Integrating ID, substance use care reduces risk for readmission, death
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Patients with injection drug use-associated infections were less likely to be readmitted to the hospital or die when they were treated by a clinical team that integrated infectious disease and substance use disorder care, researchers found.
Patients treated by the integrated ID/substance use disorder (SUD) team — implemented at Jackson Memorial Hospital in Miami from August 2020 through May 2022 — also were more likely to initiate medication for opioid use disorder and complete antibiotic treatment and less likely to check themselves out of the hospital against medical advice, according to findings published in Open Forum Infectious Diseases.
Physicians have argued that concurrently treating infections and substance use disorder could help ease the epidemic of opioid misuse in the United States.
“I was frustrated by the ongoing suffering of people who inject drugs (PWID) hospitalized with severe infections and little being done to change the way we approach this syndrome,” David P. Serota, MD, MSc, assistant professor of clinical medicine and director of the severe injection-related infection (SIRI) team at the University of Miami Miller School of Medicine, told Healio.
Serota said there is a large and increasing evidence base supporting interventions such as medications for opioid use disorder, harm reduction, oral antibiotics for severe infections, overdose prevention and effective HIV and hepatitis C treatment in people who use drugs.
“Yet, I was rarely seeing these practices implemented, and certainly in no holistic or organized way,” he said.
To address the gap, Serota and colleagues established SIRI to treat PWID and provide medical care, SUD treatment and help patients navigate hospitalization and post-discharge care.
The researchers included 129 patients in the study — 59 in the SIRI team intervention and 70 in a pre-SIRI team control group. Most of the patients were men (62%), nearly half were non-Hispanic white and most (68.2%) were experiencing homelessness. Nearly all of the patients (99.2%) used opioids, and 86.8% used stimulants. Additionally, 78.3% were HCV- positive and 23.4% had HIV.
The researchers used a shared decision-making approach to antibiotics, finding that nearly all patients wanted to leave the hospital on oral antibiotics and avoid outpatient parenteral antimicrobial therapy or prolonged hospitalization.
Serota and colleagues found the rate of death or hospital readmission within 90 days among participants was cut nearly in half to 24.1% among SIRI team patients compared with 43.5% among control patients. After adjusting for severity of infection, SIRI team patients were 45% less likely to be readmitted or die within 90 days and 57% less likely to be readmitted to the hospital in 90 days compared with patients in the control group.
“Supporting integrated ID/SUD care is feasible and appears to have a large effect size on reducing readmissions compared to standard of care,” Serota said.
He said the study also “helps further highlight the utility of oral antibiotics for severe infections” and “that it is important to get antibiotics into the hands of patients leaving the hospital.”
Serota noted that the idea of integrating ID and SUD care and harm reduction is not new and dates to the early HIV epidemic, but roadblocks to these types of teams are common within the health care system. Despite this, he said he is optimistic about programs popping up around the country to help a “vulnerable and often-overlooked population” that needs it.
“I think the progressively dire situation with the U.S. drug overdose crisis has spurred renewed interest in exploring different approaches to this problem,” Serota said. “Most people in health care will readily agree that our current standard of care is inadequate.”
Perspective
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In this tour de force assessing the effectiveness of an incredibly innovative and important program, Serota and colleagues add to the growing ID/addiction medicine literature in a few important ways. First, they explicitly attribute the successes of the SIRI team to multiple elements, not only increasing use of medications for opioid use disorder. Although the increase in buprenorphine prescribing was certainly life-saving, also crucial were the decreases in discharges to the street, harm reduction-oriented approach, shared decision-making about antibiotics, and post-hospitalization follow-up. Given that almost all patients used both opioids and stimulants, this multifactorial approach will be key moving forward.
Also of note, it does not feel like the norm in the hospital to engage in shared decision-making about antibiotics to assess what will truly be patient centered for each individual, particularly in the case of patients using drugs, so this study (like others by Wildenthal and colleagues and Sikka and colleagues) epitomizes an important shift.
In summary, this is an important example of a program pushing our health system toward more truly whole-person, patient-centered care delivery for people who use drugs, hopefully inspiring similar programming across the country.
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