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Documenting the Value of OPAT: Outcome Studies and Patient Registries

2000; Pulsus Group; Volume: 11; Issue: A Linguagem: Inglês

10.1155/2000/769742

1918-1493

Alan D. Tice,

Central Venous Catheters and Hemodialysis

Medical care in the United States is changing rapidly. New and useful products and procedures are brought to the market almost daily. At the same time, there are increasing concerns about the cost of medical care and the reluctance to pay for it. The private companies who pay for the spiraling cost of medical benefits for their employees are concerned about their ability to pay for benefits while remaining competitive. The primary insurer, the federal Health Care Financing Administration, will be headed toward bankruptcy if it continues to provide retired Medicare beneficiaries the health care that their elected officials have promised. Although there will almost certainly be another increase in taxation to make up for the shortfall, it is only a temporary solution. As a result, there has been a critical look at health care to generate ideas for ‘reform’, and a search for answers about costs and quality of care. The now defunct Office of Technology Assessment provided some disturbing, yet truthful insight to the United States Congress in 1994 with their finding that: “The justification for most medical practices used in the United States today rests on the experience and expertise of the clinicians and patients rather than on objective evidence that these practices can measurably improve people’s health” (1). In an effort to reduce medical costs through the elimination of unnecessary services, the concept of ‘managed care’ has evolved with an increasing impact on medicine and society (2). Physicians are no longer simply asked their opinions but also to justify them. If they cannot, benefits may be denied. Health care reform has been an anathema to many doctors, but a boon to attorneys, administrators and entrepreneurs. It also led to greater accountability and a re-examination of the benefit or relative value of many medicines and procedures. The medical profession has begun to study quality of care and to look for indicators of quality, but is at a disadvantage compared with the businessmen who have a far easier measurement tool – money. A growing science of quality assurance or evidence-based medicine helps in decision-making and allocation of resources. Every field of medicine is looking for outcome measures that are useful in assessing the quality of care and justifying the therapies provided. Outpatient parenteral antibiotic therapy (OPAT) is in an enviable position compared with many other recent advances in medicine. It brings an improvement in care to selected patients but also cost savings. This is a rare combination of benefits for any new program in modern medicine, but the need for quality assurance remains, with fierce competition among home care providers as they vie for business and contracts from insurance companies. OPAT is also in need of continued reexamination because it is a relatively new form of medical therapy that occurs outside the safeguards and controlled environment of the hospital. Questions remain about undiscovered problems, standards of care and limitations to the benefits. How far can it be pushed before there are safety problems? One of the most-standardized and universally accepted measures of outcome is cost. The cost savings of OPAT have been well studied. In a 1978 article, Antoniskis and colleagues (3) compared the cost of care for patients treated in hospital with those treated for an average of 22 days outside hospital – a savings of US$165/day. Later studies examined different aspects of cost, such as transportation, child care, laundry, food and the impact on the family (Table 1) (3-8). Additional considerations included the economic advantage to the patient of returning to work or school despite ongoing OPAT (9,10). The most recent article by Hindes et al (8) investigated the financial aspects of OPAT for Medicare patients. They modelled a cost formula based on bed occupancy. The different series in