Incentive pay did not improve uptake of OPAT among ID physicians
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Financial incentive did not improve uptake of outpatient parenteral antimicrobial therapy among physicians, though uptake was already high before introduction of the incentive, suggesting that there was little room for improvement to start.
“Outpatient parenteral antimicrobial therapy (OPAT) is safe, effective, and much cheaper than keeping a patient in hospital just so they can finish their IV antibiotics,” John A. Staples, MD, MPH, clinical associate professor in the department of medicine at the University of British Columbia, told Healio.
“We realized that the introduction of the G33655 fee-for-service billing code was a natural experiment that we could use to understand whether physician financial incentives could be used to scale up OPAT,” Staples said.
Staples and colleagues conducted a retrospective cohort study using population-based data from 2004 to 2018.
They focused on infections requiring IV antimicrobials for 10 days or longer and used the monthly proportion of index hospitalizations with length of stay shorter than the guideline recommended usual duration of IV antimicrobials (LOS<UDIVA) as a proxy for population-level OPAT use. The researchers then used an interrupted time series analysis to evaluate whether policy introduction increased the proportion of hospitalizations with LOS<UDIVA.
In total, 18,513 eligible hospitalizations were identified and included in the study. Those cases identified as unlikely to have received OPAT were associated with older age, comorbidities, a greater likelihood of arrival by ambulance and more ICU use.
After assessing these hospitalizations, the study showed that the mean monthly proportion of potentially eligible hospitalizations with LOS<UDIVA was 82.3% in the pre-policy period and 80.7% in the post-policy period, suggesting that the introduction of the G33655 did not increase OPAT use (step change after policy introduction: –0.06%; 95% CI, –2.69% to 2.58%; slope change after policy introduction = –0.001% per month; 95% CI, –0.056% to 0.055% per month).
The researchers wrote that there are several possible explanations for this, including that OPAT programs may have already served a large proportion of eligible patients at baseline that left “little room for improvement”; that the proportion of hospitalizations with LOS<UDIVA may be a poor surrogate for population-level OPAT use; and that the “modest monetary value” of G33655, limited physician awareness of its availability, and other aspects of incentive design might have been insufficient to change physician behavior.
Staples added, however, that the incentive payment was not “a total failure.”
“It was also intended to remunerate infectious disease (ID) physicians for OPAT-related services and recruit ID physicians to the province,” Staples said, adding that this study did achieve those goals.
According to the study, the introduction of the G33655 policy was associated with a doubling in the aggregated fee-for-service income of all ID physicians involved in the medical care of the study cohort within 90 days of index hospitalization admission (baseline payments = $16,237 over 90 days; step-change increase = $14,358; 95% CI, $8,967-$19,748).
This step-change corresponded to an additional $279 (95% CI, $184-$373) in fee-for-service payments per ID physician in the first 90 days, the researchers found.
Additionally, the introduction was also associated with improved ID physician engagement in OPAT, corresponding to approximately one additional ID physician per year involved in the care of the study cohort.
“My advice for policymakers [is to] carefully measure the important outcomes before making any changes, design your incentives to maximize success, plan and perform a post-implementation evaluation at a prespecified interval, and modify your policies if they aren't achieving your goals,” Staples said.
“A robust system to deliver OPAT is a clear win for patients, for clinicians, and for health system payors. It's worth getting right,” he said.
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