(94) In Hospital Addiction Treatment Reduces Readmissions for Patients with Related IE

Introduction: Drug-related infective endocarditis (IE) has increased in tandem with the opioid epidemic (Tan et al., 2020). Patients with IE are medically complex, requiring prolonged hospital stays, weeks of IV antibiotics, and often requiring heart valve replacement, with a mean cost of $250,994 per patient (Schranz et al., 2019). Patients with IE are at an increased risk of hospital readmission due to reinfection and complications related to untreated opioid use disorder (OUD) (Moreno et al., 2019). While studies have shown that offering Medications for Opioid Use Disorder (MOUD) can reduce hospital readmissions (Moreno et al., 2019), additional studies suggest this may not be sufficient to reduce readmissions for those hospitalized with IE (Kimmel et al., 2020).

Objective: Decrease readmission rates for patients with IE through a multidisciplinary and continuity approach utilizing an inpatient addiction consult service (ACS) and transition to an outpatient OUD treatment program.

Methods: The University of North Carolina at Chapel Hill (UNC) initiated an ACS as a quality improvement measure to connect patients hospitalized with infections from IV Drug Use, including osteomyelitis (OM) and IE, with a multidisciplinary team that consists of addiction medicine physicians, case managers and peer support specialists (those with lived experience in recovery). The ACS offers MOUD, specialized case management, peer support services, harm reduction education, safe injection practices, resources for syringe service programs, and connection to outpatient addiction treatment. Patients who choose to follow the UNC outpatient addiction treatment program have a continuity experience, seeing the same physicians, peer support specialists, and case managers in inpatient and outpatient settings. The initiative tracked the frequency of consults, infection type, initiation of MOUD, and hospital readmissions at 30, 60, and 90 days.  

Population: Between July 1, 2020, and June 30, 2021, 83 patients with IVDU related infections were served: 36 with IE (43%), 19 with OM (23%), 28 with other abscesses (33%). Of these, 61% were uninsured, 59% were women, 88% were White, 10% were Black, and 57% were <35 years old.

Results: Sixty-five patients (74%) were discharged with MOUD (methadone or buprenorphine), 14 patients (17%) declined MOUD, and four patients (5%) were discharged with opioid agonists. 54% of the patients chose to follow the UNC outpatient addiction treatment program (19 with IE, 7 with OM, and 19 with other infections), while 46% of patients either engaged in another outpatient treatment program or declined treatment. Patients hospitalized with IE, OM and other infections who chose outpatient addiction treatment with UNC experienced a > 50% reduction of hospital readmission rates at 30 days (UNC=7%, Other=21%), 60 days (UNC=10%, Other=29%), and 90 days (UNC=17%, Other=37%).

Conclusion: An integrated multidisciplinary approach with an inpatient addiction consult service linked to an outpatient addiction treatment program successfully decreases hospital readmissions at 30, 60, and 90 days by >50% for those with IE, OM, and other abscesses.

References: Kimmel, S. D., Walley, A. Y., Li, Y., Linas, B. P., Lodi, S., Bernson, D., Weiss, R. D., Samet, J. H., & Larochelle, M. R. (2020). Association of Treatment With Medications for Opioid Use Disorder With Mortality After Hospitalization for Injection Drug Use-Associated Infective Endocarditis. JAMA Network Open, 3(10), e2016228. https://doi.org/10.1001/jamanetworkopen.2020.16228
Moreno, J. L., Wakeman, S. E., Duprey, M. S., Roberts, R. J., Jacobson, J. S., & Devlin, J. W. (2019). Predictors for 30-Day and 90-Day Hospital Readmission Among Patients With Opioid Use Disorder. Journal of Addiction Medicine, 13(4), 306–313. https://doi.org/10.1097/ADM.0000000000000499
Schranz, A. J., Fleischauer, A., Chu, V. H., Wu, L.-T., & Rosen, D. L. (2019). Trends in drug use-associated infective endocarditis and heart valve surgery, 2007 to 2017. Annals of Internal Medicine, 170(1), 31–40. https://doi.org/10.7326/M18-2124
Tan, C., Shojaei, E., Wiener, J., Shah, M., Koivu, S., & Silverman, M. (2020). Risk of New Bloodstream Infections and Mortality Among People Who Inject Drugs With Infective Endocarditis. JAMA Network Open, 3(8), e2012974–e2012974. https://doi.org/10.1001/jamanetworkopen.2020.12974

Diversity, Equity, and Inclusion: The culture of the University of North Carolina at Chapel Hill (UNC) Addiction Medicine Program (AMP) is to create an environment that is safe and accepting to all people, particularly focused on trauma-informed care and harm reduction. The UNC-AMP recognizes the need to expand cultural sensitivity to include minority populations as an area for development, particularly given the historic and current systemic barriers that occlude Black, Indigenous, and Persons of Color (BIPOC) and LGBTQI people from accessing life-saving addiction treatment. The UNC-AMP is committed to exploring and understanding systemic racial disparities and how these disparities impact care for BIPOC/LGBTQI people. The UNC-AMP chose to take action by focusing on two areas: 1) enhance education of UNC-AMP faculty and staff through participation in the UNC School of Medicine’s Diversity, Equity and Inclusion certificate course; and 2) creation of referral pathways for the prison and jail systems of NC to transition people to addiction treatment upon release from incarceration. By taking these steps, the UNC-AMP seeks to expand knowledge about treatment disparities and to expand access to care for those from diverse backgrounds.