4944 individuals. Demographics, number of co-morbidities, length of hospital stay, number of admissions, distance from OPAT unit and Scottish Index of Multiple Deprivation (SIMD; as a metric of deprivation) were recorded. Adjusted odds of a referral to OPAT across SIMD quintiles and for females compared to males were calculated using multiple logistic regression.ResultsInequitable access to OPAT was identified. Deprivation was negatively associated with likelihood of OPAT referral. Inpatients from the most affluent SIMD quintile were more than twice as likely to have received an OPAT referral compared to those resident in the most deprived quintile (adjusted OR 2.08, 95% CI: 1.60–2.71, p < 0.0001). Women were almost a third less likely to receive an OPAT referral than men (adjusted OR 0.69, 95% CI: 0.58 to 0.82, p < 0.001). Results were adjusted for age, number of co-morbidities, admissions, length of stay, distance from nearest OPAT unit, time since first admission, deprivation and gender.ConclusionsOPAT services and other ambulatory care programmes should routinely evaluate the equity of their service provision and consider how they can reduce any identified imbalance. It is a critical responsibility of service planning to ensure an inequitable system does not develop, with those least able to access ambulatory care dispossessed of the associated benefits.

Highlights

Outpatient Parenteral Antimicrobial Therapy (OPAT) is a widely used and growing approach in high income countries to early discharge or admission avoidance for patients requiring intravenous antimicrobials
Inpatients from the most affluent Scottish Index of Multiple Deprivation (SIMD) quintile were more than twice as likely to have received an OPAT referral compared to those resident in the most deprived quintile
It is a critical responsibility of service planning to ensure an inequitable system does not develop, with those least able to access ambulatory care dispossessed of the associated benefits

Summary

Introduction

OPAT is a widely used and growing approach in high income countries to early discharge or admission avoidance for patients requiring intravenous antimicrobials. OPAT is a safe and efficacious modality for managing infection in an outpatient or home setting [2]. OPAT is considered to be significantly cost saving to overall health budgets through facilitating early discharge and avoidance of admission to inpatient settings [3]. The OPAT approach is growing in the UK [1] and globally [2]. In the UK this has been driven in part by the potential for cost saving and as part of the drive to provide health services closer to patient homes [5]. The good practice recommendations in the UK suggest that OPAT should always be offered as an alternative to inpatient care and that patients should be able to choose between these options [1]

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